Peritonsillar Cellulitis and Abscess - UpToDate

3/26/2017 PeritonsillarcellulitisandabscessUpToDate
OfficialreprintfromUpToDate
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Peritonsillarcellulitisandabscess
Author: EllenRWald,MD
SectionEditors: MorvenSEdwards,MD,GlennCIsaacson,MD,FAAP,StephenJTeach,MD,MPH,StephenB
Calderwood,MD
DeputyEditor: JamesFWiley,II,MD,MPH
Alltopicsareupdatedasnewevidencebecomesavailableandourpeerreviewprocessiscomplete.
Literaturereviewcurrentthrough:Feb2017.|Thistopiclastupdated:Feb28,2017.
INTRODUCTIONTheclinicalfeatures,evaluation,andmanagementofperitonsillarcellulitis(alsocalled
peritonsillitis)andabscesswillbediscussedhere.Cervicallymphadenitis,retropharyngealcellulitisand
abscess,andotherdeepneckspaceinfectionsarediscussedseparately.(See"Cervicallymphadenitisin
children:Etiologyandclinicalmanifestations"and"Retropharyngealinfectionsinchildren"and"Deepneck
spaceinfections".)
BACKGROUNDSuppurativeinfectionsoftheneckareuncommon.However,theyarepotentiallyvery
serious.Suppurativecervicallymphadenitisisthemostcommonsuperficialneckinfection.Peritonsillar
abscess(PTA,quinsy)isthemostcommondeepneckinfection[1,2].Otherdeepneckinfectionsinclude
retropharyngealabscessandparapharyngealspaceabscess(alsoknownaspharyngomaxillaryorlateral
pharyngealspaceabscess).Pharyngealspaceinfectionmostoftenarisesviacontiguousspreadofinfection
fromaperitonsillarorretropharyngealabscess.
DEFINITIONTwotermsareusedtodescribeinfectionoftheperitonsillarregion:
PeritonsillarcellulitisPeritonsillarcellulitisisaninflammatoryreactionofthetissuebetweenthecapsule
ofthepalatinetonsilandthepharyngealmusclesthatiscausedbyinfection,butnotassociatedwitha
discretecollectionofpus.Analternatetermforcellulitisisphlegmon.
PeritonsillarabscessPeritonsillarabscessisacollectionofpuslocatedbetweenthecapsuleofthe
palatinetonsilandthepharyngealmuscles.
Inmanypatients,diagnosingthetypeofperitonsillarinfectionpresentrequiresneedleaspirationorincision
anddrainagetodetermineifpusispresent.
ANATOMYANDPATHOGENESISTheperitonsillarspaceconsistsoflooseareolartissueoverlyingthe
tonsilandissurroundedbythesuperiorpharyngealconstrictormuscleandtheanteriorandposteriortonsillar
pillars.Thepalatinetonsilsarelocatedbetweenthepalatoglossalandpalatopharyngealarches(figure1)[3].
Theyaresurroundedbyacapsulethatprovidesapathforbloodvesselsandnerves.
Peritonsillarabscess(PTA)usuallyoccursinthesuperiorpoleofthetonsil,manifestedbyadefinedcollection
ofpusbetweenthetonsillarcapsule,thesuperiorconstrictor,andthepalatopharyngeusmuscle.PTAalso
mayoccurinthemidpointorinferiorpoleofthetonsil,ormaybedispersedwithmultipleloculationsinthe
peritonsillarspace[4].
Peritonsillarinfectiongenerallyisprecededbytonsillitisorpharyngitisandprogressesfromcellulitisto
phlegmontoabscess[4].PTAalsomayoccurwithoutprecedinginfectionsuchcasesarethoughttobe
causedbyobstructionoftheWeberglands(agroupofsalivaryglandsinthesoftpalatejustsuperiortothe
tonsilandconnectedtothesurfaceofthetonsilbyaduct)[57].Smokingappearstobeariskfactor[8,9].
Peritonsillarinfectionmaycompromisetheupperairwayorspreadtothesurroundingstructures,includingthe
masseterandpterygoidmusclesandthecarotidsheath(figure2)[3,4].(See'Complications'below.)
https://www.uptodate.com/contents/peritonsillarcellulitisandabscess/print?source=search_result&search=peritonsillar%20cellulitis%20and%20absces 1/28
EPIDEMIOLOGYPeritonsillarabscess(PTA)isthemostcommondeepneckinfectioninchildrenand
adolescents,accountingforatleast50percentofcases[1,2].Itoccursmostfrequentlyinadolescentsand
youngadultsbutcanalsooccurinyoungerchildren[10].
TheestimatedannualincidenceofPTAis30per100,000persons5to59yearsofage[11].Inapopulation
basedreview,theoverallincidenceofsuspectedPTA,baseduponclinicalsuspicioninchildren<18yearswas
14per100,000theincidenceinadolescentswas40per100,000[12].TheincidenceofconfirmedPTAbythe
presenceofpuswithdrainageprocedureswas3per100,000forallages.
MICROBIOLOGYPeritonsillarabscessesareoftenpolymicrobial.Thepredominantbacterialspeciesare
Streptococcuspyogenes(groupAstreptococcus[GAS]),Streptococcusanginosus,Staphylococcusaureus
(includingmethicillinresistantS.aureus[MRSA]),andrespiratoryanaerobes(includingFusobacteria,
Prevotella,andVeillonellaspecies)[1317].Haemophilusspeciesarefoundoccasionally.Ifappropriate
microbiologictechniquesareused,aerobesandanaerobesarecommonlyrecoveredsimultaneously.
EVALUATION
AssessairwayTheinitialstepintheevaluationofthepatientwithpotentialdeepneckspaceinfectionis
rapidassessmentofthedegreeofupperairwayobstruction.Anxious,illappearingpatientswithdroolingand
posturingmustbemonitoredcontinuouslyinasettingwhereemergentartificialairwaycanbeestablishedif
necessary.(See"Emergencyevaluationofacuteupperairwayobstructioninchildren",sectionon'Initialrapid
assessment'and"Epiglottitis(supraglottitis):Clinicalfeaturesanddiagnosis",sectionon'Clinicalfeatures'.)
