Peritonsillar Abscess (Quinsy)

Peritonsillar abscess is a complication of acute tonsillitis, where a collection of pus forms in the peritonsillar space.  This pushes the affected tonsil inferomedially into the oropharyngeal space.

 

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.
  • Rarely patients with quinsy can present with profound sepsis.

 

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, 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 e.g. 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 can be discharged after drainage, some intravenous antibiotics and a few hours' observation if they are well and able to swallow

 

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.

Typical 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.

  • Sore throat, often much worse on one side than the other (+/- otalgia)
  • 'Thick' or 'hot potato' voice (not hoarse, croaky voice)
  • Stertor
  • Trismus
  • Inability to swallow more than saliva or a sip or water
     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. 

The key signs that differentiate quinsy from tonsillitis are:

    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 be pushed away from the affected side
  • On the affected side, the mucosa of the arch and palate may look angrily erythematous

An asymmetrically swollen tonsil is NOT a peritonsillar abscess.

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 and discharged if they improve clinically. 

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 or I&D and, if trismus is not too much of a problem, early intervention 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 that there is a possibility of a "dry tap" - most are desperate to get better.

It may be difficult to examine the mouth if there is significant trismus. In this case, admit the patient, give them some IV treatment (see below) and re-examine later. The initial treatment can improve your view. 

A good starting point when admitting patients:

  • IV access
  • FBC, U&Es, LFTs, glandular fever screen
  • Regular basic IV/PO analgesia e.g. paracetamol and ibuprofen, with stronger PRNs
  • Topical analgesic spray e.g. benzydamine spray
  • Fluid resuscitation - the vast majority of patients are young and dehydrated, and perk up after 1L of normal saline
  • Some surgeons prescribe a single dose of steroid (eg 6.6mg 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).

Recurrent tonsillitis can disrupt school and working life significantly. In the UK, something like 35 million days are lost annually to sore throats (ENT UK 2009).  A history of quinsy is usually felt to be a reasonable indication for elective tonsillectomy.  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: 29 July 2018