QUINSY
Synonym: Peritonsillar abscess.
Definition: A peritonsillar abscess is collection of pus between the fibrous capsule of tonsil and the superior constrictor muscle of the pharynx.
Aetiology:
- Usually seen in adult males.
- As a complication of acute tonsillitis.
- Foreign bodies like small fish bone embedded into tonsillar tissue.
Bacteriology:
Beta haemolytic streptococcus is the most frequent organism along with other aerobic and anaerobic organisms.
Pathophysiology:
Clinical features:
Symptoms:
- Usually seen in young adult males.
- Patients may have had repeated attacks of acute tonsillitis or may be de-novo.
- It is preceded by sore throat 2 or 3 days which gradually becomes more severe and unilateral. Occasionally can be bilateral.
- Patient presents with high grade fever and often has a toxic appearance.
- Speech is muffled and thick, often called ‘hot potato voice’.
- Foetor may be present due to secondary infection.
Signs:
1) Classical appearance is striking asymmetry, enlargement, hyperemia and displacement of the affected tonsil with oedema and hyperemia of soft palate.
2) Tender, enlarged lymph nodes in the jugulodigastric region on same side.
3) Patient has foul oral odour (Halitosis).
Treatment:
Medical:
- Hospitalization.
- Antibiotics: Antibiotics, either orally or intravenously, are required to treat peritonsillar abscess medically, although most peritonsillar abscess are refractory to antibiotic therapy alone. Penicillin and its congeners example Amoxicillin + Clavulanic acid, Cephalosporins and Clindamycin are appropriate antibiotics.
- Analgesics and oral antiseptic gargles.
- Supportive treatment includes IV fluids etc for hydration.
Surgical:
Incision and drainage if:
- Presence of discrete abscess.
- Infection not responding to antibiotics.
- Patient should undergo interval tonsillectomy after 4-6 weeks after the acute attack subsides.
- Emergency abscess tonsillectomy: Also called “hot” tonsillectomy. This is rarely done due to the increased chances of bleeding and thromboembolism and the risk of rupture of the abscess during anesthesia
Incision sites for drainage of Quinsy:
- A horizontal line is drawn through the base of the uvula and vertical line along the anterior tonsillar pillar. The incision is taken at this site.
- At the site of maximum projection.
- Through the Intratonsillar cleft.
After drainage of the abscess, dilute hydrogen peroxide and povidone iodine gargles are given.
Complications:
a) Rapidly increasing inflammation can lead to laryngeal oedema with respiratory obstruction. Hence patient may require tracheostomy.
b) Parapharyngeal abscess involving carotid sheath leading to jugular vein thrombosis or fatal carotid hemorrhage.
c) In severe cases mediastinitis.
Differential diagnosis:
a) Abscess related to an upper molar tooth.
b) Para pharyngeal swelling.
c) Tonsillolith.
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