I-Peritonsillar Abscess (Quinsy): I-Hot Potato Voice, i-Uvular Deviation, i-Trismus, i-Drooling, ne-Needle Aspiration vs. Parapharyngeal Spread¶

Lapho umphimbo obuhlungu uphenduka kabuhlungu ohlangothini olulodwa**, ohambisana nezwi elithi "izambane elishisayo" (elizwakala sengathi umuntu ukhuluma nezambane elishisayo emlonyeni), ukungakwazi ukuvula umlomo ngendlela evamile (trismus noma umhlathi okhiyiwe), ubuhlungu obukhulu obuphuma endlebeni ngakolunye uhlangothi, ukugwinya amathe, ukugwinya okuthambile, ukucwilisa amathe nobuhlungu. iphusha okulengayo uvula uwele umugqa omaphakathi kuya ohlangothini oluphambene (olunempilo), ukuxilongwa kuyithumba elithi peritonsillar abscess (PTA), ngokomlando elaziwa ngokuthi quinsy. Iya ngokushesha emnyangweni wezimo eziphuthumayo esibhedlela onekhono lokuhlinza i-otolaryngology (ENT), noma shayela inombolo yakho yasendaweni yezimo eziphuthumayo (911 e-United States nase-Canada, 112 ngaphesheya kwe-European Union, 999 e-United Kingdom; bona izinombolo eziphuthumayo) ngaso leso sikhathi uma umuntu econsa, edonsa umoya, noma engakwazi ukugwinya. Ngenkathi ulungiselela ukuthutha, hlukanisa ithumba elihlangene le-peritonsillar kusuka ekuvuvukeni kwaphansi komlomo usebenzisa Ludwig's angina airway guide, qhathanisa izifo zomphimbo wangemuva kweyethu ithumba retropharyngeal kanye mediastinitis guide, futhi ubuke izimpawu ze-jugular vein sepsis yangaphakathi yethu Umhlahlandlela we-Lemierre's syndrome.

I-peritonsillar abscess iwukutheleleka okukodwa okuvame kakhulu kwentamo ejulile ezinganeni, intsha, kanye nabantu abadala. Lwakha lapho ukutheleleka ngebhaktheriya (ngokuvamile ingxube ye-polymicrobial Iqembu A beta-hemolytic Streptococcus pyogenes, Streptococcus anginosus iqembu, kanye ne-anaerobes yomlomo efana ne-Fusobacterium kanye Prevotella) igqekeza i-fibrous outer capsule ye-palaorlivary obstruct izindlala** esigxotsheni esiphezulu sethoni) futhi iqoqa njengephakethe elishubile lobovu ngaphakathi kwesikhala esingaba khona phakathi kwe-tonsillar capsule ngokumaphakathi kanye ne-superior pharyngeal constrictor muscle* ngaseceleni. Ngenxa yokuthi umsipha ophakeme we-pharyngeal constrictor uwukuphela kodonga oluncane lwemisipha oluhlukanisa ithumba le-peritonsillar kusukela ku-parapharyngeal space kanye ne-carotid sheath (lapho umthambo we-carotid wangaphakathi uvame ukuhlala ngamasentimitha angu-1.0 kuya kwangu-2.5 ngemuva kanye neceleni kwe-obstructed cannsillar engaphansi), umoya, ukugqashuka ngokuzenzekelayo emaphashini ngesikhathi sokulala (okubangela inyumoniya ebulalayo), noma ukuguguleka eceleni ukuze kubangele ithumba le-parapharyngeal, i-Lemierre's syndrome, noma ukopha kwe-carotid artery eyinhlekelele. Uma ubovu bubumba ngaphakathi kwalesi sikhala, imithi elwa namagciwane yomlomo iyodwa ayikwazi ukwelapha ithumba le-peritonsillar; ukukhululeka okuqinisekile kudinga isimo esiphuthumayo ukuhunyushwa kwenaliti noma ukusika nokukhipha amanzi eduze kwemithi elwa namagciwane efakwa emthanjeni kanye ne-corticosteroids.

