Peritonsillar Abscess (Quinsy): Pomitoro kan funteni, Uvular Deviation, Trismus, Drooling, ani Needle Aspiration ni Parafarinji jɛnsɛnni¶

Ni galaka dimi juguyara kosɛbɛ fan kelen fɛ, ka fara "pɔmitɛri funteni" kan dɔ kan min bɛ sɔgɔsɔgɔ (a bɛ fɔ i n’a fɔ a tigi bɛ kuma ni pɔmitɛri funteni jenilen ye a da la), sebaliya ka da wuli cogo bɛnnen na (trismus walima dawolo datugulen), dimi jugumanba bɛ bɔ tulo la fan kelen fɛ, ka sɔgɔsɔgɔ barisa daji munumunu ye dimi kojugu, ani dawolo nɔgɔlen funun min bɛ uvula jɛngɛlen gɛrɛ cɛmancɛ la ka taa fan dɔ fɛ (kɛnɛya), o sɛgɛsɛgɛli ye peritonsillar abscess (PTA) ye, tariku kɔnɔ a bɛ fɔ a ma ko quinsy. Aw bɛ taa dɔgɔtɔrɔso la joona dɔgɔtɔrɔso la min bɛ se ka opereli kɛ ni tulolabanaw (ENT) ye, walima aw bɛ aw ka sigida kɔrɔtɔko nimɔrɔ wele (911 Ameriki ni Kanada, 112 Erɔpu tɔnba bɛɛ kɔnɔ, 999 Angletɛri; an ka kɔrɔtɔko nimɔrɔw) o yɔrɔnin bɛɛ ni a tigi bɛ ka sɔgɔsɔgɔ, ni a bɛ gɛlɛya ka ninakili, walima ni a tɛ se ka munumunu. Ni aw bɛ aw labɛn ka taa ni aw ye, aw bɛ ɲɛgɛnɛsiralabanaw ni da duguma funu fan fila ni ɲɔgɔn cɛ ni aw ye Ludwig ka angina fiɲɛbɔyɔrɔw ɲɛminɛbaga, ka kɔfɛla banakisɛw suma ɲɔgɔn na an ka kɔfɛla sɔgɔsɔgɔninjɛ ni cɛmancɛladimi ɲɛminɛbaga, ani ka kɔnɔbara basigilen taamasiɲɛw kɔlɔsi an ka Lemierre ka syndrome gafe ɲɛminɛbaga.

peritonsillar abscess ye kɔkolo yɔrɔ jugumanba banakisɛ kelen ye min ka ca denmisɛnw, funankɛninw ani baliku fitiniw na. A bɛ sɔrɔ ni banakisɛfagalan dɔ (a ka ca a la, banakisɛ caman ɲagaminen don Group A beta-hemolytic Streptococcus pyogenes, Streptococcus anginosus kulu, ani da kɔnɔ banakisɛw i n’a fɔ Fusobacterium ani Prevotella) karilen don palatine tonsil (walima a datugulanw) kɛnɛma ɲɛgɛnɛsira fibrous kɔnɔ Weber ka sɔgɔsɔgɔninjɛ misɛnninw tonso sanfɛla la) ani ka ɲɔgɔn lajɛ i n’a fɔ sɔgɔsɔgɔninjɛ bɔrɔ tensionnen yɔrɔ min bɛ se ka kɛ tonsila kapisi cɛmancɛ la ani superior pharyngeal constrictor muscle cɛ kɛrɛfɛ. Ikomi farigan sanfɛla sɔgɔsɔgɔninjɛ ye farikolo kogo finman kelenpe ye min bɛ ɲɛgɛnɛsiralabanaw faranfasi ka bɔ parafarinji yɔrɔ ni karotidi sɔgɔsɔgɔninjɛ la (a ka ca a la karotidi kɔnɔna na bɛ sigi santimɛtɛrɛ 1,0 fo 2,5 dɔrɔn a kɔfɛ ani a kɛrɛfɛ), kɔnɔbara basigilen kuru min ma furakɛ, o bɛ se ka teliya ka fiɲɛbɔyɔrɔ sanfɛla bali, ka kari a yɛrɛ ma ka don fogonfogon la sunɔgɔ waati (o bɛ kɛ sababu ye ka sɔgɔsɔgɔninjɛ fagalen bila mɔgɔ la), walima ka sɔgɔsɔgɔ kɛ kɛrɛfɛ walasa ka kɛ sababu ye ka parafarinji kurukuru, Lemierre ka bana, walima karotidi joli bɔli jugumanba lase mɔgɔ ma. Ni kuru jɛlen bɔra o yɔrɔ in kɔnɔ dɔrɔn, banakisɛfagalan da la dɔrɔn tɛ se ka kɔnɔbara basigilen furakɛ; lafiya dafalen bɛ ɲini kɔrɔtɔko la ni pikirijikɛlan fiyɛ walima ka a tigɛ ani ka a ji bɔ ka fara banakisɛfagalanw ni kɔritikositɛriw kan jolisira fɛ.