TypicalpresentationThetypicalclinicalpresentationofperitonsillarabscess(PTA)isaseveresore
throat(usuallyunilateral),fever,anda"hotpotato"ormuffledvoice.Poolingofsalivaordroolingmaybe
present.Trismus,relatedtoirritationandreflexspasmoftheinternalpterygoidmuscle,occursinnearlytwo
thirdsofpatientsithelpstodistinguishPTAfromseverepharyngitisortonsillitis[1,18].Patientsoftenhave
neckswellingandpainandmayhaveipsilateralearpain[3].Fatigue,irritability,anddecreasedoralintake
mayoccurasaresultofdiscomfort.
Historicalfeaturesareimportantinguidingmanagement.Importantaspectsofthehistoryincludefrequency
andseverityofrecurrentepisodesofinfectiouspharyngitis,previousepisodesofPTA,andsnoringorother
symptomsofobstructivesleepapnea.(See"Tonsillectomyand/oradenoidectomyinchildren:Indicationsand
contraindications"and"Evaluationofsuspectedobstructivesleepapneainchildren".)
ExaminationThepresenceoftrismusmaylimittheabilitytoperformanadequateexamination.Ifdrooling
ispresent,suggestingthepossibilityofepiglottitis,caremustbetakennottobeaggressiveduringthe
examinationoftheoralcavity.IfthereisdoubtaboutwhetherthepatienthasaPTA,epiglottitis,orotherdeep
neckspaceinfection,imagingorexaminationintheoperatingroommaybenecessary.Examinationinthe
operatingroompermitscontrolledplacementofanartificialairway[13].(See'Imaging'belowand
"Retropharyngealinfectionsinchildren"and"Epiglottitis(supraglottitis):Clinicalfeaturesanddiagnosis",
sectionon'Diagnosis'.)
ExaminationfindingsconsistentwithPTAincludeanextremelyswollenand/orfluctuanttonsilwithdeviationof
theuvulatotheoppositeside(picture1)[4,5,19].Alternatively,theremaybefullnessorbulgingofthe
posteriorsoftpalatenearthetonsilwithpalpablefluctuance(picture2).Findingsinchildrenwithperitonsillar
cellulitismayincludeanerythematouspharynxandenlargedtonsilswithexudateuvulardeviationandtrismus
areusuallyabsent[18].CervicalandsubmandibularlymphadenopathymaybepresentinchildrenwithPTAor
cellulitis.
BilateralPTAisrare.Clinicaldiagnosismaybedifficultbecausetheclassicasymmetricfindingsareabsent
[2023].Symptoms,suchasodynophagiaandtrismus,maysuggestthediagnosis,butarenotalways
present.Theuvulamaybedisplacedanteriorly[24].BilateralPTAmaybecomplicatedbyupperairway
obstructionandsnoring[20].(See'Complications'below.)
LaboratoryevaluationLaboratoryevaluationisnotnecessarytomakeadiagnosisofPTA,butmayhelp
gaugethelevelofillnessanddirecttherapy[25].
Thelaboratoryevaluationofachildwithperitonsillarinfection,therefore,mightinclude[19]:
Acompletebloodcountwithdifferential:thewhitebloodcellcount(WBC)isusuallyelevatedwitha
predominanceofpolymorphonuclear(PMN)leukocytes,althoughthisisanonspecificfinding.
Serumelectrolytesifthepatient'soralintakehasbeendecreased.(See"Clinicalassessmentand
diagnosisofhypovolemia(dehydration)inchildren".)
AroutinethroatcultureforgroupAstreptococcus.
Gramstain,culture(aerobicandanaerobic),andsusceptibilitytestingofabscessfluidifadrainage
procedureisperformed.Althoughtheseresultsdonotnecessarilyaffectmanagementofuncomplicated
patients[11],theymayhelpguideantimicrobialtherapyinimmunocompromisedpatientsorthosewith
complicationsorextensionofinfection.(See'Drainage'below.)
ImagingImagingisnotnecessarytomakethediagnosisofPTAbutmaybenecessarytodifferentiate
PTAfromperitonsillarcellulitis,deepneckspaceinfections(eg,retroorparapharyngealabscess),or
epiglottitis:
DistinguishingcellulitisfromabscessIntraoralorsubmandibularultrasonography(US)canhelp
distinguishPTAfromcellulitisandguidetheneedforneedleaspiration[2633].Evidenceforthe
sensitivityandspecificityofthesetechniquesislimitedbythelownumbersofpatients(primarilyadults)
examinedinthesestudiesandtheexperienceofthepersonperformingtheUS.However,theysuggesta
sensitivityforabscessof89to100percent.PerformanceofintraoralUSmaybehamperedbytrismus,
pain,orgagging.SubmandibularUSavoidstheselimitationsandisuniquelysuitedforpatientswithan
inadequateoropharyngealexamination.USoftheregionbyeitherapproachappearstobemore
sensitiveandspecificthanclinicalexamination[26,32].PTAappearsasanechofreecavitywithan
irregularborder,andperitonsillarcellulitisappearsasahomogeneousorstriatedareawithnodistinct
fluidcollection[27,28,33].
Inpatientswithoutairwaycompromiseorothercomplications,responsetoatrialofantimicrobialtherapy
isanoptionifUSisnotdefinitiveornotavailable(See'Overviewofapproach'below.)
Becauseoftheradiationexposure,wedonotrecommendcomputedtomography(CT)solelyto
distinguishPTAfromcellulitis.However,contrastCTmaydemonstratePTAinsomepatientsundergoing
evaluationfordeepneckinfections.OnCTwithcontrast,PTAappearsasahypodensemasswithring
enhancement[34].Findingsconsistentwithperitonsillarcellulitisincludesofttissueswelling,lossofthefat
planes,andlackofringenhancement.
DeepspaceneckinfectionCTwithIVcontrastisthepreferredimagingmodalityforidentifyingdeep
spaceneckinfectionssuchasretroorparapharyngealabscess(image1)andshouldbeobtained
insteadofUSinpatientswithsuggestiveclinicalfindingsoftheseconditions(eg,neckstiffness,
respiratoryobstruction,toxicappearanceand/ortrismus).(See"Deepneckspaceinfections",sectionon
'Imaging'and"Deepneckspaceinfections",sectionon'Parapharyngealspaceinfections'and"Deep
neckspaceinfections",sectionon'Retropharyngealanddangerspaceinfections'.)
Whenperformed,carefulmonitoringduringtransportationandCTscanningisimperativemildairway
distresscanbeexacerbatedbysedationandpositioning.CTshouldbeomittedinchildrenwithmoderate
tosevererespiratorydistress,particularlywhensedationisnecessarysuchchildrengenerallyundergo
evaluationintheoperatingroom,whereanartificialairwaycanbeestablishedasneeded.
