Peritonsillar Abscess (Quinsy)


Peritonsillar Abscess (Quinsy)

Red flags

  • Severe sore throat, hoarse/croaky voice, dysphagia and fever is epiglottitis until proven otherwise. Stridor may be a late sign and patients can decompensate rapidly.
  • Severe sore throat where you cannot see evidence of tonsillitis/pharyngitis is epiglottitis until proven otherwise.

 

Why is this important?

  1. Although rare, epiglottitis can present with sore throat as the primary symptom so it is important to have a high index of suspicion.
  2. It's important to recognise peritonsillar abscesses as they usually need aspiration.
  3. If left untreated for a while, peritonsillar abscesses may spread, resulting in deep neck space infections (para- and retropharyngeal abscesses), which are an airway emergency.

 

When to involve the ENT Registrar

Immediately: If you suspect that you may be dealing with epiglottitis or a deep neck space infection, see stridor for immediate management.

Soon: You should inform your senior if you think there may be any sort of pharyngeal airway compromise eg stertor from a large peritonsillar abscess.

 

Who to admit 

  • A good principle: admit anyone unable to swallow at least a few sips of fluid regularly
  • Patients with a peritonsillar abscess (if they can swallow good amounts after aspiration it would be reasonable to discharge after some intravenous antibiotics and a few hours' observation)

 

Assessment and recognition

  Photo A. Tonsillitis for comparison: note the asterisks over the peritonsillar space, where an abscess would collect.

 

Photo A. Tonsillitis for comparison: note the asterisks over the peritonsillar space, where an abscess would collect.

There will be signs and symptoms of a general malaise and sore throat. 'Good' symptoms for peritonsillar abscess include: 

  Photo B: Right peritonsillitis/peritonsillar cellulitis. Notice that a) there is no trismus; b) there is erythema of the right anterior arch and palate; c) the right anterior arch is pushed medially but there is still a reasonable view of the right tonsil; d) there is no swelling or convexity of the palate. Compare the photo below.

 

Photo B: Right peritonsillitis/peritonsillar cellulitis. Notice that a) there is no trismus; b) there is erythema of the right anterior arch and palate; c) the right anterior arch is pushed medially but there is still a reasonable view of the right tonsil; d) there is no swelling or convexity of the palate. Compare the photo below.

  • 'Thick' or 'hot potato' voice (not hoarse, croaky voice)
  • Stertor
  • Trismus
  • Inability to swallow more than saliva or a sip or water
  • Pain much worse on one side than the other (+/- otalgia)
  Photo C: Right peritonsillar abscess.. Notice that a) there is moderate trismus; b) the right anterior arch is being pushed medially; c) the uvula is very obviously deviated to the left (the midline is in the middle of the tongue depressor - note where the upper incisors are); d) there is a convex swelling of the palate. 

 

Photo C: Right peritonsillar abscess.. Notice that a) there is moderate trismus; b) the right anterior arch is being pushed medially; c) the uvula is very obviously deviated to the left (the midline is in the middle of the tongue depressor - note where the upper incisors are); d) there is a convex swelling of the palate. 

To differentiate it from tonsillitis, a peritonsillar abscess will have many of the following signs:

  Photo D. Annotation to help visualisation of the location of the abscess in the peritonsillar space.

 

Photo D. Annotation to help visualisation of the location of the abscess in the peritonsillar space.

  • There is usually a degree of trismus
  • On the affected side, the anterior arch will be pushed medially 
  • On the affected side, the palate will bulge towards you ie the normally concave palate becomes convex
  • The uvula may or may not be pushed away from the affected side
  • On the affected side, the mucosa of the arch and palate may look angrily erythematous

A swollen tonsil is NOT a peritonsillar abscess; a swollen tonsil is a swollen tonsil

A peritonsillar abscess collects in the peritonsillar space, lateral to the tonsil - see photos below. 

When there is less pronounced swelling, it may be that there is peritonsillar cellulitis (an 'early quinsy'), as in photo B. On aspiration, no pus is forthcoming. These people would still be managed as per peritonsillar abscess. 

If photos B and C look similar, that is because the two conditions represent part of a spectrum from peritonsillar celllulitis through to formation of a peritonsillar abscess. It is more important to be able to distinguish tonsillitis from peritonsillar abscess/cellulitis 

 

Immediate and overnight management

Abscesses need aspiration and, if trismus is not too much of a problem, early aspiration brings significant relief.

If you cannot be sure whether there is a peritonsillar abscess or just cellulitis, it would be prudent to get a second opinion and, if still unsure, to aspirate the possible abscess, given the potential benefits. Just be honest with the patient - most are desperate to get better.

It may be difficult to examine the mouth if there is significant trismus. In this case, it's reasonable to admit the patient, give them some IV medication and re-examine later. The initial treatment can improve your view. 

Assess patients with 'thick' or 'hot potato' voices and increased nighttime snoring for stertor, the snoring sound of pharyngeal obstruction. Those with stertor should be admitted.

A good starting point when admitting patients:

  • IV access
  • FBC, U&Es, glandular fever screen
  • Regular basic IV/PO analgesia eg paracetamol with stronger PRNs
  • Topical analgesic spray eg Difflam
  • Active fluid resuscitation - the vast majority of patients are young and dehydrated and perk up after fluid
  • Some surgeons prescribe a single dose of steroid (eg 4-8mg dexamethasone IV) to kick-start recovery, especially in those who have stertor
  • Advise those with increased snoring or stertor to sleep semi-upright

 

Further management

Arrange follow-up for any patients aged over 50 with a peritonsillar abscess. There may be an underlying pathology (see Fort et al below).

Tonsillitis and peritonsillar abscess can disrupt school and working life significantly. In the UK, something like 35 million days are lost annually to sore throats (ENT UK 2009). Here are some consensus statements for offering tonsillectomy: 

 

References

ENT UK Position Paper on Tonsillectomy (2009)

Scottish Intercollegiate Guidelines Network (SIGN) Indications for Tonsillectomy (2010)

Fort et al, Am J Emerg Med 2013 

 

 

 

 

 

 

Page last reviewed: 23 September 2016