Management of Peritonsillar Abscess
Common Bed Side Procedure No. 8
Section Editor: Prof. T.K. Partha Sarathy

Peritonsillar abscess or Quinsy is a collection of pus between the fibrous capsule of the tonsil usually in the upper pole and the super constrictor muscle of the pharynx. It frequently follows as a complication of acute-tonsillitis. Even though tonsillitis is common among children peritonsillar abscess occurs more often in young adults than in children or the aged. The abscess is usually secondary to Beta-Hemolytic streptococcus and at times due to anerobes.

Signs and symptoms
The inflammation is usually unilateral and is preceded by sore throat, headache and fever. The pain becomes severe and aggravated by the swelling. It becomes difficult for the person to swallow and as a result he accumulates saliva which drools from his mouth. Patient is ill looking with fever and has significant trismus. He keeps his face tilted towards the side of the abscess. Occasionally there may be enlarged lymph nodes in the neck in the jugulaodigastric region. The diagnosis of quinsy is usually made readily after a careful history and examination. Rarely a pharyngeal abscess or swelling in relation to the uvula may be mistaken. Sore throat, unilateral tonsillar swelling, trismus, fever and ear ache usually points to peritonsillar abscess and a direct examination of the oral cavity would readily provide the answer.

Management
Management strategies of peritonsillar abscess are as follows:
1. Antibiotics - Penicillin is recommended, as it is sensitive against streptococci as well as anerobes. Alternatively erythromycin could be considered.
2. Needle aspiration - done and repeated if necessary
3. Incision and drainage.

Procedure:

• Every patient is started on antibiotic.
• All aspirations or incision and drainage should be carried out with the patient in siting position.
• No general anesthesia is given.
• Adequate facilities for suction is available.
• Making the patient open the mouth wide enough to provide exposure to the affected tonsil with so much trismus is not easy and would require gentle handling and reassurance and use of a tongue depressor.
• Once adequate exposure is obtained the involved tonsil would look prominent going towards the midline and pushing the uvula upwards and to the other side.
• Application of xylocaine (4%) jelly over the affected tonsil with a cotton applicator should be adequate anesthesia.
• Alternately limited Lidocaine spray could be utilized.
• A wide bore (18 gauge) needle is attached to a syringe and is passed through the prominent upper part of the tonsil and aspiration is carried out. Promptly thick purulent material is aspirated and the swelling comes down.
• If necessary this process can be repeated in a day or two while antibiotic is continued.

Incision and drainage of peritonsillar abscess
The most effective way of handling peritonsillar abscess (quinsy) once the diagnosis is made, is to incise and drain the abscess. Again it is very important to have a suction machine readily available to prevent aspiration of the purulent material into the lungs. A 15 blade knife is prepared and guarded by taping the proximal half of the knife with regular zinc oxide tape thereby exposing only the distal 0.5 to 1 cm of the knife blade. Preliminary application of xylocaine viscus jelly is done and after a minute or two the procedure is done. Xylocaine or Lidocaine spray also could be utilized. With the knife prepared as stated above, the superior portion of the tonsil is punctured and incised with a quick controlled movement and the knife withdrawn from the oral cavity briskly. A gush of purulent materials is expected to come out which should be suctioned out. The incision can be further gently deepened using a hemostat and spreading the opened edges carefully. Most of the pus would come out once the procedure is completed and whatever is left behind will come out each time the patient attempts to swallow and thereby the tonsil will get back to normal. Elective tonsillectomy is recommended in these patients six weeks after the procedure to prevent similar episodes.

Post operative care
Saline gargle and continuation of antibiotics and analgesics till patient is symptom free and infection free.

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