Peritonsillar Abscess — MCQs
A patient presented with 2 days history of fever. On examination there was a swelling in the neck and one side tonsil was pushed to midline. What is the most likely diagnosis:-
A 6-year-old boy came to the hospital with complaints of sore throat and difficulty in swallowing. His left tonsil was pushed medially and had swelling over the left side upper part of neck. What will be the diagnosis?
A 21-year-old college student presents with hot potato voice and trismus. Clinical diagnosis is?
A 25-year-old woman presents with severe throat pain, difficulty swallowing, and trismus. CT neck shows a peritonsillar fluid collection and inflammation. What is the next best step?
A 3-year-old boy presents with fever, throat pain, and difficulty swallowing. On examination, there is unilateral tonsillar swelling with deviation of the uvula. What is the most likely diagnosis?
All are absolute indications of tonsillectomy except which of the following?
Tonsillectomy is typically indicated after how many episodes of quinsy (peritonsillar abscess)?
A patient presents with fever and dysphagia. An image shows a tonsil that is pushed medially. What is the most likely diagnosis?
Early tonsillectomy is not done in?
Trismus is commonly seen in
Peritonsillar Abscess Indian Medical PG Practice Questions and MCQs
Question 1: A patient presented with 2 days history of fever. On examination there was a swelling in the neck and one side tonsil was pushed to midline. What is the most likely diagnosis:-
- A. Retropharyngeal abscess
- B. Parapharyngeal abscess
- C. Tonsillitis
- D. Quinsy (Correct Answer)
Explanation: ***Quinsy (Peritonsillar abscess)*** - **Quinsy** is a **peritonsillar abscess** that presents with fever, severe throat pain, and the pathognomonic sign of **unilateral tonsil pushed toward the midline**. - The abscess forms in the **peritonsillar space** (between the tonsillar capsule and superior constrictor muscle), causing **medial displacement of the tonsil** and **bulging of the soft palate**. - Patients typically have **trismus, dysphagia, "hot potato voice"** and may have visible neck swelling. - This clinical presentation exactly matches the description: tonsil pushed to midline is the **classic finding for peritonsillar abscess**. *Parapharyngeal abscess* - A **parapharyngeal abscess** involves the deep parapharyngeal space lateral to the pharynx. - While it can cause neck swelling and fever, it typically causes **fullness and induration of the lateral pharyngeal wall** rather than prominent medial displacement of the tonsil itself. - The **tonsil is usually NOT pushed to the midline** in parapharyngeal abscess; instead, there is lateral pharyngeal wall bulging. - Often presents with more prominent external neck swelling below the angle of mandible. *Retropharyngeal abscess* - A **retropharyngeal abscess** occurs in the retropharyngeal space behind the posterior pharyngeal wall. - Presents with **posterior pharyngeal wall bulge**, neck stiffness, and dysphagia. - Does **NOT cause medial displacement of the tonsil** as the abscess is posterior, not lateral to the tonsil. *Tonsillitis* - **Acute tonsillitis** causes bilateral tonsillar inflammation with erythema and exudates. - While both tonsils may be enlarged, there is **no unilateral medial displacement** of one tonsil. - Less likely to cause significant neck swelling compared to deep space infections.
Question 2: A 6-year-old boy came to the hospital with complaints of sore throat and difficulty in swallowing. His left tonsil was pushed medially and had swelling over the left side upper part of neck. What will be the diagnosis?
- A. Ludwig's angina
- B. Peritonsillar abscess (Correct Answer)
- C. Retropharyngeal abscess
- D. Parapharyngeal abscess
Explanation: ***Peritonsillar abscess*** - A **peritonsillar abscess** (quinsy) is the most common deep neck space infection and characteristically causes **medial displacement of the tonsil**, which is the key clinical finding in this case. - The patient presents with classic features: severe unilateral sore throat, difficulty swallowing, and the hallmark sign of **tonsillar displacement medially**. - The swelling in the **upper lateral neck** can occur with peritonsillar abscess, especially when there is significant inflammation extending into the surrounding tissues. - Other typical features include trismus, "hot potato voice," and uvular deviation (though not mentioned here). *Parapharyngeal abscess* - A **parapharyngeal abscess** can develop as an extension of a peritonsillar abscess, but the primary finding would be **bulging of the lateral pharyngeal wall** rather than medial displacement of the tonsil itself. - While neck swelling is prominent in parapharyngeal abscess, the specific finding of **medial tonsillar displacement** is more characteristic of peritonsillar abscess. - Parapharyngeal abscess typically presents with more systemic toxicity and can involve cranial nerve complications. *Retropharyngeal abscess* - A **retropharyngeal abscess** typically causes severe dysphagia and odynophagia with posterior pharyngeal wall bulging. - It does not cause **medial displacement of the tonsil**, which is the key finding in this case. - Neck swelling would be more posterior and midline, and patients often present with neck hyperextension and respiratory distress. *Ludwig's angina* - **Ludwig's angina** is a severe bilateral cellulitis of the floor of the mouth involving the submandibular, sublingual, and submental spaces. - It characteristically causes painful swelling and **elevation of the tongue**, creating a "bull neck" appearance. - It does not cause **tonsillar displacement** or localized unilateral upper neck swelling as described in this case.
