Quinsy (Peritonsillar Abscess)

1. Clinical Overview

Summary

Quinsy, also known as Peritonsillar Abscess (PTA), is a collection of pus in the peritonsillar space—the potential space located between the tonsillar capsule and the superior pharyngeal constrictor muscle. It is the most common deep neck space infection presenting to emergency departments and ENT services, predominantly affecting adolescents and young adults (peak incidence 15-35 years). [1,2]

The condition typically arises either as a complication of acute bacterial tonsillitis (the classical hypothesis) or from infection of Weber's glands (minor salivary glands in the supratonsillar fossa), or represents a combination of both pathogenic mechanisms. [3,4] The most common causative organisms are Group A Streptococcus (Streptococcus pyogenes) and anaerobes, particularly Fusobacterium necrophorum and other oral anaerobes. [5,6]

Clinical Presentation: The classic triad consists of severe unilateral sore throat, trismus (difficulty opening mouth due to pterygoid muscle spasm), and uvular deviation (pushed away from the affected side). Additional features include the characteristic "hot potato" voice (muffled speech), odynophagia (pain on swallowing), high fever, drooling, and referred otalgia. [1,7]

Diagnosis is primarily clinical, based on history and characteristic examination findings. Imaging (contrast-enhanced CT neck) is reserved for cases with diagnostic uncertainty, concern for deeper space infection, or poor treatment response. [8]

Management involves abscess drainage (needle aspiration or incision and drainage) combined with broad-spectrum antibiotics covering streptococci and anaerobes. Single-dose dexamethasone (8 mg IV) is increasingly used as adjunctive therapy to reduce pain, trismus, and accelerate recovery. [9,10] Supportive care includes analgesia, IV fluids for dehydration, and occasionally admission for airway monitoring.

Complications are uncommon but potentially life-threatening: airway obstruction (rare, less than 2% but requiring emergency management), parapharyngeal/retropharyngeal spread, Lemierre syndrome (septic thrombophlebitis of internal jugular vein with septic pulmonary emboli), mediastinitis, and rarely carotid artery involvement. [11,12] Recurrence occurs in approximately 10-15% of cases following initial drainage; interval tonsillectomy (performed 6-8 weeks after acute episode) is recommended for recurrent disease or history of recurrent tonsillitis. [13,14]

Clinical Pearls

"Trismus + Unilateral Sore Throat + Uvular Deviation = Quinsy Until Proven Otherwise": This classic triad has high specificity for diagnosis. [7]

"Hot Potato Voice": Muffled, thick voice quality due to oropharyngeal swelling—a pathognomonic feature that clinically distinguishes quinsy from simple tonsillitis.

"Drain the Pus": Antibiotics alone are insufficient in established abscess. Drainage (needle aspiration or I&D) is therapeutic and diagnostic. [15]

"Watch the Airway—But Don't Panic": Airway compromise is rare (less than 2%) but potentially catastrophic. Maintain high vigilance for stridor, respiratory distress, or rapidly spreading swelling requiring urgent senior ENT/anaesthetic review. [1]

"Fusobacterium = Lemierre Risk": Consider Lemierre syndrome in patients with persistent sepsis post-drainage, especially with pulmonary symptoms. Blood cultures are crucial. [12]

"Steroids Help": Single-dose dexamethasone 8 mg IV reduces pain scores (by 1.5-2 points on 10-point scale), trismus, and time to oral intake resumption. Evidence from multiple RCTs supports routine use. [9,10]

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2. Epidemiology

Demographics

Risk Factors

Microbiology

Culture Yield: Only 30-60% of needle aspirates yield positive cultures due to prior antibiotic exposure, inadequate anaerobic culture technique, or sampling issues. [6]

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3. Pathophysiology

Pathogenic Hypotheses

There are two primary competing theories regarding the pathogenesis of peritonsillar abscess:

Theory 1: Acute Tonsillitis Complication (Classical Hypothesis)

1. Acute bacterial tonsillitis develops, usually Group A Streptococcus.
2. Infection penetrates through tonsillar crypts and breaches the tonsillar capsule.
3. Spreads to the peritonsillar space (potential space between capsule and superior constrictor muscle).
4. Peritonsillar cellulitis develops initially (inflammatory phase without abscess formation).
5. Progresses to abscess formation (pus collection), typically 3-5 days after onset of tonsillitis symptoms. [2]

Supporting Evidence:

• 75-88% of quinsy patients report preceding sore throat/tonsillitis. [2]
• Positive throat swabs for Streptococcus pyogenes in many cases.

