Peritonsillar Abscess
Quinsy
Presentation
The following system wise signs and symptoms are commonly seen in peritonsillar abscess formation among patients:
- General Appearance: Patients usually comes in with complains of fever and chills. The pathognomonic muffling of voice or “hot potato” voice heralds the disease.
- Integumentary: The skin may appear flushed due to fever. Facial cellulitis may be seen as complications of the disease.
- Head and Neck: Painful swallowing (odynophagia) is noted in all cases of peritonsillar abscess. There is difficulty in swallowing (trismus) and patients may drool out their saliva because they are unable to swallow it. Significant findings of uvular deviation and the inferior displacement of the superior pole of the tonsils correlates with the profile of peritonsillar abscess formation [3]. Facial and neck swelling may also be evident. Patients may subsequently complain of headaches.
- Chest and Heart: Tachycardia may follow with high fever and murmurs may be appreciated when the disease complicates to endocarditis. Dyspnea or difficulty of breathing may be noted with pneumonia, pleural effusion and large empyema of the lungs.
- Extremities: Peripheral pulses will be fast and weak especially during complicated endocarditis. Microhemorrages may be seen in the fingernails with bacterial endocarditis.
Hematological
Spontaneous Hemorrhage
- Review of the literature and features of the present case demonstrate the following findings suggestive of erosion of the internal carotid artery as a result of peritonsillar abscess: (1) spontaneous hemorrhage from a peritonsillar abscess, (2) persistent[ncbi.nlm.nih.gov]
Entire Body System
Fever
- We describe a left frontal brain abscess accompanied by fever, headache, and weight loss for a 3-month period. The presumptive source of the brain abscess involved a left peritonsillar abscess.[ncbi.nlm.nih.gov]
- The following system wise signs and symptoms are commonly seen in peritonsillar abscess formation among patients: General Appearance: Patients usually comes in with complains of fever and chills.[symptoma.com]
Streptococcal Pharyngitis
- More severe symptoms may indicate illness other than simple viral or streptococcal pharyngitis and require immediate medical care ( Table 2 ). 5 Table 2.[clinicaladvisor.com]
- pharyngitis [1] Diagnostic method Based on the symptoms [1] Differential diagnosis Retropharyngeal abscess, infectious mononucleosis, epiglottitis, cancer [1] Treatment Remove pus, antibiotics, fluids, pain medication, steroids [1] Frequency 3 per 10,000[en.wikipedia.org]
- The condition occurs primarily in young adults, most often during November to December and April to May, coinciding with the highest incidence of streptococcal pharyngitis and exudative tonsillitis.[aafp.org]
- Clinical practice guideline for the diagnosis and management of group A streptococcal pharyngitis: 2012 update by the Infectious Diseases Society of America.[ncbi.nlm.nih.gov]
Respiratoric
Stridor
- Sore throat associated with stridor and increased respiratory effort can signal imminent respiratory distress and requires immediate evaluation and management in a hospital emergency department. 4 Making the diagnosis PTAs may present with a variety of[clinicaladvisor.com]
- When to involve the ENT Registrar Immediately: If you suspect that you may be dealing with epiglottitis or a deep neck space infection, see stridor for immediate management.[entsho.com]
- The patient was noted to have a “hot potato” voice and was spitting frequently, but had no trismus or stridor. The head and neck exam showed bilateral erythematous tonsils with the right tonsil enlarged to 2.0 cm.[ncbi.nlm.nih.gov]
- Unfortunately, that night he had a recurrence of dyspnea with stridor, which required transfer back to the ICU with repeat I&D of the abscess.[casesjournal.biomedcentral.com]
Tonsillar Mass
- Quinsy abscess Needle aspiration: All such patients require needle aspiration of the tonsillar mass and cultures. Aspiration of pus differentiates abscess from cellulitis.[smartypance.com]
- All such patients require needle aspiration of the tonsillar mass and cultures. Aspiration of pus differentiates abscess from cellulitis.[merckmanuals.com]
- The right tonsillar mass was evaluated with transoral ultrasound using the endocavitary probe on the Zonare Z.one (Zonare, Mountain View, CA), which confirmed a PTA ( Figure 2 ).[ncbi.nlm.nih.gov]
Absent Tonsils
