WARNING: Airway assessment is critical - may require emergency drainage if compromised
Quinsy - Diagnosis and Management
Peritonsillar abscess (PTA) usually occurs in the superior pole of the tonsil, manifested by a defined collection of pus between the tonsillar capsule, the superior pharyngeal constrictor muscle, and the palatopharyngeus muscle.
Peritonsillar infection generally is preceded by tonsillitis or pharyngitis and progresses from pharyngitis to cellulitis to abscess. Smoking appears to be a risk factor. Peritonsillar abscesses are often polymicrobial. The predominant bacterial species are Streptococcus pyogenes (group A streptococcus [GAS]), Streptococcus anginosus, Staphylococcus aureus (including methicillin-resistant S. aureus [MRSA]), and respiratory anaerobes (including Fusobacteria, Prevotella, and Veillonella species).
The typical clinical presentation of PTA is a severe sore throat (usually unilateral), fever, and a "hot potato" or muffled voice. Pooling of saliva or drooling may be present. Trismus, related to irritation and reflex spasm of the internal pterygoid muscle, occurs in nearly two-thirds of patients; it helps to distinguish PTA from severe pharyngitis or tonsillitis. Patients often have neck swelling and pain and may have ipsilateral ear pain. Fatigue, irritability, and decreased oral intake may occur as a result of discomfort.
The presence of trismus may limit the ability to perform an adequate examination. If drooling is present, suggesting the possibility of epiglottitis, care must be taken not to be aggressive during the examination of the oral cavity. Examination findings consistent with PTA include an extremely swollen and/or fluctuant tonsil with deviation of the uvula to the opposite side. Alternatively, there may be fullness or bulging of the posterior soft palate near the tonsil with palpable fluctuance. Cervical and submandibular lymphadenopathy may be present in children with PTA.
Imaging: Not necessary to make the diagnosis of PTA but may be necessary to differentiate PTA from peritonsillar cellulitis, deep neck space infections (e.g. retro- or parapharyngeal abscess), or epiglottitis.
Prompt surgical intervention is indicated in patients who present with impending airway compromise, complications, enlarging masses, or significant comorbidities (e.g. immunodeficiency). Drainage (needle aspiration or incision and drainage), antimicrobial therapy, and supportive care are the cornerstones of management for PTA. Supportive care includes provision of adequate hydration and analgesia and monitoring for complications.
Complications of PTA may include:
Rare but life-threatening complication characterized by septic thrombophlebitis of the internal jugular vein with metastatic infections (often lung abscesses). Caused by Fusobacterium necrophorum. Presents with persistent fever, neck pain/swelling, and pulmonary symptoms days to weeks after pharyngitis.