Aspiration of a Peritonsillar Abscess

Some surgeons advocate incision and drainage with a small blade rather than aspiration.  This practice is becoming less common for various reasons, but is highly effective.

Before attempting aspiration make sure you explain the procedure to the patient and take consent.  Let them know that aspiration is uncomfortable, but that patients often feel a lot better after some pus is drained. They must be able to keep still and to keep their mouth open as wide as possible for a short time (seconds). They should expect some bleeding and for the pus to drop into their throat and mouth. The main risks are of more bleeding and reaccumulation of pus.

Aspiration can be difficult when the patient has moderate to severe trismus. In these circumstances, we suggest administering IV fluids, steroid and both IV and topical analgesia before reassessing. Frequently, initial treatment reduces the degree of trismus.

This page is for reference, not instruction: you should be shown how to do this before attempting it on your own. 

EQUIPMENT

• A head torch

• Plastic apron, non-sterile gloves and consider eye/mouth protection

• A metal Lack's tongue depressor (this gives much better control than a wooden tongue depressor)

• Xylocaine (Lidocaine) topical spray

• 10ml syringe

• The largest bore needle/cannula you can find eg 16G

• Sterile specimen pot (for MC&S)

• Glass of water

• Sick bowls

• Tissues

PROCEDURE

• Position your patient sitting upright, at a good height for you to work (you shouldn't have to stoop). They should rest their head back with their neck slightly extended, and with the couch/pillow as support.

• Using the head torch and tongue depressor, visualise the quinsy and give two or three sprays of Xylocaine. Warn the patient that the spray can make them gag; ask them to keep it in their throat without swallowing for as long as possible.

• While the Xylocaine is working, prepare your equipment and the sterile pot.

• One suggested method is to remove all the parts of a cannula, including both white and clear plastic tips, leaving just the needle. Attach this to the 10ml syringe. Some surgeons cut the tip off the needle sheath and then replace it over the needle, creating a guard. Be careful if you do this as it is easy to catch your finger on the needle.

• The above method is becoming more difficult with the proliferation of "safety" cannulas. An alternative is to use a large-bore hypodermic needle with some tape wrapped around it, to reduce the insertable length.

• A commonly taught landmark for aspiration: trace a line superiorly from the medial surface of the molars until it meets with a line traced horizontally from the base of the uvula. This is aspiration point one. Insert your needle, angling very slightly laterally and aspirating continuously. Withdraw the needle when no more pus is forthcoming.

• If you get little or no pus, then you can identify further aspiration points (two and three). Ask the patient if they are happy for you to try again. Point two is 8-10mm superomedially to point one, towards the base of the uvula; point three is 8-10mm inferolaterally, towards the molars.

• NB Aspiration points are more lateral than you would initially guess on looking in the mouth. The internal carotid artery is lateral and, although the wall of the quinsy is thick, you should be mindful of this.

• Ask the patient to rinse their mouth and spit out. Expect some bleeding.

• Send pus in the specimen pot for microbiological analysis.

• Re-examine the oropharynx after the patient has had a rest.

• Re-examine the oropharynx 12-24 hours later to ensure the abscess hasn't recollected.

• For patients whose quinsy recollects, consider incision and drainage: ask someone to show you how. Usually, a size 15 blade is used. Some surgeons wind tape around the base as a guard. An short incision is made in the plane of the three points described above.

Page last reviewed: 5 May 2020