Trick of the Trade: Peritonsillar abscess needle aspiration

How do you drain a peritonsillar abscess?

When evaluating a patient with a sore throat and “hot potato voice,” peritonsillar abscess (PTA) is at the top of the differential diagnosis list. As with all abscesses, the definitive treatment involves drainage of pus. This can be done either by incision and drainage or, more commonly, by needle aspiration.

Unlike surface abscesses on the skin, there are unique challenges for accessing the PTA.

• The peritonsillar area is not as easily accessed as the skin, and, for this reason, is often poorly lit.
• Patients with PTAs often have associated trismus which make it harder for the practitioner to even see, much less aspirate, the PTA.
• Vascular structures, such as the carotid artery, lie in close proximity to the peritonsillar space and add a level of complexity to the procedure.

Trick of the trade: Shed some light on the situation

Visualization is key when aspirating a PTA. Appropriate visualization of the pharynx is made possible by abundant lighting with adequate exposure. A laryngoscope with a curved blade provides both of those elements. With the patient sitting upright and after appropriate anesthesia, gently insert the blade into the patient’s mouth, as far posteriorly as tolerated without gagging. The laryngoscope blade should be inserted, similar to the technique for endotracheal intubation.

A variation on this theme is to use a video laryngoscope in lieu of a direct laryngoscope when teaching this procedure to others. It can both be used to demonstrate the procedure, and to oversee and guide the learner’s technique. Projecting the procedure on a digital screen allows multiple providers to view the pharynx, instead of just the person directly in front of the patient.

Another variation on this theme is actually to have a cooperative patient control the laryngoscope handle. Patients often can provide a great view when they pull their own tongue inferiorly. They can pull without triggering their gag reflex.

Trick of the trade: Use a long spinal needle

Needle aspiration of a PTA can be done with a 1.5 inch needle on a syringe. However, the barrel of the syringe often can obscure the practitioner’s line of sight, as shown in this photo. To optimize the view, use a 3.5 inch spinal needle so that the syringe remains outside of the patient’s mouth.

Trick of the trade: When using a spinal needle, always use protection.

A worrisome concern with using a 3.5 inch spinal needle for PTA drainage is advancing the needle too deeply and inadvertently puncturing the carotid artery. A trick to help prevent this is to use a protective guide. Trim the needle’s plastic sheath so that when replaced, only 1.5 cm of the needle tip is exposed. When using the needle to aspirate the abscess, the sheath prevents the needle from over-advancing beyond 1.5 cm.

Thanks to Dr. Hagop Afarian (Fresno), who co-authored this topic with me in a recent ACEP News Tricks of the Trade column!

Update April 6, 2014:

Thanks to Drs. Salil Bhandari and Anand Swaminathan from Bellevue/NYU Emergency Department

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