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PeritonsillarAbscess.InformationaboutQuinsy.|Patient

PeritonsillarAbscess
PatientPlus articles are written by UK doctors and are based on research evidence, UK and European Guidelines.
They are designed for health professionals to use, so you may find the language more technical than the condition
leaflets.
Seealso:Antibioticswrittenforpatients
Synonym: quinsy
Peritonsillar abscess is a complication of acute tonsillitis. Tonsillitis is inflammation of the pharyngeal tonsils (see
separate article Tonsillitis).[1] In peritonsillar abscess, there is pus trapped between the tonsillar capsule and the lateral
pharyngeal wall.[2]

Pathophysiology
It usually starts with acute follicular tonsillitis, progresses to peritonsillitis and results in formation of a peritonsillar
abscess. It can arise without previous tonsillitis.
An alternative theory suggests involvement of the Weber glands.[3] These are a group of salivary glands, immediately
above the tonsillar area in the soft palate. They are thought to play a minor role in clearing any trapped debris from
the tonsillar area. Tissue necrosis and formation of pus produce an abscess between the tonsillar capsule, lateral
pharyngeal wall and supratonsillar space. There is scarring and obstruction of the ducts that drain the glands. They
swell and progress to abscess formation.

Epidemiology
Tonsillitisispredominantlyadiseaseofchildren.Peritonsillarabscessusuallyaffectsteenagersandyoungadultsbut
canoccurinyoungerchildren.[2]Thispicturemay,however,bechanging.OneIsraelistudyfoundadistinctcohortof
peopleover40sufferingfromperitonsillarabscesswhohadmoreseveresymptomsandamoreprolongedcourse.
Tonsillitiswasnotalwaysaprecursortotheconditionoritsometimesoccurreddespiteprioradequateantibiotic
therapy.Smokingwasthoughttobeariskfactor.[4]
ItismostcommoninNovembertoDecemberandApriltoMay,coincidingwiththehighestincidenceofstreptococcal
pharyngitisandexudativetonsillitis.[2]

Causativeorganisms[5]
Culturenearlyalwaysshowsamixedflora.Mostcommonorganismsinclude:
Streptococcuspyogenes(usuallythepredominantorganism).
Staphylococcusaureus.
Haemophilusinfluenzae.
AnaerobicorganismsincludingPrevotellaspp.,Porphyromonasspp.,Fusobacteriumspp.andPeptostreptococcus
spp.
Peritonsillarabscesscanalsobeacomplicationofinfectiousmononucleosis.[6]

History
Severethroatpainwhichmaybecomeunilateral.
Fever.
Droolingofsaliva.
Foulsmellingbreath.
Swallowingmaybepainful.
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Trismus(difficultyopeningthemouth).
Alteredvoicequality('hotpotatovoice')duetopharyngealoedemaandtrismus.
Earacheontheaffectedside.
Neckstiffnesssymptoms.
Headacheandgeneralmalaise.

Examination
Examinationmaybedifficultastrismusmaymakeitdifficulttoopenthemouthinuptotwothirdsofcases.
Breathisfetid.
Theremaybedroolingandsalivation.
Lookforatemperature.
Tender,enlargedipsilateralcervicallymphnodes.
Torticollismaybepresent.
Thereisunilateralbulging,usuallyaboveandlateraltooneofthetonsilsoccasionallythebulgingisinferiorly.
Thereismedialoranteriorshiftoftheaffectedtonsilandthetonsilmaybeerythematous,enlargedandcoveredin
exudate.
Theuvulaisdisplacedawayfromthelesion.
Examineforsignsofdehydration.
Compromiseoftheairwayisrare.
Spontaneousruptureoftheabscessintothepharynxcan(rarely)occurandcanleadtoaspiration.[7]
Apatientwithasuspectedperitonsillarabscessshouldbereferredtoanear,noseandthroat(ENT)specialistthatday.[8]

Investigations
Thediagnosisisclinical.
CTscanningisnotgenerallyneededbutmaybeusedinatypicalpresentationssuchasaninferiorpoleabscess,orif
thepatientishighriskforadrainageprocedure(eg,ableedingdisorder).Itmayalsobehelpfultoguidedrainagein
difficultcases.
Onestudyofacaseofperitonsillarabscesswithuvularhydropsreportedthatultrasoundwasahelpfulinvestigation.[9]
Evidencesupportingtheuseofscreeningforinfectiousmononucleosisisequivocal.Onestudyfoundthatonly4%of
quinsypatientstestedpositiveforinfectiousmononucleosis,allofthemundertheageof30.

