ENT (Otorhinolaryngology) · MU Sofia

36. Peritonsillar abscess.

Covers the peritonsillar abscess, from its definition and bacterial causes, including Weber's gland spread, through its three-stage classification and the clinical picture of symptoms and examination signs. It then sets out investigations such as needle aspiration, ultrasound and CT, the medical and surgical treatment options including the Quinsy point and tonsillectomy indications, possible complications, and differential diagnoses.

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Topic 36 of 52 in the MU Sofia syllabus for ENT (Otorhinolaryngology) (Medicine, Year 4). The free AceMed note covers it in 1 section, about 644 words (4 min of reading), with 14 flashcards.

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  1. Peritonsillar abscess.

Peritonsillar abscess.

1. Definition: A Peritonsillar Abscess (Quinsy) is a localized collection of pus in the peritonsillar space, which lies between the capsule of the palatine tonsil and the superior pharyngeal constrictor muscle. It is the most common deep neck space infection.

2. Etiopathogenesis

  • Source of Infection: after acute tonsillitis, can also arise from Weber’s glands infection (minor salivary glands in the supratonsillar fossa that clear debris from the tonsillar area).
  • Bacteriology: Typically, polymicrobial.
  • Aerobes: Streptococcus pyogenes (Group A Beta-hemolytic Strep - most common), Staphylococcus aureus, Haemophilus influenzae.
  • Anaerobes: Fusobacterium necrophorum (most common anaerobe), Bacteroides, Prevotella.
  • Mechanism: Inflammation leads to ductal obstruction of Weber’s glands or spread from tonsillar crypts into the loose connective tissue of the peritonsillar space, progresses to localized pus formation → peritonsillar abscess

3. Classification

  1. 1. Peritonsillitis (Cellulitis): Inflammation/edema without a discrete pus collection.
  2. 2. Peritonsillar Phlegmon: A firm, inflammatory mass.
  3. 3. Peritonsillar Abscess: A localized, fluctuant collection of pus.
  • Location-based variations include Supratonsillar (most common), Anterosuperior, or Infratonsillar (rare)

4. Clinical Picture

The patient typically presents with a "toxic" appearance and a history of a sore throat that has worsened on one side.

Symptoms

  • Severe Unilateral Sore Throat: Radiating to the ear (referred otalgia via CN IX).
  • Odynophagia: Extremely painful swallowing, often leading to drooling.
  • "Hot Potato Voice": Muffled speech due to edema and restricted palate movement.
  • Trismus: Inability to open the mouth fully (due to irritation of the internal pterygoid muscle).
  • Systemic Signs: High fever, chills, malaise, and headache.

Signs (Examination)

  • Patient looks toxic and febrile
  • Oropharynx: Congested, bulging soft palate and anterior pillar. The uvula is deviated to the contralateral (healthy) side.
  • Tonsil: Pushed medially and downward.
  • Lymphadenopathy: Tender enlargement of the jugulodigastric lymph nodes.
  • Fetor Oris: Foul breath due to poor oral hygiene and sepsis.

5. Paraclinical & Radiological Examinations- clinical

  • Laboratory: Elevated WBC (leukocytosis) and CRP. A Monospot test may be done to rule out infectious mononucleosis.
  • Needle Aspiration: The gold standard for both diagnosis and immediate relief. Aspiration of pus confirms an abscess vs. cellulitis.
  • Ultrasound (USG): Differentiates cellulitis from abscess
  • Intraoral USG: Highly sensitive for identifying the abscess and its distance from the carotid artery.
  • Transcutaneous USG: Done if trismus prevents an intraoral probe.
  • CT scan (with contrast): Indicated if complications are suspected or if physical exam is limited by severe trismus. It shows a hypodense area with peripheral rim enhancement.

6. Treatment Options

  1. 1. Medical Management:

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