Aw bɛ nin kɛ sisan¶

1. Aw bɛ taa dɔgɔtɔrɔso la joona joona (walima aw bɛ telefɔni 911 / 112 / 999 wele ni aw bɛ sɔgɔsɔgɔ, ni ninakili bɛ gɛlɛya, walima ni aw bɛ stridor mankanba bɔ). Aw kana taa furakɛliso feereyɔrɔ la walima ka tile caman makɔnɔ furakɛli fɔlɔ la, ani aw kana a miiri ko amɔkisisilini da la walima penisilini min sɛbɛnna dɔgɔkun daminɛ na, o bɛna wuli ka bɔ abscess (banakisɛfagalan). Peritonsillar kurukuruni bɛ a ɲini dɔgɔtɔrɔso la joona joona, ka ji di a ma jolisira fɛ, ka furakisɛw ta joli la, ani banakisɛfagalanw minnu tɛ fiɲɛ bila mɔgɔ la.
2. Aw bɛ to ka a tigi sigilen to ka a biri dɔɔni ɲɛfɛ ka tasa walima finimugu di a ma walasa a ka daji bɔ. Aw kana banabagatɔ wajibiya abada min bɛ sɔgɔsɔgɔ walima min bɛ kuma ni "pɔmitɛri funteni" kanba ye, o ka da a kɔ kan, o bɛ a to a dawolo nɔgɔlen fununen ni a tonso ka bɔ kɔfɛ ka taa kɔfɛ fiɲɛbɔyɔrɔ la ani ka dɔ fara a ka sɔgɔsɔgɔninjɛ kan min bɛ daji dalajɛ walima a yɛrɛma kari.
3. Aw bɛ "Two-Finger Trismus Check" kɛ ka uvula lajɛ ni telefɔni lanpan ye (k'a sɔrɔ aw ma foyi don da kɔnɔ). Aw bɛ a ɲini a tigi fɛ a ka a da wuli ka se a dan na:
4. A ka ca a la, baliku walima denmisɛn kɔrɔba bɛ se ka bolokɔni saba sigilenw (milimɛtɛrɛ 35 fo 50) don nɔgɔya la ka jɔ u ɲɛfɛla sanfɛla ni duguma ɲinw cɛ. Ni u bɛ se k’u da da bolokɔni kelen walima fila dɔrɔn (< milimɛtɛrɛ 20 fo 25) ka a sababu kɛ dimi ye ka dawolo kɛrɛ fɛ, trismus bɛ yen (o b’a jira ko funu ye cɛmancɛ farikolo yɔrɔ dimi).
5. Aw bɛ lanpan yeelen da kɔnɔ ka sɔrɔ aw ma kɛ ni kuyɛri walima kanjibɔlan ye: ni kɔnɔbara basigilen don, dawolo nɔgɔlen min bɛ tonso sanfɛ, o bɛ wuli ka jigin ka taa ɲɛfɛ i n’a fɔ balon bilenman sirilen, ka tonso gɛrɛntɛ ka jigin/kɔnɔna na ani ka uvula gɛrɛntɛ k’a kɔlɔsi kɛrɛfɛ ka taa fan dɔ fɛ (kɛnɛya).
6. Aw kana a ɲini abada ka tonso fununen pop, ka a sɔgɔ, ka a sɔgɔ, walima ka a sɔgɔ so kɔnɔ ni bɔgɔmugu ye, ni bolokɔni ye, ni pikirijikɛlan ye, walima ni pince ye. Tonsi kɛrɛfɛla kɔfɛ, kɔnɔna karotidi joli bɛ yen. Ni aw ye fiyentɔya kɛ ka ɲɛgɛnɛsira sɔgɔsɔgɔninjɛ dɔ digi walima ka a digi so kɔnɔ, o bɛ se ka karotidi kɔnɔna joli sira tigɛ (o bɛ kɛ sababu ye ka joli bɔli faga sekɔndi damadɔ kɔnɔ) walima ka sɔgɔsɔgɔninjɛ belebeleba dɔ kari ka jigin ka taa fiɲɛbɔlan kɔnɔ.
7. Aw bɛ banabagatɔ to Foyi da la (NPO) ni aw taara dɔgɔtɔrɔso la dɔrɔn. Hali ni minnɔgɔba bɛ banabagatɔ la ka a sababu kɛ a munumunubaliya ni a farigan donbaliya donw ye, aw kana a to u ka dumuni kɛ walima ka minni kɛ sira kan ka taa kɛnɛyaso la. Pikirijikɛlan fiyɛli, tigɛcogo ani ji bɔli sigida/yɔrɔ la anestezi fɛ, walima opereli yɔrɔ ji bɔli bɛ kɔnɔbara lankolon de wajibiya walasa banabagatɔ kana fɔɔnɔ ani ka fiɲɛ sama a dawolo la.
8. Aw bɛ aw janto darapo bilenmanw na minnu ka bana karilen don ka bɔ tonso yɔrɔ la ka don kɔ juguman na (Parapharyngeal Spread). Ni funu, bilenni, walima nɔgɔ jugumanba bɛ taa dawolo kɛrɛ jukɔrɔ ka jigin kɔ kɛrɛ fɛ (sɔgɔsɔgɔninjɛ farikolo ɲɛfɛla fɛ), walima ni banabagatɔ kɔ gɛlɛyara, farigan bɛ lamaga (rigors), walima disi dimi, aw bɛ dɔgɔtɔrɔ kɔrɔtɔlen lasɔmi joona walasa u ka yamaruya di kɔla CT scan min bɛ kɛ ni danfara ye sani u ka pikirijikɛlan kɛcogo si kɛ.

