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.

• 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]

• 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]

  Often there is high fever and general prostration. Although acute tonsillitis is usually caused by streptococci, these organisms are not always present in the quinsy pus. [britannica.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]

  Streptococcal pharyngitis: placebo-controlled double-blind evaluation of clinical response to penicillin therapy. JAMA. 1985;253:1271-1274. Google Scholar Medline ISI 47. Flodström, A, Hallander, HO. [journals.sagepub.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]

• Camping

  During an otolaryngology emergencies boot camp, expert otolaryngologists performed abscess drainage and subsequently instructed novice learners on the techniques of the procedure. [ncbi.nlm.nih.gov]

• Stridor

  No stridor, but the same area was now swollen as well as reddened. [nature.com]

  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]

  Stridor and shortness of breath should prompt the clinician to consider epiglottitis. It may be difficult to differentiate peritonsillar cellulitis from true abscess by physical examination alone. [journals.lww.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]

• 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]

  Common to both conditions include odynophagia, halitosis, fever, constitutional symptoms but these tend to be more severe with peritonsillar abscess. On examination both have hyperemia of the pillar, soft palate and uvula. [youtube.com]

• Dysphagia

  Children with PTA often present with sore throat, dysphagia, peritonsillar bulge, uvular deviation, trismus, and a muffled voice. The diagnosis of PTA can be made based on history and physical examination in the majority of children. [ncbi.nlm.nih.gov]

• Choking

  Choking[edit] After falls, choking on food presents as the second highest cause of preventable death in aged care.[28] Although food choking risk is commonly associated with young children, data shows that individuals over 65 years of age have a choking [en.wikipedia.org]

  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]

• Jaundice

  These nonfunctional islet cell tumors / pancreatic endocrine neoplasms present with clinical manifestations such as abdominal pain, weight loss and jaundice (105, 106), resulting from space-occupying lesions in the pancreas. [pathology.jhu.edu]

• 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.medscape.com]

• 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]

  Pain can be severe, associated with otalgia, trismus, dysphagia and drooling of saliva. Patient usually pyrexial and systemically unwell. [gloshospitals.nhs.uk]

  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 Difficulty opening the mouth, and pain with opening the mouth Swallowing problems Drooling or inability to swallow saliva Facial or neck swelling [cmc.ph]

  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]

  Common to both conditions include odynophagia, halitosis, fever, constitutional symptoms but these tend to be more severe with peritonsillar abscess. On examination both have hyperemia of the pillar, soft palate and uvula. [youtube.com]

  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]

  Other symptoms include: Fever "Hot potato" voice Drooling Bad breath (halitosis) Trismus (difficulty opening mouth) is always present but may vary in severity Painful swallowing (odynophagia) Difficulty swallowing (dysphagia) Ear pain Diagnosis Tests [verywellhealth.com]

• 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]

  Pain can be severe, associated with otalgia, trismus, dysphagia and drooling of saliva. Patient usually pyrexial and systemically unwell. [gloshospitals.nhs.uk]

  Trismus and otalgia may be present. This infection usually affects young adults, but all ages can be affected. Older adults may have more subtle symptoms. Laboratory findings include leukocytosis. [visualdx.com]

  Symptoms and Signs Symptoms include gradual onset of severe unilateral sore throat, dysphagia, fever, otalgia, and asymmetric cervical adenopathy. [merckmanuals.com]

• Neck Swelling

  Symptoms of peritonsillar abscess include: Fever and chills Severe throat pain that is usually on one side Difficulty opening the mouth, and pain with opening the mouth Swallowing problems Drooling or inability to swallow saliva Facial or neck swelling [cmc.ph]

  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]

• Neck Mass

  Worsening sore throat, dysphagia, poor oral intake, neck pain or neck mass, fever, trismus and increased irritability in young children are highly suspicious for PTA. [cancertherapyadvisor.com]

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].

• Nocardia Asteroides

  A 22-year-old man with recurrent pharyngitis developed a peritonsillar abscess from which aspirated material yielded a pure culture of Nocardia asteroides. [ncbi.nlm.nih.gov]

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].

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].

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.

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.

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.

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].

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.

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.

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3. Kilty SJ, Gaboury I. Clinical predictors of peritonsillar abscess in adults. J Otolaryngol Head Neck Surg. Apr 2008; 37(2):165-8.
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