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Peritonsillar Abscess
ALTERNATIVE NAMES: Tonsillar abscess; quinsy.
DEFINITION: Abscess formation in the peritonsillar space.
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WHAT IS GOING ON IN MY BODY? The tonsils are part of a ring of tissue, Waldeyer's ring, at the back part of the pharynx. Waldeyer's ring consists of the palatine tonsils, lingual tonsils (tonsillar tissue at the back of the tongue), the adenoid (tonsil-like tissue in the back of the nasal cavity), and the lateral pharyngeal bands (bands of tonsil-like tissue on the back wall of the throat behind the tonsils). One of the roles of Waldeyer's ring tissue is to secrete antibody which binds and inactivates viruses, bacteria, and other toxins. As they are involved in the infection-fighting process, they too can become infected. The tonsil sits in the tonsillar fossa, which is an oval-shaped bed formed of the muscles of the side of the throat. Between the tonsil and the underlying muscles is a potential space termed the peritonsillar space that contains a loose tissue called fascia and is traversed by blood vessels supplying the tonsil and lymphatics. Lymphatic vessels connect the lymphatic drainage system of the tonsil to the neck lymphatics, including the neck lymph nodes. This lymphatic system explains why with tonsillar infection there is often swelling and tenderness of the lymph nodes in the upper part of the neck.
The peritonsillar abscess forms when there is an infection within the tonsil itself that breaks out of the tonsil into the space between the tonsil and the underlying musculature. This infection then forms a gradually enlarging abscess.
WHAT ARE THE SIGNS AND SYMPTOMS? Most individuals with a peritonsillar abscess have had a sore throat for a number of days which dramatically increases in its severity. It most often involves only one side and almost never occurs after a previous tonsillectomy. These individuals often have a mild to significant fever and severe unilateral throat pain. One of the main symptoms is difficulty opening the mouth (trismus). The pain with swallowing can be quite severe to the point where the patient completely avoids any oral intake and starts to become dehydrated. The individual may often complain of significant ear pain on the affected side.
When someone with a peritonsillar abscess is examined, they usually have fairly prominent lymph node involvement in the upper part of the neck just below the angle of the jaw. There are varying degrees of difficulty opening the mouth. Since the abscess collection is between the tonsil and the muscles of the throat, the tonsil is often displaced toward the middle of the throat and downward. The uvula, which hangs down from the center part of the palate, is pushed to the opposite side, and there are varying degrees of swelling and redness of the palate.
WHAT ARE THE CAUSES AND RISKS? As mentioned above, the main cause is pharyngitis or tonsillitis. A previous history of a peritonsillar abscess or chronic tonsillitis can increase an individual's risk of developing an abscess.
HOW TO PREVENT THE DISEASE: The only real way to prevent the disease is to have the tonsils removed. Individuals even on appropriate antibiotics can develop a peritonsillar abscess – usually it develops several days after a sore throat has been present. Most viral sore throats resolve in 24 to 48 hours. Therefore, if a sore throat is persisting for more than about two days, it would be prudent to seek medical attention.
HOW IS IT DIAGNOSED? It is diagnosed mostly based on physical examination. Sometimes it is difficult to tell if it is just significant inflammation of the soft tissues of the palate (peritonsillar cellulitis) or if an abscess is in fact developing. Placement of a needle into the peritonsillar space can sometimes be a useful way to try to make this differentiation. If there is significant concern, a CT scan with intravenous dye could be employed.
WHAT ARE THE LONG-TERM EFFECTS? One of the main concerns with peritonsillar abscess is the spread of the infection to adjacent areas in the neck. It can extend into an adjacent space termed the parapharyngeal space, which houses the carotid artery, jugular vein, vagus nerve, spinal accessory nerve, and glossopharyngeal nerve. Prolonged infection in this space can weaken the carotid artery and jugular vein, with resultant life-threatening hemorrhage. The infection can also spread into the retropharyngeal space or the pre-vertebral space. If it gets into the retropharyngeal space, it can then descend into the chest and cause mediastinitis (infection in the soft tissue around the heart, esophagus, and trachea) or empyema (pus collection around the lungs). If it gets into the pre-vertebral space, it can descend through the thorax and into the abdominal cavity. Peritonsillar abscess can also cause an infected clot to form in the jugular vein, with spread of small infected clots throughout the body, particularly the lungs.
AM I PUTTING OTHERS AT RISK? No.
WHAT ARE THE TREATMENTS? If caught early in the cellulitis phase, it usually responds to high-dose oral antibiotics and oral steroids. Oral steroids have to be used judiciously because they can mask the spread of the infection. Once it has formed the abscess stage, it can be managed in one of several different manners. Some patients will respond to oral antibiotics, analgesics, and repeat needle aspiration of the abscess. The most time-honored form of therapy is opening up the abscess cavity and draining it. This can easily be done in the office setting, but at times, because of significant difficulty opening the mouth, young age, or previous peritonsillar abscess, it is probably best done in the operating room. If the patient goes to surgery, most would advocate removal of the tonsils (quinsy tonsillectomy). The decision to proceed with tonsillectomy depends upon the clinical situation. In the literature, those individuals who have not had a previous history of recurrent or chronic tonsillitis or peritonsillar abscess can have their abscess cavity drained, and do not need to go on to mandatory tonsillectomy at a later time. However, if the patient has had a previous abscess or history of chronic or recurrent tonsillitis, then either the abscess can be drained under local anesthetic followed in several weeks by removal of the tonsils, or they can proceed to immediate quinsy tonsillectomy. Because of the risk of spread of the infection into other compartments in the chest, abdomen, and neck, this is not a disease that in general will respond curatively to intravenous or oral antibiotics.
WHAT ARE THE SIDE EFFECTS TO THE TREATMENTS? If the abscess is needle aspirated, there are very few side effects. Usually the patient dramatically feels much better once it is drained. Opening the abscess cavity with a knife also has very few side effects. There may be some temporary bleeding. If removal of the tonsil to drain the abscess (quinsy tonsillectomy) is employed, it can be complicated by a post-operative hemorrhage in about 3% of patients. Pain usually rapidly subsides if the abscess is drained through a small incision or needle aspirated. However, significant painful throat lasts for seven to 10 days following tonsillectomy.
WHAT HAPPENS AFTER TREATMENT? If treatment is successful, the trismus, ear pain, and sore throat rapidly improve, and the patient is much less toxic and returns rapidly to a healthy state.
HOW DO I MONITOR THE DISEASE? Any unrelenting sore throat complicated by difficulty opening the mouth, severe ear pain, severe difficulty swallowing, and inability to maintain sufficient oral intake must be immediately examined. Any delay can put the patient at risk for complications from spread of the infection.
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