Yenza lokhu manje¶

1. Yiya kumnyango wezimo eziphuthumayo esibhedlela ngokushesha (noma ushayele ku-911 / 112/999 uma uconsisa amathe, uphelelwa umoya, noma wenza imisindo ephezulu ye-stridor). Ungayi emtholampilo wekhemisi noma ulinde izinsuku ukuze uthole isikhathi sokubonana nokunakekelwa okuyinhloko, futhi ungacabangi ukuthi i-amoxicillin noma i-penicillin enikezwe ekuqaleni kwesonto izoncibilikisa ithumba elihlanganisiwe. Ithumba le-peritonsillar lidinga ukugeleza okuphuthumayo kwezokwelapha, ukugeleza kwamanzi nge-intravenous, i-intravenous steroids, kanye nama-antibiotic asebenzayo.
2. Gcina umuntu ohlezi eqondile encike phambili kancane bese umnikeza inkomishi noma ithawula ukuze akhiphe amathe. Ungalokothi uphoqe isiguli esiconsisa amathe noma esikhuluma ngezwi eliwugqinsi "lezambane elishisayo" ukuthi silale phansi ngomhlane, okuvumela ulwanga oluvuvukele oluthambile kanye nethonsi ukuthi lihlehle libheke emuva endleleni yomoya futhi kwandise ingozi yokuququda amathe echibini.
3. Yenza "Ukuhlola I-Trismus Yeminwe Emibili" bese ubheka i-uvula ngethoshi lefoni (ngaphandle kokufaka noma yini emlonyeni). Cela umuntu ukuthi avule umlomo wakhe banzi ngangokunokwenzeka:
4. Ngokuvamile, umuntu omdala noma ingane endala ingangena kalula iminwe emithathu eyisitakikhi (amamilimitha angu-35 kuya kwangu-50) iqonde phakathi kwamazinyo ayo angaphambili nangaphansi. Uma bekwazi ukuvula umlomo kuphela ububanzi bomunwe owodwa noma emibili (< 20 kuya ku-25 millimeters) ngenxa ye-spasm ebuhlungu ohlangothini lomhlathi, **i-trismus ikhona ** (okubonisa ukuthi ukuvuvukala kucasule imisipha eseduze **medial pterygoid **).
5. Khanyisa ithoshi emlonyeni ngaphandle kokusebenzisa isipuni noma isinciphisi solimi: ethumbani le-peritonsillar,ulwanga oluthambile olungaphezu kwethoni luqhuma luye phansi naphambili njengebhaluni elibomvu*, luphushela ithoni liye phansi/ngaphakathi bese liphusha uvula ngokuphawulekayo emaceleni ohlangothini oluphambene (olunempilo).
6. UNGALOKOTHI uzame ukukhipha, ukukhama, ukujula, noma ukuchoboza ithoni evuvukele ekhaya ngeswabhu kakotini, umunwe, inaliti, noma ama-tweezers. Ngemuva konqenqema lwethoni kukhonaumthambo we-carotid wangaphakathi. Ukupopoza ngobumpumputhe noma ukucindezela iqhubu le-peritonsillar ekhaya kungabhodloza umthambo we-carotid wangaphakathi (okubangele ukuphuma okubulalayo ngemizuzwana) noma kuqhume isikhukhula sobovu obujiyile buqonde phansi epayipini lomoya.
7. Gcina isiguli Singenalutho Ngomlomo (NPO) ngokushesha nje lapho uya esibhedlela. Ngisho noma isiguli some kakhulu ngenxa yezinsuku zokugwinya okungekuhle kanye nomkhuhlane, ungasivumeli sidle noma siphuze endleleni eya emnyangweni wezimo eziphuthumayo. Ukujula inaliti, ukusika nokukhipha amanzi ngaphansi kwe-anesthesia yendawo/esendaweni, noma ukugeleza kwamanzi kwegumbi lokuhlinza kudinga isisu esingenalutho ukuze isiguli singaphalazi futhi sishise ngesikhathi sokuxhaphaza umphimbo.
8. Qaphela amafulegi abomvu ukuthi ukutheleleka kuphume esikhaleni se-tonsillar kwangena entanyeni ejulile (Parapharyngeal Spread). Uma ukuvuvukala, ububomvu, noma ukuthamba okwedlulele kunwebeka ngezansi kwe-engeli yomhlathi kwehle ohlangothini lwentamo (phambi komsipha we-sternocleidomastoid), noma uma isiguli siba nokuqina kwentamo, phatha kabi intamo ngokushesha, izinhlungu eziphuthumayo, izinhlungu eziphuthumayo ngokushesha. bayala i-CT scan ethuthukisiwe yentamo ngaphambi kokuzama noma iyiphi inaliti.

