Introduction
What is a peritonsillar abscess
Peritonsillar Abscess (PTA) or quinsy,1,2,4,7 is a condition where the region around the tonsils at the back of the mouth becomes filled with pus.
An overview
Tonsils play an important part in the body’s immune system, to fight against infection and disease. They are located in the upper region of the throat at the back of the mouth. When the area around the tonsils is filled with pus (a thick yellow liquid containing bacteria), known as a peritonsillar abscess. Following an infection, the tonsil tissue and surrounding area are extremely soft and prone to pus accumulation.
There is a specific cell layer found in the tonsils, which increases the surface area of the tonsils. This layer is considered to be the starting point of infection and its dispersal into the tonsils and surrounding tissue. The Weber’s gland clears waste from the tonsils when obstructed and is located near the tonsillar’ region.2 In an exceptional case, a peritonsillar abscess was found to be caused by undigested hair.10 An abscess is the most common emergency infection in head and neck patient care, the frequency of infection is approximately 1 in 10,000 times. It may occur at any age, most commonly seen in adolescents during the early years of adulthood and uncommon in children under the age of 5 years.2
Peritonsillar abscess complications
When an abscess is left untreated, it can progress leading to a number of complications that may be life-threatening.2,3,13,16
Airway obstruction
Airway obstruction is the most common reason patients visit the emergency department in a hospital.13,17 It can occur when a patient has difficulty breathing on inhalation and/or exhalation. In PTA, pus formation narrows the airway leading to obstruction. It may be partial or complete obstruction, depending on the volume of pus. Complete airway obstruction is an emergency requiring immediate action within minutes. Maintaining the airway requires extraction of the pus and/or insertion of a special kind of tube from the mouth/nose to the lungs.
Aspiration pneumonitis
Is a medical condition in which the lungs are injured due to the inhalation of irritation-causing toxic substances (pus). In patients suffering from PTA, if the abscess bursts, then pus can reach the lungs via the windpipe and affect it so badly that the patient may die.
Breathing issues can make a patient unable to explain the history of events they went through. In this situation, the health care professionals treating the patient would choose the most appropriate treatment based on the information provided by the family. Treatment for aspiration pneumonia involves removing the contents inhaled, by suction, and sometimes patients require artificial ventilation under special circumstances.1,14
Post-streptococcal glomerulonephritis
This condition is not directly related to PTA, however, it occurs when the body’s defence mechanism starts fighting against an organism causing PTA and becomes so intense that kidney function deteriorates.
It takes around 45 days to develop PSGN, once the organism mentioned earlier causes infection. This condition disrupts the balance of the acid-base proportions of the body, which can be fatal. PSGN is a kind of self-controlling condition, and only the symptoms are treated.11,12
Carotid artery haemorrhage
A medical condition where the abscess may erode the carotid artery wall. The carotid artery is a muscular tube in the body that supplies oxygenated blood to the head and neck. This complication is rare with the discovery of antibiotics. However, if it happens it might be difficult to diagnose early as well.8
The artery lies at the frontal part of the throat, near the region of the tonsils. Haemorrhage may occur with occasional bleeding or irregular bleeding, and then intensified by the pressure of the abscess exerted on the carotid artery, leading to heavy bleeding.
Carotid artery haemorrhage can accidentally take place when the abscess is drained.18
Mediastinitis
A condition in which the mediastinum (a space in the rib cage that holds vital organs such as the heart, large-sized blood vessels, muscular tubes such as the windpipe, food pipe and unique nerves that control digestion, heart rate and immune system) becomes inflamed and infected.9,15
Peritonsillar abscess is one of the major causes of mediastinitis; this occurs in two ways:
- Spread of infection to adjacent tissues reaching the mediastinum
- The abscess bursts and pus enters the trachea and starts rupturing it.19
Mediastinitis is a condition treated with specific antibiotics. Simultaneously, the abscess is cleaned and disinfected.
Lemierre syndrome
A condition in which the jugular vein (carries blood from the head and neck) becomes infected and blood clots form to block the vein. The abscess infection ruptures local veins in the area around the tonsils and untreated further deterioration occurs and impacts the jugular vein. Treatment starts with antibiotic therapy and surgical intervention may be required in rare situations. When Lemierre syndrome advances, it may threaten a patient’s life.
In conjunction with the complications described, and associated with peritonsillar abscess, there are a few other complications important to document.16
Septic arthritis
Sepsis is the result of an infection in the body. An abscess may cause infection and sepsis of the temporomandibular joint. The immune system responds to infection, but special antibiotic treatment and drainage are required for the patient’s health restoration.3
Brain abscess
Abscess has been seen in the brain, on the same side as the PTA. Antibiotic therapy and surgery have been successfully used to improve patient outcomes and complete recovery.3
Pointing to the root cause
Since, all the complications mentioned earlier are associated with PTA, the treatment or prevention of minor symptoms at an early stage can support the patient and avoid any of these serious life-threatening complications.2,5
Signs and symptoms
There are a few important signs and symptoms to be noted at the early stages of PTA.1,2,3,4,7
- Chills
- Fever
- Headache
- Tonsillitis
- Muffled sound while speaking
- Troublesome feeling while swallowing
- Saliva accumulation in the mouth
- Pain in the ear on the same side where pus is filled
- Swelling in the neck
- Neck rigidity
Risk factors
- Poor patient oral
- Untreated early symptoms
- Smoking4
Diagnosis
PTA is diagnosed by oral examination, in which the throat is viewed, for any signs of:
- Pus accumulation
- Swelling in the peritonsillar region
- Change in the soft palate
Blood tests including complete blood count might be useful and neck soft tissues can be seen using X-ray.2
Management
In PTA, a patient may be taken to hospital and intravenous fluids administered to maintain body fluid equilibrium. This fluid management is necessary when the patient has difficulty swallowing.