Lateralneckradiographscanalsoindicateretropharyngealabscess(image2)butarenotdefinitive
studiestoestablishthediagnosis.Theyaremostusefulwhennormal.(See"Deepneckspaceinfections",
sectionon'Imaging'.)
Magneticresonanceimagingorangiography(MRIorMRA)maybetterdelineatesofttissueinvolvement
andvascularcomplicationsinpatientswithdeepneckinfectionsrelativetoCTbuttakelonger.Inaddition,
thesestudieshavethedisadvantageofrequiringapatientwithpotentiallycompromisedswallowing
functionand/orairwaypatencytoliesupine.Sedationand,inyoungchildrenorpatientswithairway
compromise,anesthesiawithendotrachealintubationmaybenecessarytoobtainhighqualityimages.
Forthesereasons,MRIorMRAareseldomused.(See"Deepneckspaceinfections",sectionon
'Imaging'.)
EpiglottitisPatientswithepiglottitistypicallypresentwithsignsofupperairwayobstructionand
respiratorydistresswhichtypicallydifferentiatesitfromPTA.Epiglottitisislesscommoninpatientswho
havereceivedvaccinationagainstHaemophilusinfluenzae,typeb.Directvisualizationofaninflamed
epiglottisisthepreferredmethodofdiagnosis.However,alateralneckplainradiograph,obtainedinthe
presenceofpersonnelwithairwayexpertiseandequipmenttosecuretheairwayimmediatelyavailable,
maybehelpfulinselectedpatients(image3).(See'Differentialdiagnosis'belowand"Epiglottitis
(supraglottitis):Clinicalfeaturesanddiagnosis",sectionon'Radiographicfeatures'.)
DIAGNOSISThediagnosisofPTAcanusuallybemadeclinicallywithoutlaboratorydataorimagingofany
kindinthepatientwithmedialdisplacementofthetonsilanddeviationoftheuvula(picture1).Diagnosisis
confirmedbycollectionofpusatthetimeofdrainage[3,35].Alternatively,ifthereisdiagnosticuncertainty,an
abscessmaybeconfirmedbyintraoralorsubmandibularultrasonographypriortoaspiration(algorithm1).
(See'Imaging'above.)
ClinicalfeaturesandimagingcannotalwaysdistinguishPTAfromcellulitis[12,36].A24hourtrialof
antimicrobialtherapy(withorwithoutantecedentimaging)maybehelpfulinthisregard[36,37].Failureto
respondtoatrialofappropriateantibiotictherapysuggestsPTA,whereasresponsetotherapysuggests
cellulitis.Responseisdefinedbyimprovementinatleastoneclinicalparameter:sorethroat,fever,trismus,or
tonsillarbulge.(See'Imaging'aboveand'Needleaspiration'belowand'SuspectedPTA'below.)
DIFFERENTIALDIAGNOSISThedifferentialdiagnosisofperitonsillarabscess(PTA)includesother
causesofsorethroat,upperairwayobstruction,andpharyngealswelling.Clinicalfeaturesmaybehelpfulin
differentiatingPTAfromtheseconditions,butinsomecases(particularlyinyoungchildren)imagingand/or
examinationintheoperatingroommaybenecessarytomakeadefinitivediagnosis(algorithm1).
MajorconsiderationsinthedifferentialdiagnosisofPTAinclude[19]:
EpiglottitisTheclassicteachingisthatepiglottitisismorerapidlyprogressivethanPTAandoccursin
youngerchildren.However,withwidespreadimmunizationofinfantsagainstHaemophilusinfluenzaetype
b,epiglottitisismorecommonlyseeninolderchildrenandadultsinthesepatientsthepresentationof
epiglottitismaybesubtle.Thus,epiglottitisisadiagnosticconsiderationinanypatientwithfever,sore
throat,drooling,difficultyswallowing,andrespiratorydistress.(See"Epiglottitis(supraglottitis):Clinical
featuresanddiagnosis",sectionon'Presentation'.)
Oropharyngealexaminationshouldbeavoidedinpatientswithmarkedrespiratorydistress.These
patientsshouldfirsthavetheairwaysecured.Arapidoverviewprovidestheapproachtodiagnosisand
management(table1).(See"Epiglottitis(supraglottitis):Management",sectionon'Approachtoairway
management'.)
RetropharyngealabscessorcellulitisRetropharyngealabscessorcellulitistypicallyoccursmost
commonlyinyoungerchildrenbetweentwoandfouryearsofageandisassociatedwithminimal
peritonsillarfindings.
FindingscommontobothPTAandretropharyngealabscessincludedifficultyswallowing,drooling,hot
potatoormuffledvoice,andtrismus,althoughtrismusispresentinonlyabout20percentofpatientswith
retropharyngealabscess.(See"Retropharyngealinfectionsinchildren",sectionon'Presentation'.)
UnlikePTA,childrenwithretropharyngealabscessfrequentlyhaveneckstiffness,painonmovement,
especiallyneckextension(asopposedtoincreasedpainwithflexionasobservedinmeningitis),neck
swellingormass,necktenderness,andifthereismediastinalextensionoftheabscess,chestpain.(See
"Retropharyngealinfectionsinchildren",sectionon'Presentation'.)
AbscessoftheparapharyngealspaceInpatientswithabscessoftheparapharyngealspace,
examinationmayrevealbulgingbehindtheposteriortonsillarpillarratherthansuperiortothetonsil[35].
Thesoftpalateandtonsilstypicallyappearnormal.
SeveretonsillopharyngitisSeveretonsillopharyngitispresentswithbilateralequaltonsillarswelling
withviralenanthemorexudate.CommoncausesincludeEpsteinBarrvirus,herpessimplexvirus,
coxsackievirus(herpangina),adenovirus,diphtheria,orgonorrhea.Rarely,bilateralPTAcancomplicate
severetonsillopharyngitis.Severetrismusislesscommon.Thepresenceofpalpablefluctuanceor
ultrasonographycanhelpdistinguishbilateralPTAfromtonsillopharyngitis.
MANAGEMENT
OverviewofapproachPromptsurgicalinterventionisindicatedinpatientswhopresentwithimpending
airwaycompromise,complications,enlargingmasses,orsignificantcomorbidities(eg,immunodeficiency)
[13,25].(See'Drainage'below.)