Question 3: A 21-year-old college student presents with hot potato voice and trismus. Clinical diagnosis is?
- A. Chronic Tonsillitis
- B. Epiglottitis
- C. Quinsy (Correct Answer)
- D. Infectious mononucleosis
Explanation: ***Quinsy*** - **Quinsy**, or **peritonsillar abscess**, is characterized by a "hot potato" or muffled voice and **trismus** (difficulty opening the mouth) due to inflammation and muscle spasm. - The abscess typically forms adjacent to the palatine tonsil, causing severe unilateral throat pain and difficulty swallowing. *Chronic Tonsillitis* - **Chronic tonsillitis** is characterized by recurrent episodes of throat pain, fever, and enlarged tonsils, but does not typically present with acute **trismus** or a "hot potato" voice. - It results from persistent or repeated bacterial infections of the tonsils, often without significant abscess formation. *Epiglottitis* - **Epiglottitis** presents with rapid onset of severe sore throat, **dysphagia**, drooling, and inspiratory stridor, and can be life-threatening due to airway obstruction. - While it causes significant throat pain and difficulty swallowing, it does not typically present with a "hot potato" voice or **trismus**, but rather a muffled voice and tripod positioning. *Infectious mononucleosis* - **Infectious mononucleosis** leads to swollen tonsils with exudates, fatigue, and lymphadenopathy, but usually does not cause **trismus** or the distinctive "hot potato" voice. - It is caused by the **Epstein-Barr virus** and can lead to significant pharyngitis, but is not associated with peritonsillar abscess formation.
Question 4: A 25-year-old woman presents with severe throat pain, difficulty swallowing, and trismus. CT neck shows a peritonsillar fluid collection and inflammation. What is the next best step?
- A. Immediate tonsillectomy
- B. Needle aspiration and antibiotics (Correct Answer)
- C. Oral corticosteroids
- D. Empirical antibiotics alone
Explanation: ***Needle aspiration and antibiotics*** - The presence of a **peritonsillar fluid collection** on CT neck, along with severe throat pain, **dysphagia**, and **trismus**, is indicative of a **peritonsillar abscess (PTA)**. - **Needle aspiration** provides immediate relief by draining the pus and allows for culture-guided antibiotic therapy, while broad-spectrum **antibiotics** address the bacterial infection. *Immediate tonsillectomy* - **Tonsillectomy** is generally reserved for recurrent peritonsillar abscesses or chronic tonsillitis, not as the primary immediate treatment for an acute PTA. - Doing so acutely carries a higher risk of complications due to the **inflammation** and potential compromise of the airway. *Oral corticosteroids* - While corticosteroids can reduce inflammation and pain, they do not resolve the underlying bacterial infection or drain the **pus collection**. - Using **corticosteroids alone** risks worsening the infection by masking symptoms without treating the cause. *Empirical antibiotics alone* - Although antibiotics are crucial for treating the bacterial infection, they may not be sufficient on their own to resolve a **frank abscess**, especially one causing significant symptoms. - **Drainage** is often necessary to achieve clinical improvement and prevent complications such as airway obstruction or spread of infection.
Question 5: A 3-year-old boy presents with fever, throat pain, and difficulty swallowing. On examination, there is unilateral tonsillar swelling with deviation of the uvula. What is the most likely diagnosis?
