Quinsy

Quinsy, also termed peritonsillar abscess, is a collection of pus in the peritonsillar space.

It occurs most commonly as a complication of bacterial tonsillitis. Unlike simple tonsillitis it mandates surgical intervention to drain the collection. Group A beta-haemolytic streptococcus and haemophilus influenzae are commonly implicated.

Note: In patients presenting with any of a severe sore throat, drooling, stridor or trismus – epiglottitis – a rare but potentially life-threatening condition should be considered.

Patients present with sore throat, fevers and may complain of trismus or altered voice.

Symptoms

• Sore throat
• Fever
• Trismus
• Dysphagia
• Altered voice

Signs

• Peritonsillar swelling
• Exudate
• Drooling
• Stertor
• Displacement of uvula
• Fetid breath

Note: If there is clinical evidence of spreading of infection through the deep spaces of the neck, senior ENT and anaesthetic review should be arranged.

Quinsy tends to be a clinical diagnosis, intraoral ultrasound may be used to confirm it.

Bedside

• Observations

Bloods

• FBC
• UE
• CRP
• LFT
• EBV IgM antibody (if infectious mononucleosis is suspected)

Imaging

• Intraoral ultrasound: rarely used but offers reasonable sensitivity and specificity for peritonsillar abscess.
• CT/MRI: if there is suspicion the infection has spread beyond the peritonsillar space, axial imaging is required. 

Special tests

• Pus cultures: may be sent but rarely impact management

Patients with quinsy should be referred for urgent ENT review.

1. Medical

IV access should be obtained and routine blood tests sent. Patients have frequently had reduced oral intake and benefit from IV fluids. Adequate analgesia, topical where possible, should be administered. 

Most will commence IV antibiotics (e.g. penicillin and metronidazole) and some give a dose of IV steroids (6.6mg IV dexamethasone). 

2. Surgical

Quinsy’s require surgical intervention. An ENT surgeon will normally either aspirate the abscess or complete an incision and drainage.

Patients should complete a course of antibiotics (follow local guidelines) following their surgical intervention.

In some centres an ENT surgeon will carry out a tonsillectomy acutely to treat quinsy (quinsy tonsillectomy).

Note: Recurrent quinsy is an indication for elective tonsillectomy.