Theory 2: Weber's Gland Infection Hypothesis

1. Weber's glands (minor salivary glands located in the supratonsillar fossa) become infected.
2. Glandular duct obstruction leads to salivary stasis and bacterial overgrowth.
3. Abscess forms in the peritonsillar space at the superior pole (most common location—80-90% of cases).
4. May occur without preceding clinical tonsillitis. [3,4]

Supporting Evidence:

• Histological studies confirm presence of minor salivary glands in peritonsillar space (Weber's glands). [4]
• 12-25% of quinsy cases report no preceding tonsillitis symptoms. [3]
• Superior pole predominance (where Weber's glands concentrate).

Current Consensus: Both mechanisms likely contribute in varying proportions. Some cases arise from tonsillitis spread, others from primary Weber's gland infection, and many from combined pathology. [3]

Anatomical Considerations

Abscess Location Distribution

• Superior pole (supratonsillar): 80-90% (most common—Weber's gland concentration).
• Inferior pole: 5-10%.
• Anterior (between anterior pillar and tonsil): 5-10%.
• Posterior (rare): less than 5%. [1]

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4. Clinical Presentation

Symptoms

Examination Findings

Red Flags (Indications for Urgent Senior/Specialist Review)

Differential Diagnosis

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5. Investigations

Diagnosis is Primarily Clinical

• Diagnosis of quinsy is made clinically based on:
  1. History: Severe unilateral sore throat, odynophagia, trismus, fever (3-7 days evolution).
  2. Examination: Uvular deviation, peritonsillar swelling/bulging, trismus.
• Imaging not routinely required if typical presentation with clear unilateral peritonsillar abscess on examination. [1,7]

When to Investigate

Indications for Imaging (CT Neck with IV Contrast):

1. Diagnostic uncertainty: Unable to visualize oropharynx due to severe trismus.
2. Concern for deeper space infection: Neck swelling, neurological signs, rapidly spreading cellulitis, or respiratory compromise.
3. Treatment failure: Persistent fever/sepsis > 24-48 hours post-drainage.
4. Suspected alternative diagnosis: Retropharyngeal/parapharyngeal abscess, malignancy.
5. Suspected complications: Lemierre syndrome (need IJV imaging), carotid involvement. [8]

Investigations

Imaging Features (CT Neck with IV Contrast)

Peritonsillar Abscess:

• Rim-enhancing hypodense collection in peritonsillar space (superior pole most common).
• Mass effect: Deviation of uvula, medial displacement of tonsil, narrowing of oropharyngeal airway.
• Asymmetric soft tissue swelling and stranding.

Complications to Look For:

• Parapharyngeal spread: Abscess extending lateral to superior constrictor into parapharyngeal space.
• Retropharyngeal abscess: Fluid collection posterior to pharyngeal wall (widened prevertebral space > 7 mm at C2, > 22 mm at C6).
• IJV thrombosis (Lemierre): Filling defect in internal jugular vein, surrounding inflammatory change.
• Carotid pseudoaneurysm: Extremely rare but catastrophic if present.