Isihlahla sesinqumo somtholampilo somphimbo obuhlungu ohlangene ohlangothini olulodwa, i-trismus, nokuchezuka kwe-uvular¶

Sebenzisa leli shadi lomtholampilo eliphuthumayo ukuze uhlukanise i-exudative tonsillitis elula, i-peritonsillar cellulitis (phlegmon), i-frank peritonsillar abscess (quinsy), kanye nokusabalala kwesikhala esijulile se-parapharyngeal/carotid.

flowchart TD
    Start["Umphimbo Obuhlungu Kakhulu (Okubi Kakhulu Eceleni OLULODWA),<br/>Imfiva, i-Odynophagia, noma Ubuhlungu Bendlebe Obubhekiselwe"] --> Exam["Hlola Indlela Yomoya futhi Wenze Ukuhlola Okunamaphuzu Ama-3 Omlomo/Intamo:<br/>1. 'Izambane Elishisayo' Izwi noma Ukuconsa <br/>2. I-Trismus (I-Inter-Incisor Opening < 25 mm)<br/>3. I-Unilateral Soft Palate Bulge + Uvula Iphushelwe Ohlangothini Oluphambene"]

    Exam --> AirwayCheck{"Ingabe Kukhona I-Stridor, I-Dyspnea Enzima,<br/>Cyanosis, noma Ukungakwazi Ukulala Phathi?"}

    AirwayCheck -->|"YEBO: UKUVIMBEKA OKUMANDLA komoya"| EmergentAirway["IKHODI YEMOYA YEGUMBI LOKUSEBENZA OKUSHESHA:<br/>1. Gcina Isiguli Sihlezi I-Bolt Iqondile (90 Degrees)<br/>2. Hlanganisa i-Anesthesiology + ENT ye-Awake Fiberoptic<br/> Intubation noma i-Awake Tracheostomy Backup<br/>3. Nikeza i-Stat IV Dexamethasone 10 mg + IV Antibiotics<br/>4. Yenza Ukugeleza Kokuhlinza NOMA Uma Usuvikelekile Indlela Yomoya"]

    AirwayCheck -->|"CHA: I-Airway Stable Ngenkathi Uhlezi Uqondile"| DeepSpread{"Ingabe Izimpawu Ze-Deep Parapharyngeal noma<br/>Carotid Sheath Spread Present?<br/>(Ukuvuvukala Kwentamo Yangaphandle Ngaphansi Kwe-engeli Yomhlathi,<br/>Ubumnene be-SCM Yangaphambili, Ukuqina, I-Torticollis,<br/>noma I-Trismus Enzima Evimba Ukubuka Komlomo)"}

    DeepSpread -->|"YEBO: Umsolwa i-Parapharyngeal Abscess<br/>noma i-Lemierre's Syndrome"| ContrastCT["UMTHETHO OQINISEKISIWE WENTAMO:<br/>1. I-Maps Exhibition Ithumba Indawo Ihlobene <br/> Ne-Internal Carotid Artery & Internal Jugular Vein<br/>2. Qala i-IV Ampicillin-Sulbactam 3 g q6h (noma i-Ceftriaxone<br/> + Metronidazole) + Vancomycin + IV Dexamethasone<br/>3. I-ENT Drainage yeGumbi Lokuhlinza (I-Transoral noma Yangaphandle)"]

    DeepSpread -->|"CHA: I-Classic Isolated Unilateral<br/>Supratonsillar Soft Palate Bulge"| Ultrasound["I-BEDSIDE INTRAORAL / TRANSCUTANEOUS ULTRASOUND<br/>(Ihlukanisa i-Phlegmon vs. I-Drainable Pus Pocket<br/>futhi Ihlonza Ukugeleza Kwe-Doppler Kwe-Carotid Artery)"]

    Ultrasound -->|"Iqoqo Le-Hypoechoic Fluid<br/>(Ithumba Langempela Le-Peritonsillar)"| Drainage["UKUDULA OKUPHUTHUMAYO + UKUHLANGANISWA KWEZOkwelashwa:<br/>1. I-Topical/Local Anesthetic + IV Hydration +<br/> IV Dexamethasone 10 mg Umthamo Owodwa<br/>2. I-Needle Aspiration (Inaliti engu-18G ene-Depth Guard<br/> <= 1.0 kuya ku-1.5 cm ku-Superior Pole) NOMA<br/> I-Guarded Scalpel Incision & Drainage<br/>3. IV/Oral Ampicillin-Sulbactam noma Amoxicillin-Clavulanate"]

    Ultrasound -->|"I-Edema Eqinile Kuphela, Akukho Ubomvu<br/>(Peritonsillar Cellulitis)"| Cellulitis["I-PERITONSILLAR CELLULITIS (PHLEGMON):<br/>1. Ungabuhlisi (Awukho Ubovu Ozobukhipha Okwamanje)<br/>2. Nikeza i-IV Hydration, IV Dexamethasone 10 mg,<br/> kanye ne-IV Ampicillin-Sulbactam / Ceftriaxone + Metronidazole<br/>3. Qaphela Amahora angu-12 kuya kwangu-24 Okulungiswa Kuqhathaniswa Nokuxubha"]

I-Anatomy kanye ne-pathophysiology: Isikhala se-peritonsillar, izindlala ze-Weber, kanye nengozi yangaphakathi ye-carotid artery¶

Ukuqonda imingcele eqondile ye-anatomical yombhede we-tonsillar kuchaza zonke izimpawu zomtholampilo ze-quinsy futhi kuveza ukuthi kungani ukulangazelela inaliti kufanele kulandele izimpawu zendawo eziqinile zejometri ukuze kugwenywe umthambo wangaphakathi we-carotid.

