Peritonsillar Abscess (Quinsy) Management

Algorithm Steps

1. ▶

   Start

   Suspected Peritonsillar Abscess

   Patient with severe unilateral throat pain, trismus, muffled voice, fever

   1. ●

      Action

      Clinical Examination

      Look for classic triad: Trismus (limited mouth opening), Uvular deviation (away from affected side), Muffled 'hot potato' voice. Also: unilateral tonsillar bulge, soft palate erythema/edema.

      1. ◆

         Decision

         Airway Compromise?

         Signs of impending airway obstruction: stridor, drooling, inability to swallow, respiratory distress?

         1. ⚠

            Warning

            ⚠️ Airway Emergency

            Call anesthesia and ENT STAT. Prepare for difficult airway. Avoid sedation. Consider awake fiberoptic intubation or surgical airway.

            1. ●

               Action

               Initial Medical Management

               IV fluids for hydration. Dexamethasone 10mg IV (reduces pain and edema). IV antibiotics: Ceftriaxone 2g IV + Metronidazole 500mg IV OR Ampicillin-sulbactam 3g IV OR Clindamycin 600-900mg IV.

               • Dexamethasone 10mg IV single dose
               • Pain control: NSAIDs, acetaminophen, opioids PRN
               • NPO until drainage completed
               1. ◆

                  Decision

                  Drainage Method?

                  Both needle aspiration and incision & drainage have similar success rates. Choice depends on operator experience and patient factors.

                  1. ●

                     Action

                     Needle Aspiration

                     18G needle on 10mL syringe. Topical anesthesia + local infiltration. Aspirate at point of maximal fluctuance (usually superior pole). May need multiple passes.

                     • Position: upright, slight head extension
                     • Landmark: superior-lateral to tonsil
                     • Protect needle with guard (leave 1cm exposed)
                     • Aspirate until pus obtained or dry tap
                     1. ◆

                        Decision

                        Successful Drainage?

                        Was pus obtained? Did patient have symptomatic relief (reduced pain, improved mouth opening)?

                        1. ●

                           Action

                           Failed Initial Drainage

                           Consider: phlegmon (no abscess yet), wrong location, deep space extension. Obtain CT if not already done. ENT consultation.

                           1. ●

                              Action

                              CT Neck with Contrast

                              Obtain if: unclear diagnosis, concern for deep space extension, failed initial drainage, or immunocompromised patient.

                        2. ◆

                           Decision

                           Disposition

                           Admit if: unable to tolerate PO, immunocompromised, concern for deep space infection, airway compromise, failed drainage, unreliable follow-up.

                           1. ✓

                              Outcome

                              Discharge with Follow-up

                              Oral antibiotics x 10 days: Amoxicillin-clavulanate 875/125mg BID or Clindamycin 300-450mg TID. Follow-up in 24-48 hours. Return precautions. ENT referral for tonsillectomy consideration.

                           2. ✓

                              Outcome

                              Admit for IV Antibiotics

                              Continue IV antibiotics. ENT consultation. Serial examinations. Repeat drainage if needed. Consider OR for tonsillectomy in recurrent cases.

                  2. ●

                     Action

                     Incision & Drainage

                     Scalpel incision at point of maximal fluctuance. Blunt dissection with hemostats to break loculations. May be preferred for larger abscesses or failed aspiration.

                     • Local anesthesia: lidocaine with epinephrine
                     • Incision: 1-2cm at superior pole
                     • Blunt dissection to open loculations
                     • Express pus, irrigate if needed
         2. ◆

            Decision

            Phlegmon or Abscess?

            Point-of-care ultrasound (POCUS): Sensitivity ~91%, specificity ~75% per 2023 meta-analysis. CT with contrast if POCUS equivocal or deep space concern. Fluctuance suggests abscess. Phlegmon = cellulitis without drainable collection.