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6. Management

Management Algorithm

   SUSPECTED QUINSY
   (Unilateral sore throat, Trismus, Uvular deviation, Fever)
                 ↓
   ┌─────────────────────────────────────┐
   │     ASSESS AIRWAY AND SEVERITY      │
   │  - Stridor? Respiratory distress?   │
   │  - Able to handle secretions?       │
   │  - Septic (SIRS criteria)?          │
   └─────────────────┬───────────────────┘
                     ↓
       ┌─────────────────────────────────┐
       │   AIRWAY COMPROMISED? (Rare)    │
       └──────────┬────────────┬─────────┘
                  │            │
       YES ───────┘            └──── NO
         ↓                            ↓
   **EMERGENCY**          ┌────────────────────────┐
   - Senior ENT +         │  CLINICAL EXAMINATION  │
   Anaesthetics           │  - Uvular deviation?   │
   - Humidified O₂        │  - Peritonsillar bulge?│
   - Keep upright         │  - Fluctuance?         │
   - IV Dexamethasone 8mg │  - Trismus severity?   │
   - Prepare for          └──────────┬─────────────┘
   intubation/            ┌──────────┴─────────────┐
   tracheostomy        ABSCESS        │      CELLULITIS
   - Urgent drainage   PRESENT        │      (Early stage)
   under GA         (Fluctuant,      │   (No fluctuance,
                     Pus aspirable)  │    early symptoms)
                          ↓           │            ↓
                  ┌───────────┐      │    **ANTIBIOTICS**
                  │ DRAINAGE  │      │    **OBSERVATION**
                  └─────┬─────┘      │    - IV/PO antibiotics
                        ↓            │    - Analgesia
          ┌─────────────────────┐   │    - Fluids
          │ DRAINAGE OPTIONS:   │   │    - Review 24-48h
          │                     │   │    - May progress to
          │ 1. **NEEDLE        │   │      abscess→drainage
          │    ASPIRATION**     │   │
          │    (First-line)     │   │
          │    - LA spray +     │   │
          │      infiltration   │   │
          │    - 18-20G needle  │   │
          │    - Point of       │   │
          │      maximal bulge  │   │
          │    - Usually        │   │
          │      supratonsillar │   │
          │    - Send pus for   │   │
          │      culture        │   │
          │                     │   │
          │ 2. **INCISION &    │   │
          │    DRAINAGE (I&D)** │   │
          │    - If aspiration  │   │
          │      fails/recurs   │   │
          │    - Scalpel (No.11)│   │
          │    - ≤1cm depth     │   │
          │    - Blunt          │   │
          │      dissection     │   │
          │                     │   │
          │ 3. **QUINSY        │   │
          │    TONSILLECTOMY**  │   │
          │    (Acute/Hot TE)   │   │
          │    - Immediate TE   │   │
          │      during acute   │   │
          │      phase          │   │
          │    - Higher bleeding│   │
          │      risk (6-12%)   │   │
          │    - Indications:   │   │
          │      * Recurrent    │   │
          │        quinsy       │   │
          │      * Recurrent    │   │
          │        tonsillitis  │   │
          │        history      │   │
          │      * Failed       │   │
          │        aspiration/  │   │
          │        I&D          │   │
          └─────────────────────┘
                        ↓
          ┌─────────────────────────────┐
          │ POST-DRAINAGE MANAGEMENT    │
          └──────────┬──────────────────┘
                     ↓
   ┌────────────────────────────────────────┐
   │ **ANTIBIOTIC THERAPY**                 │
   │                                        │
   │ IF ADMITTED (Severe, Unable PO):       │
   │ - Benzylpenicillin 1.2g IV QDS    +    │
   │   Metronidazole 500mg IV TDS           │
   │ OR                                     │
   │ - Co-Amoxiclav 1.2g IV TDS             │
   │                                        │
   │ IF DISCHARGE (Mild-Moderate):          │
   │ - Phenoxymethylpenicillin 500mg PO QDS │
   │   + Metronidazole 400mg PO TDS         │
   │ OR                                     │
   │ - Co-Amoxiclav 625mg PO TDS            │
   │                                        │
   │ PENICILLIN ALLERGY:                    │
   │ - Clindamycin 300-450mg PO/IV TDS      │
   │                                        │
   │ DURATION: 7-10 days                    │
   └────────────────────────────────────────┘
                     ↓
   ┌────────────────────────────────────────┐
   │ **ADJUNCTIVE THERAPY**                 │
   │                                        │
   │ - Dexamethasone 8mg IV single dose     │
   │   (Reduces pain, trismus, accelerates  │
   │    recovery. Grade A evidence)         │
   │                                        │
   │ - Analgesia:                           │
   │   Paracetamol 1g QDS +                 │
   │   Ibuprofen 400mg TDS (if no C/I)  +   │
   │   Codeine/Tramadol (if severe)         │
   │                                        │
   │ - IV Fluids: If dehydrated, unable PO  │
   │   (0.9% NaCl or Hartmann's)            │
   └────────────────────────────────────────┘
                     ↓
   ┌────────────────────────────────────────┐
   │ **ADMISSION vs DISCHARGE CRITERIA**    │
   │                                        │
   │ ADMIT IF:                              │
   │ - Airway concerns (stridor, severe     │
   │   trismus, rapid progression)          │
   │ - Unable to tolerate oral fluids       │
   │   (dehydration)                        │
   │ - Sepsis/systemic toxicity             │
   │ - Social concerns (unable to attend    │
   │   follow-up, compliance)               │
   │ - Failed outpatient management         │
   │                                        │
   │ DISCHARGE IF:                          │
   │ - Successful drainage                  │
   │ - Able to tolerate oral fluids         │
   │ - Adequate analgesia                   │
   │ - Reliable for 24-48h review           │
   └────────────────────────────────────────┘
                     ↓
   ┌────────────────────────────────────────┐
   │ **FOLLOW-UP**                          │
   │                                        │
   │ - Review 24-48 hours (or sooner if     │
   │   deterioration)                       │
   │ - Expect improvement: reduced pain,    │
   │   fever, improved mouth opening        │
   │ - If not improving: repeat drainage,   │
   │   imaging (CT neck), admit             │
   │                                        │
   │ - Consider **INTERVAL TONSILLECTOMY**  │
   │   (6-8 weeks post-acute episode) if:   │
   │   * Recurrent quinsy (≥2 episodes)     │
   │   * History of recurrent tonsillitis   │
   │     (≥5 episodes/year for 2 years, or  │
   │      ≥7 episodes in 1 year)            │
   │                                        │
   │ - Recurrence rate ~10-15% without      │
   │   interval tonsillectomy               │
   └────────────────────────────────────────┘