Drainage,antimicrobialtherapy,andsupportivecarearethecornerstonesofmanagementforperitonsillar
abscess(PTA)peritonsillarcellulitisrespondstoantimicrobialtherapyandsupportivecarealone
[1,6,11,36,3843].Supportivecareincludesprovisionofadequatehydrationandanalgesiaandmonitoringfor
complications.
Hospitalizationmaybenecessary,particularlyinyoungerchildren[4].OlderpatientswithuncomplicatedPTA
whoarewellhydratedmaybemanagedasoutpatientsiftheyareabletotolerateadrainageprocedureand
totakeoralmedicationsaftertheprocedure[4,12].
Thereisnoconsensusregardingtheoptimalinitialmanagementfortheremainderofpatientswithsuspected
PTAwhodonotrequireurgentsurgicalintervention[5,11,44].Theapproachdependsuponanumberof
clinicalfactors,includingtheageandcooperativenessofthepatientandthedegreeofcertaintyofthe
diagnosis(abscessversuscellulitis).Consultationwithanotolaryngologistcanhelpdetermineappropriate
managementfortheindividualpatient.
ProbablePTAWesuggestneedleaspirationorincisionanddrainageforpatientswithexamination
findingsconsistentwithPTA(fever,trismus,voicechange,peritonsillarswelling,and/oruvulardeviation)who
donothaveindicationsfortonsillectomy.Needleaspirationispreferredtoincisionanddrainageifthepatient
cancooperate.Theuseofultrasonography(US)priortoneedleaspirationhasbeenassociatedwithimproved
successofaspirationcomparedwiththelandmarktechnique(useofanatomiclandmarksashasbeenthe
traditioninotolaryngology).Asanexample,inatrialof28patientsundergoingevaluationforPTAinan
emergencydepartment(18ultimatelydiagnosedwithPTA),aspirationfacilitatedbyintraoralUSwas
successfulin100percentofpatientswithPTA(8of8)comparedwith50percentundergoingaspirationusing
thelandmarktechnique(5of10withPTA)[32].Thus,whenreadilyavailablebyanexperiencedpractitioner,
USissuggestedinpatientsundergoingneedleaspirationintheemergencydepartment.(See'Needle
aspiration'belowand'Incisionanddrainage'below.)
ProbablecellulitisWesuggestatrialofantibioticsforpatientswithexaminationfindingsconsistent
withperitonsillarcellulitiswhodonothaveindicationsfortonsillectomyorurgentsurgicalintervention.Intraoral
orsubmandibularultrasonographycanincreasethediagnosticcertaintyofcellulitis.Suchpatientsmay
respondtoa24hourtrialofappropriateparenteralantimicrobialtherapy[13].(See'Imaging'aboveand
'Antibiotictherapy'below.)
SuspectedPTAWhenclinicalfindingsdonotclearlydifferentiatePTAfromcellulitis,ultrasonography,
needleaspiration,orresponsetoantimicrobialtherapycanbeusedtohelpdifferentiatethetwoconditions.
(See'Diagnosis'above.)
WesuggestthatpatientswithsuspectedPTA,indeterminateultrasonographicfindings,ifperformed,andno
airwaysymptomsbeadmittedtothehospitalfor24hoursofhydration,antibiotics,andanalgesiawithout
computedtomography(CT)oftheneck(providedthatCTisnotnecessarytoexcludeotherconditionsor
complications).(See'Imaging'above.)
Surgicalintervention(tonsillectomyorincisionanddrainage)isreservedforthosewhodonotrespondto24
hoursofmedicaltherapy[36].Thisstrategywasevaluatedinaretrospectiveseriesof102children(8months
to19years)[37].Approximately50percentofpatientsrespondedtomedicaltherapy,and50percent
underwenttonsillectomy,80percentofwhomhadabscessesatthetimeofsurgery.Childrenyoungerthansix
yearsweremorelikelytorespondtomedicaltherapy.
AntibiotictherapyWerecommendantibiotictherapyforpatientswithperitonsillarinfection.Itisrarefor
antimicrobialtherapyalonetobesufficienttotreatatrueabscessoftheperitonsillarspace.However,aninitial
24hourtrialofappropriateparenteralantimicrobialsisjustifiableinpatientswithpresumedperitonsillar
cellulitiswhoshownoevidenceofairwaycompromise,septicemia,severetrismus,orothercomplications
[13,36].Patientsmostlikelytorespondtoatrialofantibioticsarethosewithprobablecellulitis.
ChildrenwithPTAmostlikelytorespondtoantibioticsarethoselessthansevenyearsofage,withsmall
abscessesandfewerepisodesofprevioustonsillitis[45].
ParenteralEmpirictherapyshouldincludecoverageforGroupAstreptococcus,Staphylococcus
aureusandrespiratoryanaerobes.Empirictherapycanbeamendedasnecessarybaseduponcultureresults
ifdrainageisperformedorbaseduponclinicalresponsetotreatment.Whentailoringtherapybasedupon
cultureresults,itisimportanttobearinmindthatPTAsarefrequentlypolymicrobial,andnotallmicrobesare
consistentlycultured[25].
Ifdrainageisnotperformed,wedecideaboutcoverageformethicillinresistantS.aureus(MRSA)based
uponthepatientsseverityofillness,theprevalenceofMRSAinthecommunity,andwhetherthepatientis
likelytobecolonizedwithMRSA.
Empiricregimensinclude[19]:
Ampicillinsulbactamintravenously(50mg/kgperdose[maximumsingledose3g]everysixhoursin
children3geverysixhoursinadults)
Or
Clindamycinintravenously(13mg/kgperdose[maximumsingledose900mg]everyeighthoursin
children600mgeverysixtoeighthoursinadults)
AmpicillinsulbactamdoesnotprovideantibacterialactivityagainstMRSAand,dependinguponlocal
susceptibilitypatterns,clindamycinmaynotbeactiveagainstmethicillinsusceptibleS.aureus,and/orMRSA.
Rarely,groupAStreptococcusmayberesistanttoclindamycin[46].(See"Methicillinresistant
Staphylococcusaureusinchildren:Treatmentofinvasiveinfections",sectionon'Clindamycin'.)
Accordingly,inpatientswhodonotrespondtoinitialtreatmentwithampicillinsulbactamorclindamycinorin
thosepatientswhopresentwithmoderateorseveredisease(eg,toxicappearance,temperature>39C,
drooling,and/orrespiratorydistress),intravenousvancomycinorlinezolidshouldbeaddedtoempiric
treatmentwitheitherampicillinsulbactamorclindamycintoprovideoptimalcoverageforpotentiallyresistant
Grampositivecocci.(See"MethicillinresistantStaphylococcusaureusinchildren:Treatmentofinvasive
infections",sectionon'Clindamycin'.)
