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.

• Fever

  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]

  A 19-year-old woman presented to the emergency department with a 10-day history of intermittent odynophagia, voice changes, and fever. [nejm.org]

  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]

  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]

• 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]

  There are some differences between group A and group C streptococcal pharyngitis. [casesjournal.biomedcentral.com]

  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]

• Asymptomatic

  One hundred and four of the 129 adults (88.3%) and 5 out of the 6 children (83.2%) who did not undergo a tonsillectomy remained asymptomatic after the single isolated attack of peritonsillitis/quinsy. [ncbi.nlm.nih.gov]

  FIGURE 58-2 Computed tomographic (CT) scan with contrast of the chest shows (right arrow) asymptomatic pulmonary emboli and (left arrow) mediastinal lymphadenopathy. [accesssurgery.mhmedical.com]

  • An 18-year-old woman with bilateral pheochromocytomas and an asymptomatic islet cell adenoma of the pancreas represents the 11th patient to be described with this combination of endocrine tumors. [jamanetwork.com]

  […] hyperparathyroidism, due to hyperplasia and/or adenoma of parathyroid glands, is the most common manifestation of multiple endocrine neoplasia type 1 (MEN1) and occurs in approximately 90% of all patients. [2] Primary hyperparathyroidism in MEN1 can have a long-term asymptomatic [emedicine.medscape.com]

  Patients may remain asymptomatic after acid aspiration. Others may develop dyspnea, pleuritic chest pain, cough, fever, bloody or frothy sputum, and respiratory failure. Aspiration pneumonia may develop. [en.wikipedia.org]

• 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]

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

• Odynophagia

  A 19-year-old woman presented to the emergency department with a 10-day history of intermittent odynophagia, voice changes, and fever. [nejm.org]

  A progressively severe sore throat on one side and pain during swallowing (odynophagia) usually are the earliest symptoms. [dbpedia.org]

  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]

• Dysphagia

  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]

  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. [casesjournal.biomedcentral.com]

  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]

• 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]

  # Description HPO Frequency HPO Source Accession 1 hyperhidrosis 32 HP:0000975 2 proteinuria 32 HP:0000093 3 congestive heart failure 32 HP:0001635 4 pheochromocytoma 32 HP:0002666 5 hypercalcemia 32 HP:0003072 6 cerebral hemorrhage 32 HP:0001342 7 tachycardia [malacards.org]

  Profuse sweating Sweating Sweating profusely Sweating, increased [ more ] 0000975 Hypertensive retinopathy 0001095 Pheochromocytoma 0002666 Positive regitine blocking test 0003574 Proteinuria High urine protein levels Protein in urine [ more ] 0000093 Tachycardia [rarediseases.info.nih.gov]

• 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]

• Trismus

  Two groups were compared based on time to oral intake, grade of trismus, pain severity and duration of hospitalization. [ncbi.nlm.nih.gov]

  Symptoms are severe sore throat, trismus, "hot potato" voice, and uvular deviation. Diagnosis requires needle aspiration. [merckmanuals.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]

  Signs and symptoms Symptoms of quinsy can include: a severe and quickly worsening sore throat, usually on one side swelling inside the mouth and throat difficulty opening your mouth pain when swallowing difficulty swallowing, which may cause you to drool [nhsdirect.wales.nhs.uk]

• 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]

• Flushing

  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. [symptoma.com]

  The occurrence of episodic facial flushing and/or chronic diarrhea not diagnosed by standard tests as being a result of more common causes should lead to suspicion of carcinoid syndrome. [rarediseases.org]

  Carcinoid syndrome is 1 sign of a “functional” NET in which a substance called serotonin is released that can cause diarrhea and facial flushing (see Symptoms and Signs ). [cancer.net]

  Symptoms related to the tumor and its factors may be intermittent and vague, but the most common presentation is periodic abdominal pain sometimes accompanied by malignant carcinoid syndrome, characterized by flushing of the face, severe diarrhea, and [pancreatica.org]