Management
Medical
Intravenousfluidsmayberequiredtocorrectdehydration.
Analgesiashouldbeprescribed.
Intravenousantibioticsgivehigherbloodlevelsthanoraltherapyandareusuallyused.
Penicillin,cephalosporins,amoxicillin+clavulanicacidandclindamycinareallappropriateantibiotics.[5]Metronidazole
pluspenicillinmaybehelpfulinselectedcases.[10]
Intravenousimmunoglobulinsaresometimesusedinrarecases(eg,inassociationwithS.pyogenesinfection).[11]
Studieshavealsoshownthattheuseofsingledoseintravenoussteroidsaswellasantibioticsmaybebeneficial.
[12]Theymayhelptoreducesymptomsandtospeedrecovery. [2]
Onestudyreportedthesuccessfuluseofintravenousantibioticsandsteroids.[13]

Surgical
Antibioticsalonearenotusuallysufficientastreatment.Changesinthemicrobiologyofthecausativeorganismsand
theirresistancehasresultedinsurgerybeingthepreferredoptioninmostcases.[14]
Needleaspiration,incisionanddrainageandquinsytonsillectomyareallconsideredacceptableforthesurgical
managementofacuteperitonsillarabscess.Anevidencebasedreviewfailedtodifferentiatebetweenthemintermsof
effectivenessandrecurrencerates.[15]
Ultrasoundguidedaspirationisoccasionallyusedifsurgeryisunsuccessfulortheabscessisinalocationthatis
difficulttoreach.[16]
Intervaltonsillectomyisusuallycarriedoutifthereisabackgroundofchronicorrecurrenttonsillitis.
Somesurgeonsadvocateacute(immediate)tonsillectomyasatreatmentforperitonsillarabscess.Acaseseries
reviewfoundnosignificantdifferencesintotalhospitaldays,bloodloss,operativetime,orpostoperativecomplications
betweenimmediatetonsillectomyandintervaltonsillectomyinthetreatmentofpaediatricperitonsillarabscess.[17]
TonsillectomyisdiscussedinmoredetailintheseparatearticleTonsillitis.

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Complications
Theabscesscanspreadtothedeepernecktissuesandcanresultinnecrotisingfasciitis.[18]Infectioncanspreadfrom
theparapharyngealspacethroughtheanatomicalplanestocausemediastinitis,pericarditisandpleuraleffusions.[19]
Airwaycompromiseisrare.
Recurrenceofperitonsillarabscesscanoccur.
Haemorrhagemayfollowtonsillectomy.
Deathcanoccurfromaspiration,airwayobstruction,erosionintomajorbloodvesselsorextensiontothemediastinum.
[7]

Prognosis
Therateofrecurrenceispoorlydefinedbutisaround922%.[20]
Recurrencecanfollowtonsillectomybutisrare.[21]

Prevention
ACochranereviewfoundthatthebenefitsoftreatingsorethroatswithantibioticswasmoderateandthatmany
patientswouldneedtobetreatedtopreventonecaseofquinsy.[22]Thenumberneededtotreat(NNT)wasestimated
byaCanadianstudyasbeingabout30.[23]
Afallof50%intheprescribingofantibioticstochildreninEnglishgeneralpracticehasnotbeenaccompaniedbyan
increaseinhospitaladmissionsforperitonsillarabscess.[24]
TheguidanceregardingantibioticsandsorethroatisfurtherdiscussedintheseparatearticlesSoreThroatand
Tonsillitis.
ProvideFeedback