Dɔgɔtɔrɔso latigɛjiri min bɛ kɛ ni dawolo dimi jugumanba ye fan kelen fɛ, trismus ani uvular deviation¶

Aw bɛ baara kɛ ni nin kɛnɛyaso kɔrɔtɔlen taabolow ye walasa ka tonso bɔli nɔgɔman, ɲɛgɛnɛsiralabanaw (plégmon), ɲɛgɛnɛsiralabana jɛlen (quinsy), ani parafarinji/karotidi yɔrɔ jugumanba jɛnsɛnni danfara don.

flowchart TD
    Start["Galakalabana jugumanba (A ka jugu fan KELEN fɛ),<br/>Sumaya, Odynophagie, walima Tulodimi min bɛ taa ɲɛ"] --> Exam["Aw bɛ fiɲɛbɔyɔrɔ jateminɛ & ka da/kɔ sɛgɛsɛgɛli kɛ yɔrɔ 3 la:<br/>1. ‘Pomitɛri funteni’ kan min bɛ dabila walima min bɛ sɔgɔsɔgɔ<br/>2. Trismus (Tigɛsiraw ni ɲɔgɔn cɛ da wulilen < milimɛtɛrɛ 25)<br/>3. Unilateral Soft Palate Bulge + Uvula A bɛ gɛlɛya ka taa fan dɔ fɛ"]

    Exam --> AirwayCheck{"Yala Stridor, Dyspnea jugumanba,<br/>Cyanosis, walima Sebaliya ka da flakɛlen bɛ yen wa?"}

    AirwayCheck -->|"ƆWƆ: FIƝƐW ƝƐNABƆLI MIN BƐ SƆRƆ"| EmergentAirway["YƆRƆBƆLI KƆRƆBƆLI FIƝƐLA KODƆN:<br/>1. Aw bɛ banabagatɔ sigilen to bololanɛgɛ jɔlen na (Degɛrɛ 90)<br/>2. Mobilize Anestezi + ENT ka ɲɛsin Awake Fibreoptic<br/> Intubation walima Awake Trachéostomie Backup ma<br/>3. Aw bɛ Stat IV Dexamethasone miligaramu 10 + IV Banakisɛfagalanw di a ma<br/>4. Aw bɛ Opereli jibɔ kɛ OR kɔnɔ ni fiɲɛbɔyɔrɔ lakananen don siɲɛ kelen"]

    AirwayCheck -->|"AYI: Fiɲɛbɔyɔrɔ bɛ sabati ka a sigilen to a jɔlen na"| DeepSpread{"Yala Parafarinji walima<br/>Carotid sheath jɛnsɛnni juguman taamasiɲɛw bɛ yen wa?<br/>(Kɔnɔna funu bɛ jaw Angle duguma,<br/>SCM ɲɛfɛla sɔgɔsɔgɔ, a gɛlɛya, Torticollis,<br/>walima Trismus jugumanba min bɛ da yecogo bali)"}

    DeepSpread -->|"ƆWƆ: Aw bɛ siga la ko Parafarinji Abscess<br/>walima Lemierre ka bana bɛ a la"| ContrastCT["STAT CONTRAST-ENHANCED CT OF THE NECK:<br/>1. Maps Exact Abscess Location Relative to the<br/>   Internal Carotid Artery & Internal Jugular Vein<br/>2. Start IV Ampicillin-Sulbactam 3 g q6h (or Ceftriaxone<br/>   + Metronidazole) + Vancomycin + IV Dexamethasone<br/>3. ENT Operating Room Drainage (Transoral or External)"]

    DeepSpread -->|"NO: Classic Isolated Unilateral<br/>Supratonsillar Soft Palate Bulge"| Ultrasound["BEDSIDE INTRAORAL / TRANSCUTANEOUS ULTRASOUND<br/>(A bɛ danfara don Flegmon ni Pus Pocket Drainable<br/>ani ka Doppler Flow of Carotid Artery dɔn)"]

    Ultrasound -->|"Fluid Hypoechoïque Collection<br/>(Abscès péritonsilaire lakika) ."| Drainage["KƆRƆBƆLI ƝƐNABƆLI + DƆGƆTƆRƆW KISI:<br/>1. Farikolo la/Sigida la anestezi + IV jilama +<br/> IV Dexamethasone miligaramu 10 A tata hakɛ kelen<br/>2. Needle Aspiration (18G Needle with Depth Guard<br/> <= 1,0 ka se 1,5 cm ma Superior Pole la) OR<br/> Garadilen Scalpel Incision & Drainage<br/>3. IV/Anpisilini-Sulbactam walima Amɔkisisilini-Klavulanate da la"]

