PERITONSILLAR ABSCESS(QUINSY)

It is a collection of pus in the peritonsillar space
which lies between capsule of tonsil and the
superior constrictor muscle.
AETIOLOGY:

Usually follows acute tonsillitis or denovo without
history of sore throat.
First crypta magna get infected and sealed off .
Which forms the intratonsillar abscess which then
brust through tonsillar capsule causing
peritonsillitis and then abscess.
CLINICAL FEATURES:

Peritonsillar abscess mostly affects adults and rarely children.

Usually it is unilateral.

Clinical features are divided into :
A)General:
they are due to septicaemia .they include fever chills and rigors, general
malaise , body aches, headache, nausea and constipation.
B) Local:

Severe pain in throat usually unilateral.

Marked odynophagia.

Patient is usually dehaydrated.
 Muffled and thick speech, often called “ hot potato voice”
 Foul breath due to sepsis in oral cavity and poor hygiene.
 Ipsilateral earache.( ref pain via CN IX which supplies both
tonsil and ear.
 Trismus due to spasm of pterygoid muscles .
EXAMINATION:

1) Tonsil, pillars and soft palate on involved side are swollen and
congested. Tonsil itself may not appear enlarged as it gets buried in
the oedematous pillars.

2) Uvula is swollen and oedematous and pushed to opposite side.

3)Bulging of soft palate and anterior pillar above tonsil.

4)Mucopus may be seen covering the tonsillar region.

5) Cervical lymphadenopathy. Involves jugulodiagastric nodes.

6)Torticollis– to the side of the abscess
INVESTIGATION

SWAB CULTURE :
GROWTH OF Strep pyogenes, Staph. Aureus or
anaerobic organisms.
 More often the growth is mixed, with both
aerobic and anaerobic organism.

TREATMENT:
Hospitalisation
Intravenous fluids for dehydration.
IV Antibiotics covering both aerobic
and anaerobic
 Analgesics
 Oral hygiene.
 If frank abscess has formed incision and
drainage should be done.
 Interval tonsillectomy: tonsils are
removed 4-6 weeks following an attack.
 Abscess or hot tonsillectomy.



COMPLICATIONS:






Parapharyngeal abscess
Oedema of larynx
Septicaemia
Pneumonitis or lung abscess
Jugular vein thrombosis.
Spontaneous haemorrhage from carotid
artery or jugular vein.
APPLIED ANATOMY:
 It lies behind the pharynx between the
buccopharyngeal fascia covering phayngeal constrictor
muscles and prevertebral fascia.
 It extends from base of skull up to bifurcation of
trachea.
 This space is divided into two lateral compartment by
fibrous raphe.
 Retropharyngeal space infection can pass down
behind oesophagus into mediastinum.
PREVERTEBRAL SPACE:

It lies between the vertebral bodies posteriorly and
prevertebral fascia anteriorly.

It extends from base of skull to coccyx.

Infection of this space usually comes from caries of spine.

Abscess of this space produces midline bulge.
ACUTE RETROPHARYNGEAL ABSCESS
Aetiology:
 Commonly seen in child below 3 yrs.
 It result from suppuration of retropharyngeal
lymphnodes.
 In adult it may result from penetrating injury of
posterior pharyngeal wall or cervical oesophagus.
CLINICAL FEATURES:
Dysphagia and difficulty in breathing are
prominent symptoms.
 Stridor and croupy cough may be present
 Torticollis.
 Bulge in posterior pharyngeal wall usually
seen on one side of midline.
 X-ray soft tissue neck lateral view show
widening of prevertebral shadow.

TREATMENT:

Incision and drainage of abscess.

Systemic antibiotics.

Tracheostomy.
CHRONIC RETROPHARYNGEAL ABSCESS
AETIOLOGY:
 It is tubercular in nature and is the result of
1.Caries of cervical spine
2.TB infection of retropharyngeal
lymphnodes secondary to TB of deep
cervical nodes.
 The former presents centrally behind the
prevertebral fascia while the latter is limited to one
side of midline as in true retropharyngeal abscess
CLINICAL FEATURES:
Discomfort in throat.
 Dysphagia but not marked.
 Posterior pharyngeal wall shows a
fluctuant swelling centrally or on one side
of midline.
 Neck may show TB lymphnodes.


TREATMENT:

Incision and drainage:


Can be done through a vertical incision along the
anterior border of sternomastoid or along its
posterior border.
Full course of antitubercular therapy should be
given.
PARAPHARYNGEAL ABSCESS

Also known as pharyngomaxillary or lateral
pharyngeal space.
APPLIED ANATOMY:
 Parapharyngeal space is pyramidal in shape
with its base at the base of skull and its apex
at hyoid bone.




MEDIAL: buccopharyngeal fascia covering the
constrictor muscles.
POSTERIOR: prevertebral fascia .
LATERAL: medial pterygoid muscle, mandible
and deep surface of parotid gland.
Styloid process and muscles attached to it divide
parapharyngeal space into anterior and
posterior compartments.
Anterior compartment is related to tonsillar
fossa.
 Posterior compartment is related to post part
of lat. Pharyngeal wall medially and parotid
gland laterally.
 Through post. Compartment pass the carotid
artery, jugular vein, IX,X,XI,XII th cranial
nerves and sympathetic trunk.

Infection of parapahryngeal space can occur
from:
 Pharynx
 Teeth
 Ear
 Other spaces like infection of parotid,
retropharyngeal and submaxillary spaces.
 External trauma.
CLINICAL FEATURES:

It depends upon compartment involved.
Anterior compartment:
 Prolapse of tonsil and tonsillar fossa.
 Trismus due to spasm of medial pterygoid
muscle.
 External swelling behind the angle of jaw.
Marked odynophagia.
Posterior compartment:
 Bulge of pharynx behind the posterior pillars.
 Paralysis of CN IX, X, XI,XII and sympathetic
chain
 Swelling of parotid region.
 There is minimal trismus or tonsillar prolapse.
 Fever , odynophagia, sore throat, torticollis and
sign of toxaemia are common to both
compartments.

TREATMENT:

Systemic antibiotics.

Drainage of abscess.
COMPLICATIONS:
Acute edema of larynx with respiratory
obstruction.
 Thrombophlebitis of jugular vein with septcaemia.
 Spread of infection to retropharyngeal space.
 Spread of infections to mediastinum along carotid
space.
 Mycotic aneurysm of carotid artey.
 Carotid blow out with massive haemorrhage.

Caused due to elongated styloid process or calcification
of stylohyoid ligament.

Patient complains of pain in tonsillar fossa and upper
neck which radiates to the ipsilateral ear.


It gets aggaravated on swallowing
Diagnosis can be made by transoral palpation of the
styloid process in the tonsillar fossa and by a radiograph
such as anteroposteror view with open mouth or lateral
view of skull.

Many persons may have elongated styloid
process but remain asymptomatic and do not
need treatment
 Symptomatic styloid process can be excised by
transoral or cervical approach.

PBL
 Case 34: A 25 year old farmer has been complaining of
nasal obstruction, greenish nasal discharge and nasal
deformity of one year duration.
 On examination the nose was broad and contained a
lobulated firm mass that may bleed on touch. Also,
there was a hard swelling below the medial canthus of
the right eye.
 One week ago, he noticed a change in his voice that
was followed by respiratory distress.
 On examination there was marked stridor and
laryngeal examination showed a subglottic laryngeal
web.