Furtherreading&references
1.SidellD,ShapiroNLAcutetonsillitis.InfectDisordDrugTargets.2012Aug12(4):2716.
2.GaliotoNJPeritonsillarabscess.AmFamPhysician.2008Jan1577(2):199202.
3.KordelukS,NovackL,PutermanM,etalRelationbetweenperitonsillarinfectionandacutetonsillitis:mythorreality?
OtolaryngolHeadNeckSurg.2011Dec145(6):9405.doi:10.1177/0194599811415802.Epub2011Aug2.
4.MaromT,CinamonU,ItskovizD,etalChangingtrendsofperitonsillarabscess.AmJOtolaryngol.2010May
Jun31(3):1627.Epub2009Apr23.
5.ZautnerAE,KrauseM,StropahlG,etalIntracellularpersistingStaphylococcusaureusisthemajorpathogenin
recurrenttonsillitis.PLoSOne.2010Mar15(3):e9452.doi:10.1371/journal.pone.0009452.
6.RyanC,DuttaC,SimoRRoleofscreeningforinfectiousmononucleosisinpatientsadmittedwithisolated,unilateral
peritonsillarabscess.JLaryngolOtol.2004May118(5):3625.
7.BrookIMicrobiologyandmanagementofperitonsillar,retropharyngeal,andparapharyngealabscesses.JOral
MaxillofacSurg.2004Dec62(12):154550.
8.SorethroatacuteNICECKS,October2012(UKaccessonly)
9.MillsLD,MayK,MihlonFPeritonsillarabscesswithuvularhydrops.WestJEmergMed.2010Feb11(1):835.
10.RepanosC,MukherjeeP,AlwahabYRoleofmicrobiologicalstudiesinmanagementofperitonsillarabscess.J
LaryngolOtol.2009Aug123(8):8779.doi:10.1017/S0022215108004106.Epub2008Dec4.
11.WongSetalEmergingMicrobesandInfections,Nature.com,2012
12.ChauJK,SeikalyHR,HarrisJR,etalCorticosteroidsinperitonsillarabscesstreatment:ablindedplacebocontrolled
clinicaltrial.Laryngoscope.2014Jan124(1):97103.doi:10.1002/lary.24283.Epub2013Jul9.
13.PelazAC,AllendeAV,LlorentePendasJL,etalConservativetreatmentofretropharyngealandparapharyngeal
abscessinchildren.JCraniofacSurg.2009Jul20(4):117881.
14.SowerbyLJ,HussainZ,HuseinMTheepidemiology,antibioticresistanceandpostdischargecourseofperitonsillar
abscessesinLondon,Ontario.JOtolaryngolHeadNeckSurg.2013Jan3142:5.doi:10.1186/19160216425.
15.LinYY,LeeJCBilateralperitonsillarabscessescomplicatingacutetonsillitis.CMAJ.2011Aug9183(11):12769.doi:
10.1503/cmaj.100066.Epub2011May16.
16.CostantinoTG,SatzWA,DehnkampW,etalRandomizedtrialcomparingintraoralultrasoundtolandmarkbased
needleaspirationinpatientswithsuspectedperitonsillarabscess.AcadEmergMed.2012Jun19(6):62631.doi:
10.1111/j.15532712.2012.01380.x.
17.SimonLM,MatijasecJW,PerryAP,etalPediatricperitonsillarabscess:Quinsyieversusintervaltonsillectomy.IntJ
PediatrOtorhinolaryngol.2013Aug77(8):13558.doi:10.1016/j.ijporl.2013.05.034.Epub2013Jun28.
18.LosanoffJE,MissavageAENeglectedperitonsillarabscessresultinginnecrotizingsofttissueinfectionoftheneck
andchestwall.IntJClinPract.2005Dec59(12):14768.
19.CollinJ,BeasleyNTonsillitistomediastinitis.JLaryngolOtol.2006Nov120(11):9636.Epub2006Jul6.
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20.PowellJ,WilsonJAAnevidencebasedreviewofperitonsillarabscess.ClinOtolaryngol.2012Apr37(2):13645.doi:
10.1111/j.17494486.2012.02452.x.
21.FarmerSE,KhatwaMA,ZeitounHMPeritonsillarabscessaftertonsillectomy:areviewoftheliterature.AnnRColl
SurgEngl.2011Jul93(5):3535.doi:10.1308/003588411X579793.
22.SpinksA,GlasziouPP,DelMarCBAntibioticsforsorethroat.CochraneDatabaseSystRev.2013Nov
511:CD000023.
23.WorrallGAcutesorethroat.CanFamPhysician.2011Jul57(7):7914.
24.SharlandM,KendallH,YeatesD,etalAntibioticprescribingingeneralpracticeandhospitaladmissionsfor
peritonsillarabscess,mastoiditis,andrheumaticfeverinchildren:timetrendanalysis.BMJ.2005Aug
6331(7512):3289.Epub2005Jun20.
Disclaimer:This article is for information only and should not be used for the diagnosis or treatment of medical
conditions. EMIS has used all reasonable care in compiling the information but make no warranty as to its accuracy.
Consult a doctor or other health care professional for diagnosis and treatment of medical conditions. For details see
our conditions.
OriginalAuthor:
DrMichelleWright

CurrentVersion:
DrLaurenceKnott

PeerReviewer:
DrHelenHuins

DocumentID:
2600(v22)

LastChecked:
16/10/2014

NextReview:
15/10/2019

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