What is Peritonsillar Abscess?
Peritonsillar abscess, sometimes known as quinsy, is a condition where pus builds up in a specific area near the tonsils, between the tonsillar capsule and a muscle called the superior constrictor muscle. This condition was first mentioned in the 14th century, and it became more widely recognized in the 20th century when antibiotics became common.
In terms of the body’s layout, the peritonsillar space is the area that contains soft, connective tissue and is located between the tonsils and the superior constrictor muscle. This space has front and back boundaries made up by the anterior and posterior tonsillar pillars, respectively. The upper part of this space is connected to a structure called the torus tubarius, while a structure called the pyriform sinus forms the lower boundary.
Since the peritonsillar space contains loose connective tissue, it’s very prone to forming an abscess, or a pocket of pus, if an infection occurs. Understanding this is key if a peritonsillar abscess develops, as it informs the treatment required to address the condition.
What Causes Peritonsillar Abscess?
Peritonsillar abscess, a type of throat infection, usually happens after a bout of tonsillitis, another type of throat infection. Occasionally, it can result from a condition called infectious mononucleosis. There’re also cases where it can just appear out of the blue without any previous complaint of a sore throat. Activities like smoking and having chronic gum disease could also lead to a peritonsillar abscess, also known as ‘quinsy’.
The bacterial cultures (tests done to identify bacteria) for this abscess typically shows the presence of a type of bacteria known as Group A beta-hemolytic streptococcus. Other bacteria that are often found are types of staph, pneumococcus, and hemophilus bacteria. It’s not common, but sometimes, bacteria like Lactobacillus and other forms like Actinomyces and Micrococcus might also be present. Usually, the bacterial cultures show a mix of different bacteria, including those that need oxygen (aerobic) and those that don’t (anaerobic) to survive.
Risk Factors and Frequency for Peritonsillar Abscess
Peritonsillar abscess, an infection in the head and neck area, is quite common with about 1 in 10,000 people affected by it. This makes it the most frequent severe infection in the head and neck region seen in emergency departments.
It’s typical among teenagers, but anyone can get it. It doesn’t matter what your gender or race is. The frequency of this infection in the United States is 30 out of every 100,000 people aged between 5 to 59. However, it’s worth noting that this condition is rare in children under five years old.
- Peritonsillar abscess is a frequent head and neck infection.
- About 1 in 10,000 people have it, making it a common serious infection in the head and neck area seen in emergency departments.
- Teens are more likely to have it, but it can happen to anyone, regardless of gender or race.
- In the United States, it affects 30 out of 100,000 people between the ages of 5 to 59.
- It’s rare in children under five years old.
Signs and Symptoms of Peritonsillar Abscess
Throat pain that gets worse over time is a common symptom in this case, commonly on one side of the throat. The patient may also feel a corresponding earache. Swallowing can be painful, and in severe instances, the patient may even be unable to swallow their own saliva. This can cause bad breath due to poor oral hygiene. As the condition progresses, the person’s speech may become muffled and they may experience neck pain due to inflamed lymph nodes in the neck. Opening the mouth wide might be difficult due to muscle inflammation near the throat. Other symptoms can include:
- Fever with chills and shivers
- Tiredness
- Body aches
- Headache
- Nausea
- Constipation
If the inflammation worsens, an abscess (a swollen area filled with pus) can extend to nearby areas, causing difficulty in breathing.
On physical examination, the patient often looks sick and has a fever. Signs can range from a swollen throat with a small bulge on one side to severe dehydration and infection. Furthermore, opening the mouth may be difficult to varying degrees. The tonsil seems compressed and shifts downward and inward, and sometimes turns pale when lightly touched. The small piece of tissue hanging from the back of the mouth (uvula) often appears swollen and pushes to the other side. There may be a noticeable bulge on the soft part of the roof of your mouth (palate) and in front of the tonsil. Mucus may be seen covering the tonsil area.
Swelling in the neck area, particularly in the jugulodigastric lymph nodes, is observed. The patient may also keep their neck tilted towards the affected side.