Needle Aspiration vs Incision & Drainage (I&D)

Evidence Base: Cochrane systematic review (2016) found no significant difference in treatment success, recurrence, or complication rates between needle aspiration and I&D. [15] Needle aspiration is less painful and preferred as first-line in most cases.

Quinsy Tonsillectomy (Acute/Hot Tonsillectomy)

Definition: Tonsillectomy performed during the acute phase (immediate drainage + tonsillectomy at same procedure).

Indications:

1. Recurrent quinsy (≥2 episodes). [13]
2. Recurrent tonsillitis history (meets tonsillectomy criteria). [14]
3. Failed aspiration/I&D (re-accumulation or persistent abscess).
4. Suspected malignancy (unilateral tonsil mass—need histology).

Advantages:

• Definitive treatment. Prevents recurrence (0% vs 10-15% for drainage alone). [13]
• Single procedure (drainage + tonsillectomy).

Disadvantages:

• Higher post-tonsillectomy hemorrhage (PTH) risk: 6-12% (vs ~3-5% for elective tonsillectomy). [19]
• More complex surgery (inflamed tissues, difficult dissection).
• Requires general anesthesia.

Interval Tonsillectomy (Preferred): Tonsillectomy performed 6-8 weeks post-quinsy after acute inflammation resolves. Lower bleeding risk (~3-5%). Recommended for recurrent quinsy or recurrent tonsillitis. [13,14]

Antibiotic Therapy

Principles:

• Cover Streptococcus pyogenes (penicillin-sensitive).
• Cover anaerobes (Fusobacterium, Prevotella, Peptostreptococcus) → Requires metronidazole or clindamycin. [5,6]
• Duration: 7-10 days.

Regimens:

Adjunctive Corticosteroids

Evidence: Multiple RCTs and systematic reviews (2016-2018) demonstrate single-dose dexamethasone 8-10 mg IV provides:

• Reduced pain (1.5-2 points on 10-point VAS at 24 hours). [9,10]
• Improved trismus (increased mouth opening by ~5-8 mm at 24 hours).
• Faster return to normal diet (by 12-24 hours).
• Reduced hospital stay (by ~1 day if admitted).
• No increase in complications (re-accumulation, bleeding).

Recommendation: Dexamethasone 8 mg IV single dose at time of presentation (alongside drainage and antibiotics). Grade A recommendation (multiple RCTs). [9,10]

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7. Complications

Acute Complications

Severe/Late Complications

Recurrence

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8. Prognosis and Outcomes

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9. Evidence and Guidelines

Key Evidence

Guidelines Summary

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10. Patient and Layperson Explanation

What is Quinsy?

