Peritonsillar abscess

Disclaimer These guidelines have been produced to guide clinical decision making for the medical, nursing and allied health staff of Perth Children’s Hospital. They are not strict protocols, and they do not replace the judgement of a senior clinician. Clinical common-sense should be applied at all times. These clinical guidelines should never be relied on as a substitute for proper assessment with respect to the particular circumstances of each case and the needs of each patient. Clinicians should also consider the local skill level available and their local area policies before following any guideline.  Read the full PCH Emergency Department disclaimer.

Aim 

To guide PCH ED staff with the assessment and management of children with peritonsillar abscess.

Definition

A peritonsillar abscess (also called paratonsillar abscess or quinsy) is a collection of pus in the space between the tonsil and the superior pharyngeal constrictor muscle. 

Background

A peritonsillar abscess is often considered to be a complication of tonsillitis. However, it is now thought to be secondary to infection of a peritonsillar salivary gland (Weber gland) which is located between the tonsillar capsule and the muscle of the tonsillar fossa.

Assessment

Patients often present with:

• Severe sore throat
• Odynophagia (painful swallowing) with drooling
• Muffled voice ( ‘Hot Potato Voice’)
• Difficulty opening mouth (trismus).

Examination often reveals:

• Limited mouth opening (trismus), less than three finger width
• Unilateral swollen enlarged tonsil with fluctuant swelling extending up to the soft palate (most characteristic)
• Deviation of the uvula away from the affected side
• Enlarged tender cervical lymph node on the associated side
• The patient is usually febrile, and often ‘toxic’ looking. 

Management

• Patients require hospitalisation for rehydration, intravenous antibiotics, analgesia and, in most cases, surgical drainage of the abscess
• Refer suspected peritonsillar abscesses to ENT
• Antibiotics need to cover Streptococcus pyogenes and anaerobes
  • Antibiotics are guided by the Children's Antimicrobial Management Program (ChAMP) - Ear, nose, throat and dental
• As a rule of thumb, all peritonsillar abscesses should be drained
  • Generally, children less than 7-10 years of age will not tolerate oropharyngeal procedures under local anaesthetic very well. Needle aspiration or incision and drainage of the abscess under general anaesthesia is usually required.
  • Patients who are septic and have airway obstruction may be considered for quinsy tonsillectomy.

It is worth noting that in some very young children quinsy tends to resolve with IV antibiotics, hence medical treatment and observation for 24 hours may be worthwhile. 

Bibliography

1. Wald ER (2014) Peritonsillar Cellulitis and Abscess. UpToDate. Accessed at www.uptodate.com 
2. WA Health Child and Adolescent Health Service. Ear, Nose, Throat and Dental ChAMP Empiric Guidelines Version 2, February 2014

Endorsed by:	Executive Director, Medical Services	Date:
		Review date:	Oct 2021

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