PERITONSILLAR ABSCESS (QUINSY)

Definition: A collection of pus in the peritonsillar space (between the tonsil capsule and the superior constrictor muscle).

Etiology

• Pathogenesis: Usually follows acute tonsillitis.
  Infection of Crypta Magna → Intratonsillar Abscess → Bursts through capsule → Peritonsillitis/Abscess.
• Organisms: Mixed growth (Aerobes + Anaerobes).
  • Strep. pyogenes, S. aureus.
• Demographics: Mostly Adults (Rare in children). Usually Unilateral.

Clinical Features

1. Symptoms

• General: High fever (104°F), chills, malaise (Septicaemia-like).
• Throat: Severe unilateral pain.
• Odynophagia: Extreme difficulty swallowing; saliva dribbles from mouth.
• Voice: Muffled, thick speech known as "Hot Potato Voice".
• Referred Pain: Ipsilateral earache (via CN IX).
• Trismus: Spasm of pterygoid muscles (difficulty opening mouth).
• Breath: Foul halitosis.

2. Examination Findings

• Tonsil: Congested; may appear "buried" in oedematous pillars.
• Soft Palate: Bulging of soft palate and anterior pillar above the tonsil.
• Uvula: Swollen, oedematous, and pushed to the opposite side.
• Neck: Jugulodigastric lymphadenopathy + Torticollis (neck tilted to diseased side).

Treatment

1. Medical (Conservative)

• Hospitalization & IV Fluids (for dehydration).
• Antibiotics: High dose IV (covering aerobes/anaerobes).
• Analgesics: Paracetamol/Pethidine.
  *Avoid Aspirin (risk of bleeding).
• Oral Hygiene (H2O2 mouth wash).

2. Surgical Interventions

A. Incision and Drainage (I&D)

✂ Site of Incision:
1. Point of maximum bulge.
2. Intersection of: Line through base of uvula AND Line along anterior pillar.

Technique: Stab incision with guarded knife → Sinus forceps to open abscess.

B. Tonsillectomy Options

• Interval Tonsillectomy: Done 4–6 weeks after quinsy subsides (Standard).
• Abscess ("Hot") Tonsillectomy: Immediate removal.
  *Risks: Rupture of abscess during anesthesia, Excessive bleeding.

Complications

• Parapharyngeal Abscess.
• Laryngeal Oedema (May need tracheostomy).
• Pneumonitis/Lung Abscess (Aspiration of pus).
• Jugular Vein Thrombosis.
• Secondary Haemorrhage (Carotid/Jugular).
📚 Ref: Diseases of Ear, Nose & Throat (Dhingra)