- Computed tomography performed in two cases confirmed absent tonsil tissue. 2 One patient received six months of prophylactic antibiotics to prevent a recurrence. 2 Discussion Section: PTA has been reported in patients who have undergone tonsillectomy.[dx.doi.org]
Gastrointestinal
Odynophagia
- Abstract Peritonsillar abscess (PTA) is the most common complication of acute tonsillitis resulting in fever, unilateral sore throat, odynophagia and trismus.[ncbi.nlm.nih.gov]
- A progressively severe sore throat on one side and pain during swallowing (odynophagia) usually are the earliest symptoms.[dbpedia.org]
- A 19-year-old woman presented to the emergency department with a 10-day history of intermittent odynophagia, voice changes, and fever.[nejm.org]
- Clinical features include a unilateral odynophagia, dysphagia , voice changes (sometimes classically referred to as a ‘hot potato’ voice), trismus, and excessive drooling 5 .[radiopaedia.org]
Choking
- I could feel the swelling in my tonsil come back and I choked on a pill around five o’clock am. I tried to take some extra water to help with the pill but I started to panic again. It seemed like twenty people came into the room.[ncbi.nlm.nih.gov]
- I could feel the swelling in my tonsil come back and I choked on a pill around five o'clock am. I tried to take some extra water to help with the pill but I started to panic again. It seemed like twenty people came into the room.[casesjournal.biomedcentral.com]
Jaw & Teeth
Trismus
- Two groups were compared based on time to oral intake, grade of trismus, pain severity and duration of hospitalization.[ncbi.nlm.nih.gov]
Drooling
- Children younger than 5 years who present with poor oral intake, high fever, drooling, and trismus should be suspected of having a peritonsillar abscess. A computed tomographic scan of the neck is usually required to confirm a suspected diagnosis.[ncbi.nlm.nih.gov]
- Clinical features include a unilateral odynophagia, dysphagia , voice changes (sometimes classically referred to as a ‘hot potato’ voice), trismus, and excessive drooling 5 .[radiopaedia.org]
- There is drooling of saliva and bad breath. The voice is indistinct and muffled It is referred to as "hot potato speech". On examination, there is a tense swelling of the soft palate and anterior pillar above the tonsil.[ghorayeb.com]
Difficulty Opening the Mouth
- The student just happens to mention that when he was gargling with warm salt water this morning that he had difficulty opening his mouth. WHAT DO YOU THINK HE HAS? If you said PERITONSILLAR ABSCESS, you are correct![pitt.edu]
- The patient is febrile (102 F) , has a muffled (hot potato) voice , and extreme difficulty opening his mouth (trismus) . He opens it just far enough for you to note uvular deviation.[smartypance.com]
- Symptoms of peritonsillar abscess include: Fever and chills Severe throat pain that is usually on one side Ear pain on the side of the abscess Difficulty opening the mouth, and pain with opening the mouth Swallowing problems Drooling or inability to swallow[nlm.nih.gov]
Halitosis
- Furthermore, we could identify halitosis, trismus, uvula edema, and unilateral swelling of the arched palate to be characteristic symptoms for PTA.[ncbi.nlm.nih.gov]
- Trismus, "hot potato" voice (speaking as if a hot object was in the mouth), a toxic appearance (eg, poor or absent eye contact, failure to recognize parents, irritability, inability to be consoled or distracted, fever, anxiety), drooling, severe halitosis[merckmanuals.com]
- […] includes : Sore throat Difficulty swallowing Painful swallowing Trismus – pain and difficulty when opening mouth Muffled voice, also described as a “hot potato” voice Excessive salivation and drooling Tonsil swelling is more one one side Bad breath (halitosis[healthhype.com]
Cardiovascular
Tachycardia
- Chest and Heart: Tachycardia may follow with high fever and murmurs may be appreciated when the disease complicates to endocarditis. Dyspnea or difficulty of breathing may be noted with pneumonia, pleural effusion and large empyema of the lungs.[symptoma.com]
- Clinical examination revealed a pyrexia and tachycardia. Examination of his oral cavity and oropharynx showed swelling of the right soft palate and the uvula was pushed to the left. There was no residual tonsil tissue.[dx.doi.org]
- Fever Malaise Headache Neck pain Throat pain (more severe on the affected side; occasionally referred to the ipsilateral ear) Dysphagia Change in voice Otalgia Odynophagia Physical findings may include the following: Mild-to-moderate distress Fever Tachycardia[emedicine.com]
Ears
Otalgia
