Peritonsillar abscess

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Peritonsillar abscess
Other namesQuinsy, quinsey
PeritonsilarAbsess.jpg
Right sided peritonsillar abscess
Specialty Otorhinolaryngology
Symptoms Fever, throat pain, trouble opening the mouth, change to the voice [1]
Complications Blockage of the airway, aspiration pneumonitis [1]
CausesMultiple types of bacteria [1]
Risk factors Streptococcal pharyngitis [1]
Diagnostic method Based on the symptoms [1]
Differential diagnosis Retropharyngeal abscess, infectious mononucleosis, epiglottitis, cancer [1]
TreatmentRemove pus, antibiotics, fluids, pain medication, steroids [1]
Frequency~3 per 10,000 per year (USA) [1]

Peritonsillar abscess (PTA), also known as quinsy, is an accumulation of pus due to an infection behind the tonsil. [2] Symptoms include fever, throat pain, trouble opening the mouth, and a change to the voice. [1] Pain is usually worse on one side. [1] Complications may include blockage of the airway or aspiration pneumonitis. [1]

Contents

PTA is typically due to infection by a number of types of bacteria. [1] Often it follows streptococcal pharyngitis. [1] They do not typically occur in those who have had a tonsillectomy. [1] Diagnosis is usually based on the symptoms. [1] Medical imaging may be done to rule out complications. [1]

Treatment is by removing the pus, antibiotics, sufficient fluids, and pain medication. [1] Steroids may also be useful. [1] Admission to hospital is generally not needed. [1] In the United States about 3 per 10,000 people per year are affected. [1] Young adults are most commonly affected. [1]

Signs and symptoms

Physical signs of a peritonsillar abscess include redness and swelling in the tonsillar area of the affected side and swelling of the jugulodigastric lymph nodes. The uvula may be displaced towards the unaffected side. [3]

Unlike tonsillitis, which is more common in children, PTA has a more even age spread, from children to adults. Symptoms start appearing two to eight days before the formation of an abscess. A progressively severe sore throat on one side and pain during swallowing (odynophagia) usually are the earliest symptoms. As the abscess develops, persistent pain in the peritonsillar area, fever, a general sense of feeling unwell, headache, and a distortion of vowels informally known as "hot potato voice" may appear. Neck pain associated with tender, swollen lymph nodes, referred ear pain and foul breath are also common. While these signs may be present in tonsillitis itself, a PTA should be specifically considered if there is limited ability to open the mouth (trismus). [3]

Complications

While most people recover uneventfully, there is a wide range of possible complications. [4] These may include: [1]

Difficulty swallowing can lead to decreased oral intake and dehydration.

Causes

PTA usually arises as a complication of an untreated or partially treated episode of acute tonsillitis. The infection, in these cases, spreads to the peritonsillar area (peritonsillitis). This region comprises loose connective tissue and is hence susceptible to formation of an abscess. PTA can also occur de novo . Both aerobic and anaerobic bacteria can be causative. Commonly involved aerobic pathogens include Streptococcus, Staphylococcus and Haemophilus . The most common anaerobic species include Fusobacterium necrophorum , Peptostreptococcus , Prevotella species , and Bacteroides . [5] [6] [7] [8] [9] [10]

Diagnosis

Peritonsillar abscess on the person's right as seen on CT imaging Peritonsilarabs.png
Peritonsillar abscess on the person's right as seen on CT imaging

Diagnosis is usually based on the symptoms. [1] Medical imaging may be done to rule out complications. [1] Medical imaging may include CT scan, MRI, or ultrasound is also useful in diagnosis. [1]

Treatment

Medical treatment with antibiotics, volume repletion with fluids, and pain medication is usually adequate, although in cases where airway obstruction or systemic sepsis occurs, surgical drainage may be necessary. [1] [11] Corticosteroids may also be useful. [1] Admission to hospital is generally not needed. [1]

