Peritonsillar Abscess - Causes, Symptoms, Diagnosis, and Treatment

Introduction

Cough and sore throat are common conditions of the head and neck. People develop tonsillitis - a condition in which the tonsils become swollen and painful. This condition is recurrent and more common in children. Antibiotic therapy treats the inflammation, and the condition subsides within one week.

If the tonsillitis is not treated well, it may develop further complications such as peritonsillar abscess - a painful condition characterized by the pus formation between the tonsillar capsule and superior constrictor muscle. One in every 10,000 cases is of peritonsillar abscess, which is commonly seen in young adults.

What Is an Abscess?

An abscess is a pus-filled pocket that causes discomfort and pain. The pus formation and collection can take place in any part of the body.

What Are the Types of Abscesses?

There are two types of abscess:

1. Skin Abscess: It develops under the skin.

2. Internal Abscess: It develops within the body, such as in an organ or spaces between the organs.

What Is Peritonsillar Abscess?

It is the collection of pus between the tonsillar capsule and superior constrictor muscle - peritonsillar space. The peritonsillar abscess is the most frequent and common type of infection in the head and neck region of the human body. It also occurs as a complication of tonsilitis.

What Is Peritonsillar Abscess Commonly Called?

It is also called quinsy.

Peritonsillar Abscess Is Commonly Seen in Which Age Group?

It commonly occurs in young children who are more than five years of age, teenagers, and young adults.

Where Is Peritonsillar Abscess Located?

It is present near the uvula, at the posterior or back of the mouth.

What Does Peritonsillar Abscess Look Like?

It looks like a swollen area with a reddish or pinkish appearance.

What Is the Anatomy of Peritonsillar Space?

Two tonsils are present in a depression or space between the two tonsillar pillars (front and back). The front of the anterior tonsillar pillar is called the palatoglossal arch, and the posterior tonsillar pillar is called the palatopharyngeal arch. These two pillars create a depression where the tonsils are located. The tonsils are formed before birth and then grow in size after birth till the age of seven years. Tonsils have various vaults or chamber-like shallow depressions on the surface, surrounded by a capsule and constrictor muscle. The space between the capsule and the constrictor muscle is called the peritonsillar space. This space contains loose connective tissue that makes it susceptible to infection or abscess formation.

What Causes Peritonsillar Abscess?

The cause of the peritonsillar abscess formation is unknown, but there are a few theories that explain the mechanism, such as:

1. The infection does not occur in the tonsils but in crypta magna, that spreads within the tonsillar pillars. This begins with peritonsillitis, and later on, peritonsillar abscess. This is the most accepted theory.

2. Another mechanism is the necrosis and pus within the capsule region. This creates obstruction in the minor salivary glands present in the peritonsillar space - Weber's glands and results in abscess formation.

What Bacteria Causes Peritonsillar Abscess?

There are a few bacteria that cause peritonsillar abscesses:

• Staphylococcus pyogenes or group A streptococcus.

• Staphylococcus aureus.

• Fusobacterium.

• Prevotella.

• Veillonella.

What Are the Symptoms of Peritonsillar Abscess?

• Increased pain in the throat.

• Pain while swallowing.

• Changed speech (muffled speech or “hot potato voice”).

• Neck pain.

• Trismus (inability to open mouth more than 35 mm).

• Fever with chills.

• Body pain.

• Headache.

• Respiratory infection and distress in severe cases.

• Cervical lymphadenopathy (swollen lymph nodes of head and neck region more than 1 cm).

• Torticollis (twisted neck that causes tilting of head).

How to Diagnose Peritonsillar Abscess?

1. Physical Examination: The patient may have a fever and looks dull. A bulge would be present on both or one side of the throat. The doctor will also check the mouth opening and may find a trismus of some degree. The place of the tonsil may change and is pushed downwards. The tonsil may appear pale when slightly pressed by the doctor. The uvula appears swollen.

2. Medical History: The patient will have a history of acute tonsillitis and/or sore throat before the abscess formation.

3. Lab Tests: Different lab tests may be required to confirm the diagnosis, such as complete blood count (CBC), heterophile antibody test, and pus culture.

4. Imaging Tests: X-ray of the neck, computed tomography of the patient if young in age, and intra-oral ultrasound are done to detect the exact location of the abscess and the difference between simple infection and peritonsillar abscess.

How to Treat Peritonsillar Abscess?

The pus present in the peritonsillar region is drained out by two different methods as mentioned below:

1. Needle Aspiration Method:

• A topical anesthetic is applied to the palate area in the mouth.

• A local anesthetic of 6 to 10ml of one to two percent of Lidocaine with Epinephrine is injected.

• The tongue of the patient is retracted with a tongue depressor.

• An 18-gauge needle with a syringe is inserted and aspirated to drain out the pus.

2. Incision and Drainage Method:

• A topical anesthetic is applied to the palate area in the mouth.

• A local anesthetic of 6 to 10ml of one to two percent of Lidocaine with Epinephrine is injected.

• The tongue of the patient is retracted with a tongue depressor.

• An incision is made on the abscess area at a point where the maximum bulge is present.

• Quinsy forceps or a guarded blade are inserted into the abscess area.

• The area is left open so that the pus drains out on its own.

• The patient is asked to gargle with sodium chloride solution.

3. Tonsillectomy: It is a rarely performed procedure in which the tonsils are removed permanently. This is indicated in patients who have a frequent recurrence of tonsillitis.

4. Medications: Antibiotics are given through injections and/or orally based on the type of causative microorganism. It is important to identify the causative bacteria through pus culture before prescribing the antibiotic therapy that lasts for 10 to 14 days. Commonly prescribed antibiotics are:

• Penicillin G.

• Ampicillin.

• Third-generation Cephalosporin and Metronidazole.

• Piperacillin.

Analgesics (painkillers) and antipyretics are given to relieve pain and fever symptoms.

How Long Does It Take for Peritonsillar Abscess to Heal?

After the surgical treatment, it takes up to one week to heal.

What Happens to Untreated Peritonsillar Abscess?

If the abscess is not drained out, then it can cause further serious complications such as:

• Respiratory and lung infections.

• Airway obstruction or blockage.

• Aspiration pneumonitis (abscess in the lungs).

• Spread of infection into deep tissues and bone.

• Septic necrosis (a condition of bone due to poor blood supply).

• Rheumatic fever (a disease that affects the heart, joints, skin, etc.).

When Is Peritonsillar Abscess Not Contagious Anymore?

If the fever subsides and the antibiotics are taken for one day, then the peritonsillar abscess becomes non-contagious.

Conclusion

The peritonsillar abscess has an unknown cause but can be prevented by treating early signs and symptoms of sore throat and/or tonsillitis. It is the most frequent and common type of infection in the head and neck region and is a complication of tonsilitis. If pus formation occurs, needle aspiration drainage must be done because it is the most effective method to drain out the pus, followed by an immediate antibiotic regimen for up to ten days.