Dr. T. Balasubramanian M.S. D.L.O.
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
Infection usually starts in the crypta magna
from where it spreads beyond the confines of the capsule causing
peritonsillitis initially, and peritonsillar abscess later.
proposed mechanism is necrosis and pus formation in the capsular area,
which then obstructs the weber glands, which then swell, and the
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.
of peritonsillar abscesses in patients who have undergone tonsillectomy
further supports the theory that Weber's glands have a role in the
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.
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
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.
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
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.