Residency · Residency · Emergency Medicine
Airway Foreign Body and Peritonsillar Abscess
Introduction
Airway foreign bodies and peritonsillar abscesses represent two of the most important ENT emergencies managed by the emergency physician. Foreign body aspiration can produce acute airway obstruction and death within minutes, while peritonsillar abscess (PTA), the most common deep space neck infection, can progress to airway compromise, mediastinitis, or sepsis if untreated. Both conditions require rapid clinical recognition and procedural competency.
Airway Foreign Body
Epidemiology
Approximately 5,000 deaths from foreign body aspiration occur annually in the United States. The age distribution is bimodal: children under 3 years have the highest incidence due to the oral exploration phase, immature airway protective reflexes, and lack of molars, while elderly adults are at risk from poor dentition, impaired swallowing, and neurologic disease. Common objects in children include hot dogs, grapes, nuts, coins, small toy parts, and balloons (the most lethal non-food object). Common objects in adults include meat boluses, bones, dental appliances, and pills.
Anatomy and Location
The right mainstem bronchus is the most common site of distal lodgment because of its wider diameter, more vertical orientation, and shorter length. Laryngeal foreign bodies at the supraglottic, glottic, or subglottic level cause the most acute and severe obstruction. Tracheal foreign bodies may produce an audible slap, a palpable thud, and an expiratory wheeze.
Clinical Presentation
Acute complete obstruction presents with the universal choking sign of hands clutching the throat, inability to speak, cough, or breathe, rapidly progressive cyanosis, loss of consciousness, and cardiac arrest. Partial obstruction produces stridor (inspiratory if supraglottic or glottic, biphasic if subglottic or tracheal), cough (forceful cough indicates partial obstruction with adequate air exchange), wheezing (unilateral wheeze suggests a bronchial foreign body), and dysphonia or aphonia if there is laryngeal involvement. A choking episode followed by an asymptomatic interval is a classic pediatric history, but the asymptomatic phase does not mean the foreign body has been cleared. Delayed presentation days to weeks later may include recurrent pneumonia in the same lobe, persistent cough, and unilateral wheeze, often misdiagnosed as asthma or recurrent bronchitis. A high index of suspicion is warranted in children with new-onset unilateral wheeze without prior history of reactive airway disease.
<image>Anteroposterior chest radiograph of a child with right mainstem bronchus foreign body showing hyperinflation of the right lung due to ball-valve obstruction, with comparison to the normal left lung, mediastinal shift to the left on expiratory film, and annotations explaining the air-trapping mechanism</image>
Diagnosis
On chest X-ray (AP and lateral), radiopaque objects are directly visible, while radiolucent objects (the majority of food items) require indirect signs: unilateral hyperinflation from air trapping due to ball-valve effect, mediastinal shift away from the affected side (best seen on expiratory film or bilateral decubitus views in children), atelectasis from complete obstruction, and rarely pneumomediastinum or subcutaneous emphysema. Inspiratory and expiratory films, or bilateral decubitus films in children unable to cooperate, demonstrate failure of the affected side to deflate on expiration or persistent hyperinflation in the dependent position. CT airway offers higher sensitivity and is useful when clinical suspicion is high despite negative X-ray. Neck soft tissue X-ray is indicated for suspected laryngeal or hypopharyngeal foreign bodies. Rigid bronchoscopy is both diagnostic and therapeutic and is the gold standard for airway foreign body removal in children. Flexible bronchoscopy may be used for diagnosis and removal in adults.
Emergency Management
For complete obstruction in an unconscious patient, the BLS airway obstruction algorithm is initiated with CPR and chest compressions, performing direct laryngoscopy and removing any visible foreign body with Magill forceps. For infants under 1 year, 5 back blows plus 5 chest thrusts are administered, followed by direct laryngoscopy if the patient becomes unconscious. For children over 1 year and adults, abdominal thrusts (Heimlich maneuver) are used, followed by CPR if unconscious. A surgical airway via cricothyrotomy is indicated if complete obstruction above the level of the cricoid membrane persists and standard maneuvers fail, with needle cricothyrotomy used in children under 8 years.
For partial obstruction with adequate air exchange, the patient should be allowed to cough spontaneously, and abdominal thrusts or back blows should not be performed as they may convert partial to complete obstruction. Supplemental oxygen and continuous monitoring are provided while preparing for emergent airway intervention. ENT or pulmonology consultation is obtained for bronchoscopic removal. For bronchial foreign bodies, rigid bronchoscopy under general anesthesia is definitive in children, and flexible bronchoscopy with retrieval devices in adults. A post-removal chest X-ray confirms complete removal and excludes complications.
Peritonsillar Abscess (PTA)
Pathophysiology
PTA is the most common deep space head and neck infection. It results from progression of peritonsillar cellulitis, with infection spreading from the tonsil through the capsule into the peritonsillar space between the tonsillar capsule and the superior constrictor muscle. It most commonly involves the superior pole of the tonsil. The microbiology is polymicrobial, with Group A Streptococcus being the most common organism, followed by Fusobacterium necrophorum (associated with Lemierre syndrome), anaerobes, and Staphylococcus aureus.
Clinical Presentation
Patients present with severe sore throat, typically unilateral and worsening despite antibiotic therapy. Odynophagia is often severe, with difficulty managing secretions and drooling. Trismus, or difficulty opening the mouth due to inflammation of the pterygoid muscles adjacent to the peritonsillar space, is highly specific for PTA. The voice is described as "hot potato" or muffled. On examination, the uvula deviates away from the affected side, and there is a unilateral tonsillar bulge with erythema and fluctuance, with the soft palate and anterior pillar displaced medially. Fever, malaise, and cervical lymphadenopathy are present. Referred ear pain occurs through CN IX (ipsilateral otalgia).
