The most common complication of tonsillitis is a deep infection of the head and neck known as a peritonsillar abscess (PTA or “Quinsy”). Traditionally, a PTA has been considered the last stage of a bad case of tonsillitis, but a PTA is different. Fortunately, PTAs occur less often than tonsillitis.
PTAs can be a complication of streptococcal tonsillitis, but there is no definite correlation. In fact, peritonsillar abscesses are often caused by more than one oral pathogen, and they usually occur in young adults, not children. Even the clinical presentation is different and more dramatic both in the short and long term. Lastly, does an episode of a PTA mean the patient should have a tonsillectomy?
What is a Peritonsillar Abscess?
A peritonsillar abscess is a localized infection and collection of pus that develops between the fibrous capsule and the muscles, not in the tonsils themselves. In fact, most peritonsillar abscesses probably do not originate in the tonsils, but instead in minor salivary glands called Weber glands. Weber glands are located just above or superior to the tonsil and are connected by a duct to the surface of the tonsil. It is thought that the Weber glands, not the tonsils, get infected as they try to assist the tonsils in clearing tonsillar debris.
These infections form in the soft palate just above the tonsil. It is often unilateral, but it can be bilateral and that involves a different clinical approach which I will not cover here since it is so rare. Similarly, it is equally rare to have a patient present with a PTA who has already undergo a tonsillectomy in the past which supports the theory regarding the Weber glands being the etiology of a PTA.
What are the signs and symptoms of a PTA?
These are acutely ill patients who present at off hours to the hospital emergency room or clinic. Many have not had tonsillitis for some time since they were young or ever before. It is surprise infection with characteristic signs and symptoms.
- Worsening throat pain, usually more one-sided
- Dysphagia (trouble swallowing)
- Ear pain (this is “referred” pain from the throat)
- Trismus (this is pain and difficulty with opening the mouth due to inflammation and spasm of the masticator muscles we use to chew)
- Drooling and pooling of saliva
- Hot potato voice
- Tender swollen neck lymph nodes, particularly on the affected side
- The tonsil is often displaced inferiorly (downward) and medially (to the middle) with a deviation of the uvula (the fleshy extension of the soft throat which hangs down) and soft palate.
- Redness and swelling of the soft palate (unilateral)
- Rancid, foul-smelling breath (fetor)
How is a PTA diagnosed?
A PTA is diagnosed on clinical presentation along with physical examination. There are other possibilities in the differential diagnosis such as peritonsillar cellulitis, just inflammation, or a dental abscess, but the diagnosis is usually straightforward.
In younger patients, it should be noted that upwards of 5% can have a coinfection with infectious mononucleosis. The PTA should still be treated in the same way but testing for infectious mononucleosis should be performed in many of these patients. If the patient has infectious mononucleosis, penicillin or amoxicillin should be avoided because it will induce an associated drug-induced rash.
Many emergency room physicians will obtain a CT scan of the neck for several reasons:
- No presence of pus on needle aspiration of the soft palate
- Severity of patient’s clinical presentation to rule out complications (see description below)
How is a PTA treated?
Treatment should be swift and efficient since these patients are in distress and complications are possible without it. The cornerstone of treatment involves:
- Surgical drainage (mostly done with local anesthesia)
- Hydration (IV fluids short-term in many cases)
- Supportive therapy to control fever and other symptoms
- Steroids (decreases swelling, particularly for patients with trouble swallowing or breathing)
In some cases, admission to the hospital for at least overnight is needed depending on the severity of the dehydration and pain. Many patients are unable to eat or drink initially. Fortunately, successful surgical drainage alleviates most of the symptoms almost immediately and then the patient just needs time for recovery.
Many emergency room and family physicians have become proficient in surgical drainage in routine cases. However, because of the level of difficulty in doing the procedure in patients who are unable to open their mouths (trismus), severity of pain, risks to the airway or bleeding, a well-trained ENT surgeon is often needed.
These patients can become medically fragile quickly. I tell all of my patients with a suspected PTA to come in immediately or stay there in the emergency room until I get there. It is generally not good practice to make these patients wait.
What are the possible complications of a PTA?
This article is not meant to instill fear since the vast majority of patients with a PTA do very well, particularly if treatment is done early. The point is that without treatment or improper treatment initially, there can be severe consequences. Hence, getting to the doctor and getting taken care of is paramount.
Complications may include:
- Airway obstruction
- Lung infection
- Worsening deep neck infection
- Poststreptococcal sequelae such as kidney or heart problems
It is also worth noting that patients with comorbidities such as diabetes mellitus, immunosuppression, or signs of sepsis (whole body infections) should be admitted to the hospital. Complication rates can be higher for adults, particularly those over 40 years as well.
Close monitoring of in-patients and out-patients is necessary since even in the best situations, PTAs can recur. Yes, you read that right. Recurrence is always a possibility, and a repeated surgical drainage can be necessary, infrequently.
A final word: do I need a tonsillectomy after having a PTA?
The answer is maybe. Fully, one-third of patients having been treated for a PTA, will satisfy the relative criteria for undergoing an elective tonsillectomy later. Just as it is important to not ignore or delay treatment of the PTA in the first place, it is important to follow through with elective tonsillectomy to avoid repeated infections.
A good question I always face is, why can’t I have my tonsillectomy done now when I have the PTA? This is known as performing a “hot” tonsillectomy. It is usually avoided because there are increased risks of bleeding, infection, airway problems, or risks of anesthesia. Waiting until the initial infection subsides is best in the majority of patients.
There are rare exceptions, however, and the only way to effectively treat a severe PTA with a neck infection or airway problem is to proceed with the surgical drainage and urgent tonsillectomy. Fortunately, almost everyone reading this will never experience that situation in themselves or anyone they know.