OralParenteraltreatmentismaintaineduntilthepatientisafebrileandclinicallyimproved.Oral
antibiotictherapyshouldthenbecontinuedtocompletea14daycourse.Coursesshorterthan10daysmay
beassociatedwithrecurrence[47].
AppropriateoralregimensforcontinuationoftherapyinareaswhereS.aureusremainssusceptibleto
methicillininclude:
Amoxicillinclavulanate(45mg/kgperdose[maximumsingledose875mg]every12hoursinchildren
875mgevery12hoursinadults)
Or
Clindamycin(10mg/kgperdose[maximumsingledose600mg]everyeighthoursinchildren300to450
mgeverysixhoursinadults)
Whenvancomycinhasbeenaddedtotheparenteralregimen,oraltherapycanbebaseduponsusceptibility
testingoftheisolates,ifavailable.
IfempirictherapyisemployedforpresumedMRSAinfection,regimenscaninclude:
Clindamycin(10mg/kgperdose[maximumsingledose600mg]everyeighthoursinchildren300to450
mgeverysixhoursinadults),unlessisolateisresistant.
Linezolid(<12years:30mg/kgperdayinthreedoses12years:20mg/kgperdayintwodosesin
children600mgtwiceperdayinadultsmaximumdailydose1200mg).
DrainagePTAusuallyrequiressurgicaldrainagethroughneedleaspiration,incisionanddrainage,or
tonsillectomy,proceduresthataretypicallyperformedbyanotolaryngologist[6].Drainagewithanyofthese
procedures,incombinationwithantimicrobialtherapyandhydration,resultsinresolutioninmorethan90
percentofcases[6,44].Giventhattheproceduresarecomparableinefficacy,thechoiceofprocedure
dependsuponotherfactors,suchastheskillandexperienceofthehealthcareprovider,ageandabilityofthe
patienttocooperate,cost,andwhetherthepatienthasindicationsfortonsillectomy(eg,recurrentacutethroat
infection).Eachprocedurehasadvantagesincertainsituations[2,13].
Anolder,cooperativechild,teenager,oradultwithouttrismusoraprevioushistoryofpharyngitismaybeable
toundergoaneedleaspirationorsimpleincisionanddrainageprocedureasanoutpatientwithtopical
anesthesiaorproceduralsedation[6,4851].However,ifthechildisyoungandunabletocooperate,the
proceduremustbeperformedintheoperatingsuite.Specialcaremustbetakenwiththeadministrationof
proceduralsedationbecausetheriskofairwaycomplicationisincreased.
Intheabsenceofaprevioushistoryofrecurrentpharyngitis,needleaspirationorincisionanddrainagemay
besufficient.Incontrast,iftherehavebeenpreviousepisodesofpharyngitisorPTA(eitherofwhichpredict
thepossiblerecurrenceofthePTA),thenaquinsytonsillectomymaybeperformed.(See'Tonsillectomy'
below.)
NeedleaspirationNeedleaspirationofPTA(picture3)maybeperformedintheoutpatientsettingwith
topicalanesthesiabyanexperiencedclinician(usuallyanotolaryngologist)[6,41,52].Ultrasoundmaybe
helpfultoconfirmtheclinicalsuspicionofanabscessandguidetheprocedure[27,31,32].
Patientsgenerallytolerateneedleaspirationbetterthanincisionanddrainagebecauseitislessinvasiveand
lesspainful[11,40].Needleaspirationistheprocedureofchoiceforchildrenwhosegeneralconditionistoo
poortotolerateageneralanestheticandthosewithableedingdiathesiswhowishtoavoidbloodtransfusion
[13].
Inrandomizedtrialscomparingneedleaspirationtoincisionanddrainage,theprocedureshadsimilarinitial
successratesof>90percent[40,44,5254].Inonemetaanalysis,needleaspirationhada94percentsuccess
rateforacuteresolution(range85to100percent)[11].Aseparatemetaanalysisof10trials(612patients,
primarilyadults)foundthatearlyrecurrentabscesswasmorelikelywithneedleaspirationthanincisionand
drainage(RR3.7).However,therewasmoderateheterogeneityinthispooledestimateandtheevidencefor
recurrencewasconsideredtobeofverylowquality[55].Furthermore,therecurrenceratevariedgreatlyby
eachprocedure(5to80percentinpatientsundergoingneedleaspirationand0to20percentinpatients
undergoingincisionanddrainage)whichdiffersmarkedlyfromthe10to15percentrecurrenceratetypically
described[11,44,47,52].Thiswidevariationsuggeststhattherewerelikelysignificantdifferencesinthe
competenceofthephysiciansperformingtheproceduresorthedeterminationofrecurrencethatmayhave
confoundedtheresults[55].
Complicationsofneedleaspirationmayincludehemorrhageandaspirationofpusandbloodintotheairway
[56].CarotidarteryinjuryhasnotbeenreportedasacomplicationofneedleaspirationofPTA[6]however,
catastrophichemorrhagemayresultfromaspirationofapseudoaneurysmmimickingPTAornecrosisofthe
carotidartery[57,58].(See'Differentialdiagnosis'aboveand'Complications'below.)
Thepatientmustbeobservedaftertheneedleaspirationtomakesureheorshecantolerateoral
antimicrobialtherapy,painmedications,andliquids.Ifthepatientisnotadmittedtothehospital,heorshe
shouldbeseenforfollowupin24to36hours[3].(See'Dischargeinstructions'below.)
IncisionanddrainageIncisionanddrainageofPTAisusuallyperformedbyanotolaryngologist
(picture4)[6].Inolderchildren,itmaybeperformedintheoutpatientsettingwithtopicalanesthesiaor
proceduralsedationgeneralanesthesiaisusuallyrequiredforyoungchildren[6,35,4749,52].
Incisionanddrainageismorepainfulthanneedleaspirationandcausesmorebleeding[6,35].Asecond
proceduremayberequiredforcompleteresolution.Complicationsmayincludeaspirationoftheabscess
contents.
Patientsmustbeobservedaftertheproceduretomakesuretheycantolerateoralantimicrobialtherapy,pain
medications,andliquids.Patientswhoarenotadmittedtothehospitalshouldbeseenforfollowupin24to36
hours[3].(See'Dischargeinstructions'below.)
