Incision and Drainage of a Peritonsillar Abscess
Some surgeons advocate aspiration with a cannula rather than incision and drainage. You should find out what your local policy is.
Make sure you explain the procedure to the patient and take consent.
Let them know that infiltrating the anaesthetic stings, but that after this, the procedure is mostly painless. Patients often feel a lot better after some pus is drained, and incision and drainage means you are sure you have hit the pocket of pus. Leaving a larger wound also allows remaining pus to drain out more readily, which can be helped by gargling.
The patient 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 heavier bleeding and reaccumulation of pus (this may be rarer with incision and drainage than with aspiration).
Incision and drainage can be easier than aspiration when the patient has moderate to severe trismus. You may still want to give initial treatment (plenty of IV fluids, analgesia etc.) to improve your view. Frequently, initial treatment like this reduces the degree of trismus.
You will need an assistant.
This page is for reference, not instruction: you should be shown how to do this before attempting it on your own.
- A head torch
- Plastic apron, non-sterile gloves and consider eye/mouth protection
- A metal Lack's tongue depressor (this gives much better control)
- Dental local anaesthetic (eg Lignospan lignocaine with adrenaline) with the fine dental needle
- Scalpel with a 15 blade
- Tilley's or artery forceps
- Suction with Yankauer and Zoellner catheters
- A wound swab
- Glass of water/mouthwash
- Sick bowls
- 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.
- Landmark: 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 where the quinsy lies. Imagine a slightly curved line centred around on this landmark, parallel to the roof of the mouth (see photo below).
- Using the head torch and tongue depressor, get a good view of the quinsy. After warning the patient about pain and stinging, gently infiltrate 1-2ml of the local anaesthetic where you intend to make your incision (make sure you inject superficially so that the mucosa blanches). Memorise your incision site (there'll be a needle mark) and leave for three or four minutes.
- While the anaesthetic is working, prepare your equipment. Warn the patient that, once you have made the incision, they will get blood and pus in their mouth. It is critically important for them not to move while you have the scalpel still in their mouth. It will take a few seconds to make the incision and then they should wait for the command to sit forwards and spit. They will feel movement/pulling but not pain.
- Carefully make a 1-1.5cm incision based on your landmark. Look for the spurt of pus from the quinsy. Remember that the mucosal wall of the quinsy is 5mm or more thick, so be careful not to make just a superficial cut. Carefully remove your scalpel and tell the patient to sit forwards and spit.
- After giving the patient time to recover, ask them to gargle (water or mouthwash).
- Once the patient is ready, re-examine the oropharynx. You can take a wound/pus swab at this stage.
- If needed, open the wound gently with a pair of forceps (Tilley's or artery) and, with suction on low, clear the cavity with the Zoellner catheter. If the mucosa is very swollen, you may need to stretch the wound very gently but warn the patient first as this can be painful.
- Ask the patient to gargle every 30min for a few hours, and after eating, to ensure the quinsy cavity is being flushed out regularly.
- Re-examine the oropharynx 12-24 hours later to ensure the abscess hasn't recollected.
- For patients whose quinsy recollects, usually it's because the mucosa is so oedematous it has swollen shut. Often, just opening and gently stretching the wound with a pair of forceps will allow more pus to escape. Continue with regular gargles.
In our experience, many patients prefer this technique because, once the anaesthetic is infiltrated, they do not feel any pain. Needle aspiration requires blind sampling in different planes, so can be more unpleasant than one short, stinging injection (this depends on the experience of the aspirator).
Many ENT juniors seem to prefer this technique because there is little doubt whether you have hit the quinsy, since you can see into the peritonsillar space. Incision and drainage does, however, require a degree of training and ENT experience/confidence so may not be as easy to learn as needle aspiration.
Page last reviewed: 23 September 2017