Peritonsillar abscess
A peritonsillar abscess does not resolve itself. Any intense throat pain associated with difficulty opening the mouth, swallowing or speaking requires immediate medical evaluation, preferably in an emergency room or ENT. In the event of breathing difficulties, call 911 immediately.
How does a peritonsillar abscess form?
Peritonsillar abscesses most often result from inadequately treated bacterial angina or infection of the minor salivary glands located at the upper pole of the tonsil (Weber's glands). Infection progressively spreads to the loose cellular tissue surrounding the tonsil, leading first to cellulitis (phlegmon), then to a localized purulent collection (constituted abscess). The bacteria involved are often polymicrobial: Streptococcus pyogenes (group A streptococcus) is frequently found, as well as anaerobic oral flora such as Fusobacterium necrophorum, Prevotella and Peptostreptococcus.
What are the symptoms?
The signs of a peritonsillar abscess are usually unilateral, and set in over several days, often following an initial sore throat:
| Symptom | Description |
|---|---|
| Intense pharyngeal pain | Unilateral, very sharp, often radiating to the ear on the same side (reflex otalgia) |
| Trismus | Difficulty or inability to open mouth normally due to spasm of adjacent masticatory muscles |
| Severe dysphagia | Intense pain on swallowing, making it very difficult to take liquids and solids |
| Hot potato« voice» | Muffled, nasal or muffled voice, characteristic of a constituted peritonsillar abscess |
| Hypersalivation | Inability to swallow saliva, leading to oral discharge or accumulation |
| High fever | Often higher than 38.5°C, with chills and general ill-being |
| Cervical adenopathy | Painful, palpable lymph nodes on the affected side |
| Halitosis | Bad breath linked to polymicrobial bacterial infection |
Who's most at risk?
- Adolescents and young adults aged 15 to 35: the age group most frequently affected
- People with a history of recurrent angina or chronic tonsillitis
- Active smoking: alters the local defences of the pharyngeal mucosa
- Poor oral hygiene and untreated dental pathologies
- Immunosuppression: diabetes, immunosuppressive therapy, HIV infection
- Recent angina treated incompletely or with an inappropriate antibiotic
How is the diagnosis made?
Diagnosis is primarily clinical, performed by a doctor or ENT specialist on examination of the throat. Characteristic features include unilateral protrusion of the tonsil and soft palate, displacement of the uvula towards the healthy side, trismus and a muffled voice. Additional tests may be ordered to confirm the diagnosis and assess severity:
- Cervical CT scan with contrast injection: the gold standard for confirming a purulent collection, delimiting its extent and ruling out extension to the deep neck spaces.
- Cervical or endobuccal ultrasound: a less radiation-intensive alternative, useful for guiding drainage in certain contexts
- Biological workup: blood count (hyperleukocytosis), CRP, blood cultures if sepsis suspected
- Bacteriological sampling of pus during drainage: helps identify the causative germ(s) and adapt antibiotic therapy
What is the treatment?
Management of peritonsillar abscess is based on two complementary pillars: drainage of the purulent collection and antibiotic therapy.
| Treatment | Terms and objectives |
|---|---|
| Surgical drainage | Needle aspiration or incision-drainage under local anaesthetic by ENT specialist: evacuation of pus and rapid relief of symptoms. Reference technique for constituted abscesses |
| Antibiotic therapy | Amoxicillin-clavulanic acid as first-line treatment to cover aerobic and anaerobic germs. Usually lasts 10 to 14 days. Adaptation according to pus culture |
| Corticosteroid therapy | Short course of corticosteroids sometimes combined to reduce swelling, relieve pain and improve food tolerance |
| Analgesia | Analgesics and anti-inflammatories to control pain, allow feeding and maintain adequate hydration |
| Hospitalization | Necessary in cases of severe trismus, risk of airway obstruction, extension to deep spaces, inability to feed or immunosuppression |
| Tonsillectomy | Tonsil removal considered at a distance, particularly in cases of recurrent abscesses or severe chronic tonsillitis |
What are the possible complications?
If not treated promptly, peritonsillar abscesses can develop into serious complications:
- Extension to deep neck spaces: retropharyngeal or parapharyngeal abscesses, which may compress the airways or large vessels
- Descending necrotizing mediastinitis: spread of infection to the mediastinum, a rare but potentially fatal complication
- Thrombophlebitis of the internal jugular vein (Lemierre syndrome): rare complication associated with Fusobacterium necrophorum, with possible pulmonary septic emboli.
- Airway obstruction: a vital emergency in cases of massive pharyngeal edema
- Sepsis and septic shock: systemic bacterial dissemination
- Recurrence of abscess: risk of 10 to 15 % without remote tonsillectomy
How can peritonsillar abscess be prevented?
- Treat all documented strep throat with a suitable antibiotic, and complete the full course of treatment prescribed, even in the event of rapid improvement.
- Seek prompt medical attention if symptoms worsen despite ongoing treatment, or if trismus develops
- Maintain good oral hygiene and treat infectious dental foci
- Stop smoking, which weakens the local defences of the pharyngeal mucosa
- Discuss with an ENT specialist the advisability of tonsillectomy in cases of recurrent tonsillitis (three or more episodes per year over several consecutive years).
Consult at Clinique Omicron
If you experience intense, unilateral throat pain, difficulty opening your mouth or swallowing, or if an ongoing sore throat does not improve after 48 to 72 hours of treatment, seek prompt medical attention. Clinique Omicron's teams, at our points of service in Quebec, can assess your clinical picture, initiate the appropriate antibiotic therapy and refer you to an ENT specialist or to the emergency room, depending on the severity of your presentation.
The content of this page is provided for informational purposes only and is not intended to replace the advice of a qualified healthcare professional. Consult a physician for any symptoms, questions or decisions you may have regarding your health.
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