- A. Parapharyngeal abscess
- B. Ludwig's angina
- C. Peritonsillar abscess (Correct Answer)
- D. Retropharyngeal abscess
Explanation: ***Peritonsillar abscess*** - This is the most common deep neck infection and typically presents with **unilateral tonsillar swelling**, **uvular deviation**, fever, and severe sore throat with difficulty swallowing (dysphagia) or speaking (muffled voice). - It usually develops as a complication of **acute tonsillitis**, where infection spreads from the tonsil into the peritonsillar space. *Parapharyngeal abscess* - While it can cause fever and severe throat pain, it typically presents with **trismus**, neck swelling below the angle of the mandible, and medial displacement of the lateral pharyngeal wall, rather than direct uvula deviation. - This type of abscess is located in the **parapharyngeal space**, which is lateral to the pharynx, and causes more diffuse swelling. *Ludwig's angina* - This is a rapidly spreading cellulitis of the **submandibular** and **sublingual spaces** and does not primarily involve the tonsils or cause uvular deviation. - Patients typically present with **symmetrical submental swelling**, painful swallowing, and tongue elevation, which can lead to airway obstruction. *Retropharyngeal abscess* - This abscess forms in the space behind the posterior pharyngeal wall and is more common in young children. - It often causes **neck stiffness**, muffled voice, stridor, and difficulty breathing, but less commonly presents with unilateral tonsillar swelling and uvular deviation.
Question 6: All are absolute indications of tonsillectomy except which of the following?
- A. Peritonsillar abscess
- B. Tonsils causing obstructive sleep apnea
- C. Chronic tonsillitis (Correct Answer)
- D. Suspicious malignancy
Explanation: ***Chronic tonsillitis*** - **Chronic tonsillitis** is a **relative indication** for tonsillectomy, not an **absolute indication**. - It becomes an indication based on frequency criteria (e.g., Paradise criteria: ≥7 episodes in 1 year, ≥5 episodes per year for 2 years, or ≥3 episodes per year for 3 years). - Absolute indications involve conditions requiring urgent surgical intervention. *Suspicious malignancy* - Suspected **malignancy** is an **absolute indication** for tonsillectomy to obtain tissue for histopathological diagnosis. - Early diagnosis and treatment of tonsillar malignancy is critical for patient outcomes. *Peritonsillar abscess* - **Peritonsillar abscess** (quinsy) is typically managed with needle aspiration or incision & drainage plus antibiotics, NOT immediate tonsillectomy. - Acute tonsillectomy during active infection ("hot tonsillectomy") is generally **contraindicated** due to increased bleeding risk and surgical complications. - **Recurrent peritonsillar abscess** may warrant **interval tonsillectomy** (4-6 weeks after resolution) as a **relative indication**, not an absolute one. *Tonsils causing obstructive sleep apnea* - **Obstructive sleep apnea (OSA)** caused by tonsillar hypertrophy is an **absolute indication** for tonsillectomy, particularly in children. - Untreated OSA can lead to serious complications including failure to thrive, cor pulmonale, developmental delays, and neurocognitive problems.
Question 7: Tonsillectomy is typically indicated after how many episodes of quinsy (peritonsillar abscess)?
- A. 12
- B. 2 (Correct Answer)
- C. 4
- D. 6
Explanation: ***2*** - For recurrent quinsy (peritonsillar abscess), **tonsillectomy** is generally considered after **two documented episodes** to prevent further recurrences. - This recommendation is based on the increased likelihood of recurrence after a second episode, weighed against the risks and benefits of surgery. *12* - Waiting for 12 episodes of quinsy before considering tonsillectomy is **excessive** and would subject the patient to undue pain, discomfort, and potential complications from multiple infections. - Current guidelines recommend intervention much sooner for recurrent cases to improve patient quality of life and prevent severe outcomes. *4* - While 4 episodes might be considered in some contexts for recurrent tonsillitis, for **recurrent quinsy**, the threshold for tonsillectomy is typically lower due to the more severe nature and potential complications of abscess formation. - Four episodes would be an unnecessarily prolonged delay for a patient experiencing multiple peritonsillar abscesses. *6* - Similar to 4 episodes, 6 episodes of quinsy before tonsillectomy is **not standard practice** as it exceeds the typically recommended intervention threshold. - Prolonged recurrence of quinsy increases the risk of airway obstruction, deep neck space infection, and other serious complications.
Question 8: A patient presents with fever and dysphagia. An image shows a tonsil that is pushed medially. What is the most likely diagnosis?
