When infection penetrates the tonsillar capsule and involves the surrounding tissues, peritonsillar cellulitis results. Following therapy, peritonsillar cellulitis usually either resolves over several days or evolves into peritonsillar abscess (eFigure 8–7). Peritonsillar abscess (quinsy) and cellulitis present with severe sore throat, odynophagia, trismus, medial deviation of the soft palate and peritonsillar fold, and an abnormal muffled (“hot potato”) voice. CT may be a useful adjunct to clinical suspicion, but imaging is not required for the diagnosis. The existence of an abscess may be confirmed by aspirating pus from the peritonsillar fold just superior and medial to the upper pole of the tonsil (eFigure 8–8). A 19-gauge or 21-gauge needle should be passed medial to the molar and no deeper than 1 cm, because the internal carotid artery may lie more medially than its usual location and pass posterior and deep to the tonsillar fossa. Most commonly, patients with peritonsillar abscess present to the emergency department and receive a dose of parenteral amoxicillin (1 g), amoxicillin-sulbactam (3 g), or clindamycin (600–900 mg). Less severe cases and patients who are able to tolerate oral intake may be treated for 7–10 days with oral antibiotics, including amoxicillin, 500 mg three times a day; amoxicillin-clavulanate, 875 mg twice a day; or clindamycin, 300 mg four times daily.
Appearance of the oral cavity with peritonsillar abscess located in the right supratonsillar fossa. The soft palate is swollen, and the uvula is displaced inferiorly and medially. (Reproduced with permission from Saunders CE, Ho MT [editors]. Current Emergency Diagnosis & Treatment, 4th ed. Appleton & Lange: The McGraw-Hill Companies, Inc.; 1992.)
When needle aspiration is used to manage peritonsillar abscess, aspiration should be attempted at each of these three anatomic locations. (Reproduced with permission from Saunders CE, Ho MT. Current Emergency Diagnosis & Treatment, 4th ed. Appleton & Lange: The McGraw Hill LLC Companies, Inc; 1992.)
Although antibiotic treatment is generally undisputed, there is controversy regarding the surgical management of peritonsillar abscess. Methods include needle aspiration, incision and drainage, and tonsillectomy. Some clinicians incise and drain the area and continue with parenteral antibiotics, whereas others aspirate only and monitor as an outpatient. The data are largely equivocal for all three approaches. In patients with more severe or recurrent peritonsillar abscesses, it may be appropriate to consider immediate tonsillectomy (quinsy tonsillectomy) in the acutely infected setting, although practitioners have moved away from this approach because of the potential for complications. About 10% of patients with peritonsillar abscess exhibit relative indications for tonsillectomy after the infection as resolved. All three approaches are effective. Regardless of the method used, one must be sure the abscess is adequately treated, since complications such as extension to the retropharyngeal, deep neck, and posterior mediastinal spaces are possible. Bacteria may ...