Peritonsillar abscess (quinsy) 

Epidemiology

• Occurs mainly in young adults: 20- 40s
• Most common deep space neck infection

Pathophysiology

• In most textbooks, it is taught that PTA is the end-point on the pharyngitis continuum where bacterial pharyngitis progress to tonsillitis developing into peritonsillar cellulitis then ultimately abscess formation.
• Controversy: no real evidence to support the above proposed mechanism and there exist various inconsistencies in the above process
  • Peak incidence of acute pharyngitis occurs ages 5-15
  • peak incidence of PTA ages 20-40
  • If they are on the same spectrum, there should be an age overlap.
  • Both acute pharyngitis and PTA have peak symptoms at 3-5 days.
  • If PTA is a complication from the progression of acute pharyngitis, it would make sense that there is a time lag between the peak onset of pharyngitis and PTA.

Symptoms

• Drooling
• Fever
• Sore throat
• Dysphonia
• Dysphagia
• Odynophagia
• Otalgia

Physical Exam Findings

• Abscess collection at superior pole of tonsils/ Unilateral swelling of tonsil
• Edematous uvula that deviates towards the normal tonsil
• Erythematous elevated soft palate
• Patient can appear uncomfortable
• Muffled/hot-potato voice
• Trismus (Suspect deeper neck infection if trismus persist after sufficient pain management.)
• Cervical lymphadenopathy

Clinical features associated with airway obstruction or deep neck space infection

• muffled voice
• stertor (snoring-type sound)
• stridor
• trismus
• drooling
• neck swelling
• torticollis
• severe neck pain
• unilateral throat pain
• respiratory distress
• signs of sepsis or septic shock

Conditions associated with airway obstruction or deep neck space infection

• acute epiglottitis
• peritonsillar abscess (quinsy) and peritonsillar cellulitis
• retropharyngeal abscess
• parapharyngeal abscess
• pharyngeal diphtheria
• severe Epstein–Barr virus (EBV) infection
• severe croup or bacterial tracheitis
• spreading odontogenic infections (including Ludwig angina)
• septic jugular thrombophlebitis (part of Lemierre syndrome).

• Ultrasound Diagnosis
  • Ultrasound significantly increases the sensitivity and specificity of diagnosis. 
  • can also identify the location of the carotid artery, which lies only 5-25mm posteriorly and laterally. 
• CT Scans
  • has 100% sensitivity for diagnosis of PTA, it should not be a routine test.
    • There is a significant amount of radiation involved
  • CT scan should be considered in patients where alternate diagnoses are suspected (retropharyngeal abscess, Lemierre’s syndrome etc).

Initial Management: 

• begins with A.B.Cs (airway, breathing, circulation). 

Abscess drainage

• Needle aspiration vs. I&D vs. Quinsy Tonsillectomy
• No statistical difference in drainage success and time to return to normal diet (Johnson 2003)
• Needle aspiration of preferred technique in ED because of decreased pain (in comparison to I&D) and necessity of hospitalization (in quinsy tonsillectomy)

Antibiotics

• benzylpenicillin 1.2 g (child: 50 mg/kg up to 1.2 g) intravenously, 6-hourly
  • For patients hypersensitive to penicillins, use:
• clindamycin 600 mg (child: 15 mg/kg up to 600 mg) intravenously, 8-hourly; 

         OR

• lincomycin 600 mg (child: 15 mg/kg up to 600 mg) intravenously, 8-hourly     

continue intravenous therapy for 1 to 2 days following successful abscess drainage, then switch oral therapy

Antibiotics should cover both for GAS (gram positive) as well as Fusobacterium (anaerobic)

No statistical difference found between IV and PO antibiotics in the treatment of PTA in morbidity, recovery time as well as recurrence rate (Powell 2012)

Steroids

• Steroids decrease time to tolerating PO and decrease pain scores in first 24 hours (Chau 2014)
• Unclear which steroid is better. The only 2 clinical trials on steroids given in context of PTA used different medications but both were single dose IV steroids; one used IV methylprednisolone (2-3mg/kg up to 230mg) and the other used IV dexamethasone (10mg)

Take Home Points

• Use ultrasound to help with diagnosis and identify abscess in relationship to carotid artery
• Use advanced imaging (CT) in patients who have severe symptoms or are toxic appearing
• After needle aspiration (or I&D) treat patients with 10 days of antibiotics