1. Imingcele ye-anatomical yesikhala se-peritonsillar kanye nezindlala ze-Weber¶

I-palatine tonsil ihlezi ngaphakathi kwe-depression engunxantathu odongeni oluseceleni lwe-oropharynx olubizwa ngokuthi tonsillar fossa, olufakwe phambi kwe-insika yethoni yangaphambili (umsipha we-palatoglossus) nangemuva nge-insika yethoni engemuva (umsipha we-palatopharyngeus). - Isikhala Se-Peritonsillar: Ezungeza uhlangothi olujulile lwe-tonsil indawo engaba khona ye-ayolar evulekile eboshwe ngu: - Phakathi: I-fibrous capsule ye-palatine tonsil. - Kamuva: I-superior pharyngeal constrictor muscle* (ehlukanisa isikhala se-peritonsillar ne ** isikhala se-parapharyngeal ). - Ngaphambili: Insika yethoni yangaphambili (umsipha we-palatoglossus). - Ngasemuva: Insika yethoni yangemuva (umsipha we-palatopharyngeus). - Izindlela Ezimbili Zokwakheka Kwethumba (I-Tonsillitis Progression vs. I-Weber's Gland Sialadenitis): 1. Isandiso Sethoni Esiqondile: I-acute bacterial tonsillitis yephula i-fibrous tonsillar capsule endaweni yayo encane kakhulu, idlulela esigabeni samahora angama-24 kuya kwangama-48 se-peritonsillar cellulitis (phlegmon), bese ixukuza ibe yi-cessillar evalwe ngezindonga*i-peritonsillar. 2. I-Weber's Gland Obstruction (Ichaza Isizathu Sokuba I-PTA Ingenzeka Ngaphandle Kwe-Tonsillitis Enzima Yangaphambili Noma Ngisho Nangemva Kwe-Tonsillectomy Engxenye): Ishutheke olwangeni oluthambile ngenhla kwesigxobo esingenhla (isigxobo esingaphezulu) sethoni iyiqoqo lama-20 kuya kwangu-25 amancane amathe amathe abizwa ngokuthi **i-Webereyizindlala eziphuma emlonyeni ama-crypts ukuze kukhishwe imfucumfucu. Uma ukuvuvukala noma izibazi kuvala imigudu yezindlala ze-Weber, ukutheleleka okungenamsoco ngaphakathi kwezindlala kudala ithumba ngqo ku-supratonsillar soft palate (okuchaza ukuthi kungani amaphesenti angu-90 amathumba e-peritonsillar ehlala esigxotsheni esiphezulu ngaphezu kwethonsi kunokuba ngemuva kwesigxobo saso esingezansi).

+-------------------------------------------------------------------------+
|     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. Kungani i-Peritonsillar Abscess idala izimpawu zomtholampilo ezi-4 zakudala¶

