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Peritonsillar cyst — Clinical Guidelines

Overview

Peritonsillar cysts are rare benign lesions that occur in the peritonsillar space, often mimicking symptoms of peritonsillar abscess or cellulitis, leading to diagnostic challenges and potential delays in appropriate management. 1 4 7

Diagnosis

Clinical Presentation: Symptoms include sore throat, dysphagia, and muffled voice; physical examination may reveal unilateral tonsillar swelling. 1 7

Diagnostic Imaging:

- Ultrasound: Transoral ultrasonography (TUS) is highly effective, with high sensitivity and specificity for differentiating between abscess and cellulitis. 5 8 9 - CT Scan: Computed tomography can also differentiate between abscess and cellulitis but involves radiation exposure. 11

Aspiration: Needle aspiration can be diagnostic but is invasive; typically reserved when abscess is suspected. 9

PTA Score: The PTA score may help identify patients with peritonsillar inflammation who could benefit from medical treatment, though primarily validated for PTA and peritonsillitis. 3

Management

Medical Treatment:

- Antibiotics: High-dose penicillin remains the preferred first-line treatment. Clindamycin can be considered as an alternative, though comparative efficacy studies show mixed results. 2 12

Surgical Intervention:

- Incision and Drainage: Necessary for confirmed peritonsillar abscess to prevent complications. 12 - Tonsillectomy: Considered for recurrent infections or severe cases; interval tonsillectomy may be advised for patients with a history of multiple infections. 6 12

Special Populations

Pediatrics: Peritonsillar infections are common in children, with clinical differentiation between abscess and cellulitis being particularly challenging. Ultrasound is recommended for accurate diagnosis. 10 9

Comorbidities: No specific guidelines provided in the abstracts regarding management adjustments for comorbidities; individualized care based on clinical judgment is advised. 1 7

Key Recommendations

Utilize transoral ultrasonography for accurate diagnosis of peritonsillar cysts and to differentiate between abscess and cellulitis (Evidence: Strong 5 8 9).

Initiate treatment with high-dose penicillin for peritonsillar infections; consider clindamycin as an alternative based on clinical judgment (Evidence: Moderate 2 12).

Perform incision and drainage for confirmed peritonsillar abscess to prevent complications (Evidence: Expert opinion 12).

Evaluate patients with recurrent peritonsillar infections for potential interval tonsillectomy (Evidence: Moderate 6).

In pediatric patients, prioritize ultrasound over invasive methods for diagnosing peritonsillar infections (Evidence: Moderate 10 9).

References

1 García-Callejo FJ, Alba-García JR, Orozco-Núñez S, Martínez-Giménez L, Balaguer-García R, Ruescas-Gómez L. Healthcare aspects of peritonsillar infection before and during the COVID-19 pandemic. Acta otorrinolaringologica espanola 2023. link 2 Hallgren F, Lindell E, Nilsson-Helger B, Lundqvist A. Antibiotics in treatment of peritonsillar infection: clindamycin versus penicillin. The Journal of laryngology and otology 2021. link 3 Spiekermann C, Roth J, Vogl T, Stenner M, Rudack C. Potential of the Novel PTA Score to Identify Patients with Peritonsillar Inflammation Profiting from Medical Treatment. Disease markers 2018. link 4 Bandarkar AN, Adeyiga AO, Fordham MT, Preciado D, Reilly BK. Tonsil ultrasound: technical approach and spectrum of pediatric peritonsillar infections. Pediatric radiology 2016. link 5 Salihoglu M, Eroglu M, Yildirim AO, Cakmak A, Hardal U, Kara K. Transoral ultrasonography in the diagnosis and treatment of peritonsillar abscess. Clinical imaging 2013. link 6 Wikstén J, Hytönen M, Pitkäranta A, Blomgren K. Who ends up having tonsillectomy after peritonsillar infection?. European archives of oto-rhino-laryngology : official journal of the European Federation of Oto-Rhino-Laryngological Societies (EUFOS) : affiliated with the German Society for Oto-Rhino-Laryngology - Head and Neck Surgery 2012. link 7 Ong YK, Goh YH, Lee YL. Peritonsillar infections: local experience. Singapore medical journal 2004. link 8 Miziara ID, Koishi HU, Zonato AI, Valentini M, Miniti A, De Menezes MR. The use of ultrasound evaluation in the diagnosis of peritonsillar abscess. Revue de laryngologie - otologie - rhinologie 2001. link 9 Scott PM, Loftus WK, Kew J, Ahuja A, Yue V, van Hasselt CA. Diagnosis of peritonsillar infections: a prospective study of ultrasound, computerized tomography and clinical diagnosis. The Journal of laryngology and otology 1999. link 10 Szuhay G, Tewfik TL. Peritonsillar abscess or cellulitis? A clinical comparative paediatric study. The Journal of otolaryngology 1998. link 11 Sakaguchi M, Sato S, Asawa S, Taguchi K. Computed tomographic findings in peritonsillar abscess and cellulitis. The Journal of laryngology and otology 1995. link 12 Hardingham M. Peritonsillar infections. Otolaryngologic clinics of North America 1987. link

Peritonsillar cyst