Differential Diagnosis
Peritonsillar cellulitis is the precursor to abscess and shows diffuse peritonsillar inflammation without a discrete fluid collection; it may respond to antibiotics alone. Retropharyngeal abscess presents with midline posterior pharyngeal swelling, neck stiffness, and dysphagia, is more common in children under 4 years, and requires CT diagnosis. Parapharyngeal abscess causes lateral neck swelling with medial displacement of the tonsil and lateral pharyngeal wall, requiring CT and surgical drainage. Epiglottitis presents with drooling, stridor, and tripod positioning with supraglottic swelling on lateral neck X-ray. Infectious mononucleosis shows bilateral tonsillar hypertrophy, exudates, and splenomegaly with a positive heterophile antibody or monospot. Tonsillar malignancy presents with unilateral tonsillar enlargement and weight loss, requiring biopsy.
<image>Intraoral photograph illustration of a peritonsillar abscess showing unilateral tonsillar bulge at the superior pole, uvular deviation away from the affected side, erythematous and edematous soft palate, and annotations indicating the preferred needle aspiration site at the most fluctuant point of the abscess</image>
Diagnosis
The diagnosis is clinical in most cases, based on trismus, unilateral bulge, uvular deviation, and muffled voice. Intraoral ultrasound using an endocavitary probe placed intraorally or transcervically can identify a fluid collection and guide aspiration with sensitivity of approximately 90%. CT neck with IV contrast is indicated when clinical examination is equivocal, retropharyngeal or parapharyngeal abscess is suspected, or the patient is unable to open the mouth for adequate examination. CT findings include a rim-enhancing hypodense collection in the peritonsillar space.
Management
Drainage is the definitive treatment. Needle aspiration is the first-line procedure in the ED. After topical anesthesia with benzocaine spray or lidocaine with epinephrine injected into the mucosa, an 18-gauge needle on a 10 mL syringe is inserted at the point of maximal fluctuance, typically the superior pole of the tonsil. The depth of insertion is limited to 1 cm because the internal carotid artery lies only 2 to 2.5 cm posterolateral to the tonsil. Aspiration of purulent material confirms the diagnosis. The success rate is 85 to 95%, with 10 to 15% needing repeat aspiration. Incision and drainage is an alternative using a number 11 or 15 blade scalpel at the point of fluctuance, followed by blunt dissection with hemostats to break up loculations. Quinsy tonsillectomy, an immediate tonsillectomy during acute infection, is performed by ENT for recurrent PTA or failed drainage.
Medical therapy includes antibiotics: amoxicillin-clavulanate 875/125 mg PO twice daily covers streptococci and anaerobes, with clindamycin 300 mg PO three times daily as an alternative for penicillin allergy. IV antibiotics such as ampicillin-sulbactam 3 g IV every 6 hours are used for toxic-appearing patients or failed oral therapy. Dexamethasone 10 mg IV as a single dose reduces pain, edema, and trismus and facilitates oral intake. Analgesics include ibuprofen, acetaminophen, and viscous lidocaine gargle, though excessive sedation should be avoided in patients with potential airway compromise. IV fluid hydration is provided for patients unable to tolerate oral intake.
Complications
Airway obstruction may result from progressive abscess enlargement or rupture with aspiration. Lemierre syndrome is septic thrombophlebitis of the internal jugular vein, typically caused by Fusobacterium necrophorum, presenting with persistent fever, neck pain or swelling, and septic pulmonary emboli, requiring prolonged IV antibiotics and anticoagulation. Extension to deeper spaces including parapharyngeal, retropharyngeal, and mediastinal spread may occur. Aspiration pneumonia can result from abscess rupture.
Disposition
Discharge criteria include successful drainage, ability to tolerate oral antibiotics and fluids, no signs of airway compromise, and reliable follow-up in 24 to 48 hours. Admission criteria include airway compromise, inability to swallow, failed drainage, suspected deep space extension, immunocompromised host, and toxic appearance. ENT follow-up for consideration of interval tonsillectomy is recommended after 2 or more episodes.
<image>Anatomical cross-section at the level of the oropharynx showing the peritonsillar space between the tonsillar capsule and superior constrictor muscle, the abscess cavity, and the relationship to the internal carotid artery posterolaterally with safe needle aspiration trajectory and depth limit annotated</image>
Clinical Pearls
A witnessed choking episode followed by an asymptomatic interval in a child does not exclude airway foreign body, and a high index of suspicion should be maintained with appropriate imaging. Unilateral wheezing in a child without prior asthma history should raise immediate concern for an aspirated foreign body. The combination of trismus, unilateral tonsillar bulge, and uvular deviation equals peritonsillar abscess until proven otherwise, and needle aspiration is the first-line ED procedure. Needle depth should be limited to 1 cm during PTA aspiration because the internal carotid artery is only 2 to 2.5 cm posterolateral to the tonsil. Lemierre syndrome should be considered in any young adult with persistent fever, neck pain, and pulmonary infiltrates after a recent throat infection, prompting CT neck with contrast and blood cultures for Fusobacterium.
References
- Foltran F, et al. "Foreign Bodies in the Airways: A Meta-Analysis of Published Papers." International Journal of Pediatric Otorhinolaryngology. 2012;76(S1):S12-S19.
- Galioto NJ. "Peritonsillar Abscess." American Family Physician. 2017;95(8):501-506.
- Johnson RF, Stewart MG. "The Contemporary Approach to Diagnosis and Management of Peritonsillar Abscess." Current Opinion in Otolaryngology & Head and Neck Surgery. 2005;13(3):157-160.
- Passali D, et al. "Peritonsillar Abscess: Treatment and Complications." Clinical Practice. 2018;15(3):115-120.
