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| {{Infobox_Disease | | __NOTOC__ |
| | Name = Peritonsillar abscess
| | {{Peritonsillar abscess}} |
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| | Caption =
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| | DiseasesDB = 11141
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| | ICD10 = {{ICD10|J|36||j|30}}
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| | ICD9 = {{ICD9|475}}
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| | ICDO =
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| | OMIM =
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| | MedlinePlus =
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| | eMedicineSubj = emerg
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| | eMedicineTopic = 417
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| | MeshID =
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| }}
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| __Notoc__
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| {{SI}}
| | {{CMG}}; {{AE}} {{PTD}} |
| {{CMG}}; {{KS}} {{PTD}} | |
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| ==Overview==
| | {{SK}} PTA, Tonsillar abscess, Intratonsillar abscess, Quinsy |
| Peritonsillar abscess (PTA), also commonly referred to as quinsy, is defined as a collection of [[pus]] located between the tonsillar capsule and the pharyngeal constrictor muscles.
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| It is the most common deep tissue infection of the neck.<ref name="pmid18246890">{{cite journal| author=Galioto NJ| title=Peritonsillar abscess. | journal=Am Fam Physician | year= 2008 | volume= 77 | issue= 2 | pages= 199-202 | pmid=18246890 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18246890 }} </ref>
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| Historically, it has been thought of as a complication of acute [[tonsillitis]]. However, recent studies have proposed additional hypothesis surrounding its pathogenesis making the understanding of the disease a medical dilemma.<ref name="pmid23612569">{{cite journal| author=Powell EL, Powell J, Samuel JR, Wilson JA| title=A review of the pathogenesis of adult peritonsillar abscess: time for a re-evaluation. | journal=J Antimicrob Chemother | year= 2013 | volume= 68 | issue= 9 | pages= 1941-50 | pmid=23612569 | doi=10.1093/jac/dkt128 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23612569 }} </ref>
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| ==Historical perspective==
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| The outline below shows the historical perspective of peritonsillar abscess.<ref name="pmid8302122">{{cite journal| author=Passy V| title=Pathogenesis of peritonsillar abscess. | journal=Laryngoscope | year= 1994 | volume= 104 | issue= 2 | pages= 185-90 | pmid=8302122 | doi=10.1288/00005537-199402000-00011 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=8302122 }} </ref>
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| *In Second and third century BC, Celcius was the first to document in literature the treatment and pathogenesis of tonsillar pathology.
| | ==[[Peritonsillar abscess overview|Overview]]== |
| *In 1700s peritonsillar abscess was first described.
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| *In the 1930s and 1940s prior to the advent of antibiotics, surgical management was the most common treatment option for peritonsillar abscess. Interval tonsillectomy was mostly done after symptom resolution.
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| *By 1947, Chaud tonsillectomy or immediate surgical tonsillectomy became the treatment option.
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| ==Classification== | | ==[[Peritonsillar abscess historical perspective|Historical Perspective]]== |
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| ==Pathophysiology== | | ==[[Peritonsillar abscess classification]]== |
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| ===Anatomy=== | | ==[[Peritonsillar abscess pathophysiology|Pathophysiology]]== |
| A good understanding of the [[tonsil]] and its surrounding space is important in the pathogenesis of peritonsillar abscess. Located within the soft palate is the supratonsillar space occupied by series of 20 to 25 salivary glands described as Weber's glands. The ducts of these glands form a common duct which opens onto the posterior surface of the [[tonsil]] after passing through the tonsillar capsule. It is proposed that the secretions from these [[glands]] play a rule in food [[digestion]].
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| The palatine tonsils are found in an anatomical structure called tonsillar fossa. This fossa is bounded anteriorly by palatoglossal muscle, posteriorly by palatopharyngeal muscle, laterally by a fibrous capsule and tonsillar crypts medially. Contents of the tonsillar crypts are expelled by contraction of the tonsillopharyngeus muscle.<ref name=abd>L. Michaels, H.B. Hellquist Ear, nose and throat histopathology (2nd ed.)Springer-Verlag, London (2001), pp. 281–286</ref>
| | ==[[Peritonsillar abscess causes|Causes]]== |
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| ===Pathogenesis=== | | ==[[Peritonsillar abscess differential diagnosis|Differentiating Peritonsillar abscess from other Diseases]]== |
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| The pathogenesis of peritonsillar abscess is still not well-understood.<ref name="pmid23612569">{{cite journal| author=Powell EL, Powell J, Samuel JR, Wilson JA| title=A review of the pathogenesis of adult peritonsillar abscess: time for a re-evaluation. | journal=J Antimicrob Chemother | year= 2013 | volume= 68 | issue= 9 | pages= 1941-50 | pmid=23612569 | doi=10.1093/jac/dkt128 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23612569 }} </ref> There are two proposed theories believed to be involved in the pathogensis of peritonsillar abscess formation.<ref name=abd>L. Michaels, H.B. Hellquist Ear, nose and throat histopathology (2nd ed.)Springer-Verlag, London (2001), pp. 281–286</ref><ref name="pmid8302122">{{cite journal| author=Passy V| title=Pathogenesis of peritonsillar abscess. | journal=Laryngoscope | year= 1994 | volume= 104 | issue= 2 | pages= 185-90 | pmid=8302122 | doi=10.1288/00005537-199402000-00011 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=8302122 }} </ref><ref name="pmid25865201">{{cite journal| author=Blair AB, Booth R, Baugh R| title=A unifying theory of tonsillitis, intratonsillar abscess and peritonsillar abscess. | journal=Am J Otolaryngol | year= 2015 | volume= 36 | issue= 4 | pages= 517-20 | pmid=25865201 | doi=10.1016/j.amjoto.2015.03.002 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=25865201 }} </ref>
| | ==[[Peritonsillar abscess epidemiology and demographics|Epidemiology and Demographics]]== |
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| *1. It is proposed to arise from an extension of exudative tonsillitis.