TonsillectomyPossibleindicationsfortonsillectomyinpatientswithPTAinclude[24,6,13]:
Significantupperairwayobstructionorothercomplications.
PreviousepisodesofsevererecurrentpharyngitisorPTA(eachofwhichpredictsthepossiblerecurrence
ofPTA).
Otherindicationsfortonsillectomy(eg,chronicsymptomsorsignsofupperairwayobstruction,suchas
snoring).(See"Tonsillectomyinadults:Indications"and"Tonsillectomyand/oradenoidectomyinchildren:
Indicationsandcontraindications".)
Failureoftheabscesstoresolvewithotherdrainagetechniques.
Iftonsillectomyisrequired,itmaybeperformedimmediately(quinsytonsillectomyor"tonsillectomyachaud")
orafterresolutionoftheacuteinfection(intervaltonsillectomy)[2,52,5961].Quinsytonsillectomyavoidsthe
needforrepeathospitalizationandanesthesia,andminimizeslosstofollowup,butmaybeassociatedwith
increasedriskofbleeding.Intervaltonsillectomymaybemoredifficulttechnicallyifthereisfibrosisfollowing
theacuteinfection.
Tonsillectomyisthemostexpensiveofthedrainageprocedures,requiresgeneralanesthesiaand
hospitalization,andmaydelaydrainage[6,35].Infiveseriesinvolving1027patients,theoverallincidenceof
bleedingafterquinsytonsillectomyinchildrenandadultswas1percent(range0to7percent)[13].Intheonly
seriesconfinedtochildren,noneofthe55patientshadpostoperativeordelayedbleeding[62].Additional
complicationsandadverseeffectsoftonsillectomyarediscussedseparately.(See"Tonsillectomyinadults",
sectionon'Complications'and"Tonsillectomyand/oradenoidectomyinchildren:Indicationsand
contraindications".)
GlucocorticoidsEvidenceregardingthebenefitsofglucocorticoidsinthemanagementofPTAis
inconsistent[12,63,64].Inonetrialof62patients,glucocorticoidsappearedtohastensymptomatic
improvementinadolescent(>16years)andadultpatientstreatedwithneedleaspirationandintravenous
antimicrobialtherapy[63].Inanothersmalltrialof41adultpatientsundergoingneedleaspirationforPTA,
intravenousdexamethasonewasassociatedwithlesspainat24hoursthanplacebobutnootherbenefits
[64].Inaretrospectivecaseseriesof249episodesofPTAinchildren<18years,glucocorticoidswereusedin
37percentbutwithoutclearbenefitoradverseoutcomes[12].Giventhesmallnumberofpatientsinthetrials
anddifferentresultsofthesestudies,additionalinformationisnecessarybeforetheroutineuseof
glucocorticoidscanberecommendedinthemanagementofPTA[6].
DischargeinstructionsPatientswhoaredischargedfromtheemergencydepartmentorhospitalafter
treatmentforperitonsillarinfectionshouldbeinstructedthatpromptreevaluationisnecessaryfor[25]:
Dyspnea
Worseningthroatpain,neckpain,ortrismus
Enlargingmass
Fever
Neckstiffness
Bleeding
Patientswhoaretreatedasoutpatientsshouldbeseenforfollowupin24to36hours.Thosewhohavebeen
admittedtothehospitalshouldhavefollowupwithinseveraldaysofdischarge.
ResponsetotreatmentSuccessfultreatmentisdefinedbysymptomaticimprovementinsorethroat,
fever,and/ortonsillarswellingwithin24hoursofintervention.
Treatmentfailureisdefinedbylackofsymptomaticimprovementorworseningdespite24hoursof
antimicrobialtherapy(withorwithoutsurgicaldrainage).Treatmentfailuremayoccurinpatientswhohave
developedcomplications,areinfectedwithunusualorganisms,orhaveunderlyingproblems(eg,congenital
cystortract)[25].Reevaluationofsuchpatientsmayincluderepeatimaging(CTwithcontrasttolookfor
extensionofinfection)orsurgicalintervention.Broadeningantimicrobialtherapyalsomaybeindicated.
COMPLICATIONSEarlydiagnosisandprompt,appropriatemanagementofperitonsillarinfectioniscritical
toavoidingcomplications.Complicationsofperitonsillarabscess(PTA)occurrarely,butarepotentiallyfatal.
Infectioncanspreadfromtheperitonsillarspacetootherdeepneckspaces,toadjacentstructures,andtothe
bloodstream.
ComplicationsofPTAmayinclude[3,4,13,65]:
Airwayobstruction
Aspirationpneumoniaiftheabscessrupturesintotheairway
Septicemia
Internaljugularveinthrombosis
Jugularveinsuppurativethrombophlebitis(Lemierresyndrome)[66,67](see"Deepneckspace
infections",sectionon'Complications')
Carotidarteryrupture
Pseudoaneurysmofthecarotidartery(suggestedbyrecurrentbleedingfromtheear,nose,orthroat,
prolongedcourse,tachycardia,anemia,or10thor12thcranialnervepalsies)[68]
Mediastinitis
Necrotizingfasciitis[69,70]
SequelaeofGroupAstreptococcusinfection(whenthatorganismisisolated)(see"Complicationsof
streptococcaltonsillopharyngitis")
PROGNOSISWithearlyandappropriatetreatment,mostperitonsillarinfectionsresolvewithoutsequelae.
Recurrenceisestimatedtooccurin10to15percent[11,44,47,52].Theriskofrecurrenceisincreasedin
patientswithahistoryofrecurrenttonsillitisbeforedevelopmentoftheabscess(40versus9.6percent)[71].
SUMMARYANDRECOMMENDATIONS
Twotermsareusedtodescribeinfectionoftheperitonsillarregion:
PeritonsillarcellulitisPeritonsillarcellulitisisaninflammatoryreactionofthetissuebetweenthe
capsuleofthepalatinetonsilandthepharyngealmusclesthatiscausedbyinfection,butnot
associatedwithadiscretecollectionofpus.Analternatetermforcellulitisisphlegmon.
PeritonsillarabscessPeritonsillarabscess(PTA)isacollectionofpuslocatedbetweenthe
capsuleofthepalatinetonsilandthepharyngealmuscles.
ThetypicalclinicalpresentationofPTAisaseveresorethroat,fever,a"hotpotato"ormuffledvoice,
drooling,andtrismus.(See'Typicalpresentation'above.)