Medication

The infection is frequently penicillin resistant. [1] There are a number of antibiotics options including amoxicillin/clavulanate, ampicillin/sulbactam, clindamycin, or metronidazole in combination with benzylpenicillin (penicillin G) or penicillin V. [1] [12] Piperacillin/tazobactam may also be used. [1]

Surgery

The pus can be removed by a number of methods including needle aspiration, incision and drainage, and tonsillectomy. [1] Incision and drainage may be associated with a lower chance of recurrence than needle aspiration but the evidence is very uncertain. Needle aspiration may be less painful but again the evidence is very uncertain. [13]

Treatment can also be given while a patient is under anesthesia, but this is usually reserved for children or anxious patients. Tonsillectomy can be indicated if a patient has recurring peritonsillar abscesses or a history of tonsillitis. For patients with their first peritonsillar abscess most ENT-surgeons prefer to "wait and observe" before recommending tonsillectomy. [14]

Epidemiology

It is a commonly encountered otorhinolaryngological (ENT) emergency. [14]

The number of new cases per year of peritonsillar abscess in the United States has been estimated approximately at 30 cases per 100,000 people. [15] In a study in Northern Ireland, the number of new cases was 10 cases per 100,000 people per year. [16] In Denmark, the number of new cases is higher and reaches 41 cases per 100,000 people per year. [17] Younger children who develop a peritonsillar abscess are often immunocompromised and in them, the infection can cause airway obstruction. [18]

Etymology

The condition is often referred to as "quincy", "quinsy", [19] or "quinsey", anglicised versions of the French word esquinancie which was originally rendered as squinsey and subsequently quinsy. [20]

Notable cases

The ancient Roman goddess Angerona was claimed to cure quinsy (Latin angina) in humans and sheep. [28] [29]

Related Research Articles

<span class="mw-page-title-main">Abscess</span> Localized collection of pus that has built up within the tissue of the body

An abscess is a collection of pus that has built up within the tissue of the body. Signs and symptoms of abscesses include redness, pain, warmth, and swelling. The swelling may feel fluid-filled when pressed. The area of redness often extends beyond the swelling. Carbuncles and boils are types of abscess that often involve hair follicles, with carbuncles being larger. A cyst is related to an abscess, but it contains a material other than pus, and a cyst has a clearly defined wall.

<span class="mw-page-title-main">Brain abscess</span> Medical condition

Brain abscess is an abscess within the brain tissue caused by inflammation and collection of infected material coming from local or remote infectious sources. The infection may also be introduced through a skull fracture following a head trauma or surgical procedures. Brain abscess is usually associated with congenital heart disease in young children. It may occur at any age but is most frequent in the third decade of life.

<span class="mw-page-title-main">Streptococcal pharyngitis</span> Medical condition

Streptococcal pharyngitis, also known as streptococcal sore throat, is pharyngitis caused by Streptococcus pyogenes, a gram-positive, group A streptococcus. Common symptoms include fever, sore throat, red tonsils, and enlarged lymph nodes in the front of the neck. A headache and nausea or vomiting may also occur. Some develop a sandpaper-like rash which is known as scarlet fever. Symptoms typically begin one to three days after exposure and last seven to ten days.

<span class="mw-page-title-main">Lemierre's syndrome</span> Medical condition

Lemierre's syndrome is infectious thrombophlebitis of the internal jugular vein. It most often develops as a complication of a bacterial sore throat infection in young, otherwise healthy adults. The thrombophlebitis is a serious condition and may lead to further systemic complications such as bacteria in the blood or septic emboli.

<span class="mw-page-title-main">Trismus</span> Condition of limited jaw mobility

Trismus is a condition of restricted opening of the mouth. The term was initially used in the setting of tetanus. Trismus may be caused by spasm of the muscles of mastication or a variety of other causes. Temporary trismus occurs much more frequently than permanent trismus. It is known to interfere with eating, speaking, and maintaining proper oral hygiene. This interference, specifically with an inability to swallow properly, results in an increased risk of aspiration. In some instances, trismus presents with altered facial appearance. The condition may be distressing and painful. Examination and treatments requiring access to the oral cavity can be limited, or in some cases impossible, due to the nature of the condition itself.