| | ==[[Peritonsillar abscess screening|Screening]]== |
| Some authorities believe that blockage of drainage from tonsillar crypt in acute tonsillitis results in spread of infection into the peritonsillar space.
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| *2. Involvement of Weber's gland account for the abscess formation. Some believe that peritonsillar abscess arises from infectious process involving group of salivary glands called Weber's glands located in the supratonsillar space.
| | ==[[Peritonsillar abscess risk factors|Risk Factors]]== |
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| Antigenic response following any disturbance arising from within the tonsillar crypt mucosa allows for lymphocytic interaction. This disruption in the crypt epithelium may be preceded by infectious process. Invasion and proliferation of the tonsillar crypt by infectious pathogens results in localized edema and influx of neutrophils. This is clinically seen as inflammed tonsil with or without exudation.<ref name=abd>L. Michaels, H.B. Hellquist Ear, nose and throat histopathology (2nd ed.)Springer-Verlag, London (2001), pp. 281–286</ref> Pus accumulation within tissue behind the supratonsillar space leads to tonsillar bulging, uvula and palate deviation.
| | ==[[Peritonsillar abscess natural history, complications and prognosis|Natural History, Complications and Prognosis]]== |
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| ==Causes==
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| PTA usually arises as a complication of an untreated or partially treated episode of acute tonsillitis. The infection, in these cases, spreads to the peritonsillar area (peritonsillitis). This region comprises loose connective tissue and is hence susceptible to formation of abscess. Peritonsilar abscess can also occur ''de novo''.
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| Both aerobic and anaerobic bacteria can be causative.
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| ===Life-threatening causes===
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| Life-threatening conditions may result in death or permanent disability within 24 hours if left untreated. Peritonsillar abscess may become a life-threatening condition and must be treated as such irrespective of the cause.
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| ===Most common cause===
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| The most frequent pathogen of peritonsillar abscess is Streptococcus pyogenes.
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| ===Common causes===
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| Some common causes of peritonsillar abscess include:
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| Fusobacterium necrophorum
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| Streptococcus milleri
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| [[Staphylococci]]
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| [[Haemophilus]] | |
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| ==Differentiating Peritonsillar abscess from Other Diseases==
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| ==Epidemiology and Demographics==
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| ==Risk Factors==
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| ==Screening==
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| ==Natural History, Complications, and Prognosis==
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| ===Natural history===
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| ===Complications===
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| The following are some complications that may follow peritonsillar abscess:
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| *Extraperitonsillar spread example parapharyngeal extension<ref name="pmid25255362">{{cite journal| author=Coughlin AM, Baugh RF, Pine HS| title=Lingual tonsil abscess with parapharyngeal extension: a case report. | journal=Ear Nose Throat J | year= 2014 | volume= 93 | issue= 9 | pages= E7-8 | pmid=25255362 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=25255362 }} </ref><ref name="pmid26591220">{{cite journal| author=Deeva YV| title=[SURGICAL TREATMENT OF TONSILLAR NECK PHLEGMON]. | journal=Klin Khir | year= 2015 | volume= | issue= 7 | pages= 47-8 | pmid=26591220 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26591220 }} </ref><ref name="pmid26527518">{{cite journal| author=Kawabata M, Umakoshi M, Makise T, Miyashita K, Harada M, Nagano H et al.| title=Clinical classification of peritonsillar abscess based on CT and indications for immediate abscess tonsillectomy. | journal=Auris Nasus Larynx | year= 2016 | volume= 43 | issue= 2 | pages= 182-6 | pmid=26527518 | doi=10.1016/j.anl.2015.09.014 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26527518 }} </ref>
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| Peritonsillar abscess may spread through the deep fascia of the neck with associated rapid progression to a more serious infection.
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| ===Prognosis===
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| ==Diagnosis== | | ==Diagnosis== |
| | | [[Peritonsillar abscess history and symptoms|History and Symptoms]] | [[Peritonsillar abscess physical examination|Physical Examination]] | [[Peritonsillar abscess laboratory findings|Laboratory Findings]] | [[Peritonsillar abscess x rays|X Rays]] | [[Peritonsillar abscess other imaging findings|Other Imaging Findings]] | [[Peritonsillar abscess other diagnostic studies|Other Diagnostic Studies]] |
| ===History and Symptoms===
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| * Unlike tonsillitis, which is more common in the pediatric age group, peritonsillar abscess has a more even age spread — from children to adults.