1. I-Trismus Enzima (Ikhona ezigulini ezimbili kwezintathu, kanye nesihlukanisi esingu-#1 esivela ku-tonsillitis elula): Ngokushesha ngaphandle komsipha ophezulu we-pharyngeal constrictor kukhona umsipha ophakathi (wangaphakathi) we-pterygoid, omunye wemisipha enamandla ye-mastication evala umhlathi. Lapho ubomvu kanye nama-cytokines avuthayo eqoqa endaweni ye-peritonsillar, ukuvuvukala okuhlangene kucasula imisipha ye-pterygoid ephakathi ibe ubudlova ** i-reflex muscle spasm **. Ukuzama ukuvula umlomo kwelula imicu yemisipha evuvukele, okubangela ubuhlungu obubuhlungu obuvala umhlathi uvuleke ngaphansi kwamamilimitha angu-15 kuya kwangu-25. (Iparele Lomtholampilo: I-uncomplicated acute viral or strep tonsillitis UNGALOKOTHI ibangele i-trismus enzima; uma isiguli esinomphimbo obuhlungu singakwazi ukuvula umlomo waso kakhulu, sola ithumba le-peritonsillar noma i-parapharyngeal ngokushesha).
2. Izwi elithi "Hot Potato" Elivalekile (Rhinolalia Clausa): Ukuze ukhulume ngokucacile, ulwanga oluthambile (i-velum) kufanele luphakamise futhi luthinte udonga lwangemuva lwepharyngeal ukuze luvale umgodi wamakhala ngendlela efanele. Lapho iqoqo elikhulu lobovu likhipha ulwanga oluthambile oluhlangene futhi luvimbela imisipha ye-palatoglossus kanye ne-levator veli palatini, isiguli asikwazi ukuphakamisa ulwanga lwaso oluthambile futhi ngokungazi sibambe ingemuva lomphimbo waso livuleke kalukhuni ukuze kuncishiswe ubuhlungu, kukhiqizwe umsindo ongenalutho, ongaqondakali womuntu ozama ukukhuluma ezungeza izambane.
3. I-Contralateral Uvular Deviation and Inferior-Media Tonsil Displacement: Ngenxa yokuthi ithumba lihlala ngaphakathi kolwanga oluthambile lwe-supratonsillar ngenhla nangaseceleni ku-capsule yethoni, ibhola elikhulayo lobovu liphushela ithonsila ngokwalo liye phansi futhi liye maphakathi nomphimbo, kuyilapho liphusha ulwanga oluseceleni oluthambile* oluphambene nethishu* enempilo.
4. I-Ipsilateral Referred Ear Pain (Otalgia via Jacobson's Nerve): Ngisho noma isigubhu sendlebe nendlebe emaphakathi kujwayelekile ngamaphesenti angu-100 ku-otoscopy, iziguli zikhala kabuhlungu ngokuhlaba kwendlebe okubukhali, okugwazwa ohlangothini olufanayo nethumba. Lokhu kwenzeka ngoba inzwa ethi glossopharyngeal nerve (cranial nerve IX) ihlinzeka ngemicu yezinzwa kuzo zombili i-tonsillar fossa/pharynx kanye nembobo yendlebe emaphakathi nge-tympanic branch (i-Jacobson's nerve); ubuchopho buhumusha ngokungeyikho i-capsule ye-tonsillar enwebekayo njengobuhlungu obuvela ekujuleni kwendlebe.

Ukwehlukanisa Ithumba Le-Peritonsillar Ku-Peritonsillar Cellulitis, I-tonsillitis, kanye Ne-Deep Neck Spread¶

Sebenzisa leli thebula lokuqhathanisa lomtholampilo ukuze uhlukanise ithumba le-peritonsillar elidonsa amanzi kusukela esigabeni salo sangaphambi kwethumba (i-peritonsillar cellulitis) kanye nezifo ezijulile, ezisongela ukuphila zentamo:

Umnyango Wezimo Eziphuthumayo Esibhedlela kanye nephrothokholi yokuphatha ye-ENT¶

+-------------------------------------------------------------------------+
|     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. Kungani i-Point-of-Care Ultrasound (POCUS) iguqule ukunakekelwa kwe-Peritonsillar Abscess¶

Ngokomlando, odokotela babekwazi ukuhlukanisa kuphela i-peritonsillar cellulitis (phlegmon) ne-ithumba le-peritonsillar ngokufaka inaliti ngobumpumputhe kulwanga oluthambile oluvuvukele ("isifiso senaliti sokuxilonga esiyimpumputhe"), eyayinezinga ** elisuka ku-10 kuya kwangu-24 lamaphesenti angamanga-elibi** futhi libe sengozini yokushaya imithambo yegazi. - Namuhla, odokotela bezimo eziphuthumayo kanye nama-otolaryngologists babeka i-high-frequency curved intracavitary ultrasound probe (embozwe emgodleni oyinyumba enejeli) ngobumnene ngokumelene nolwanga oluthambile oluvuvukele (noma sebenzisa i-linear/curvilinear probe ngaphandle ngaphansi komhlathi uma i-trismus iqine kakhulu). - Izinzuzo Ezintathu Ezinkulu Ze-Ultrasound: 1. Ngokushesha ihlukanisa okuqinile i-peritonsillar cellulitis (edinga ama-antibiotic e-IV nama-steroid ngaphandle kwezinti yenaliti ezibuhlungu) kusukela ku-hypoechoic/heterogeneous imbobo yethumba eliwuketshezi elinesithuthukisi esingemuva kwe-acoustic. 2. Ivula I-Doppler Yombala ukuze kumephu ukujula okunembile kanye nokuhamba kwe- umthambo we-carotid wangaphakathi (okuvame ukuba amasentimitha angu-1.5 ukuya kwangu-2.5 ngemuva kwethonsil, kodwa engakwazi ukugoba ngokuhlukumezayo eduze kodonga lwepharyngeal kwezinye iziguli). 3. Ivumela isikhathi sangempela sokulangazelela inaliti eqondiswa yi-ultrasound, okwandisa impumelelo yokukhipha amanzi edlula kuqala amaphesenti angama-90 kuye kwangama-95.