ExaminationfindingsconsistentwithPTAincludeanenlargedandfluctuanttonsilwithdeviationofthe
uvulatotheoppositeside(picture1).Alternatively,theremaybefullnessorbulgingoftheposteriorsoft
palatenearthetonsilwithpalpablefluctuance.(See'Examination'above.)
ThediagnosisofPTAcanbemadeclinicallywithoutlaboratoryorimagingstudiesinthepatientwith
medialdisplacementofthetonsilanddeviationoftheuvula(picture1).However,clinicalfeaturescannot
alwaysdistinguishPTAfromperitonsillarcellulitisorotherseriousinfectionssuchasparaor
retropharyngealabscessorepiglottitis.Ultrasoundimaging,aspiration,oratrialofappropriateantibiotic
therapymayhelpmakethisdistinction(algorithm1).(See'Diagnosis'above.)
Promptsurgicalinterventionisindicatedinpatientswithimpendingairwaycompromise,complications,
enlargingmasses,orsignificantcomorbidities.(See'Overviewofapproach'above.)
Werecommendantibiotictherapyforallpatientswithsuspectedperitonsillarinfection(Grade1B).
EmpirictherapyshouldincludecoverageforGroupAstreptococcus,S.aureus,andrespiratory
anaerobes.Therapyshouldbecontinuedfor14days.Thechoiceofantibioticandrouteoftreatment
dependsuponthepatientsdegreeofillnessandlocalpatternsofantibioticresistance.(See'Antibiotic
therapy'above.)
Inadditiontoantibiotictherapy,wesuggestneedleaspirationorincisionanddrainageforcooperative
patientswithexaminationfindingsconsistentwithPTAiftheydonothaveindicationsfortonsillectomy
(Grade2C).(See'ProbablePTA'aboveand'Drainage'above.)
Wesuggestatrialofantibioticsforpatientswithexaminationfindingsconsistentwithcellulitiswhodonot
haveindicationsfortonsillectomyorurgentsurgicalintervention(Grade2C).(See'Probablecellulitis'
aboveand'Antibiotictherapy'above.)
WesuggestthatpatientswithsuspectedPTA,indeterminatefindingsonultrasound,ifperformed,andno
airwaysymptomsbeadmittedtothehospitalwithoutcomputedtomography(CT)oftheneck(provided
thatCTisnotnecessarytoexcludeotherconditionsorcomplications)for24hoursofhydration,
antibiotics,andanalgesia(Grade2C).Surgicalintervention(tonsillectomyorincisionanddrainage)is
reservedforthosewhodonotrespondto24hoursofmedicaltherapy.(See'SuspectedPTA'aboveand
'Antibiotictherapy'above.)
https://www.uptodate.com/contents/peritonsillarcellulitisandabscess/print?source=search_result&search=peritonsillar%20cellulitis%20and%20absce 10/28
Wesuggestthattonsillectomybereservedforpatientswhofailtorespondtootherdrainagetechniques,
developcomplications,orhaveotherindicationsfortonsillectomy(eg,previousepisodesofPTAor
recurrentseverepharyngitis,chronicupperairwayobstruction)(Grade2C).(See'Tonsillectomy'above.)
ComplicationsofPTAarepotentiallyfatal.Infectioncanspreadtootherdeepneckspaces,toadjacent
structures,andtothebloodstream.(See'Complications'above.)
UseofUpToDateissubjecttotheSubscriptionandLicenseAgreement.
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Topic6079Version31.0
GRAPHICS
Anatomyofthepalatinetonsil
Thetonsilsarepositionedlaterallyinthepharyngealwallbetweenthepalatoglossalarchand
palatopharyngealarch(theanteriorandposteriortonsillarpillars),whichmergesuperiorlyto
becomethesoftpalate.FigureAshowsasagitattalsectionthroughtheoropharynx.Figure
Bshowsacoronalsectionthroughthetonsillarregionfrommedial(palatoglossusmuscle)to
lateral(palatopharyngeusmuscle).
Graphic72358Version5.0
Anatomyoftheparapharyngealspace
Peritonsillarabscess
Alargeunilateralabscessisvisibleinthepharynxofapatientexaminedinthe
EmergencyDepartment.Prominentswellingoftheanteriorpillarandsoftpalate
ispresent.
CourtesyofLawrenceBStack,MD.
Peritonsillarabscesswithexudate
Notethebulgingofthesoftpalateandincreasedtonsillarhypertrophyontheleft.
CourtesyofDianeHeatley,MD.
Retroandparapharyngealabscess
Thecomputedtomographyoftheneckshowsretroandparapharyngealabscess
(A,B)asindicatedbyalowdensitycore,softtissueswelling,obliteratedfat
planes,masseffect,andrimenhancement.
Retropharyngealabscess
Lateralneckradiographdemonstratingwideningoftheretropharyngealspace
andreversalofthenormalcervicalspinecurvature.Theretropharyngealspace
normallymeasuresonehalfthewidthoftheadjacentvertebralbodyandis
consideredwidenedifitisgreaterthanafullvertebralbodyatC2or3whenthe
spineisproperlyextendedinaninfantorchildyoungerthan5yearsofage.The
epiglottisandsubglotticareainthisradiographarenormal.
CourtesyofJoeBlack,DepartmentofDiagnosticImaging,TexasChildren'sHospital.
Epiglottitis:Lateralradiograph
Lateralneckradiographdemonstratingswollenepiglottis(arrow)and
aryepiglotticfoldsinachildwithepiglottitisduetoHaemophilusinfluenzaetype
b.Theswollenepiglottisisoftencalleda"thumbsign."
CourtesyofEvelynYAnthony,MD,WakeForestUniversitySchoolofMedicine.
Approachtothediagnosisandtreatmentofperitonsillarabscessinthe
emergencydepartment
IV:intravenousUS:ultrasoundOR:operatingroom.
*Maintenanceoftheairwayisthemainstayoftreatment.Inpatientswithsignsoftotalorneartotalairway
obstructionairwaycontrolnecessarilyprecedesdiagnosticevaluation.Ifavailable,activateacriticalairwayteam
consistingofananesthesiologist,emergencyand/orcriticalcarespecialist,andanotolaryngologisttoassistwith
securingtheairway.
Intraoralorsubmandibularultrasoundhassignificantlybettersensitivityfordistinguishingperitonsillarabscess
fromperitonsillarcellulitisthanphysicalexaminationaloneandimprovesthesuccessofneedleaspiration.Needle
aspirationshouldbeperformedbyaproperlytrainedandexperiencedphysician,typicallyanotolaryngologist.
