Quinsy


By

Dr. T. Balasubramanian M.S. D.L.O.

Definition:

Quinsy otherwise also known as peritonsillar abscess is a collection of pus in the peritonsillar space between the superior constrictor and capsule of the tonsil.  It is usually unilateral, and commonly affects adolescent males.
Pathophysiology:
     Infection usually starts in the crypta magna from where it spreads beyond the confines of the capsule causing peritonsillitis initially, and peritonsillar abscess later.

Another proposed mechanism is necrosis and pus formation in the capsular area, which then obstructs the weber glands, which then swell, and the abscess forms.

Weber's glands:

These are mucous (minor) salivary glands present in the space superior to the tonsil, in the soft palate. There are 20 - 25 such glands in this area. These glands are connected to the surface of the tonsil by ducts. The glands clear the tonsillar area of debris and assist with the digestion of food particles trapped in the tonsillar crypts. If Weber's glands become inflamed, local cellulitis can develop. Inflammation causes these glands to swell up causing tissue necrosis and pus formation i.e. the classic features of quinsy. These abscesses generally form in the area of the soft palate, just above the superior pole of the tonsil, in the location of Weber's glands.

The occurrence of peritonsillar abscesses in patients who have undergone tonsillectomy further supports the theory that Weber's glands have a role in the pathogenesis.

Aetiology:
     Recurrent attacks of tonsillitis cause obstruction and obliteration of intra tonsillar clefts and the infection spreads to peritonsillar area causing suppuration. Smoking and chronic periodontal disease could also cause quinsy.

Clinical features:
1. Patient looks very ill and febrile
2. Odynophagia (painful swallowing)
3. Dribbling of saliva
4. Inability to open mouth
5. Muffled / Hot potato voice other wise known as rhinolalia clausa
On examination:
     The tonsil is found pushed downwards and medially, it blanches on slight pressure.  The uvula is edematous and is pushed to the opposite side.  Tonsillar pillars are congested.  Patient also has halitosis (bad breath), trismus and tender enlarged jugulodigastric nodes.

Medical management:

1. Broad spectrum antibiotics.  The anti bacterial spectrum should ideally innclude gram postive, gram negative and anaerobes.  Commonly used drugs are broad spectrum penicillins like ampicillin / amoxycillin, in addition to which metronidazole or clindamycin can be combined to take care of anaerobes.
2. Antiinflammatory drugs like Ibuprofen and antipyretics like paracetomol.

Surgical management:
Incision and drainage:  This is perrformed with patient in sitting position to prevent aspiration of pus into the larynx.  First the oral cavity and throat of the patient is sprayed with 4 % topical xylocaine spray to anaesthetise the mucosa.
A Saint claire Thompson qunisy forceps, or a gaurded 11 blade can be used.  The 11 blade is gaurded to prevent the blade from penetrating the tonsillar substance deeply and damaging underlying vital structures like internal carotid artery.
Site of incision:
Is commonly over the point of maximum bulge.  It can also be made at the junction between a horizontal imaginary line drawn from the base of the uvula to the anterior pillar and a vertical imaginary line drawn along the anterior pillar.  After incison is made a sinus forceps is introduced to complete the drainage procedure.

     Six weeks after I&D tonsillectomy is performed in this patient to prevent further rucurrence.  This is known as interval tonsillectomy.
Some authors prefer to do tonsillectomy immediatly on a quinsy patient.  This is known as Hot tonsillectomy.  But this method is fraught with danger because of excessive bleeding and impending risk of thromboembolism.