    Ultrasound -->|"Odema solide Dɔrɔn, Pus<br/>(Céritonsilaire Cellulitis) ."| Cellulitis["PERITONSILLAR CELLULITES (PHLEGMON):<br/>1. Ɲɛgɛnɛsiraw ani mɔgɔ dogoyɔrɔw. Aw kana tigɛ (Aw tɛ Pus ka ji bɔ fɔlɔ)<br/>2. Aw bɛ jibolisira IV, Dexamethasone miligaramu 10,<br/> ani Anpisilini-Sulbactam / Sɛfitiriakzɔni + Mɛtɔrɔnidazɔli<br/>3. Aw bɛ Lɛrɛ 12 fo 24 Kɔlɔsi ka ɲɛsin Resolution vs. Liquefaction ma"]

Farikoloɲɛnajɛ ni banakɔtaa: Peritonsillar yɔrɔ, Weber ka glandes, ani carotid artery kɔnɔna farati¶

Tonsila dilancogo dancɛ tigitigiw faamuyali bɛ quinsy taamasiɲɛ bɛɛ ɲɛfɔ kɛnɛyaso la ani k’a jira mun na pikirijikɛlan tali ka kan ka tugu jateminɛ taamasiɲɛ gɛlɛnw kɔ walasa ka a yɛrɛ tanga kɔnɔna karotidi joli ma.

1. Peritonsillar yɔrɔ ni Weber ka glandes dancɛw farikolola¶

Palatine tonsil sigilen bɛ sigi ka don kɛrɛ saba kɔnɔ degun dɔ kɔnɔ min bɛ dawolo kɛrɛfɛ kogo la min bɛ wele ko tonsillar fossa, a bɛ kɛ ɲɛfɛ ni tonsillar pillar anterior (palatoglossus muscle) ye ani kɔfɛ ni tonsil postérieur pillar (palatopharyngeus muscle) ye. - Peritonsillar Space: Tonsili fan jugumanba lamini ye areolar potential space lafiyalen ye min dan ye: - Dɔgɔtɔrɔso la: A fibrous gɛlɛn capsule de la palatine tonsil. - Kɛrɛfɛla: superior pharyngeal constrictor muscle (o bɛ peritonsillar yɔrɔ ni parapharyngeal space faranfasi). - Kɔnɔna na: Tonsila ɲɛfɛla (palatoglossus muscle). - Kɔnɔna: Kɔfɛla tonso (palatopharyngeus muscle). - Kurukuruw bɔli fɛɛrɛ fila (Tonsilite Progression vs Weber’s Gland Sialadenite): 1. Tonsila janya tilennen: Tumu jugumanba bɛ tonso fiyɛlen kari a sanfɛla fan fɛ min ka fin kosɛbɛ, a bɛ taa ɲɛ ka tɛmɛ lɛri 24 fo lɛri 48 kɔnɔ peritonsillar cellulitis (phlegmon), ka kɛ ji ye ka kɛ peritonsillar abscess ye min kogo bɛ a la. 2. Weber ka glande obsstruction (A ɲɛfɔ mun na PTA bɛ se ka kɛ ni tonso jugumanba tɛ ka kɔn o ɲɛ walima hali ni tonso bɔli kɔfɛ): A dogolen don dawolo nɔgɔlen na tonso sanfɛla (superior pole) sanfɛ yɛrɛ, o ye sɔgɔsɔgɔninjɛ misɛnnin 20 fo 25 ye minnu bɛ wele ko Weber ka glands, minnu ka sira misɛnninw bɛ kɛ lankolon don tonso sanfɛla kriptiw kɔnɔ walasa ka nɔgɔw bɔ. Ni funu walima ŋɛɲɛ ye Weber ka ɲɛgɛnɛsiraw datugu, banakisɛ min bɛ ɲɛgɛnɛsira kɔnɔ, o bɛ kuru bɔ supratonsillar soft palate la k’a ɲɛsin a ma (o de b’a ɲɛfɔ mun na kɔnɔbara basigilen kɛmɛsarada la 90 bɛ sigi superior pole la tonso sanfɛ sanni ka kɛ a dugumayanfan kɔfɛ).

+-------------------------------------------------------------------------+
|     ANATOMY OF A PERITONSILLAR ABSCESS & INTERNAL CAROTID PROXIMITY     |
+-------------------------------------------------------------------------+
|  VIEW LOOKING INTO THE OPEN MOUTH (EXAMPLE: LEFT PERITONSILLAR ABSCESS) |
|                                                                         |
|   * Soft Palate & Anterior Pillar on Affected Side:                     |
|     - Swollen, erythematous, bulging DOWNWARD and FORWARD               |
|     - Effaces (flattens out) the normal fold of the anterior pillar     |
|   * Palatine Tonsil on Affected Side:                                   |
|     - Pushed DOWNWARD, MEDIALLY (toward midline), and FORWARD           |
|   * Uvula (Midline Marker):                                             |
|     - Pushed across the midline AWAY from the abscess toward the        |
|       HEALTHY (opposite) tonsil                                         |
+-------------------------------------------------------------------------+
|  WHAT LIES DIRECTLY LATERAL & POSTERIOR TO THE ABSCESS (THE DANGER):    |
|   * Thin Superior Pharyngeal Constrictor Muscle (only 2-3 mm thick)     |
|   * Lateral to that muscle = PARAPHARYNGEAL SPACE & CAROTID SHEATH      |
|   * INTERNAL CAROTID ARTERY + Ascending Pharyngeal/Facial Arteries      |
|     sit just 1.0 to 2.5 cm posterolateral to the inferior/middle tonsil |
|   * Medial Pterygoid Muscle (chewing muscle) sits immediately lateral   |
|     to the superior constrictor -> Irritation causes SEVERE TRISMUS     |
+-------------------------------------------------------------------------+

