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ENT (Ear, Nose, Throat Conditions)

Peritonsillar Abscess (Quinsy)

A collection of pus that forms in the space between the tonsil capsule and the pharyngeal muscles, typically as a complication of acute tonsillitis.

Also known as: Quinsy

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Referral and warning signs

When to refer

Urgent Referral to ENT Specialist/Hospital (HC4/H/RR) for ALL suspected cases of peritonsillar abscess for confirmation, drainage procedure, and IV antibiotics.

Red flags

  • Difficulty breathing / Stridor.
  • Severe trismus (unable to open mouth).
  • Significant neck swelling or tenderness.
  • Muffled voice.
  • Drooling.
  • Signs of sepsis.

Signs and symptoms

  • Severe unilateral sore throat.
  • Fever, chills, malaise.
  • Odynophagia (painful swallowing) - often severe, leading to drooling.
  • Trismus (difficulty opening the mouth / lockjaw).
  • Muffled voice ('hot potato voice').
  • Ear pain (referred pain, otalgia) on the affected side.
  • Unilateral swelling of the soft palate and peritonsillar area.
  • Displacement of the uvula away from the affected side.
  • Enlarged, tender cervical lymph nodes on affected side.
  • Bad breath (halitosis).

Risk factors

  • Recent or concurrent acute tonsillitis.
  • Smoking.
  • Chronic tonsillitis.
  • Periodontal disease.
  • Infectious mononucleosis (less common).

Diagnosis

Clinical assessment

Diagnosis based on characteristic clinical presentation: severe unilateral throat pain, fever, trismus, muffled voice, and examination findings of unilateral peritonsillar swelling with uvular deviation.

Differential diagnosis

  • Severe tonsillitis/pharyngitis.
  • Peritonsillar cellulitis (inflammation without discrete pus collection).
  • Retropharyngeal or parapharyngeal abscess.
  • Dental abscess.
  • Salivary gland infection.
  • Epiglottitis (rare in adults).
  • Tumour.

Investigations

  • Clinical examination is usually sufficient.
  • Needle Aspiration: Can confirm presence of pus (diagnostic) and provide sample for culture (therapeutic).
  • CT Scan with Contrast (Neck): Useful if diagnosis uncertain, deep neck space infection suspected, or poor response to treatment.
  • Throat swab C&S (may identify pathogens but less reliable than abscess aspirate).
  • FBC (leucocytosis).

Diagnostic criteria

Clinical diagnosis based on characteristic signs/symptoms. Confirmation by aspiration of pus.

Management

Non-pharmacological management

  • Airway Assessment: Ensure airway is patent. Admit patient.
  • Hydration: IV fluids if unable to swallow adequately.
  • Pain Relief.
  • Drainage of Abscess (Essential):
  • - Needle Aspiration: Often first-line. Aspirate pus from most prominent/fluctuant point after topical/local anaesthesia.
  • - Incision and Drainage (I&D): Small incision made over fluctuant area to allow drainage. Performed by trained personnel (ENT).
  • - Quinsy Tonsillectomy: Removal of tonsils immediately or shortly after abscess drainage (interval tonsillectomy 4-6 weeks later is also an option). Specialist decision.

Pharmacological treatment

  • Analgesia: Opioids often required initially, then NSAIDs/Paracetamol.
  • Antibiotics: Start IV antibiotics promptly, covering common pathogens (Strep pyogenes, Staph aureus, anaerobes).
  • - Standard: Benzylpenicillin 1.2g (2 MU) IV Q6H + Metronidazole 500mg IV Q8H. (LOC: HC4/H)
  • - Alternative: Ceftriaxone 1-2g IV OD + Metronidazole 500mg IV Q8H. OR Clindamycin IV.
  • - Switch to oral antibiotics (e.g., Amoxicillin/Clavulanate OR Clindamycin) once improving, to complete 7-14 day total course.
  • Corticosteroids: A single dose of IV Dexamethasone may help reduce swelling and pain (controversial, specialist use).

Monitoring

Monitor airway, hydration, pain control, resolution of trismus and swelling. Observe for re-accumulation after drainage.

Complications

  • Airway obstruction.
  • Spread of infection to deep neck spaces (parapharyngeal/retropharyngeal abscess).
  • Aspiration pneumonia.
  • Sepsis.
  • Internal jugular vein thrombosis (Lemierre's syndrome - rare).
  • Haemorrhage (rare, post-drainage or erosion).

Prevention

  • Prompt and adequate treatment of acute tonsillitis.
  • Tonsillectomy for recurrent severe tonsillitis or previous quinsy.

Patient education

  • Explanation of the condition as an abscess behind the tonsil.
  • Need for hospital admission, drainage, and IV antibiotics.
  • Importance of completing full antibiotic course.
  • Pain management.
  • Advise soft diet initially.
  • Risk of recurrence and potential need for tonsillectomy in future.
  • When to seek review if symptoms worsen.

Uganda-specific notes

Quinsy requires prompt recognition and referral for drainage, which is usually done at hospital level by trained MOs or ENT specialists. Standard antibiotic regimens (Penicillin/Metro or Ceftriaxone/Metro) are used.

References

  • Uganda Clinical Guidelines (UCG) 2023

    Chapter 21, Section 21.3.5

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