2. Imishini yokuphepha ye-Needle Aspiration kanye ne-Icision & Drainage (Ukugwema Umthambo We-Carotid)¶

Lapho udokotela ophuthumayo noma uchwepheshe we-ENT edonsa ithumba le-peritonsillar kumuntu osemusha noma omdala osebenzisana naye: 1. I-Topical and Submucosal Anesthesia: Isiguli sihlala siqondile sibambe ithiphu ye-Yankauer yokumunca ngesandla saso (ukuze sikwazi ukumunca ngokushesha igazi kanye nobomvu obunambitheka kabi ngokushesha nje lapho buphuma). I-mucosa phezu kweqhubu le-supratonsillar ifafazwa nge-4% i-lidocaine ye-topical noma i-benzocaine/cetacaine, ilandelwa ukungena kwe-submucosal ye- 1% kuya ku-2% ye-lidocaine ene-1: 100,000 epinephrine kusetshenziswa inaliti yamazinyo enhle engu-27-gauge. 2. Isivikelo Sokujula Kwenaliti Esiyisibopho (Ubukhulu obungu-1.0 kuye ku-1.5 Amasentimitha): Ngaphambi kokunamathisela inalithi engu-18-gauge yomgogodla noma ende esirinjini engu-10 mL, udokotela ukhipha ikepisi lepulasitiki eliyisivikelo enalitini futhi asuse i-science eyi-dital 1.0 kuya ku-1.5 centi yepulasitiki ishelela i-plastic sheath emuva yenaliti. Le plastic depth guard yenza kube nzima ngokomzimba ukuthi ithiphu yenaliti lingene lijule kune 1.0 kuya ku-1.5 centimeter olwangeni oluthambile, livimbele ngokuphelele ukubhoboza ngengozi komthambo we-carotid wangaphakathi ngisho noma isiguli sikhwehlela noma sinyakazela phambili. 3. I-Aspiration Target (I-Superior Pole kuqala, UNGALOKOTHI inferolateral): - Ngenxa yokuthi amaphesenti angu-90 amathumba e-peritonsillar ahlala esigxotsheni esiphezulu (supratonsillar) futhi ngenxa yokuthi umthambo we-carotid wangaphakathi uhlala eduze kakhulu nezigxobo ezingaphansi nezingemuva, inaliti ishuthekwa ngokuqinile ku-sagittal plane (iqonde phambili ukuya emuva, AKUKHO i-engeli ebheke ngaseceleni ephuzwini lendlebe noma ephuzwini lendlebe) isigxobo** (empambanweni yomugqa ovundlile odwetshwe phansi kwe-uvula kanye nomugqa oqondile odwetshwe eduze kwensika yethoni yangaphambili). - Uma isigxobo esiphezulu singakhiqizi ubomvu futhi i-ultrasound ibonisa iphakethe le-paddle-pole, i-aspiration yesibili yenziwa isentimitha engu-1 phansi eduze kwensika yangaphambili; isigxobo esingaphansi siyagwenywa ngenxa yokuba seduze komthambo we-carotid. 4. I-Incision and Drainage (I&D) vs. Needle Aspiration vs. Interval Tonsillectomy: - I-Needle Aspiration: Ixazulula amaphesenti angu-85 kuya kwangu-92 amathumba angeyona inkimbinkimbi e-peritonsillar ephasini lokuqala anobuhlungu obuncane bangemva kwenqubo nokopha. - I-Incision and Drainage (I&D): Esebenzisa i-scalpel blade egadiwe engu-#11* (eqoshwe ukuze kuvezwe ithiphu le-blade elingu-0.5 kuya ku-1.0 cm), udokotela wenza umthambo omncane wokusika phezu kweqhubu eliphezulu, abese efaka okuvaliwe okugobile okugobile okulandelwa yi-Kelly hemostat, kuvuleke i-jacula i-saline / i-hydrogen peroxide i-gargles. I-I&D inezinga lokwelapha eliyisisekelo eliphakeme kancane (93 kuya kumaphesenti angama-95) kumathumba amakhulu noma axubile. - I-Tonsillectomy esheshayo ("Quinsy") vs. I-Interval Tonsillectomy: Ezinganeni ezincane ezingakwazi ukubambisana ne-drainage ephapheme, noma ezigulini ezinamathumba avela njalo e-peritonsillar (amaphesenti angu-10 kuya kwayi-15) noma ukwehluleka kokukhipha inaliti/ukusika, udokotela ohlinzayo we-ENT wenza noma i-anesthesia yendawo yokuhlinza i-anesthesia ejulile i-interval tonsillectomy Emasontweni angu-4 kuya kwangu-6 kamuva lapho ukuvuvukala okunamandla sekudambile.

