Daily Bolus of LR: Needle drainage of a peritonsillar abscess

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February 28, 2011 by dailybolusoflr

A peritonsillar abscess is a focal infection of the palatine tonsils that most commonly develops after a streptococcal infection.

 

There are two methods to drain a peritonsillar abscess:

  1. Needle drainage
  2. Traditional incision and drainage (less commonly used by ED physicians)

 

The following are some pearls for having a successful needle drainage procedure:

  1. The best position is with the patient sitting up with their head supported (by the stretched, ENT chair or someone’s hand).   This will prevent them from moving away from you.
  2. Apply topic anesthetic to the targeted entry point.  You can also try injecting lidocaine with epinephrine (to anesthetize and limit bleeding)
  3. Have your supplies, including suction ready and at the bedside.
  4. Assure good visualization and light.
    1. Using a Macintosh laryngoscope will enable you to inferiorly retract the tongue as well direct a source light to the posterior pharynx.
    2. In a cooperative, calm patient you can attempt this with the patient sitting up and holding the laryngoscope themselves.
    3. You can also simply push the tongue to the side with your hand, although this takes up of your hands.
  5. Find the area of maximal fluctuance.  If this cannot be found on exam, sources recommend starting at the most superior portion of the abscess and attempting drainage here.  If this is unsuccessful, next trying the middle portion and lastly the most inferior portion.  If only the superior portion is tried,  you can miss up to 30% of abscesses
  6. Needles should be large enough to drain the pus (typically at least 18G)
  7. Use a needle guard to ensure you don’t advance the needle too deep.  Remember the carotid artery is typically located lateral and posterior. 
    1. You can make this yourself by cutting the needle cap and replacing it with only the desired amount of needle exposed.  That way, it is impossible for you to advance any deeper than you have planned.
    2. Most sources recommend not going more than 1cm deep.
  8. Talk to your patient and let them know they are doing well.
  9. Give them a “safe signal” like raising their hand in the air, so that they will be not be tempted to move their head away from you or try to talk while you have the needle in their mouth.

 

 

 

Roberts and Hedges

 

 

Linda Regan, MD FACEP

Program Director, Emergency Medicine Residency

Johns Hopkins Medical Institutions

 

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