Quinsy (also called peritonsillar abscess) is a collection of pus that forms next to your tonsil, usually at the top. It develops when a throat infection (tonsillitis) spreads deeper into the tissues around the tonsil, or when small glands in this area become infected.

What Causes It?

Quinsy is caused by bacteria—most commonly Streptococcus (the same bacteria that cause strep throat) and anaerobic bacteria (bacteria that don't need oxygen to survive). These bacteria can cause an infection that progresses from tonsillitis into an abscess (pocket of pus).

What Are the Symptoms?

• Severe sore throat on one side (much worse than a normal sore throat).
• Difficulty opening your mouth (trismus)—your jaw feels stiff and tight.
• Muffled voice—you sound like you're talking with a hot potato in your mouth.
• Difficulty swallowing—very painful to swallow, may drool saliva.
• High fever and feeling very unwell.
• Ear pain on the same side (even though the ear is fine).
• Your uvula (the small "hanging" part at the back of your throat) is pushed to one side.

How is Quinsy Diagnosed?

Your doctor can usually diagnose quinsy by:

• Listening to your symptoms (severe one-sided sore throat, difficulty opening mouth).
• Examining your throat—they will see one tonsil bulging and swollen, and your uvula pushed to the opposite side.
• No scans or blood tests are usually needed unless your doctor is concerned about complications.

How is it Treated?

1. Draining the Pus (Most Important Step)

• Your doctor will drain the abscess (remove the pus). This is done in one of two ways:
  • "Needle aspiration (first choice): A needle is inserted into the abscess to suck out the pus. Local anesthetic (numbing medicine) is used. This gives immediate relief."
  • "Incision and drainage (if the needle doesn't work): A small cut is made to release the pus."

2. Antibiotics

• You will be given antibiotic tablets or injections (e.g., penicillin and metronidazole) to kill the bacteria. Take them for 7-10 days as directed.

3. Pain Relief

• Paracetamol and ibuprofen help reduce pain and fever.
• Your doctor may give you a steroid injection (dexamethasone) to reduce swelling and pain faster.

4. Fluids

• If you can't drink enough, you may need fluids through a drip (IV fluids) in hospital.

Will I Need to Stay in Hospital?

• Most people go home the same day after drainage if they can drink fluids and take antibiotics by mouth.
• You may need to stay in hospital if:
  • You can't swallow fluids.
  • You have severe symptoms or complications.
  • Your doctor is concerned about your airway (breathing).

Will I Need My Tonsils Removed?

• Not immediately in most cases. You will recover with drainage and antibiotics.
• You may be offered a tonsillectomy later (6-8 weeks after recovery) if:
  • You have had quinsy before (it comes back).
  • You have frequent tonsillitis (sore throats many times a year).
• This operation (interval tonsillectomy) prevents quinsy from coming back.

What Should I Do After Treatment?

• Take all your antibiotics as prescribed (even if you feel better).
• Drink plenty of fluids and eat soft foods (soups, yogurt, mashed foods).
• Rest at home for a few days.
• Avoid smoking (slows healing).
• Attend your follow-up appointment (usually 1-2 days later) to check you're improving.

When Should I Seek Urgent Help?

Go to the emergency department immediately if you have:

• Difficulty breathing or noisy breathing (stridor).
• Worsening neck swelling.
• Unable to swallow at all (including your saliva).
• Fever that doesn't improve after 24-48 hours of treatment.
• Feeling very unwell or confused.

Will Quinsy Come Back?

• Quinsy comes back in about 10-15 out of 100 people (10-15%) if you don't have your tonsils removed.
• If you have had quinsy more than once, removing your tonsils prevents it from happening again.

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11. Examination Focus (MRCP, MRCS, ENT Exams)

Common Exam Questions (SBA/MCQ)

Q1: Classic Presentation A 24-year-old man presents with 4 days of severe right-sided sore throat, high fever, and difficulty opening his mouth. On examination, his uvula is deviated to the left, and there is a bulging right soft palate. What is the most likely diagnosis?

• Answer: Peritonsillar abscess (quinsy). Classic triad: unilateral sore throat + trismus + uvular deviation (away from affected side).