2. Mun na Peritonsillar Abscess bɛ kɛnɛya taamasiɲɛ 4 kɔrɔlenw lase mɔgɔ ma¶

1. Trismus jugumanba (A bɛ sɔrɔ banabagatɔ tila saba la fila la, wa a ni tonsoci nɔgɔmanw danfaralan #1 ye): O yɔrɔnin bɛɛ la, farigan sanfɛla sɔgɔsɔgɔninjɛ farikolo kɔkanna na, cɛmancɛ (kɔnɔna) sɔgɔsɔgɔninjɛ farikolo bɛ yen, o ye sɔgɔsɔgɔninjɛ farikolo barikama dɔ ye min bɛ dawolo datugu. Ni sɔgɔsɔgɔninjɛ ni funu sitokiniw dalajɛra kɔnɔbara yɔrɔ la, funu min bɛ tugu ɲɔgɔn na, o bɛ cɛmancɛla sɔgɔsɔgɔninjɛ farikolo dimi ka kɛ reflex muscle spasm fariman ye. Ni aw b’a ɲini ka da wuli, o bɛ farikolojidɛsɛbanakisɛw lamaga, o bɛ dimi jugumanba lase mɔgɔ ma min bɛ dawolo datugu fo ka se milimɛtɛrɛ 15 fo 25 ma da wulilen na. (Kɛnɛyaso perle: Tumu jugumanba min tɛ kɛ ni banakisɛ ye walima min bɛ wele ko strep tonsillitis, o tɛ trismus jugumanba lase mɔgɔ ma abada; ni banabagatɔ min galaka dimi bɛ a la, o tɛ se k’a da wuli ka ɲɛ, aw bɛ siga ko peritonsillar walima parapharyngeal abscess bɛ a la joona).
2. ** "Pomiti funteni" kan min bɛ muɲu (Rhinolalia Clausa):** Walasa ka kuma ka jɛya, dawolo nɔgɔlen (velum) ka kan ka kɔrɔta ka maga kɔfɛla kogo la walasa ka nugu datugu ka ɲɛ. Ni nɔgɔba dalajɛlen dɔ ye dawolo nɔgɔlen fan kelen janya ani ka palatoglossus ni levator veli palatini farikolo lamaga, banabagatɔ tɛ se k’a dawolo nɔgɔlen kɔrɔta ani a tɛ a dɔn k’a dawolo kɔfɛla da wuli ka gɛlɛya walasa ka dimi dɔgɔya, o bɛ kɛ sababu ye ka mɔgɔ dɔ ka rezɔn dingɛ ni mugu bɔ min b’a ɲini ka kuma pɔmitɛri funteniman lamini na.
3. Uvular Deviation Contralateral ani Inferior-Medial Tonsil Displacement: Ikomi kuru bɛ sigi supratonsillar soft palate kɔnɔ sanfɛ ani kɛrɛfɛ ka taa tonsil capsule la, o la, kurukuru min bɛ bonya, o bɛ tonsil yɛrɛ gɛrɛ duguma ani ka taa galaka cɛmancɛ la, ka sɔrɔ ka dawolo nɔgɔlen yɔrɔ nɔgɔlenw ni uvula gɛrɛ kɛrɛfɛ ka taa fan dɔ fɛ, min kɛnɛman don.
4. Ipsilateral Referred Ear Pain (Otalgia via Jacobson’s Nerve): Hali ni tulolabanaw ni cɛmancɛ tulo bɛ kɛ cogo la kɛmɛsarada la otoscopie la, banabagatɔw bɛ ŋunan kosɛbɛ tulodimi nɔgɔlen na min bɛ mɔgɔ sɔgɔ, o ni kurukurunin fan kelen na. O bɛ kɛ barisa glossopharyngeal nerve (cranial nerve IX) bɛ sensori fibres di tonsori/pharynx ani tulo cɛmancɛ tulo fila bɛɛ ma a tympanic branch (Jacobson’s nerve) fɛ kunkolo bɛ tonso kɔnɔna gɛlɛnw kɔrɔta cogo jugu la ko dimi min bɛ bɔ tulo kɔnɔna na.