<span class="mw-page-title-main">Pharyngitis</span> Inflammation of the back of the throat

Pharyngitis is inflammation of the back of the throat, known as the pharynx. It typically results in a sore throat and fever. Other symptoms may include a runny nose, cough, headache, difficulty swallowing, swollen lymph nodes, and a hoarse voice. Symptoms usually last 3–5 days, but can be longer depending on cause. Complications can include sinusitis and acute otitis media. Pharyngitis is a type of upper respiratory tract infection.

<span class="mw-page-title-main">Sore throat</span> Medical condition

Sore throat, also known as throat pain, is pain or irritation of the throat. Usually, causes of sore throat include:

<span class="mw-page-title-main">Palatine tonsil</span> Lymphoid organs at the back of the throat on both sides

Palatine tonsils, commonly called the tonsils and occasionally called the faucial tonsils, are tonsils located on the left and right sides at the back of the throat, which can often be seen as flesh-colored, pinkish lumps. Tonsils only present as "white lumps" if they are inflamed or infected with symptoms of exudates and severe swelling.

<span class="mw-page-title-main">Tonsillectomy</span> Surgical removal of the tonsils

Tonsillectomy is a surgical procedure in which both palatine tonsils are fully removed from the back of the throat. The procedure is mainly performed for recurrent tonsillitis, throat infections and obstructive sleep apnea (OSA). For those with frequent throat infections, surgery results in 0.6 fewer sore throats in the following year, but there is no evidence of long term benefits. In children with OSA, it results in improved quality of life.

<span class="mw-page-title-main">Mastitis</span> Medical condition

Mastitis is inflammation of the breast or udder, usually associated with breastfeeding. Symptoms typically include local pain and redness. There is often an associated fever and general soreness. Onset is typically fairly rapid and usually occurs within the first few months of delivery. Complications can include abscess formation.

<span class="mw-page-title-main">Cellulitis</span> Bacterial infection of the inner layers of the skin called the dermis

Cellulitis is usually a bacterial infection involving the inner layers of the skin. It specifically affects the dermis and subcutaneous fat. Signs and symptoms include an area of redness which increases in size over a few days. The borders of the area of redness are generally not sharp and the skin may be swollen. While the redness often turns white when pressure is applied, this is not always the case. The area of infection is usually painful. Lymphatic vessels may occasionally be involved, and the person may have a fever and feel tired.

<span class="mw-page-title-main">Tonsillitis</span> Inflammation of the tonsils

Tonsillitis is inflammation of the tonsils in the upper part of the throat. It can be acute or chronic. Acute tonsillitis typically has a rapid onset. Symptoms may include sore throat, fever, enlargement of the tonsils, trouble swallowing, and enlarged lymph nodes around the neck. Complications include peritonsillar abscess (Quinsy).

<span class="mw-page-title-main">Herpangina</span> Medical condition

Herpangina, also called mouth blisters, is a painful mouth infection caused by coxsackieviruses. Usually, herpangina is produced by one particular strain of coxsackie virus A, but it can also be caused by coxsackievirus B or echoviruses. Most cases of herpangina occur in the summer, affecting mostly children. However, it occasionally occurs in adolescents and adults. It was first characterized in 1920.

<span class="mw-page-title-main">Tonsil stones</span> Mineralized debris within the crevices of the tonsils

Tonsil stones, also known as tonsilloliths, are mineralizations of debris within the crevices of the tonsils. When not mineralized, the presence of debris is known as chronic caseous tonsillitis (CCT). Symptoms may include bad breath, foreign body sensation, sore throat, pain or discomfort with swallowing, and cough. Generally there is no pain, though there may be the feeling of something present. The presence of tonsil stones may be otherwise undetectable, however some people have reported seeing white material in the rear of their throat.

