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Right sided peritonsillar abscess
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Peritonsillar abscess (PTA), also known as a quinsy or quinsey, is a recognized complication of tonsillitis and consists of a collection of pus beside the tonsil in what is referred to as peritonsilar space (peri—meaning surrounding). It is a commonly encountered otorhinolaryngological (ENT) emergency.
Symptoms and signs
Unlike tonsillitis, which is more common in the pediatric age group, PTA has a more even age spread, from children to adults. Symptoms start appearing two to eight days before the formation of an abscess. Progressively worsening, unilateral sore throat and pain during swallowing usually are the earliest symptoms. As the abscess develops, persistent pain in the peritonsillar area, fever, malaise, headache and a distortion of vowels informally known as "hot potato voice" may appear. Neck pain associated with tender, swollen lymph nodes, referred ear pain and halitosis are also common. While these signs may be present in tonsillitis itself, a PTA should be specifically considered if there is limited ability to open the mouth (trismus). In short:
- Severe unilateral pain in the throat;
- Pyrexia (fever) above 39 °C (102 °F);
- Unilateral earache;
- Odynophagia (pain during swallowing) and difficulty swallowing saliva;
- Change in voice (muffled voice, thickened speech, "hot potato" voice);
- Intense salivation and dribbling, foetor oris (halitosis);
- Pain in the neck;
- Malaise, headache, stiffness.
Trismus (an inability to open the mouth completely) is common. Physical signs include redness and edema in the tonsillar area of the affected side and swelling of the jugulodigastric lymph nodes. The uvula may be displaced towards the unaffected side. Odynophagia (pain during swallowing), and ipsilateral earache also can occur.
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. PTA can also occur de novo. Both aerobic and anaerobic bacteria can be causative. Commonly involved aerobic pathogens include Streptococcus, Staphylococcus and Haemophilus. The most common anaerobic species include Fusobacterium necrophorum, Peptostreptococcus, Prevotella species and Bacteroides.
Treatment is surgical incision and drainage of the pus, thereby relieving the pain of the pressed tissues. Antibiotics are also given to treat the infection. Internationally, the infection is frequently penicillin resistant, so it is now common to treat with clindamycin or metronidazole in combination with penicillin G benzathine. Treatment can also be given while a patient is under anesthesia, but this is usually reserved for children or anxious patients. Tonsillectomy can be indicated if a patient has recurring peritonsillar abscesses or a history of tonsillitis. For patients with their first peritonsillar abscess most ENT-surgeons favour to "wait and observe" before recommending tonsillectomy.
- Retropharyngeal abscess;
- Extension of abscess in other deep neck spaces leading to airway compromise. See Ludwig's angina;
- glomerulonephritis and rheumatic fever (Strep throat chronic complications).
- decreased oral intake and dehydration.
The incidence of peritonsillar abscess in the United States has been estimated approximately at 30 cases per 100,000 people per year. In a study in Northern Ireland, the incidence was 10 cases per 100,000 people per year. In Denmark, the incidence is higher and reaches 41 cases per 100,000 people per year. Younger children who develop a peritonsillar abscess are often immunocompromised and in them, the infection can cause significant airway obstruction.
The condition Peritonsillar Abscess is also referred to as "quincy", "quinsy" or "quinsey". These terms are Anglicised versions of the French word esquinancie which was originally rendered as Squinsey and subsequently Quinsy.
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