Peritonsillar abscess

Not to be confused with Tonsillitis.

Peritonsillar abscess
Right sided peritonsillar abscess
Classification and external resources
Specialty	Otorhinolaryngology
ICD-10	J36
ICD-9-CM	475
DiseasesDB	11141
MedlinePlus	000986
eMedicine	emerg/417
Patient UK	Peritonsillar abscess
MeSH	D000039

Peritonsillar abscess (PTA), also known as a quinsy or quinsey, is a recognized complication of tonsillitis and consists of a collection of pus beside the tonsil in what is referred to as peritonsillar space (peri—meaning surrounding). It is a commonly encountered otorhinolaryngological (ENT) emergency.

Signs and symptoms

Unlike tonsillitis, which is more common in the pediatric age group, PTA has a more even age spread, from children to adults. Symptoms start appearing two to eight days before the formation of an abscess. A progressively severe sore throat on one side and pain during swallowing (odynophagia) usually are the earliest symptoms. As the abscess develops, persistent pain in the peritonsillar area, fever, a general sense of feeling unwell, headache and a distortion of vowels informally known as "hot potato voice" may appear. Neck pain associated with tender, swollen lymph nodes, referred ear pain and foul breath are also common. While these signs may be present in tonsillitis itself, a PTA should be specifically considered if there is limited ability to open the mouth (trismus).

Physical signs of a peritonsillar abscess include redness and swelling in the tonsillar area of the affected side and swelling of the jugulodigastric lymph nodes. The uvula may be displaced towards the unaffected side.

Causes

PTA usually arises as a complication of an untreated or partially treated episode of acute tonsillitis. The infection, in these cases, spreads to the peritonsillar area (peritonsillitis). This region comprises loose connective tissue and is hence susceptible to formation of an abscess. PTA can also occur de novo. Both aerobic and anaerobic bacteria can be causative. Commonly involved aerobic pathogens include Streptococcus, Staphylococcus and Haemophilus. The most common anaerobic species include Fusobacterium necrophorum, Peptostreptococcus, Prevotella species, and Bacteroides.

Treatment

Treatment is surgical incision and drainage of the pus, thereby relieving the pain of the pressed tissues. Antibiotics are also given to treat the infection. Internationally, the infection is frequently penicillin resistant, so it is now common to treat with clindamycin or metronidazole in combination with benzylpenicillin (penicillin G). Treatment can also be given while a patient is under anesthesia, but this is usually reserved for children or anxious patients. Tonsillectomy can be indicated if a patient has recurring peritonsillar abscesses or a history of tonsillitis. For patients with their first peritonsillar abscess most ENT-surgeons prefer to "wait and observe" before recommending tonsillectomy.

Complications

• Retropharyngeal abscess
• Extension of abscess in other deep neck spaces leading to airway compromise; see Ludwig's angina
• Sepsis
• Glomerulonephritis and rheumatic fever (strep throat chronic complications)
• Decreased oral intake and dehydration

Epidemiology

The incidence of peritonsillar abscess in the United States has been estimated approximately at 30 cases per 100,000 people per year. In a study in Northern Ireland, the incidence was 10 cases per 100,000 people per year. In Denmark, the incidence is higher and reaches 41 cases per 100,000 people per year. Younger children who develop a peritonsillar abscess are often immunocompromised and in them, the infection can cause significant airway obstruction.

Etymology

The condition is often referred to as "quincy", "quinsy", or "quinsey", anglicised versions of the French word esquinancie which was originally rendered as squinsey and subsequently quinsy.

Notable cases

• Sultan Tekish of Kwarezm
• Osceola
• Michel de Montaigne
• Pope Adrian IV
• George Washington was believed to have died of complications arising from quinsy, but is now thought to have died from epiglottitis.
• James Gregory of the band The Ordinary Boys almost died from quinsy because it was left untreated for so long before emergency treatment was started.
• Eiichiro Oda, author of the best-selling One Piece manga, was hospitalized due to complications.
• Ian Maclaren died of complications from quinsy while on a lecture tour of the United States.

External links

• Otolaryngology Houston (Pictures of Peritonsillar Abscess)
• Definition Cause Diagnosis And Treatment Of Peritonsillar Abscess