- A. Parapharyngeal abscess
- B. Retropharyngeal abscess
- C. Peritonsillar abscess (Correct Answer)
- D. Ludwig's angina
Explanation: ***Peritonsillar abscess*** - The image clearly shows **unilateral bulging** of the soft palate and displacement of the tonsil medially, consistent with a peritonsillar abscess. - Patients typically present with **fever**, **dysphagia**, severe sore throat, and a "hot potato" voice. *Parapharyngeal abscess* - A parapharyngeal abscess involves the **deep neck spaces** lateral to the pharynx, often presenting with neck swelling, trismus, and systemic symptoms. - While it can cause pharyngeal bulging, the classic **medial displacement of the tonsil** is more indicative of a peritonsillar abscess. *Retropharyngeal abscess* - This involves the space behind the posterior pharyngeal wall, usually presenting with **dysphagia**, **neck stiffness**, and fever. - Imaging would reveal a **prevertebral soft tissue swelling**, not primarily a medially displaced tonsil. *Ludwig's angina* - Ludwig's angina is a **rapidly spreading cellulitis** of the submandibular and sublingual spaces, typically arising from an odontogenic infection. - It presents with **woody induration** of the neck and floor of the mouth, elevation of the tongue, and potential airway compromise, but not primarily a medially displaced tonsil.
Question 9: Early tonsillectomy is not done in?
- A. Peritonsillar abscess
- B. Thyroid storm (Correct Answer)
- C. Rheumatic fever
- D. Suspected malignancy
Explanation: ***Thyroid storm*** - **Thyroid storm** is a life-threatening medical emergency caused by exaggerated hyperthyroidism, requiring immediate medical stabilization to control hormone levels and systemic effects. - Early tonsillectomy is **contraindicated** in this scenario because it would add significant surgical stress and anesthetic risks to an already critically unstable patient. *Peritonsillar abscess* - A **quinsy tonsillectomy** (abscess tonsillectomy) is often performed acutely, especially if drainage is difficult or if it's the first episode, to resolve the abscess and remove the infected tissue. - This procedure can be done in the acute phase of a peritonsillar abscess to relieve symptoms and reduce the risk of recurrence. *Rheumatic fever* - Patients with recurrent **acute tonsillitis** who are at risk of developing **rheumatic fever** are strong candidates for tonsillectomy to prevent further streptococcal infections and subsequent autoimmune complications. - Tonsillectomy is considered a prophylactic intervention in cases of recurrent strep throat leading to rheumatic fever. *Suspected malignancy* - If tonsillar asymmetry or other signs raise suspicion of **tonsillar malignancy**, prompt tonsillectomy is often performed for **diagnostic biopsy** and initial tumor removal. - Early surgical intervention is crucial for diagnosing and staging potential tonsil cancer, which can guide subsequent treatment.
Question 10: Trismus is commonly seen in
- A. Ludwig's angina
- B. Parapharyngeal abscess
- C. Retropharyngeal abscess
- D. Quinsy (Correct Answer)
Explanation: ***Quinsy*** - **Quinsy (peritonsillar abscess)** is the **most common cause of trismus** among pharyngeal infections. - Trismus occurs due to **inflammation and reflex spasm of the pterygoid muscles** adjacent to the abscess. - The severe pain and swelling in the peritonsillar region directly limit **mandibular movement**, making it difficult or impossible to open the mouth. - **Trismus is one of the cardinal clinical features** of quinsy. *Parapharyngeal abscess* - A **parapharyngeal abscess** can also cause trismus due to direct inflammation and irritation of the muscles of mastication. - However, it is **less common than quinsy** and typically presents with other prominent symptoms like **neck swelling**, lateral pharyngeal bulging, and internal carotid artery involvement risk. *Ludwig's angina* - While Ludwig's angina is a severe infection of the **submandibular and sublingual spaces**, trismus is **less common** and less pronounced compared to peritonsillar abscess. - The primary concern in Ludwig's angina is **airway obstruction** due to tongue elevation and "bull neck" swelling, not typically severe trismus. *Retropharyngeal abscess* - A **retropharyngeal abscess** is located behind the pharynx and typically manifests with **dysphagia**, **odynophagia**, **neck stiffness**, and respiratory distress. - While indirect muscle spasm can occur, **trismus is not a characteristic or common symptom** of retropharyngeal abscess, which primarily affects swallowing and neck mobility.
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