Izinkinga ezibulalayo uma i-Peritonsillar Abscess isakazeka eceleni noma ngaphansi¶

Uma ithumba le-peritonsillar linganakwa noma lingelashwa ngendlela efanele, ubovu bugqekeza umsipha ozacile ophakeme wepharyngeal constrictor uye endaweni parapharyngeal, okubangela izimo eziphuthumayo ezine ezingase zibulale: 1. I-Parapharyngeal Space Ithumba Nokuvaleka Komoya: Ukuvuvukala kunwebeka ngezansi kwe-engeli yomhlathi kwehle entanyeni esemaceleni, kusunduze lonke udonga lwepharyngeal olusemaceleni kanye ne-supraglotti kunqamuke indlela yokuphefumula. 2. I-Lemierre's Syndrome (I-Internal Jugular Vein Septic Thrombophlebitis): I-Anaerobic Fusobacterium necrophorum ihlasela i-carotid sheath, ihlule umthambo we-jugular wangaphakathi futhi ithele womabili amaphaphu nge septic pulmonary emboli Umhlahlandlela we-Lemierre's syndrome). 3. I-Internal Carotid Artery Mycotic Pseudoaneurysm and Blowout Hemorrhage: Ukugeza okuqhubekayo kodonga lwangaphakathi lwe-carotid artery kuma-enzayimu ebhaktheriya ane-necrotizing kwenza i-arterial media ibe buthaka, kwakheka i-carotid pseudoaneurysm* ethelelekile. Ngokuvamile kwandulelwa isexwayiso esincane esingu-1 noma 2 "u-sentinel bleeds" (ekhafula izipuni ezimbalwa zegazi elibomvu ngokugqamile elivela emphinjeni noma endlebeni), ukuqhuma okungazelelwe kwe-carotid pseudoaneurysm epharynx kubangela ukopha okukhulu, okubulalayo komthambo wegazi. (Noma isiphi isiguli esinethumba lamanje noma lakamuva le-peritonsillar/parapharyngeal esikhafula igazi elibomvu elikhanyayo sidinga i-CT angiogram [CTA] ephuthumayo yentamo kanye ne-neurointerventional endovascular stenting/embolization noma i-surgical ligation). 4. I-Necrotizing Mediastinitis eyehlayo: Ubovu bulandelela phansi endaweni ye-parapharyngeal kanye ne-retropharyngeal kungene emgodini wesifuba.

Umbhalo oqondile wokuxhumana wokuhlolwa esibhedlela¶

Lapho ufika emnyangweni wezimo eziphuthumayo esibhedlela nesiguli esisolwa ngokuba nethumba le-peritonsillar, sebenzisa lesi sikripthi esicacile lapho unquma:

*"Ngilapha nesiguli esinonyaka [Ubudala] esibuhlungu umphimbo ube sibi kakhulu ohlangothini [kwesokunxele/kwesokudla] ezinsukwini [Inombolo] edlule, futhi manje esenezwi elishubile lezambane elishisayo, indlebe ebuhlungu kakhulu ohlangothini olulodwa, [ukuvuza amathe / ukungakwazi ukugwinya uketshezi], kanye ne-trismus (engavula kuphela umlomo wawo emunweni othambile ngomunwe owodwa). Uhlangothi [lwesobunxele/kwesokudla] luyagobhoza futhi luphushela i-uvula ohlangothini [oluphambene] Sisola i-Peritonsillar Abscess (Quinsy) Sigcine isiguli sihlezi siqondile futhi Akukho lutho ngoMlomo, futhi sidinga udokotela ophuthumayo kanye nokuhlolwa kwe-ENT ukuze kufakwe amanzi emthanjeni, i-intravenous dexamethasone-sulfurion, i-drained-sulfuri ye-ampicillin, i-drained-sulfuri ye-ampicillin.

