Peritonsillar Abscess

Peritonsillar Abscess - Quinsy's Fiery Throat

• Collection of pus between tonsillar capsule & superior constrictor muscle.
• Usually unilateral, complication of acute tonsillitis.
• Presents with severe sore throat, dysphagia, odynophagia, trismus, muffled "hot potato" voice, drooling.
• Uvula deviated to contralateral side.

⭐ Peritonsillar abscess is the most common deep neck infection in adults.

Etiopathogenesis - Bugs & Barricades

• Bugs (Causative Organisms):
  • Polymicrobial: Streptococcus pyogenes (Group A Strep) most common. Also Staphylococcus aureus.
  • Anaerobes: F. necrophorum, Prevotella, Porphyromonas, Peptostreptococcus spp.
• Pathogenesis (Progression):
  • Complication of acute exudative tonsillitis.
  • Infection from tonsillar crypts invades peritonsillar space, often superiorly.

  ⭐ Involvement of Weber's glands (minor salivary glands in the supratonsillar fossa) is key in the pathogenesis, as their ducts can become obstructed.

Clinical Picture - Symptoms & Signs

• Symptoms:
  • Severe, progressive unilateral sore throat.
  • Odynophagia (painful swallowing) & dysphagia (difficulty swallowing).
  • Fever, chills, malaise.
  • Ipsilateral otalgia (referred ear pain).
  • Drooling, halitosis.
• Key Signs: 📌 TUV Mnemonic for classic triad:
  • Trismus (difficulty opening mouth).
  • Uvular deviation to contralateral (unaffected) side.
  • Voice change:

    ⭐ The 'hot potato voice' (muffled voice, as if speaking with a hot potato in the mouth) is a classic pathognomonic sign.

• Oropharyngeal Exam Findings:
  • Unilateral peritonsillar swelling & erythema; bulging soft palate.
  • Affected tonsil displaced medially and inferiorly.
  • Tender cervical lymphadenopathy.

Diagnosis & DDx - Spotting the Pus

• Clinical Diagnosis: Key signs: trismus, muffled voice, uvular deviation.
• Needle Aspiration:
  • Confirms pus.
  • Often therapeutic.
  • Site: Superior tonsillar pole.
• Imaging:
  • CT with contrast: For unclear diagnosis/deep neck spread. Shows collection.
  • Intraoral ultrasound: Alternative to CT.

⭐ Needle aspiration is both diagnostic (confirms presence of pus) and often therapeutic.

Differential Diagnosis:

Management - Drain & Tame

• Initial Steps:
  • Airway assessment; secure if compromised.
  • IV fluids, potent analgesia.
  • Empirical IV antibiotics (e.g., Amoxicillin-Clavulanate or Clindamycin; Penicillin G + Metronidazole).
• Drainage (Crucial):
  • Needle Aspiration: Often first-line; diagnostic & therapeutic.
  • Incision & Drainage (I&D): For larger abscesses or failed aspiration.
• Tonsillectomy Considerations:
  • Interval tonsillectomy: 4-6 weeks post-resolution for recurrent PTA.
  • Quinsy (Hot) tonsillectomy: During acute phase for specific indications.

⭐ Key indications for 'quinsy tonsillectomy' (tonsillectomy à chaud, during acute infection) include recurrent peritonsillar abscess, failure of adequate drainage, or presence of complications.

Complications - When Quinsy Spreads

• Spread to adjacent spaces:
  • Parapharyngeal abscess
  • Retropharyngeal abscess
  • Ludwig's angina
• Airway compromise:
  • Laryngeal edema, obstruction
• Systemic/Vascular:
  • Sepsis, septic shock
  • Aspiration pneumonia
  • Mediastinitis

⭐ Lemierre's syndrome: Septic thrombophlebitis of IJV (Internal Jugular Vein), often Fusobacterium necrophorum. Rare, life-threatening.

High‑Yield Points - ⚡ Biggest Takeaways

• Most common deep neck infection in adults, typically a complication of acute tonsillitis.
• Presents with severe unilateral sore throat, odynophagia, trismus, and characteristic "hot potato" voice.
• Key signs: Uvular deviation to the contralateral side and bulging of the soft palate.
• Caused by polymicrobial infection, commonly Strep. pyogenes and anaerobes.
• Management: Incision and Drainage (I&D) is crucial, along with systemic antibiotics.
• Interval tonsillectomy is often recommended after one episode to prevent recurrence.