This document provides information on peritonsillar abscess (quinsy). It defines peritonsillar abscess as a collection of pus between the tonsil capsule and superior constrictor muscle. Key points include:
- It is a common deep neck infection with an incidence of 1 in 10,000 cases.
- If left untreated, it can lead to complications like airway obstruction, abscess rupture, or sepsis.
- Proper management through surgical drainage and antibiotics is important.
- Clinical features include pain, difficulty swallowing, and a bulging on the soft palate. Diagnosis is usually made through history and exam but imaging may be used. Treatment involves incision
2. • Peritonsillar abscess (Quinsy) a localized deep neck infection that develops
between the tonsil and its capsule
• Peritonsillar abscess most common deep head and neck space infection that
presents in ED with an incidence 1 in 10.000 cases
• The infection can get complicated in rare cases and progress to airway
obstruction, abscess rupture and asphyxia by aspiration of pus and nerosis
resulting in septicemia or hemorrhage
• Therefore, proper management is foremost importance and surgical drainage as
well as proper antimicrobial therapy is warranted
INTRODUCTION
4. DEFINITION
Peritonsillar abscess (Quinsy) is a
collection of pus in the
peritonsillar space which lies
between the capsule of tonsil and
the superior constrictor muscle
5. EPIDEMIOLOGY
Incidence is 30 per
100.000
United States
There is no data shown
patients with peritonsillar
abscess
Indonesia
6. EPIDEMIOLOGY
• Research at H. Adam Malik
General Hospital for period
January 1 2013 – December
31 2018, there are 11 cases
of peritonsillar abscess from
41 cases with deep neck
abscess (26,8%)
7. ● Complication of Acute Tonsilitis
● Weber glands obstruction
● Poor oral hygiene and periodontal disease
● Smoking
● Infectious mononucleosis
ETIOLOGY
Common organisms associated with Peritonsillar Abscess
9. CLINICAL FEATURES
1. General
Fever, chills and rigors, general malaise, body
aches, headache, nausea and constipation
2. Local
• Severe pain in throat (usually unilateral)
• Odynophagia
• Muffled and thick speech “Hot potato voice”
• Halitosis
• Ipsilateral earache
• Trismus
10. DIAGNOSIS
HISTORY TAKING
• Main complaint Progressively pain in the throat which is usually unilateral
• Other complains:
- Odynophagia
- Ipsilateral otalgia
- Halitosis
- “hot potato” voice
- Trismus
• Other features : fever, chills, rigors, headache, body ache
• Prior history of upper respiratory tract infection and tonsillitis
11. DIAGNOSIS
PHYSICAL EXAMINATION
• Patient is usually ill-looking and febrile
• Mouth and oropharynx examination :
- Uvula is swollen and edematous and pushed to the opposite
side
- Bulging on the soft palate and anterior tonsillar pillar
- Mucous may be seen covering the tonsillar region
- Trismus of varying degree
- Drooling
• Neck examination :
- Cervical lymphadenopathy (jugulodigastric lymph nodes)
- Torticollis
12. DIAGNOSIS
PHYSICAL EXAMINATION
Diagnosis of peritonsillar abscess is usually
made clinically by any of the following
features:
• Unilateral swelling of the peritonsillar area
• Non-resolving acute tonsillitis with
persistent unilateral tonsillar enlargement
• A bulge on the unilateral soft palate with
anterior displacement of the ipsilateral
tonsil
13. DIAGNOSIS
INVESTIGATION
• Laboratory Studies
- Complete blood count
- Electrolytes
- C-Reactive protein
- Monospot test/heterophile antibody rule out
infectious mononucleosis
- Culture of the fluid from needle aspiration
14. DIAGNOSIS
NEEDLE ASPIRATION
• Ease procedure, decrease pain and cost-effectiveness
• Procedure :
- Patient should be sitting upright
- Lidocaine with epinephrine should be used to
anesthetize the area
- A 16 to 18 gauge needle with a 10 mL syringe
