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Referral and warning signs
When to refer
Urgent Referral to ENT Specialist/Hospital (HC4/H/RR) for ALL suspected cases of peritonsillar abscess for confirmation, drainage procedure, and IV antibiotics.
Red flags
- Difficulty breathing / Stridor.
- Severe trismus (unable to open mouth).
- Significant neck swelling or tenderness.
- Muffled voice.
- Drooling.
- Signs of sepsis.
Signs and symptoms
- Severe unilateral sore throat.
- Fever, chills, malaise.
- Odynophagia (painful swallowing) - often severe, leading to drooling.
- Trismus (difficulty opening the mouth / lockjaw).
- Muffled voice ('hot potato voice').
- Ear pain (referred pain, otalgia) on the affected side.
- Unilateral swelling of the soft palate and peritonsillar area.
- Displacement of the uvula away from the affected side.
- Enlarged, tender cervical lymph nodes on affected side.
- Bad breath (halitosis).
Risk factors
- Recent or concurrent acute tonsillitis.
- Smoking.
- Chronic tonsillitis.
- Periodontal disease.
- Infectious mononucleosis (less common).
Diagnosis
Clinical assessment
Diagnosis based on characteristic clinical presentation: severe unilateral throat pain, fever, trismus, muffled voice, and examination findings of unilateral peritonsillar swelling with uvular deviation.
Differential diagnosis
- Severe tonsillitis/pharyngitis.
- Peritonsillar cellulitis (inflammation without discrete pus collection).
- Retropharyngeal or parapharyngeal abscess.
- Dental abscess.
- Salivary gland infection.
- Epiglottitis (rare in adults).
- Tumour.
Investigations
- Clinical examination is usually sufficient.
- Needle Aspiration: Can confirm presence of pus (diagnostic) and provide sample for culture (therapeutic).
- CT Scan with Contrast (Neck): Useful if diagnosis uncertain, deep neck space infection suspected, or poor response to treatment.
- Throat swab C&S (may identify pathogens but less reliable than abscess aspirate).
- FBC (leucocytosis).
Diagnostic criteria
Clinical diagnosis based on characteristic signs/symptoms. Confirmation by aspiration of pus.
Management
Non-pharmacological management
- Airway Assessment: Ensure airway is patent. Admit patient.
- Hydration: IV fluids if unable to swallow adequately.
- Pain Relief.
- Drainage of Abscess (Essential):
- - Needle Aspiration: Often first-line. Aspirate pus from most prominent/fluctuant point after topical/local anaesthesia.
- - Incision and Drainage (I&D): Small incision made over fluctuant area to allow drainage. Performed by trained personnel (ENT).
- - Quinsy Tonsillectomy: Removal of tonsils immediately or shortly after abscess drainage (interval tonsillectomy 4-6 weeks later is also an option). Specialist decision.
Pharmacological treatment
- Analgesia: Opioids often required initially, then NSAIDs/Paracetamol.
- Antibiotics: Start IV antibiotics promptly, covering common pathogens (Strep pyogenes, Staph aureus, anaerobes).
- - Standard: Benzylpenicillin 1.2g (2 MU) IV Q6H + Metronidazole 500mg IV Q8H. (LOC: HC4/H)
- - Alternative: Ceftriaxone 1-2g IV OD + Metronidazole 500mg IV Q8H. OR Clindamycin IV.
- - Switch to oral antibiotics (e.g., Amoxicillin/Clavulanate OR Clindamycin) once improving, to complete 7-14 day total course.
- Corticosteroids: A single dose of IV Dexamethasone may help reduce swelling and pain (controversial, specialist use).
Monitoring
Monitor airway, hydration, pain control, resolution of trismus and swelling. Observe for re-accumulation after drainage.
Complications
- Airway obstruction.
- Spread of infection to deep neck spaces (parapharyngeal/retropharyngeal abscess).
- Aspiration pneumonia.
- Sepsis.
- Internal jugular vein thrombosis (Lemierre's syndrome - rare).
- Haemorrhage (rare, post-drainage or erosion).
Prevention
- Prompt and adequate treatment of acute tonsillitis.
- Tonsillectomy for recurrent severe tonsillitis or previous quinsy.
Patient education
- Explanation of the condition as an abscess behind the tonsil.
- Need for hospital admission, drainage, and IV antibiotics.
- Importance of completing full antibiotic course.
- Pain management.
- Advise soft diet initially.
- Risk of recurrence and potential need for tonsillectomy in future.
- When to seek review if symptoms worsen.
Uganda-specific notes
Quinsy requires prompt recognition and referral for drainage, which is usually done at hospital level by trained MOs or ENT specialists. Standard antibiotic regimens (Penicillin/Metro or Ceftriaxone/Metro) are used.
References
- Uganda Clinical Guidelines (UCG) 2023
Chapter 21, Section 21.3.5