<span class="mw-page-title-main">Epiglottitis</span> Inflammation of the epiglottis

Epiglottitis is the inflammation of the epiglottis—the flap at the base of the tongue that prevents food entering the trachea (windpipe). Symptoms are usually rapid in onset and include trouble swallowing which can result in drooling, changes to the voice, fever, and an increased breathing rate. As the epiglottis is in the upper airway, swelling can interfere with breathing. People may lean forward in an effort to open the airway. As the condition worsens, stridor and bluish skin may occur.

<span class="mw-page-title-main">Mastoiditis</span> Middle ear disease

Mastoiditis is the result of an infection that extends to the air cells of the skull behind the ear. Specifically, it is an inflammation of the mucosal lining of the mastoid antrum and mastoid air cell system inside the mastoid process. The mastoid process is the portion of the temporal bone of the skull that is behind the ear. The mastoid process contains open, air-containing spaces. Mastoiditis is usually caused by untreated acute otitis media and used to be a leading cause of child mortality. With the development of antibiotics, however, mastoiditis has become quite rare in developed countries where surgical treatment is now much less frequent and more conservative, unlike former times.

<span class="mw-page-title-main">Ludwig's angina</span> Form of severe cellulitis of the mouth floor

Ludwig's angina is a type of severe cellulitis involving the floor of the mouth and is often caused by bacterial sources. Early in the infection, the floor of the mouth raises due to swelling, leading to difficulty swallowing saliva. As a result, patients may present with drooling and difficulty speaking. As the condition worsens, the airway may be compromised and hardening of the spaces on both sides of the tongue may develop. Overall, this condition has a rapid onset over a few hours.

<i>Eikenella corrodens</i> Species of bacterium

Eikenella corrodens is a Gram-negative facultative anaerobic bacillus that can cause severe invasive disease in humans. It was first identified by M. Eiken in 1958, who called it Bacteroides corrodens. E. corrodens is a rare pericarditis associated pathogen. It is a fastidious, slow growing, human commensal bacillus, capable of acting as an opportunistic pathogen and causing abscesses in several anatomical sites, including the liver, lung, spleen, and submandibular region. E. corrodens could independently cause serious infection in both immunocompetent and immunocompromised hosts.

Mouth infections, also known as oral infections, are a group of infections that occur around the oral cavity. They include dental infection, dental abscess, and Ludwig's angina. Mouth infections typically originate from dental caries at the root of molars and premolars that spread to adjacent structures. In otherwise healthy patients, removing the offending tooth to allow drainage will usually resolve the infection. In cases that spread to adjacent structures or in immunocompromised patients, surgical drainage and systemic antibiotics may be required in addition to tooth extraction. Since bacteria that normally reside in the oral cavity cause mouth infections, proper dental hygiene can prevent most cases of infection. As such, mouth infections are more common in populations with poor access to dental care or populations with health-related behaviors that damage one's teeth and oral mucosa. This is a common problem, representing nearly 36% of all encounters within the emergency department related to dental conditions.

<span class="mw-page-title-main">Tubo-ovarian abscess</span> One of the late complications of pelvic inflammatory disease

A tubo-ovarian abscess (TOA) is one of the late complications of pelvic inflammatory disease (PID) and can be life-threatening if the abscess ruptures and results in sepsis. It consists of an encapsulated or confined pocket of pus with defined boundaries that forms during an infection of a fallopian tube and ovary. These abscesses are found most commonly in reproductive age women and typically result from upper genital tract infection. It is an inflammatory mass involving the fallopian tube, ovary and, occasionally, other adjacent pelvic organs. A TOA can also develop as a complication of a hysterectomy.

