Tonsillitis and Peritonsillar Abscess (Quinsy)
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Direct answer
Acute tonsillitis is infection of the palatine tonsils, most often by Streptococcus pyogenes, presenting with sore throat, fever, dysphagia and enlarged, congested tonsils with exudates. Quinsy, or peritonsillar abscess, is the collection of pus in the space between the tonsillar capsule and the superior constrictor, giving severe unilateral throat pain, trismus, muffled "hot potato" voice and a medially displaced, inflamed uvula. Quinsy is treated by drainage under local anaesthesia with antibiotics, while recurrent tonsillitis is an indication for tonsillectomy.
What you must remember
- Acute presentation: sore throat with odynophagia referred to the ear, fever, malaise and tender jugulodigastric lymph nodes; the tonsils are enlarged and studded with infected follicles or membranes.
- Organisms: Streptococcus pyogenes is the classical pathogen; viruses, Epstein-Barr virus in adolescents, and mixed flora also occur.
- Membrane comparison: a follicular or membranous tonsillitis membrane stays within the tonsil and is easily wiped off, whereas the diphtheritic membrane is grey, extends beyond the tonsil onto the pillars and uvula, is adherent and leaves a bleeding surface on removal.
- Quinsy features: unilateral severe pain, drooling and odynophagia, trismus, muffled voice, unilateral referred otalgia and, on examination, a bulging soft palate with the uvula pushed to the opposite side and the tonsil displaced medially.
- Quinsy management: needle aspiration or incision and drainage of the abscess after topical anaesthesia, intravenous antibiotics such as penicillin with anaerobic cover, analgesia and hydration; an interval tonsillectomy is advised after recurrent or severe quinsy.
- Tonsillectomy indications: documented recurrent episodes of tonsillitis (commonly seven in one year, five per year for two years or three per year for three years), obstructive sleep apnoea and sleep-disordered breathing, recurrent quinsy, suspected malignancy such as asymmetric tonsillar enlargement, and peritonsillar infection spreading to the parapharyngeal space.
- Complications of tonsillitis: paratonsillar and parapharyngeal abscess, retropharyngeal abscess in children, rheumatic fever and post-streptococcal glomerulonephritis.
Common confusion
Students confuse quinsy with peritonsillar cellulitis — the abscess stage shows a pointing bulge and often trismus with the uvula displaced, and it needs drainage, while cellulitis may settle with antibiotics alone. And the membrane: do not label every white tonsil diphtheria, but respect one that extends past the tonsil and bleeds on removal — that patient needs isolation.
Exam-focused takeaway
For theory, write the clinical features and organisms of acute tonsillitis, the full picture of quinsy with its drainage steps, and a clean list of tonsillectomy indications with complications. In viva, expect the difference between follicular and membranous tonsillitis, the trismus and uvula signs of quinsy, and the classical criteria for tonsillectomy. In the posting, examine every severe sore throat for trismus, drooling and uvular deviation.
Frequently asked questions
What is quinsy?
A peritonsillar abscess between the tonsillar capsule and the superior constrictor muscle, presenting with severe unilateral throat pain, trismus, muffled voice and uvular displacement to the opposite side.
How is a quinsy drained?
Under local anaesthesia, by needle aspiration or incision at the point of maximum bulging, usually just above the upper pole of the tonsil; intravenous antibiotics and analgesia follow.
How does a diphtheritic membrane differ?
It is grey, adherent, extends beyond the tonsil onto the soft palate, and bleeds when removed, unlike the easily removable exudates of streptococcal tonsillitis.
What are the common indications for tonsillectomy?
Recurrent documented tonsillitis, sleep-disordered breathing or obstructive sleep apnoea, recurrent quinsy, and suspicion of malignancy in an asymmetric tonsil.
Which systemic complications follow streptococcal tonsillitis?
Rheumatic fever and post-streptococcal glomerulonephritis, which is why an episode of severe exudative tonsillitis deserves proper treatment.
Why does tonsillitis cause ear pain?
The tonsillar region and the middle ear share glossopharyngeal nerve supply, so tonsillar inflammation refers pain to the ear through the tympanic branch.