Imibuzo evame ukubuzwa¶

Kungani ithumba le-peritonsillar libangela ukuthi umhlathi wakho uvale (i-trismus) futhi wenze indlebe yakho ibe buhlungu lapho isifo sisemphinjeni wakho?¶

Ngokushesha ngaphandle kodonga lwemisipha emincane ebamba ithoni yakho kukhona umsipha ophakathi we-pterygoid, ongomunye wemisipha eyinhloko yokuhlafuna evala umhlathi. Lapho ubomvu buqoqa eceleni kwe-tonsil, ukuvuvukala kucasula umsipha we-pterygoid ophakathi ube yi-spasm eqinile, ebuhlungu (trismus) ukuze ungakwazi ukuvula umlomo wakho ngokubanzi; ngesikhathi esifanayo, inzwa yesishiyagalolunye ye-cranial (i-glossopharyngeal nerve) ezwa ubuhlungu ku-tonsil yakho iphinde ithumele igatsha (i-Jacobson's nerve) endlebeni yakho ephakathi, okubangela ubuchopho bakho ukuzwa ubuhlungu be-tonsil njengendlebe ebukhali ohlangothini olufanayo.

Ngingawubona kanjani umehluko phakathi komphimbo omubi (i-tonsillitis) nethumba le-peritonsillar (quinsy)?¶

Emphinjeni evamile noma i-viral tonsillitis, womabili amathani abomvu futhi avuvukele ezinhlangothini zombili zomphimbo, usengawuvula kakhulu umlomo wakho (iminwe emithathu phakathi kwamazinyo angaphambili), futhi i-uvula encane elengayo ilenga iqonde phansi enkabeni yomphimbo wakho. Ethunjini le-peritonsillar, ubuhlungu nokuvuvukala kushintsha kakhulu ohlangothini olulodwa, umhlathi wakho ukhiye ukuze ungakwazi ukuvula umlomo wakho (i-trismus), izwi lakho lizwakala lididekile sengathi ubambe izambane elishisayo emlonyeni wakho, futhi ulwanga oluthambile oluvuvukele ngaphezu kwethoni eyodwa luphusha i-uvula yakho ngokuphawulekayo eceleni esihlathini esingaphesheya.

Kungani ama-antibiotic omlomo engakwazi ukwelapha ithumba le-peritonsillar ngaphandle kokuthi udokotela alikhiphe ngenaliti noma ukusika okuncane?¶

Ngaphambi kokuvela kwethumba (phakathi nesigaba sokuqala esibizwa ngokuthi i-peritonsillar cellulitis), igazi lisageleza esicutshini esivuvukele, ngakho-ke ama-antibiotic afakwa emthanjeni kanye nama-steroids angawelapha. Kodwa-ke, uma iphakethe elibiyelwe ngodonga lokwakheka kobovu obuwuketshezi (ithumba), isuke ingekho imithambo yegazi ngaphakathi kobovu ukuze ifake ama-antibiotic omlomo, kanti ubomvu obuneasidi, obungenawo umoya-mpilo buvala ama-antibiotic amaningi; ukukhipha ubomvu ngenaliti egadiwe noma ukusika okuncane kukhulula ngokushesha ingcindezi, kumise izinhlungu kanye ne-trismus, futhi kuvimbela ubomvu ukuthi bungene emaphashini akho noma entanyeni ejulile.

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.

Imithombo ihloliwe¶

• 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): Iziqondiso Zokuzilolonga Zokuxilongwa Nokuphathwa Kweqembu A Streptococcal Pharyngitis and Suppurative Peritonsillar/Parapharyngeal Complications (polymicrobial etiology of Streptococcus pyogenes, *Streptococcal Pharyngitis and Suppurative Peritonsillar/Parapharyngeal Complications) i-anaerobes Fusobacterium kanye Prevotella, kanye nemithi ye-empiric ampicillin-sulbactam, ceftriaxone plus metronidazole, kanye ne-clindamycin).
• I-American College of Emergency Physicians (ACEP, United States): Inqubomgomo Yomtholampilo kanye ne-Point-of-Care Ultrasound (POCUS) Imihlahlandlela ye-Intraoral and Transcutaneous Ultrasound ku-Peritonsillar Abscess (ehlukanisa i-peritonsillar cellulitis kusuka kuthumba, Umbala we-Doppler wokudweba we-artery yangaphakathi engu-1 cm kanye ne-carotid egadiwe engu-1 cm. i-superior-pole needle aspiration technique).
• 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).

Iziqondiso ezihlobene¶

• Ludwig's angina: bilateral submandibular floor-of-mouth cellulitis and woody neck induration
• Retropharyngeal abscess in children and adults, neck extension pain, and mediastinitis
• I-Lemierre's syndrome: i-internal jugular vein septic thrombophlebitis ngemva komphimbo obuhlungu
• I-post-tonsillectomy hemorrhage: usuku lwe-5 ukuya ku-10 eschar sloughing kanye nokuhlolwa kwendlela yomoya
• I-Epiglottitis, i-croup, i-stridor, nokuvinjelwa komzila womoya ophezulu