- Symptoms generally include fever, malaise, sore throat, dysphagia, and otalgia. Physical findings may include trismus and a muffled voice (also called “hot potato voice”).[aafp.org]
- Symptoms and Signs Symptoms include gradual onset of severe unilateral sore throat, dysphagia, fever, otalgia, and asymmetric cervical adenopathy.[merckmanuals.com]
- Presenting symptoms associated with a developing PTA may include severe sore throat, fever as high as 103 F (39 C), headache, malaise, odynophagia or drooling, neck pain, dysphagia and otalgia.[clinicaladvisor.com]
Face, Head & Neck
Neck Swelling
- Facial and neck swelling may also be evident. Patients may subsequently complain of headaches. Chest and Heart: Tachycardia may follow with high fever and murmurs may be appreciated when the disease complicates to endocarditis.[symptoma.com]
- swelling Fever Headache Muffled voice Tender glands of the jaw and throat An exam of the throat often shows swelling on one side and on the roof of the mouth.[nlm.nih.gov]
Workup
Peritonsillar abscess is best diagnosed by direct examination with a penlight. The presence of multiple abscess formation on the soft tissue structures of the supratonsillar fossa and the exudative formation clinches the diagnosis of peritonsillar abscess. Exudates and suppurations may be aspirated and cultured to isolate the invading pathogen and determine the best antimicrobial to be used.
Imaging modalities like Computed Tomography (CT) Scans and Magnetic Resonance Imaging (MRI) will elucidate the abscess formation in the Weber glands and identify other concurrent complications within other organs [4]. Consequently, a transoral ultrasound (TUS) can effectively identify peritonsillar abscess from pharyngeal cellulitis to prevent unnecessary surgical removal of the tonsils [5].
Treatment
The early diagnosis of peritonsillar abscess may warrant antibiotics use for a more 7 to 10 days [6]. Hospital researches confers that the use of intravenous steroids in the treatment of peritonsillar abscess relieves trismus, controls inflammation, lessens pain, subdues fever and shortens hospital stay [7].
In some cases, the abscess are incised, aspirated or drained by the otolaryngologist or ENT surgeon under local anesthesia [8]. There are cases of acute peritonsillar abscess that may require immediate tonsillectomy to prevent its progression [9].
Prognosis
Peritonsillar abscess is usually controlled with adequate antibiotic coverage. Recurrence may be expected in some cases depending on the immune status of the patient. Untreated peritonsillar abscess may rupture and aspirate to the lungs causing serious pulmonary infections that could be fatal.
Prognosis is usually good but immunocompromised hosts like the elderly, patients in immunosuppressant states and chronic steroid users may have trouble overcoming the infections.
Complications
The following possible complications may be seen in peritonsillar abscess:
- Airway obstruction: Due to pharyngeal and laryngeal inflammation.
- Cellulitis: Infection may spread to the neck and jaw.
- Pleural effusion: Lung infection may cause fluid accumulation in the pleura.
- Empyema: β-hemolytic streptococci and anaerobes may cause abscess formation in the lung tissues.
- Pneumonia: Infectious aspirates may lead to lung infections.
- Endocarditis: This is a rare complication.
- Pericarditis: Inflammation of the pericardium due to infection.
- Sepsis: The uncontrolled infection may spread to the blood stream.
- Brain abscess: This is a rare but lethal complication of peritonsillar abscess [2].
Etiology
Peritonsillar abscess is most commonly caused by group A β-hemolytic streptococcus. This is closely followed by staphylococcus, pneumococcus and Haemophilus species that abounds in young adults.
They may be caused less commonly by yeasts cells like actinomyces and micrococci. Some studies supports that anaerobic bacterial pathogens may have a major role in peritonsillar abscess formation [1].
Etiology in peritonsillar abscess mirrors that of acute tonsillitis because all organism that are known to cause acute and chronic tonsillitis may result to peritonsillar abscess.
Epidemiology
In the United States, the incidence of peritonsillar abscess averages to 30 cases per 100,000 population per annum. New cases mounts up to 45,000 each year in the Americas.
Age specific incidence rating for peritonsillar abscess peaks at ages 15 to 35 years old representing a third of all cases. There are no sexual predominance and racial predilections noted for this pharyngeal infection.