An appropriate antibiotic is administered intravenously. Medicines are also provided to tackle symptoms of pain and fever, simultaneously.
Further treatment includes needle aspiration with local anaesthetic of the abscess, or a small surgical incision (cut) at the back of the mouth to allow pus to drain from the abscess. If there is any chance of abscess recurrence, a tonsillectomy (surgical removal of the tonsils) may be the best option..2
Summary
PTA is an oral health problem related to the head and neck region of the body. However, complications related to PTA are not only limited to the head and neck area, but the rest of the body systems if not treated in time.
PTA complications can be avoided by taking care of oral hygiene and minor symptoms such as sore throat and ear pain, in the early stages. Unfortunately, symptoms can arise due to the patient
Inattentiveness, and may lead to some really serious consequences. In serious cases, high-dose antibiotics and surgical intervention may be necessary.
Frequently asked questions
How are tonsillitis and peritonsillar abscesses different?
Tonsillitis is a condition in which the tonsils are inflamed, while peritonsillar abscess is a condition where the area around the tonsil(s) is filled with pus.
References
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- Mount Sinai Health System [Internet]. [cited 2024 Mar 22]. Peritonsillar abscess information | mount sinai - new york. Available from: https://www.mountsinai.org/health-library/diseases-conditions/peritonsillar-abscess
- Klug TE, Greve T, Hentze M. Complications of peritonsillar abscess. Ann Clin Microbiol Antimicrob [Internet]. 2020 Jul 30 [cited 2024 Mar 22];19:32. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7391705/
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- Quinn N, Bliss A, Li M, Baker P, Pattisapu P. Hair, there, and everywhere: Peritonsillar abscess formation initiated by pet hair ingestion. Otolaryngology Case Reports [Internet]. 2022 Nov 1 [cited 2024 Mar 22];25:100470. Available from: https://www.sciencedirect.com/science/article/pii/S2468548822000790
- Civen R, Väisänen ML, Finegold SM. Peritonsillar abscess, retropharyngeal abscess, mediastinitis, and nonclostridial anaerobic myonecrosis: a case report. Clin Infect Dis. 1993 Jun;16 Suppl 4:S299-303. https://pubmed.ncbi.nlm.nih.gov/8324135/
- Garino JP, Ryan TJ. Carotid hemorrhage: a complication of peritonsillar abscess. Am J Emerg Med. 1987 May;5(3):220–3. https://pubmed.ncbi.nlm.nih.gov/3472527/
- Post-streptococcal glomerulonephritis (Psgn): all you need to know | cdc [Internet]. 2023 [cited 2024 Mar 22]. Available from: https://www.cdc.gov/groupastrep/diseases-public/post-streptococcal.html
- Rawla P, Padala SA, Ludhwani D. Poststreptococcal glomerulonephritis. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 [cited 2024 Mar 22]. Available from: http://www.ncbi.nlm.nih.gov/books/NBK538255/
- Brady MF, Burns B. Airway obstruction. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 [cited 2024 Mar 22]. Available from: http://www.ncbi.nlm.nih.gov/books/NBK470562/
- Sanivarapu RR, Gibson J. Aspiration pneumonia. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 [cited 2024 Mar 22]. Available from: http://www.ncbi.nlm.nih.gov/books/NBK470459/
- Nielsen TR, Clement F, Andreassen UK. Mediastinitis-a rare complication of a peritonsillar abscess. J Laryngol Otol. 1996 Feb;110(2):175–6. https://pubmed.ncbi.nlm.nih.gov/8729508/
- Allen BW, Anjum F, Bentley TP. Lemierre syndrome. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 [cited 2024 Mar 22]. Available from: http://www.ncbi.nlm.nih.gov/books/NBK499846/
- Esposito S, De Guido C, Pappalardo M, Laudisio S, Meccariello G, Capoferri G, et al. Retropharyngeal, parapharyngeal and peritonsillar abscesses. Children (Basel) [Internet]. 2022 Apr 26 [cited 2024 Mar 22];9(5):618. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9139861/
- Tasli H, Ozen A, Akca ME, Karakoc O. Risk of internal carotid injury due to peritonsillar abscess drainage. Auris Nasus Larynx [Internet]. 2020 Dec 1 [cited 2024 Mar 22];47(6):1027–32. Available from: https://www.sciencedirect.com/science/article/pii/S0385814620301449
- Kappus S, King O. Mediastinitis. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 [cited 2024 Mar 22]. Available from: http://www.ncbi.nlm.nih.gov/books/NBK559266/