Testing for Peritonsillar Abscess
A peritonsillar abscess— which is a pocket filled with pus that forms near your tonsils— can be diagnosed by inspecting for various clinical signs. The major signs that doctors look out for are one-sided swelling around the tonsil area, a sore throat that doesn’t seem to resolve with a noticeable enlargement on one tonsil, or a bulge on one side of the soft part on the roof of the mouth that forces the neighboring tonsil forward.
After a physical examination, the doctor might also order laboratory tests. The complete blood count (CBC) is a blood test used to evaluate your overall health and detect a wide range of disorders, including an infection like a peritonsillar abscess. The doctor also checks your electrolyte levels, essential minerals that help balance the amount of water in your body and the acidity of your blood. Another test you may be asked to undergo is a heterophile antibody test. This is done to rule out the possibility of infectious mononucleosis, which is a type of infection that can show similar symptoms. Additionally, a pus culture sensitivity test might be carried out. This involves taking a sample of the pus from the abscess to identify the type of bacteria causing the infection. If the doctor suspects sepsis – a life-threatening condition caused by the body’s response to an infection – a C-reactive protein blood culture might be required. This is a blood test that checks for inflammation in the body, which can be an indicator of serious infections.
Your doctor might also need to carry out some imaging tests. These could include an X-ray of the neck’s soft tissue, which can help locate the abscess or show its size. Other times, a contrast-enhanced CT scan might be recommended, especially for young patients or in cases where complications are expected, such as the development of a closely related conditions called parapharyngeal or retropharyngeal abscesses. Intraoral ultrasonography, on the other hand, is an imaging procedure that utilizes sound waves to create images of the inside of your mouth. This non-invasive method can help differentiate between a swollen tonsil and a peritonsillar abscess. It can also be useful in pinpointing the exact location of the abscess for drainage purposes.
Treatment Options for Peritonsillar Abscess
If you are diagnosed with an inflamed tonsil or a peritonsillar abscess, you’ll likely be hospitalized for treatment. The first step in treatment involves giving you fluids through an IV because dehydration is common with this condition.
You’ll also be given antibiotics that are effective against a range of bacteria, including Gram-positive, Gram-negative, and bacteria that doesn’t need oxygen to survive (anaerobes). The antibiotics you might receive include penicillins like ampicillin or amoxicillin, often combined with metronidazole or clindamycin. Once you start feeling better and can eat and drink on your own, you’ll switch to oral antibiotics.
Drug treatments to manage pain and bring down your fever will also be part of your treatment plan. Steroids, which help reduce inflammation, might also be used as part of your treatment, but this is still debated among doctors. Research suggests that a single dose of a steroid called IV dexamethasone can cut down your hospital stay and make your symptoms less severe.
Medications alone can clear up the inflammation around your tonsils, but if you have a peritonsillar abscess, draining the abscess will be necessary along with the drug treatment.
Medical professionals often use a process called aspiration to both diagnose and treat a peritonsillar abscess. They use a needle to draw out the pus, which can then be sent for testing. It’s possible that you won’t require further treatment after aspiration.
If the abscess needs to be drained, the procedure is typically done while you’re sitting up to prevent any pus from being inhaled. A local anesthetic will be used to numb your mouth and throat. The doctor will then make a small cut at the place where the abscess is most pronounced. They will break up any small pockets of pus using special forceps. The opening will be left to drain, and you’ll gargle with a saltwater solution to help get rid of any remaining pus.
Younger patients, or those with abscesses in unusual locations might need to undergo this procedure under general anesthesia.
What else can Peritonsillar Abscess be?
The conditions listed below are ones that may present similarly to certain mouth and throat-related health issues:
- Dental infections
- Epiglottitis (swelling of the flap at the base of your tongue)
- EBV infectious mononucleosis (a type of viral infection)
- Pharyngitis (sore throat)
- Retropharyngeal abscess (a deep neck infection)
Possible Complications When Diagnosed with Peritonsillar Abscess
Rare complications of a peritonsillar abscess can include:
- An abscess behind the pharynx (parapharyngeal abscess)
- An abscess behind the throat (retropharyngeal abscess)
- Swelling in the voice box that can affect breathing (laryngeal edema)
- In rare cases, pneumonia or a lung abscess if an abscess bursts and is inhaled
- Sepsis, a serious infection that spreads through the bloodstream
