Peritonsillar abscess (Quinsy)

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.

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Aim

To guide PCH Emergency Department (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.¹

Background

A peritonsillar abscess is often considered to be a complication of tonsillitis or pharyngitis. However, it can also be secondary to infection of a peritonsillar salivary gland (Weber gland).¹

Assessment

Patients often present with:

Severe sore throat
Odynophagia (painful swallowing) with drooling
Muffled voice (‘Hot Potato Voice’)
Difficulty opening mouth (trismus)¹

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.¹

Investigations

Full blood count, urea and electrolytes, C-reactive protein and consider blood cultures.
Consider imaging (computerised tomography neck) if a deep space (retropharyngeal) abscess is suspected.¹

Management

Assess airway, give one dose of IV corticosteroid (dexamethasone 0.6 mg/kg (max 10mg)³) and IV antibiotics as below, analgesia and rehydration.
Refer all suspected peritonsillar abscesses to the Ear, Nose and Throat (ENT) team. Patient to remain fasting until seen.
Antibiotics need to cover Streptococcus pyogenes and anaerobes.
- Antibiotics are guided by the Children's Antimicrobial Management Program (ChAMP) – Refer to Ear, Nose, Throat and Dental Infections – Paediatric Empiric Guidelines.²
Most children will be admitted under ENT for IV antibiotics +/- abscess drainage.

References

Wald ER. Peritonsillar Cellulitis and Abscess. UpToDate. [Last updated March 2022. Cited: 3 November 2022]. Available from: https://www-uptodate-com.pklibresources.health.wa.gov.au/contents/peritonsillar-cellulitis-and-abscess.
Ear, Nose, Throat and Dental Infections – Paediatric Empiric Guidelines. - ChAMP
Aertgeerts B, Agoritsas T, Siemieniuk R A C, Burgers J, Bekkering G E, Merglen A et al. Corticosteroids for sore throat: a clinical practice guideline BMJ 2017; 358 :j4090 doi:10.1136/bmj.j4090

Endorsed by:	Co-director, Surgical Services (Nursing)	Date:	Oct 2023
		Review date:	Sep 2026

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