UWorld says surgical drainage comes before IV antibiotics, but only mentions those two steps. What is the role of a lateral cervical x-ray? Does it come first before anything? Is it indicated at all in routine management?
Uworld is correct. There is no need for xray when you can open up the pts mouth and see the abscess. I think you are thinking about imaging for retropharyngeal abscess.
If you were to image, I think maybe Id check it out with an ultrasound (maybe) but like I said none is needed. I got to do a needle aspiration one of these bad boys in the ED a few months ago. Prob my favorite procedure (besides tubing) to date.
p.s. - dont forget the use of steriods!
From UpToDate:
"Imaging — Imaging is not necessary to make the diagnosis of peritonsillar abscess (PTA), but may be necessary to differentiate PTA from peritonsillar cellulitis and other deep neck space infections and to look for complications.
Computed tomography (CT) with IV contrast is the preferred imaging modality [
25,26]. It distinguishes PTA from cellulitis and also demonstrates the spread of infection to contiguous deep neck spaces.
Diagnosis — The diagnosis of peritonsillar abscess (PTA) can usually be made clinically without laboratory data or imaging of any kind in the patient with medial displacement of the tonsil and deviation of the uvula (
picture 1 -
http://www.uptodate.com.ezproxy.library.uq.edu.au/contents/image?imageKey=ID/69943&topicKey=EM/6079&rank=1~34&source=see_link&search=peritonsillar abscess&utdPopup=true). Diagnosis is confirmed by collection of pus at the time of drainage [
3,33].
We recommend antibiotic therapy for all patients with suspected peritonsillar infection (
Grade 1B). Empiric therapy should include coverage for Group A streptococcus, S. aureus, and respiratory anaerobes. Therapy should be continued for 14 days. (See
'Antibiotic therapy' above.)
Patients who have examination findings consistent with peritonsillar abscess (swollen, medially deviated, fluctuant tonsil, deviation of the uvula) generally require drainage in addition to antimicrobial therapy. (See
'Overview of approach' above.)"
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Once again, this is why I exhort having UpToDate open as a separate tab as you're going through UW. They go into more detail about drainage vs mere Abx therapy if you look up the full article. In general, whenever your plan is that you need to drain something, you'd do that before the Abx just because it's known that Abx can interfere with culture results. And drainage is the biggest step to resolving the infection anyway, so you don't need to worry about the "short delay" to the Abx. If you're not going to drain, then just give the Abx. UpToDate supersedes UW btw.
Standard starting therapies are amoxicillin-clavulanate or clindamycin for oral Tx. Ampicillin-clavulanate or clindamycin for IV.
