Peritonsillar Abscess (Quinsy)

What a peritonsillar abscess is

The tonsils sit in a pocket at the back of the throat. Behind each one is a thin layer of loose tissue and then the throat muscles. In a peritonsillar abscess, infection spreads from the tonsil, or from small mucus glands above it, into this space. Pus collects and pushes the tonsil inward and the soft palate forward.

It is the most common deep infection of the head and neck. The usual germs are a mix of streptococci, especially group A strep, staphylococci and anaerobic bacteria.

Quinsy symptoms in adults and teenagers

Symptoms usually follow a sore throat or tonsillitis that seemed to be improving, or that worsens despite antibiotics. Over 2 to 5 days:

• Severe sore throat, much worse on one side. This one-sidedness is the key clue.
• Painful swallowing, sometimes so severe that you cannot swallow your own saliva and start drooling.
• Trismus: spasm of the jaw muscles makes it hard to open the mouth.
• Muffled "hot potato" voice.
• Ear pain on the same side, especially when swallowing.
• Fever, chills and feeling generally unwell.
• Bad breath and swollen, tender glands in the neck.
• Neck stiffness or tilting the head toward the affected side.

When the throat is examined, one tonsil is swollen and pushed toward the middle, the soft palate above it bulges, and the uvula (the dangling tissue at the back of the mouth) is pushed toward the opposite side.

Peritonsillar abscess vs tonsillitis

Peritonsillar cellulitis, infection of the same area without a pus pocket yet, looks similar but has no fluctuant swelling. It is treated with antibiotics alone.

Causes and risk factors

• Acute tonsillitis or strep throat, especially if not treated or partly treated
• Infectious mononucleosis (glandular fever)
• Smoking
• Chronic or repeated tonsillitis
• Dental infections and gum disease

It can occur even in people who have not had a recent sore throat.

Diagnosis

Diagnosis is usually made by examining the throat. Doctors may also use:

• Needle aspiration: drawing out pus both confirms and treats the abscess.
• Ultrasound inside the mouth or through the neck, to confirm a pus pocket.
• CT scan when the mouth cannot be opened enough for examination, or if infection may have spread deeper into the neck.
• Blood tests: a raised white cell count (leukocytosis) and CRP are common but not needed for diagnosis. A mononucleosis test may be done in young adults.

Treatment

1. Drainage: after numbing the throat, a doctor drains the pus with a needle or makes a small incision. This brings fast relief of pain and jaw spasm. It may need repeating if pus builds up again.
2. Antibiotics: usually started by injection or IV if you cannot swallow, then switched to tablets to complete around 10 to 14 days. Penicillin combined with an anti-anaerobic antibiotic, or amoxicillin-clavulanate, are typical choices.
3. Steroids: a single dose may be given to reduce swelling and pain.
4. Pain relief and fluids: acetaminophen (paracetamol) or ibuprofen, and IV fluids if dehydrated.
5. Tonsillectomy: usually considered after a second episode or with repeated tonsillitis. Occasionally done urgently ("quinsy tonsillectomy") if drainage is not possible.

Most people are treated as outpatients. Admission is needed if you cannot drink, are very unwell, or the airway is at risk.

Complications

These are uncommon with prompt treatment but serious:

• airway obstruction
• spread into the deep spaces of the neck (deep neck infection) or chest (mediastinitis)
• aspiration of pus into the lungs if the abscess bursts
• a clot in the jugular vein (Lemierre syndrome)
• dehydration

Recovery and outlook

Pain and swallowing improve noticeably within 24 hours of drainage. Most people return to normal activities within a week. The abscess comes back in roughly 1 in 10 to 1 in 5 people, more often in those with repeated tonsillitis. Stopping smoking lowers the risk.

Frequently asked questions

What are the symptoms of quinsy in adults?

Adults with quinsy have a severe sore throat, much worse on one side, painful swallowing, difficulty opening the mouth, a muffled voice, ear pain on the same side, fever and swollen neck glands. Symptoms often worsen a few days after a sore throat seemed to be getting better.

Is leukocytosis a symptom of peritonsillar abscess?

Leukocytosis, a raised white blood cell count, is a common blood finding in peritonsillar abscess, but it is a lab result rather than a symptom you can feel. It is not needed for diagnosis, which rests on the throat examination and finding pus.

Can a peritonsillar abscess go away on its own?

Rarely, an abscess bursts by itself, but waiting is unsafe because the swelling can block the airway or spread into the neck. It needs prompt medical drainage and antibiotics. Do not try to burst it yourself.

Is a peritonsillar abscess contagious?

The abscess itself is not contagious, but the strep throat or tonsillitis that often leads to it can spread to others. Hand washing and not sharing cups help protect people close to you.

Will I need my tonsils out after quinsy?

Not usually after one episode. Doctors often recommend tonsillectomy after a second peritonsillar abscess, or after one if you also have frequent tonsillitis.