should be used to aspirate from the area that
is most fluctuant
- Aspirate at the superior pole initially, if there
is no pus then move to middle one third and
the lower one third
15. DIAGNOSIS
IMAGING STUDIES
• Intraoral ultrasonography
Sensitivity 95,2% and specificity
78,5%
Cost-effective and fast
Required a cooperative patient
16. DIAGNOSIS
IMAGING STUDIES
• Head and Neck CT Scan
Useful if incision and drainage fails,
patient cannot open his/her mouth or
the patient is young (< 7 yrs) and
uncooperative
If there is suspicion that infection has
spread beyond the peritonsillar space
or involving lateral neck
Rim enhancing fluid collection adjacent
to an enlarged and inflammed tonsil
17. DIAGNOSIS
IMAGING STUDIES
• Head and neck MRI
Complication beyond peritonsillar space
More superior to CT for soft tissue definition and better
at detecting internal jugular vein thrombosis or erosion
Disadvantage : longer scanning times and higher cost
19. TREATMENT
MEDICAL THERAPY
• Hospitalization
• Intravenous fluids to combat dehydration
• Antibiotics Penicillin G 10 million units/ 6hrs + metronidazole 500 mg/6hrs or
clindamycin, ideally antibiotic therapy should started as per culture reports
Other Ampicilin/sulbactam 3 g/6hrs, ceftriaxone 1 g/12hrs +
metronidazole 500mg/6 hrs, vancomycin 1g/12hrs + metronidazole 500mg
/6hrs ( for MRSA)
• Analgesics and antipyretics like paracetamol are given Paracetamol
1g/6hrs
• Steroid CONTROVERSIAL, Methylprednisolon 2-3mg/kgBW single dose
• Oral hygiene with hydrogen peroxide or saline mouth washes
20. TREATMENT
SURGICAL THERAPY
INCISION AND DRAINAGE
• The patient should be sitting upright with a pan
available to spit out any blood or pus
• Local infiltration with lidocaine 10% with
epinephrine
• No. 11 blade scalpel or forsep quinsy is used to
make a small incision 0.5 cm long and no more
than 1 cm deep. Be certain that the incision is not
extended laterally as the carotid artery lies in that
vicnity
• Use a small hemostat to probe the abscess and
release the pus
• To prevent the risk of aspiration, allow the patient
to hold Yankauer cath tip and to suction the pus
21. TREATMENT
• Not routinely performed, should be considered in
patients who have strong indications
• Tonsillectomy methods Cold instrument,
guillotine dissection, electrosurgery,
radiofrequency ablation, coblation, harmonic
scalpel, thermal welding, etc
• Tonsillectomy type :
- Tonsilektomi “a’ chaud”
- Tonsilektomi “a’ tiede”
- Tonsilektomi “a’ froid”
TONSILLECTOMY
24. TREATMENT
POST-OPERATIVE CARE
• Immediate general care
- Keep patient in coma position until fully recovered from anaesthesia
- Keep a watch on bleeding from the nose and mouth
- Keep check on vital signs
• Diet when patient fully recovered patient can take liquid (cold milk, ice cream),
diet is gradually built from soft to solid food
• Oral hygiene patient is given salt water gargles 3 – 4 times a day
• Analgesics Paracetamol, avoid aspirin and ibuprofen
• Antibiotics a suitable antibiotic can be given orally or by injection for a
week
27. • Peritonsillar abscess localized infection where pus accumulates between the
fibrous capsule of the tonsil and the superior pharyngeal constrictior muscle, it is the
endpoint of an acute tonsilitis, dental area or minor salivary glands
• The diagnosis of peritonsillar abscess is usually based on clinical presentation and
physical examination and workup investigation if needed
• Needle aspiration can be used as a diagnostic tool and definitive treatment of
peritonsillar abscess
• If needle aspiration is not successful, incision and drainage can be performed as
definitive treatment
• Then interval tonsillectomy or hot tonsillectomy, antibiotics and corticosteroids are
also necessary in treating peritonsillar abscess
CONCLUSION
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