Q2: Initial Management A patient with confirmed peritonsillar abscess is treated in the emergency department. What is the most appropriate initial management?

• Answer: Needle aspiration + antibiotics (penicillin + metronidazole) + analgesia + dexamethasone. Drainage is essential. Antibiotics alone are insufficient.

Q3: Voice Change Which voice change is characteristic of peritonsillar abscess?

• Answer: "Hot potato" voice (muffled, thick speech). Caused by oropharyngeal swelling.

Q4: Uvular Deviation Direction In a patient with a right-sided peritonsillar abscess, the uvula will be deviated in which direction?

• Answer: Deviated to the LEFT (away from the abscess, toward the unaffected side). The abscess pushes the uvula away.

Q5: Serious Complication A 22-year-old woman with quinsy is treated with drainage and antibiotics. She returns 5 days later with persistent high fever, pleuritic chest pain, and dyspnea. Chest X-ray shows multiple nodular infiltrates. What is the most likely diagnosis?

• Answer: Lemierre syndrome. Septic thrombophlebitis of internal jugular vein (usually Fusobacterium necrophorum) with septic pulmonary emboli. Requires blood cultures, CT neck/chest, prolonged IV antibiotics (4-6 weeks).

Q6: Drainage Technique Safety When performing incision and drainage of a peritonsillar abscess, the incision should be directed:

• Answer: Medially and inferiorly, depth ≤1 cm. To avoid injury to the internal carotid artery (lies 2-2.5 cm posterolateral).

Q7: Adjunctive Steroid What is the evidence for adjunctive corticosteroid use in peritonsillar abscess?

• Answer: Single-dose dexamethasone 8 mg IV reduces pain, trismus, and time to recovery based on multiple RCTs and meta-analyses. Grade A recommendation.

Q8: Interval Tonsillectomy A patient has had two episodes of peritonsillar abscess in the past 18 months. What is the most appropriate long-term management?

• Answer: Interval tonsillectomy (6-8 weeks after acute episode resolves). Recurrent quinsy (≥2 episodes) is an indication for tonsillectomy. Prevents recurrence (0% vs 10-15% without tonsillectomy).

Q9: Needle Aspiration vs I&D What does the evidence show regarding needle aspiration versus incision and drainage for peritonsillar abscess?

• Answer: No significant difference in efficacy or recurrence (Cochrane 2016). Needle aspiration is first-line (less painful, faster, fewer complications). I&D reserved for aspiration failure.

Q10: Microbiology What is the most common organism causing peritonsillar abscess?

• Answer: Group A Streptococcus (Streptococcus pyogenes)—most common single organism (20-40%). However, most cases are polymicrobial (50-75%), including anaerobes (Fusobacterium, Prevotella, Peptostreptococcus).

OSCE/Clinical Examination Scenarios

Scenario 1: History Taking A 28-year-old man presents to A&E with severe sore throat. Take a focused history.

Key Points to Cover:

• Onset/duration: How long? Sudden or gradual worsening?
• Unilateral vs bilateral: Which side worse?
• Associated symptoms: Fever? Difficulty opening mouth (trismus)? Difficulty swallowing? Voice change? Drooling? Ear pain? Neck swelling?
• Preceding illness: Recent sore throat/tonsillitis?
• PMH: Recurrent tonsillitis? Previous quinsy?
• Red flags: Difficulty breathing? Stridor? Unable to swallow saliva?

Scenario 2: Examination of Oropharynx Examine this patient's throat. They have complained of severe sore throat.

Examination Findings in Quinsy:

1. Inspect for trismus: "Can you open your mouth wide for me?" Assess mouth opening (normal = 3 fingers, ~40-50 mm).
2. Inspect oropharynx (with tongue depressor, headlight):
   • Uvular deviation (away from affected side).
   • Unilateral peritonsillar swelling: Bulging soft palate and anterior tonsillar pillar.
   • Displaced tonsil (pushed medially and inferiorly).
   • Assess fluctuance (if safe and cooperative patient—palpate with gloved finger).
3. Cervical lymphadenopathy: Palpate for tender jugulodigastric nodes.
4. Voice: Assess for "hot potato" quality.

Scenario 3: Explaining Drainage Procedure to Patient Explain to the patient that they need drainage of their peritonsillar abscess.