• Skin Disease

  Photo Credit Gracia Lam Personal Health A Little-Known Skin Disease That Can Disrupt People’s Sex Lives Patients deal with pain and itching and often encounter medical ignorance and mistreatment until affected tissues become irreparably scarred. [nytimes.com]

• Skin Bullae

  This process can result in massive fluid sequestration and the development of skin bullae and blebs. 4 Further progression results in venous gangrene when muscle ischemia becomes infarction. [emra.org]

• Fracture

  His right leg was broken, which was diagnosed as a closed fracture of the tibia and fibula, and was managed conservatively. He had fractures at the left iliac crest and the left superior pubic rami. The neurovascular conditions were normal. [ncbi.nlm.nih.gov]

  […] injury Caustic ingestion Lemierre's syndrome Peritonsillar cellulitis Lymphoma Internal carotid artery aneurysm Oral Thrush Parotitis Post-tonsillectomy hemorrhage Vincent's angina Acute necrotizing ulcerative gingivitis Dentoalveolar Injuries Dental fracture [wikem.org]

• 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]

  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]

• Euphoria

  Therapeutic doses may cause a feeling of artificial well-being ("steroid euphoria").[18] The neuropsychiatric effects are partly mediated by sensitization of the body to the actions of adrenaline. [en.wikipedia.org]

• 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]

  The uvula in the back of the throat may be shifted away from the swelling. The neck and throat may be red and swollen on one or both sides. [cmc.ph]

  A large firm swelling over his left neck, which was erythematous and warm, was noted. [casesjournal.biomedcentral.com]

• 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]

• Confusion

  That night, the patient's wife noted he began acting confused and had some trouble sleeping. The following morning, the patient developed severe shortness of breath with intermittent air gasping. [casesjournal.biomedcentral.com]

  That night, the patient’s wife noted he began acting confused and had some trouble sleeping. The following morning, the patient developed severe shortness of breath with intermittent air gasping. [ncbi.nlm.nih.gov]

  Symptoms include confusion, seizure, obtundation, personality change and coma, as well as palpitations, tremulousness, diaphoresis (sweating) and tachycardia (fast heart rate). [pathology.jhu.edu]

• Hyperactivity

  […] study by Spektor et al indicated that the risk of postoperative bleeding in children undergoing tonsillectomy is increased when the surgery is performed on a child with recurrent tonsillitis (4.5 times increased risk), on a child with attention deficit hyperactivity [emedicine.medscape.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].

• Leukocytosis

  Laboratory findings include leukocytosis. Treatment consists of antibiotic therapy and surgical drainage. Complications of this infection include airway obstruction or extension of the infection into contiguous spaces in the neck. [visualdx.com]

  He had another blood count test showing leukocytosis (17.330/mm3) even with predominance of lymphocytes. Due to therapeutic failure the ENT surgeon decided to submit him to a procedure for draining the abscesses. [hindawi.com]

  Simultaneous uvulitis and epiglottitis without fever or leukocytosis. Am J Emerg Med. 1996; 14 :551. [ PubMed ] 9. Khayr W, Taepke J. Management of peritonsillar abscess: needle aspiration versus incision and drainage versus tonsillectomy. [ncbi.nlm.nih.gov]

  Leukocytosis with predominance of neutrophils is a non-specific finding. Blood culture is not sensitive enough to be recommended routinely. [cancertherapyadvisor.com]

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.

1. Repanos C, Mukherjee P, Alwahab Y. Role of microbiological studies in management of peritonsillar abscess. J Laryngol Otol. Aug 2009; 123(8):877-9.
2. 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 
3. Kilty SJ, Gaboury I. Clinical predictors of peritonsillar abscess in adults. J Otolaryngol Head Neck Surg. Apr 2008; 37(2):165-8.
4. 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)
5. 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
6. Anthonsen K; Trolle W. Treatment of peritonsillar abscess. Ugeskr Laeger. 2012; 174(6):340-3 
7. 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
8. 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
9. 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
10. 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