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| * Symptoms start appearing 2-8 days before the formation of [[abscess]]. Common symptoms are:<ref name="pmid18246890">{{cite journal| author=Galioto NJ| title=Peritonsillar abscess. | journal=Am Fam Physician | year= 2008 | volume= 77 | issue= 2 | pages= 199-202 | pmid=18246890 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18246890 }} </ref>
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| :*[[Drooling]]
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| :*[[Dysphagia]]
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| :*Foul smelling breath
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| :*[[Fever]]
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| :*[[Headache]]
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| :*[[Hoarseness]],muffled voice (also called ''hot potato voice'')
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| :*[[Odynophagia]]
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| :*[[Otalgia]] (on the side of the abscess)
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| :*[[Sore throat]] ( may be severe and unilateral)
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| :*[[Stridor]]<ref>{{cite book | last = Ferri | first = Fred | title = Ferri's clinical advisor 2015 : 5 books in 1 | publisher = Elsevier/Mosby | location = Philadelphia, PA | year = 2015 | isbn = 978-0323083751 }}</ref>
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| ===Physical Examination===
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| Physical examination findings suggestive of peritonsillar abscess include the following:<ref name="pmid18246890">{{cite journal| author=Galioto NJ| title=Peritonsillar abscess. | journal=Am Fam Physician | year= 2008 | volume= 77 | issue= 2 | pages= 199-202 | pmid=18246890 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18246890 }} </ref><ref>{{cite book | last = Ferri | first = Fred | title = Ferri's clinical advisor 2015 : 5 books in 1 | publisher = Elsevier/Mosby | location = Philadelphia, PA | year = 2015 | isbn = 978-0323083751 }}</ref>
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| *Muffled voice (also called "hot potato voice")
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| * Contralateral deflection of the uvula
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| * Facial swelling
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| * Tender submandibular and anterior cervical lymph nodes.
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| * Tonsillar hypertrophy with likely peritonsillar edema.
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| * [[Trismus]]
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| ===Laboratory Findings===
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| ===Imaging Findings===
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| ==Treatment== | | ==Treatment== |
| ===Medical Therapy===
| | [[Peritonsillar abscess medical therapy|Medical Therapy]] | [[Peritonsillar abscess primary prevention|Primary Prevention]] | [[Peritonsillar abscess secondary prevention|Secondary Prevention]] |
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| ===Antimicrobial Regimen=== | | ==Case Studies== |
| | [[Peritonsillar abscess case study one|Case #1]] |
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| ===Surgery===
| | {{Respiratory pathology}} |
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| ==Prevention==
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| ===Primary prevention===
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| ===Secondary Prevention===
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| <div align="left">
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| <gallery heights="175" widths="175">
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| Image:Peritonsillar-abscess-001.jpg|Peritonsillar abscess <small>Image courtesy of RadsWiki and copylefted</small>
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| Image:Peritonsillar-abscess-002.jpg|Peritonsillar abscess <small>Image courtesy of RadsWiki and copylefted</small>
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| Image:Peritonsillar-abscess-003.jpg|Peritonsillar abscess <small>Image courtesy of RadsWiki and copylefted</small>
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| Image:Peritonsillar-abscess-004.jpg|Peritonsillar abscess <small>Image courtesy of RadsWiki and copylefted</small>
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| </gallery>
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| </div>
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| ==Treatment==
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| Treatment is, as for all abscesses, through surgical incision and drainage of the pus, thereby relieving the pain of the stretched tissues. The drainage can often be achieved in the Outpatient Department using a guarded No. 11 blade in an awake and co-operative patient. Sometimes, a needle aspiration can suffice. [[Antibiotic]]s are also given to treat the infection.
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| Peritonsillar abscesses are widely considered one of the most painful complications, primarily the surgical draining of the abscess itself. The patient is operated on awake, surgically slicing open the tonsil and draining the abscess.
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| ==Complications==
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| *Parapharyngeal abscess
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| *Extension of abscess in other deep neck spaces leading to airway compromise
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| *Septicaemia
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| ==Notable Quinsy sufferers==
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| *George Washington is believed to have died of complications arising from Quinsy.<ref name"MountVernon">{{cite web | author =Mount Vernon Plantation | authorlink =Mount Vernon Plantation | year=2006 | url =http://www.mountvernon.org/learn/meet_george/index.cfm/pid/208/ | title =Part 4. President and Back Home | format = | work = Meet George Washington | publisher = Mount Vernon Ladies Association | accessyear =2006 }}</ref>
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| *Michel de Montaigne's quinsy brought about the paralysis of his tongue.
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| *Georges Bizet
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| *James Gregory of the band The Ordinary Boys was almost killed by quinsy because it was left untreated
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| *Brian Sweeney
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| *Alan Burrows
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| ==References==
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| <references/>
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| ==External links==
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| *[http://icarus.med.utoronto.ca/carr/manual/pta.html Practical ENT For Primary Care Physicians web site]
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| *[http://www.drtbalu.com/quinsy.html (Detailed description with video clipping)]
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| {{Respiratory pathology}}
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