Kɔnɔbara basigilen ni kɔnɔbara basigilen, tonso ani kɔ jugumanba jɛnsɛnni danfara¶

Aw bɛ baara kɛ ni nin kɛnɛyaso tabali ye walasa ka ɲɛgɛnɛsiralabanaw danfara bɔ ni a bɔli ɲɛfɛla ye (kɔnɔnatumuw) ani ka bɔ kɔkolo yɔrɔ banakisɛw la minnu ka dun, minnu bɛ se ka mɔgɔ ka ɲɛnamaya bila farati la:

Hospital Emergency Department and ENT management protocol¶

+-------------------------------------------------------------------------+
|     EMERGENCY DEPARTMENT & ENT PROTOCOL FOR PERITONSILLAR ABSCESS       |
+-------------------------------------------------------------------------+
|  STEP 1: IMMEDIATE MEDICAL RESUSCITATION & PAIN/EDEMA CONTROL           |
|  * IV Isotonic Crystalloid Bolus: 1,000 mL Normal Saline or Lactated    |
|    Ringer's (most patients are severely dehydrated from 2-4 days of     |
|    inability to swallow liquids)                                        |
|  * Single-Dose Intravenous Corticosteroid (AAO-HNS / Evidence-Based):   |
|    - Dexamethasone 10 mg IV (Children: 0.3 to 0.6 mg/kg IV, max 10 mg)  |
|    - Meta-analyses show a single dose of IV dexamethasone rapidly       |
|      relieves trismus, reduces pain, speeds time to oral swallowing,    |
|      and decreases hospital length of stay without worsening infection  |
|  * Parenteral Analgesia & Antiemetic: IV Ketorolac (if not going to     |
|    open surgery) or IV Fentanyl + IV Ondansetron                        |
+-------------------------------------------------------------------------+
|  STEP 2: EMPIRIC POLYMICROBIAL ANTIBIOTICS (STREP + ORAL ANAEROBES)     |
|  * Intravenous Regimens:                                                |
|    - FIRST LINE: Ampicillin-Sulbactam (Unasyn) 3 g IV every 6 hours     |
|      (Children: 50 mg/kg/dose of ampicillin component IV q6h)           |
|    - ALTERNATIVE: Ceftriaxone 1 to 2 g IV daily PLUS Metronidazole      |
|      500 mg IV every 8 hours                                            |
|    - SEVERE PENICILLIN ALLERGY: Clindamycin 600 to 900 mg IV every 8h   |
|    - Add Vancomycin if MRSA risk or severe toxicity is present          |
|  * Oral Step-Down (Once Drained and Swallowing Liquids Comfortably):    |
|    - Amoxicillin-Clavulanate (Augmentin) 875/125 mg PO twice daily      |
|      for 10 to 14 days (OR Clindamycin 300-450 mg PO tid-qid)           |
+-------------------------------------------------------------------------+
|  STEP 3: ULTRASOUND LOCALIZATION & SURGICAL DRAINAGE                    |
|  * Point-of-Care Intraoral (Endocavitary) or Submandibular Ultrasound:  |
|    - Confirms liquid abscess vs. phlegmon & locates Internal Carotid    |
|  * Drainage Method 1: Guarded Needle Aspiration (18G needle with plastic|
|    sheath trimmed so ONLY 1.0 to 1.5 cm of needle tip is exposed)       |
|  * Drainage Method 2: Guarded #11 Blade Incision & Drainage + Blunt     |
|     curved Kelly Hemostat spreading in the SUPRATONSILLAR POLE           |
+-------------------------------------------------------------------------+

1. Why Point-of-Care Ultrasound (POCUS) has revolutionized Peritonsillar Abscess care¶

Historically, clinicians could only differentiate peritonsillar cellulitis (phlegmon) from a peritonsillar abscess by sticking a needle blindly into the swollen soft palate ("blind diagnostic needle aspiration"), which had a 10 to 24 percent false-negative rate and risked hitting blood vessels. - Today, emergency physicians and otolaryngologists place a high-frequency curved intracavitary ultrasound probe (covered in a sterile sheath with gel) gently against the swollen soft palate (or use a linear/curvilinear probe externally under the jaw if trismus is too tight). - Three Major Advantages of Ultrasound: 1. Immediately distinguishes solid peritonsillar cellulitis (which requires IV antibiotics and steroids without painful needle sticks) from a hypoechoic/heterogeneous liquid abscess cavity with posterior acoustic enhancement. 2. Turns on Color Doppler to map the exact depth and course of the internal carotid artery (which typically lies 1.5 to 2.5 centimeters posterolateral to the tonsil, but can tortuously curve closer to the pharyngeal wall in some patients). 3. Allows real-time ultrasound-guided needle aspiration, increasing first-pass drainage success past 90 to 95 percent.