Pathophysiology
The exact mechanism of pathology for peritonsillar abscess is still unclear. However, modern medicine confers to this mostly accepted theory that peritonsillar abscess stems out as a direct complication of exudative tonsillitis.
The inflammatory extension to soft tissues in the supratonsillar fossa spreads the infection in the salivary glands and the base of the tongue leading to abscess formation. It is also postulated that any scarring, obstruction and necrosis that occurs among the Weber glands may also lead to widespread infection and peritonsillar abscess formation.
Prevention
Peritonsillar abscess is effectively prevented by treating every episode of bacterial tonsillitis with adequate antimicrobial coverage that may preceed it. When peritonsillar abscess is noted, patients should immediately visit their ENT doctors for prompt treatment and prevent untoward complications. Patients should always be alert in identifying the signs of peritonsillar abscess for it can still recur even after tonsillectomy [10].
Summary
Peritonsillar abscess is clinical emergency characterized by an acute pharyngeal infection involving the soft tissues surrounding the tonsils.
Peritonsillar abscess may also be described as the abscess formation of the group of salivary glands located within the supratonsillar fossa known as Weber glands triggered by an episode of suppurative or exudative tonsillitis.
This acute pharyngeal infections commonly affects adolescents and young adults. They are usually characterized by a severe sore throat with “hot potato” voice and uvular deviation.
Patient Information
Definition
Peritonsillar abscess is an acute pharyngeal infection of the soft tissues that surrounds the tonsils. The abscess formation amongst the Weber glands usually occurs among adolescents and young adults.
Cause
It is caused by bacterial pathogens like β-hemolytic streptococcus, pneumococcus and Haemophilus species.
Symptoms
Throat pain, muffled voice (hot potato voice), difficulty swallowing, neck enlargement, fever and chills may occur.
Diagnosis
The diagnosis of peritonsillar abscess is done by the direct examination of the pharynx. Imaging techniques may be implored to elucidate affected structures that are otherwise inaccessible by direct examination.
Treatment and follow-up
Peritonsillar abscess is treated with antibacterial specific for the bacterial pathogen. Tonsillectomy may be done to control the abscess and spread. Patients must remain vigilant for peritonsillar abscess may recur even after treatment.
References
Article
- Repanos C, Mukherjee P, Alwahab Y. Role of microbiological studies in management of peritonsillar abscess. J Laryngol Otol. Aug 2009; 123(8):877-9.
- Sankararaman S, Riel-Romero RM, Gonzalez-Toledo E. Brain abscess from a peritonsillar abscess in an immunocompetent child: a case report and review of the literature. Pediatr Neurol. 2012; 47(6):451-4
- Kilty SJ, Gaboury I. Clinical predictors of peritonsillar abscess in adults. J Otolaryngol Head Neck Surg. Apr 2008; 37(2):165-8.
- Teschner M, Aljeraisi T, Giesemann A, Götz F, Lenarz T, Kontorinis G. The role of CT in the diagnosis of peritonsillar abscesses after Punctio Sicca .Laryngorhinootologie. 2013; 92(1):25-9 (ISSN: 1438-8685)
- Salihoglu M, Eroglu M, Yildirim AO, Cakmak A, Hardal U, Kara K. Transoral ultrasonography in the diagnosis and treatment of peritonsillar abscess. Clin Imaging. 2013; 37(3):465-7
- Anthonsen K; Trolle W. Treatment of peritonsillar abscess. Ugeskr Laeger. 2012; 174(6):340-3
- Ozbek C, Aygenc E, Tuna EU, Selcuk A, Ozdem C. Use of steroids in the treatment of peritonsillar abscess.J Laryngol Otol. Jun 2004;118(6):439-42
- Khan MI, Khan A, Muhammad. Peritonsillar abscess: clinical presentation and efficacy of incision and drainage under local anaesthesia. J Ayub Med Coll Abbottabad. 2011; 23(4):34-6
- Page C, Chassery G, Boute P, Obongo R, Strunski V. Immediate tonsillectomy: indications for use as first-line surgical management of peritonsillar abscess (quinsy) and parapharyngeal abscess. J Laryngol Otol. 2010; 124(10):1085-90
- Farmer SE, Khatwa MA, Zeitoun HM. Peritonsillar abscess after tonsillectomy: a review of the literature. Ann R Coll Surg Engl. 2011; 93(5):353-5