However,ifUSisequivocalornotavailable,thenpatientswithoutairwaycompromisemayundergoatrialofIV
antibioticsandhospitalobservationinsteadofneedleaspiration.
Forsuggestedantibioticregimens,refertoUpToDatetopicsonperitonsillarabscess.Patientswithperitonsillar
cellulitisandpatientswithimprovementafterdrainageofaperitonsillarabscessmaybedischargedhomeiftheyare
wellhydrated,havenoairwaycompromise,andcantolerateoralintakeincludingoralantibiotics.Otherwise,
hospitalizationiswarranted.
Rapidoverview:Epiglottitis(supraglottitis)inchildren
Clinicalfindings
Respiratorydistress:stridor,tachypnea,anxiety,refusaltoliedown,"sniffing"or"tripod"posture
Sorethroat,dysphagia,drooling,anteriorneckpain(atthelevelofthehyoid)
Muffled"hotpotato"voiceoraphonia
Markedretractionsandlaboredbreathingindicateimpendingrespiratoryfailure
Verbalpatientswithpainoutofproportiontooropharyngealexamination
Unimmunizedorunderimmunizedpatients
Immediatemanagement
Deferattemptsatvisualizingtheepiglottis(tonguebladeoranyotherinstrument)orinvasive
procedures(eg,IVplacement,phlebotomy,oranyotherpainfulorfrighteningintervention)untilafter
airwayassessmentandmanagement
Preparetomanagetheairwayandimmediatelyinvolveairwayspecialists(anesthesiologistorcritical
carephysicianandotolaryngologist)wheneveravailable
Patientnotabletomaintaintheairway:Attemptbagvalvemaskventilation
Unabletooxygenate(pulseoximetrylowerthanhigh80sorfalling):Attemptendotrachealintubationby
rapidsequenceintubationfirstbutbepreparedtoestablishasurgicalairway(eg,needlecricothyrotomyor
surgicalcricothyrotomy)*
Abletooxygenate(pulseoximetryhigh80sandsteadyorimproving):Endotrachealintubationbythe
mostcapableprovider,preferablyintheoperatingwithanotolaryngologistpresent
Patientabletomaintaintheairway
Providesupplementalhumidifiedoxygenandmaintainthechildinapositionofcomfortwiththeparentpresent
(eg,sittingontheparent'slaponthestretcher)
Keepthepatientinasettingwheretheairwaycanberapidlymanagedifnecessarywithcapablepersonneland
specializedairwayequipmentconstantlyavailable
Softtissueradiographofthelateralneck(portableifpossible)maybehelpfulbutnecessarypersonneland
equipmenttomanageanacuteairwayeventmustremainwiththepatientatalltimesduringtheimagingprocess.
Donotimagepatientswithsevererespiratorydistressinwhomitwilldelaydefinitiveairwaymanagement
Radiographicfindingsofepiglottitis:Enlargedepiglottis("thumb"sign),lossofvallecularairspace,thickened
aryepiglotticfolds,and/ordistendedhypopharynx
Attemptsatdirectvisualizationareonlyappropriateinpatientswithnostridororstridorwithoutsignificant
distress,noincreaseinsymptomswithagitation,andnocyanosis
Inchildren<6yearsofagewithconfirmedepiglottitisorolderchildrenwhoaretoxicappearingorhave>50
percentobstructionofthelumenbydirectvisualization,performendotrachealintubationintheoperatingroom
withanotolaryngologistpresent
Additionalmanagement
Laboratorystudies:onlyobtainaftertheairwayisassessedandmanaged
Epiglottalculturesafterestablishmentofartificialairway
Bloodculturesaftertheairwayissecured
Antimicrobialtherapy
Administerempiricantimicrobialtherapy(ceftriaxoneORcefotaximeANDanantistaphylococcalagent[eg,
vancomycinorclindamycinasdeterminedbythelocalprevalenceofmethicillinresistantStaphylococcusaureus
and,ifprevalent,itslocalsensitivityprofile])
*Needlecricothyroidotomymaybeperformedonchildrenofanyage.Theageatwhichonecansafelyperforma
surgicalcricothyroidotomyonachildisnotwellestablished,andrecommendationsvaryfrom5to12yearsold.Surgical
cricothyroidotomyisbestperformedinchildreninwhomexternallandmarksoftheneck(eg,thecricothyroid
membrane)areeasilypalapable.RefertoUpToDatetopicsonneedlecricothyroidotomywithpercutaneoustranstracheal
ventilationandemergentsurgicalcricothyroidotomy(cricothyrotomy).
RefertoUpToDatetopicsonthemanagementofepiglottitis,endotrachealintubationinthepediatricpatientwitha
difficultairwayanddevicesfordifficultendotrachealintubationinchildren.
RefertoUpToDatetopicsonthediagnosisofepiglottitisforanapproachtoexaminingtheoropharynxofchildrenwith
epiglottitis.
ForantibioticregimensrefertoUpToDatetablesonintravenousantimicrobialtreatmentregimensforepiglottitisand
UpToDatetopicsonthemanagementofepiglottitis.
Needleaspirationofperitonsillarabscess
CourtesyofGlennCIsaacson,MD,FAAP,FACS.
Surgicaldrainageofperitonsillarabscess
(A)Incision.
(B)Openingofabscess.
(C)Completedincisionanddrainage.
CourtesyofGlennCIsaacson,MD,FAAP,FACS.
ContributorDisclosures
EllenRWald,MD Nothingtodisclose MorvenSEdwards,MD Grant/Research/ClinicalTrialSupport:
PfizerInc.[GroupBStreptococcus]. GlennCIsaacson,MD,FAAP Nothingtodisclose StephenJTeach,
MD,MPH Consultant/AdvisoryBoard:Novartis[omalizumab]. StephenBCalderwood,MD PatentHolder:
VaccineTechnologiesInc[Vaccines(Choleravaccines)].EquityOwnership/StockOptions:Pulmatrix
[Infectiousdiseases(Inhaledantimicrobials)]PharmAthene[Anthrax(Antibodytherapies)]. JamesFWiley,
II,MD,MPH Nothingtodisclose
Contributordisclosuresarereviewedforconflictsofinterestbytheeditorialgroup.Whenfound,theseare
addressedbyvettingthroughamultilevelreviewprocess,andthroughrequirementsforreferencestobe
providedtosupportthecontent.Appropriatelyreferencedcontentisrequiredofallauthorsandmustconform
toUpToDatestandardsofevidence.
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