This 22-year-old woman attends the surgery complaining of persistent sore throat after being treated for suspected tonsillitis two weeks previously with a course of penicillin V. She reports that her symptoms had initially started to improve but is cagey when asked if she has taken the whole 10-day course.
Her temperature is 38.5°C and both tonsils are dark red and enlarged. Her cervical lymph nodes are enlarged and tender, particularly on the left.
She mentions that she has been gargling with warm salt water, but in the past few days has found it increasingly hard to open her mouth. She is referred the same day with a suspected peritonsillar abscess, which is confirmed before surgical incision and drainage.
- Peritonsillar abscess – or quinsy – is a complication of acute tonsillitis with pus trapped between the tonsillar capsule and the lateral pharyngeal wall.
- It usually occurs in teens or young adults but may present earlier.
- It can develop as a complication of an untreated or under-treated episode of acute tonsillitis – where the infection has spread to the peritonsillar area forming an abscess in the connective tissue – but it can develop without previous tonsillitis and in patients who have been adequately treated for tonsillitis.
- It is typically a mixed infection, but Streptococcus pyogenes usually predominates.
- A reduction in the use of antibiotics for suspected tonsillitis in children has not led to an increase in incidence.1
- Fever and general malaise
- Severe throat pain – often unilateral – particularly severe on swallowing
- Breath may smell foetid and there may be excessive salivation
- Red and oedematous tonsillar area and the uvula may be pushed away from the affected side
- Tender, enlarged cervical lymph nodes – sometimes causing neck pain
- Trismus is present in around two-thirds of cases, often making examination difficult, and is a key clinical sign.
- Any patient with a suspected peritonsillar abscess should be referred the same day.
- The diagnosis is clinical, but CT scanning may be indicated for unusual presentations or if there is increased risk with drainage procedures – for example, in those with a coagulopathy.
- IV antibiotics are usually used – clindamycin, amoxicillin/clavulanic acid or a cephalosporin are all appropriate – but are not usually sufficient on their own.
- Needle aspiration can be used to obtain pus for culture and sensitivity testing, but complete aspiration is then performed – sometimes with general anaesthesia.
- A tonsillectomy will be considered if the patient has chronic or recurrent tonsillitis.
Dr Raj Singh is an ENT GPSI in Manchester
1 Sharland M, Kendall H, Yeates D et al. Antibiotic prescribing in general practice and hospital admissions for peritonsillar abscess, mastoiditis and rheumatic fever in children. BMJ 2005;331:328-9