2. The safety mechanics of Needle Aspiration and Incision & Drainage (Avoiding the Carotid Artery)¶

When an emergency physician or ENT specialist drains a peritonsillar abscess in a cooperative adolescent or adult: 1. Topical and Submucosal Anesthesia: The patient sits upright holding a suction Yankauer tip in their own hand (so they can immediately suction out blood and foul-tasting pus as soon as it drains). The mucosa over the supratonsillar bulge is sprayed with 4% topical lidocaine or benzocaine/cetacaine, followed by submucosal infiltration of 1% to 2% lidocaine with 1:100,000 epinephrine using a fine 27-gauge dental needle. 2. The Mandatory Needle Depth Guard (1.0 to 1.5 Centimeters Maximum): Before attaching an 18-gauge spinal or long needle to a 10 mL syringe, the clinician takes the plastic protective cap off the needle and cuts off the distal 1.0 to 1.5 centimeters of the plastic cap with sterile scissors, then slides the plastic sheath back onto the needle. This plastic depth guard makes it physically impossible for the needle tip to penetrate deeper than 1.0 to 1.5 centimeters into the soft palate, completely preventing accidental puncture of the internal carotid artery even if the patient coughs or jerks forward. 3. Aspiration Target (Superior Pole first, NEVER inferolateral): - Because 90 percent of peritonsillar abscesses sit in the superior (supratonsillar) pole and because the internal carotid artery sits closest to the inferior and lateral poles, the needle is inserted strictly in a sagittal plane (straight front-to-back, NEVER angled laterally toward the ear) into the point of maximal fluctuance at the superior pole (at the intersection of a horizontal line drawn through the base of the uvula and a vertical line drawn along the anterior tonsillar pillar). - If the superior pole yields no pus and ultrasound shows a middle-pole pocket, a second aspiration is performed 1 centimeter lower along the anterior pillar; the inferior pole is avoided due to carotid artery proximity. 4. Incision and Drainage (I&D) vs. Needle Aspiration vs. Interval Tonsillectomy: - Needle Aspiration: Resolves 85 to 92 percent of uncomplicated peritonsillar abscesses on the first pass with less post-procedural pain and bleeding. - Incision and Drainage (I&D): Using a guarded #11 scalpel blade (taped so only 0.5 to 1.0 cm of blade tip is exposed), the clinician makes a small mucosal incision over the superior pole bulge, then inserts a closed curved Kelly hemostat and gently spreads the jaws open to break up loculations, followed by warm saline/hydrogen peroxide gargles. I&D has a slightly higher primary cure rate (93 to 95 percent) for large or multiloculated abscesses. - Immediate ("Quinsy") Tonsillectomy vs. Interval Tonsillectomy: In young children who cannot cooperate with awake drainage, or in patients with recurrent peritonsillar abscesses (10 to 15 percent recurrence rate) or failure of needle/incision drainage, an ENT surgeon performs either an acute quinsy tonsillectomy under general anesthesia in the operating room or an elective interval tonsillectomy 4 to 6 weeks later once acute inflammation has subsided.

Deadly complications if a Peritonsillar Abscess spreads laterally or inferiorly¶

If a peritonsillar abscess is neglected or inadequately treated, pus breaks through the thin superior pharyngeal constrictor muscle into the parapharyngeal space, triggering four potentially fatal emergencies: 1. Parapharyngeal Space Abscess and Airway Occlusion: Swelling expands below the angle of the jaw down the lateral neck, pushing the entire lateral pharyngeal wall and supraglottis across the airway. 2. Lemierre's Syndrome (Internal Jugular Vein Septic Thrombophlebitis): Anaerobic Fusobacterium necrophorum invades the carotid sheath, clotting the internal jugular vein and showering both lungs with septic pulmonary emboli (see our Lemierre ka syndrome gafe ɲɛminɛbaga). 3. Internal Carotid Artery Mycotic Pseudoaneurysm and Blowout Hemorrhage: Continuous bathing of the internal carotid artery wall in necrotizing bacterial enzymes weakens the arterial media, forming an infected carotid pseudoaneurysm. Often preceded by 1 or 2 small warning "sentinel bleeds" (spitting up a few tablespoons of bright red blood from the throat or ear), sudden rupture of the carotid pseudoaneurysm into the pharynx causes torrential, fatal arterial hemorrhage. (Any patient with a current or recent peritonsillar/parapharyngeal abscess who spits up bright red blood requires an immediate emergency CT angiogram [CTA] of the neck and neurointerventional endovascular stenting/embolization or surgical ligation). 4. Descending Necrotizing Mediastinitis: Pus tracks down the parapharyngeal and retropharyngeal spaces into the chest cavity.

Kumaɲɔgɔnya sɛbɛn tigitigi dɔgɔtɔrɔso triage kama¶

When arriving at a hospital emergency department with a patient who has a suspected peritonsillar abscess, use this clear script at triage:

"I am here with a [Age]-year-old patient whose sore throat has become severely worse on the [left/right] side over the past [Number] days, and who now has a muffled hot-potato voice, severe ear pain on the same side, [drooling / inability to swallow liquids], and trismus (can only open their mouth about one finger wide). When we looked inside with a flashlight, the soft palate on the [left/right] side is bulging down and pushing the uvula over to the [opposite] side. We suspect an acute Peritonsillar Abscess (Quinsy). We have kept the patient sitting upright and Nothing by Mouth, and need an emergency physician and ENT evaluation for intravenous hydration, intravenous dexamethasone, ampicillin-sulbactam, and ultrasound-guided needle aspiration or drainage."