Explanation Structure:

• What it is: "You have a collection of pus next to your tonsil called a quinsy. We need to drain this pus to help you recover."
• Why drainage: "Antibiotics alone won't fully treat this—we need to remove the pus."
• Procedure: "I will numb the area with spray and an injection (local anesthetic). Then I will use a needle to suck out the pus. You will feel some pressure but it shouldn't be too painful."
• After: "You should feel immediate relief. We'll give you antibiotics, painkillers, and a steroid injection to help reduce swelling. Most people go home the same day."
• Risks: "Small risk of bleeding, re-accumulation (may need repeat drainage), or infection spread (rare)."
• Follow-up: "We'll see you tomorrow to check you're improving."

Viva Voce Questions

Q: What is the anatomical location of a peritonsillar abscess? A: The peritonsillar space—a potential space between the tonsillar capsule (lateral) and the superior pharyngeal constrictor muscle (medial). Most commonly occurs at the superior pole (80-90%) where Weber's glands (minor salivary glands) are located.

Q: Explain the pathogenesis of quinsy. What are the two main theories? A: Two theories:

1. Acute tonsillitis complication: Infection spreads from tonsil crypts, breaches capsule → peritonsillar cellulitis → abscess. Supported by 75-88% of patients reporting preceding tonsillitis.
2. Weber's gland infection: Primary infection of minor salivary glands in supratonsillar fossa → duct obstruction → abscess. Supported by 12-25% having no preceding tonsillitis and superior pole predominance. Both mechanisms likely contribute.

Q: Why does trismus occur in quinsy? A: Reflex spasm of the pterygoid muscles (medial and lateral pterygoids—muscles of mastication). Inflammatory irritation from adjacent peritonsillar abscess causes muscle spasm, resulting in difficulty opening the mouth.

Q: Describe the surgical anatomy relevant to incision and drainage of quinsy. What structure is at risk? A: Internal carotid artery lies 2-2.5 cm posterolateral to the tonsil within the carotid sheath. Risk of catastrophic arterial injury if incision is too deep or directed laterally. Safe technique: Limit depth to ≤1 cm, direct incision medially and inferiorly (toward midline), use blunt dissection with forceps after incision.

Q: What is Lemierre syndrome? How does it relate to quinsy? A: Lemierre syndrome (also called "post-anginal sepsis") is septic thrombophlebitis of the internal jugular vein following oropharyngeal infection (including quinsy). Caused by Fusobacterium necrophorum (anaerobe). Infection spreads to IJV → thrombosis → septic emboli to lungs (multiple nodular infiltrates on CXR). Presents with persistent high fever despite treatment, neck pain/swelling, pleuritic chest pain, dyspnea. Diagnosis: Blood cultures (Fusobacterium), CT neck (IJV filling defect), CT chest (lung nodules). Treatment: Prolonged IV antibiotics (metronidazole or clindamycin, 4-6 weeks), consider anticoagulation, ICU support if septic shock. Mortality 5-10%.

Q: What are the indications for interval tonsillectomy following quinsy? A:

1. Recurrent quinsy (≥2 episodes).
2. Recurrent tonsillitis history (≥7 episodes in 1 year, ≥5/year for 2 years, or ≥3/year for 3 years—Paradise criteria).
3. Patient preference after discussion of risks/benefits.

Interval tonsillectomy (6-8 weeks post-acute episode) has lower bleeding risk (~3-5%) than quinsy tonsillectomy (acute/hot TE during acute phase, bleeding risk 6-12%). Recurrence rate drops from 10-15% to ~0% with tonsillectomy.

Q: What is the evidence for adjunctive corticosteroids in quinsy? A: Multiple RCTs and systematic reviews (2014-2018) demonstrate single-dose dexamethasone 8-10 mg IV provides:

• Reduced pain (1.5-2 points on 10-point VAS at 24 hours) [Chau et al 2014 RCT, Lee et al 2016 meta-analysis].
• Improved trismus (~5-8 mm increased mouth opening).
• Faster return to oral intake (12-24 hours earlier).
• Reduced hospital stay (~1 day reduction if admitted).
• No increase in complications (re-accumulation, bleeding).

Grade A recommendation: Routine use supported by high-quality evidence.

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12. References

Primary Sources

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