References

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  2. ↑ "Tonsillar Cellulitis and Tonsillar Abscess - Ear, Nose, and Throat Disorders - Merck Manuals Consumer Version". Merck Manuals Consumer Version. Archived from the original on 25 October 2017. Retrieved 24 October 2017.
  3. 1 2 "Peritonsillar Abscess". The Lecturio Medical Concept Library. Retrieved 4 October 2021.
  4. ↑ Klug TE, Greve T, Hentze M (2020). "Complications of peritonsillar abscess". Annals of Clinical Microbiology and Antimicrobials. 19 (1): 32. doi: 10.1186/s12941-020-00375-x . PMC   7391705 . PMID   32731900.
  5. ↑ Brook I, Frazier EH, Thompson DH (March 1991). "Aerobic and anaerobic microbiology of peritonsillar abscess". The Laryngoscope. 101 (3): 289–92. doi:10.1288/00005537-199103000-00012. PMID   2000017. S2CID   23505346.
  6. ↑ Sakae FA, Imamura R, Sennes LU, Araújo Filho BC, Tsuji DH (2006). "Microbiology of peritonsillar abscesses". Brazilian Journal of Otorhinolaryngology. 72 (2): 247–51. doi: 10.1016/S1808-8694(15)30063-X . PMC   9445683 . PMID   16951860.
  7. ↑ Gavriel H, Lazarovitch T, Pomortsev A, Eviatar E (January 2009). "Variations in the microbiology of peritonsillar abscess". European Journal of Clinical Microbiology & Infectious Diseases. 28 (1): 27–31. doi:10.1007/s10096-008-0583-6. PMID   18612664. S2CID   26365493.
  8. ↑ Sunnergren O, Swanberg J, Mölstad S (2008). "Incidence, microbiology and clinical history of peritonsillar abscesses". Scandinavian Journal of Infectious Diseases. 40 (9): 752–5. doi:10.1080/00365540802040562. PMID   19086341. S2CID   40973972.
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  10. ↑ Powell EL, Powell J, Samuel JR, Wilson JA (September 2013). "A review of the pathogenesis of adult peritonsillar abscess: time for a re-evaluation". The Journal of Antimicrobial Chemotherapy. 68 (9): 1941–50. CiteSeerX   10.1.1.1001.2391 . doi:10.1093/jac/dkt128. PMID   23612569.
  11. ↑ Johnson RF (October 2017). "Emergency department visits, hospitalizations, and readmissions of patients with a peritonsillar abscess". Laryngoscope. 127 (Suppl 5): S1–S9. doi:10.1002/lary.26777. PMID   28782104. S2CID   206205296.
  12. ↑ Visvanathan V, Nix P (April 2010). "National UK survey of antibiotics prescribed for acute tonsillitis and peritonsillar abscess". The Journal of Laryngology and Otology. 124 (4): 420–3. doi:10.1017/S0022215109991939. PMID   19930783. S2CID   27721802.
  13. ↑ Chang BA, Thamboo A, Burton MJ, Diamond C, Nunez DA, et al. (Cochrane ENT Group) (December 2016). "Needle aspiration versus incision and drainage for the treatment of peritonsillar abscess". The Cochrane Database of Systematic Reviews. 2016 (12): CD006287. doi:10.1002/14651858.CD006287.pub4. PMC   6463807 . PMID   28009937.
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  15. ↑ Johnson RF, Stewart MG (June 2005). "The contemporary approach to diagnosis and management of peritonsillar abscess". Current Opinion in Otolaryngology & Head and Neck Surgery. 13 (3): 157–60. doi:10.1097/01.moo.0000162259.42115.38. PMID   15908813. S2CID   38122236.
  16. ↑ Hanna BC, McMullan R, Gallagher G, Hedderwick S (April 2006). "The epidemiology of peritonsillar abscess disease in Northern Ireland". The Journal of Infection. 52 (4): 247–53. doi:10.1016/j.jinf.2005.07.002. PMID   16125782.
  17. ↑ Ehlers Klug T, Rusan M, Fuursted K, Ovesen T (November 2009). "Fusobacterium necrophorum: most prevalent pathogen in peritonsillar abscess in Denmark". Clinical Infectious Diseases. 49 (10): 1467–72. doi: 10.1086/644616 . PMID   19842975.
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  29. ↑ "Angerona - Encyclopedia". theodora.com.
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