Ɲininkali minnu bɛ kɛ tuma caman na¶

Why does a peritonsillar abscess cause your jaw to lock up (trismus) and make your ear ache when the infection is in your throat?¶

Immediately outside the thin muscle wall that holds your tonsil lies the medial pterygoid muscle, which is one of the main jaw-closing chewing muscles. When pus collects beside the tonsil, the inflammation irritates the medial pterygoid muscle into a tight, painful spasm (trismus) so you cannot open your mouth wide; at the same time, the ninth cranial nerve (glossopharyngeal nerve) that senses pain in your tonsil also sends a branch (Jacobson's nerve) to your middle ear, causing your brain to feel the tonsil pain as a sharp earache on the same side.

How can I tell the difference between bad strep throat (tonsillitis) and a peritonsillar abscess (quinsy)?¶

In ordinary strep throat or viral tonsillitis, both tonsils are red and swollen on both sides of the throat, you can still open your mouth wide (three fingers between your front teeth), and the little dangling uvula hangs straight down in the exact center of your throat. In a peritonsillar abscess, the pain and swelling shift strongly to one side, your jaw locks so you can barely open your mouth (trismus), your voice sounds muffled like you are holding a hot potato in your mouth, and the swollen soft palate above one tonsil pushes your uvula noticeably sideways toward the opposite cheek.

Why can't oral antibiotics cure a peritonsillar abscess without a doctor draining it with a needle or small incision?¶

Before an abscess forms (during the early stage called peritonsillar cellulitis), blood still flows through the swollen tissue, so intravenous antibiotics and steroids can cure it. However, once a walled-off pocket of liquid pus forms (an abscess), there are no blood vessels inside the pus cavity to carry oral antibiotics in, and the acidic, oxygen-poor pus deactivates many antibiotics; physically draining the pus with a guarded needle or tiny incision immediately relieves the pressure, stops the pain and trismus, and prevents the pus from bursting into your lungs or deep neck.

Why is spitting up even a small amount of bright red blood a medical emergency if you have or recently had a peritonsillar or deep neck abscess?¶

The internal carotid artery (the main artery carrying blood from your heart to your brain) runs in the neck tissue just 1 to 2.5 centimeters behind and to the side of your tonsil. Rarely, a deep peritonsillar or parapharyngeal infection can erode into the wall of the carotid artery or its branches, forming a fragile blister called a pseudoaneurysm; spitting up a small amount of bright red blood can be a "sentinel bleed" warning that the artery is about to rupture, requiring an immediate emergency room CT angiogram of the neck.

Sosow sɛgɛsɛgɛra¶

• American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS, United States): Clinical Practice Guideline: Tonsillectomy in Children and Management of Peritonsillar Abscess (indications for needle aspiration vs. incision and drainage vs. quinsy/interval tonsillectomy, and adjuvant single-dose intravenous corticosteroid therapy).
• Infectious Diseases Society of America (IDSA, United States): Practice Guidelines for the Diagnosis and Management of Group A Streptococcal Pharyngitis and Suppurative Peritonsillar/Parapharyngeal Complications (polymicrobial etiology of Streptococcus pyogenes, Streptococcus anginosus group, and beta-lactamase-producing oral anaerobes Fusobacterium and Prevotella, and empiric ampicillin-sulbactam, ceftriaxone plus metronidazole, and clindamycin regimens).
• Amerika ka dɔgɔtɔrɔso kɔrɔtɔlenw ka kolɛji (ACEP, Etazuni): Kɛnɛyaso politiki ni kɛnɛyaso ultrasound (POCUS) ka laadilikanw ka ɲɛsin ultrasound intraoral and transcutaneous ultrasound in Peritonsillar Abscess (a bɛ danfara don kɔnɔbara basigilen ni kurukuruni cɛ, ka kariti kɛ ni kulɛri Doppler ye kariti kɔnɔna na, ani ka a kɔlɔsi santimɛtɛrɛ 1,0 fo 1,5 supérieur-pole pikirijikɛlan aspirasi fɛɛrɛ).
• Cochrane Database of Systematic Reviews: Needle Aspiration Versus Incision and Drainage for the Treatment of Peritonsillar Abscess and Corticosteroids as Adjuvant Therapy for Peritonsillar Abscess (demonstrating significant reductions in pain, trismus, and time to swallowing with adjuvant intravenous dexamethasone).

Gafe minnu bɛ tali kɛ o ko la¶

• Ludwig ka angina : da duguma dawolo la selilulisi fan fila fɛ ani kɔkolo gɛlɛya
• Kɔnɔnatumu kɔdimi denmisɛnniw ni mɔgɔkɔrɔbaw la, kɔdimi, ani cɛmancɛladimi
• Lemierre ka bana : kɔnɔnatumuw ka jolilabanaw (tromboflébite septique de thromboflébite) galaka dimi kɔfɛ
• Post-tonsillectomy hemorrhage: day 5 to 10 eschar sloughing and airway triage
• Epiglottitis, croup, stridor, ani sanfɛla fiɲɛbɔyɔrɔ balili jugumanba