A collection of pus in the peritonsillar space which is between the capsule of the tonsil and the superior constrictor muscle.
Peritonsillar abscess is the most common deep infection of the head and neck that occurs in adults. It originates in the peritonsillar tissues as Peritonsillitis and culminates into Peritonsillar abscess.
Quinsy(used earlier)- The Latin word is cynanchia, and the Greek word kunanché, from kuon anche-dog strangulation, because persons suffering from quinsy throw open the mouth like dogs, especially mad dogs.

Aetiology

Age-PTA most commonly occurs in the third and fourth decades of life. Pediatric cases are more common in children older than 10 years, although cases have been described in children younger than 1 year.

Sex-More in males.

Recurrent tonsillitis acts as a predisposing factor(30%of cases)

Foreign body embedded in the tonsil may also lead to quinsy.

Causative organisms-Bacterial growth is often polymicrobial, including aerobic and anaerobic bacteria of oral flora origin. The aerobic ones include Group A beta-hemolytic Streptococcus pyogenes, Staphylococcus aureus, Streptococcus pneumoniae,etc and anaerobic ones include Prevotella, Porphyromonas, Fusobacterium species, Bacteroides species, Peptostreptococcus species, etc; isolates can be beta-lactamase producers.

Pathophysiology

Two mechanisms have been proposed to explain the development of a PTA:

As a result of recurrent attacks of tonsillitis,the mouth of a tonsillar crypt,usually the crypta magna, becomes fibrosed. With any fresh attack of infection, due to oedema and fibrotic stenosis, the mouth of the crypt completely closes. Instead of draining into the oral cavity, the pus breaks through the capsule of the tonsil and leads to peritonsillar cellulitis which develops into a peritonsillar abscess.

An alternative explanation is that PTA is an abscess formed in a group of salivary glands in the supratonsillar fossa, known as Weber glands.

Symptoms

Constitutional symptoms-Include fever, chills and rigors, malaise, body aches, headache, nausea, etc

Local-

Severe pain in the throat-usually unilateral.

Odynophagia.

Dribbling of saliva from the angle of the mouth.

4) Muffled and thick speech- “Hot Potato Voice”(Secondary to dysfunction of the palatal muscles on the affected side, resulting in velopharyngeal insufficiency)

5) Halitosis due to sepsis and poor hygiene.

6) Ipsilateral earache-Referred pain via CN IX.

7) Trismus-spasm of pterygoid muscles which are in close proximity to the superior constrictor.

Signs

The tonsil, pillars and soft palate on the involved side are congested and swollen. The tonsil may be pushed downwards and medially by the abscess.

Uvula is swollen and oedematous and pushed to the opposite side.

Mucopus may be seen covering the tonsillar region.

Cervical lymphadenopathy is commonly seen. This involves the jugulodigastric group of lymph nodes.

Torticollis-Patient keeps the neck tilted to the side of the abscess.
Diagnosis-

A thorough history and physical examination
can often determine a diagnosis of peritonsillar
abscess, but radiological tests may be helpful
in differentiating PTA from other conditions.
-Culture and sensitivity for aerobic and anaerobic
bacteria of purulent material from needle aspiration may be performed.
-CT with intravenous contrast-An abscess appears as a low-attenuation mass with a ring-enhancing wall. Presence of only soft tissue swelling and edema (but no mass) is consistent with peritonsillitis.
-Ultrasonography-The intraoral approach is more accurate than the transcutaneous approach. An abscess usually has an isoechoic rim with a hypoechoic center; however, some abscesses have a homogeneous isoechoic pattern.

Complications

Parapharyngeal abscess

Oedema of the larynx-Tracheostomy may be required.

Septicaemia-Complications like endocarditis,nephritis and brain abscess may occur.

Pneumonitis or lung abscess due to aspiration of pus.

Jugular vein thrombosis

Spontaneous haemorrhage from carotid artery or jugular vein.

Management

Conservative

Intravenous fluids to combat dehydration

Antibiotics-Commonly used drugs are broad spectrum penicillins like ampicillin / amoxycillin, in addition to which metronidazole or clindamycin can be combined to take care of anaerobes.

Analgesics like paracetamol is given for relief of pain and to lower the temperature. Sometimes, stronger analgesics like pethidine may be required.

Oral hygiene should be maintained by hydrogen peroxide or saline mouth washes.

B)Surgical

4 main methods:
Needle aspiration of pus
Incision and drainage
Interval tonsillectomy(4-6 weeks following an attack)
Abscess tonsillectomy(either unilateral or bilateral)

Needle aspiration of pus
Steps involved are:
Position the patient: sitting upright, eye to eye with operator, with good light (headlight or mirror with lightsource behind patient)
Explain what you’re going to do and obtain consent
Palpate the soft palate to determine the fluctuant area. This is the aspiration site. This is usually superior to the tonsil.
Spray 4% lidocaine topical on the aspiration site
Inject a small amount-0.5 cc or so-of local anesthetic at the aspiration site. Best to use a small gauge (25, 27) long needle.
Prepare the aspirating syringe:
Use about a 10 cc syringe
Needle: can use a long 18 gauge needle, an 18 gauge spinal needle, or the trocar from inside a long IV catheter
Can use a steristrip to mark one centimeter from tip of needle to prevent yourself from going too deep (don’t forget there’s a carotid artery in there!)
Incision and drainage

Once an abscess forms I&D are essential.
Anaesthesia:
Local anaesthetic agent like 4%Lignocaine is sprayed
on the area to be incised.
General anaesthesia may be required in an
uncooperative child(with cuffed endotracheal tube)
Site of incision
The intersection of an imaginary horizontal line drawn
through the base of the uvula and a vertical line
along the base of the anterior pillar.
At the point of maximum bulge above the upper pole of the tonsil.
Through the intratonsillar cleft.

Steps
This is performed with patient in sitting position to prevent aspiration of pus into the larynx.  First the oral cavity and throat of the patient is sprayed with 4 % topical xylocaine spray to anaesthetize the mucosa.A Saint Claire Thompson qunisy forceps, or a guarded 11 blade can be used.  The 11 blade is guarded to prevent the blade from penetrating the tonsillar substance deeply and damaging underlying vital structures like internal carotid artery.After incision is made a sinus forceps is introduced to complete the drainage procedure.

Interval Tonsillectomy-Tonsils are removed 4-6 weeks following an attack of quinsy(6 weeks after I&D to prevent recurrence)

Abscess Tonsillectomy (Hot tonsillectomy)-(Immediate/During an attack of quinsy under antibiotic cover) Risk of excessive bleeding and thrombo-embolism.

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Peritonsillar Abscess