Abscess (quinsy) and cellulitis probably represent a spectrum of the same process in which bacterial infection of the tonsils and pharynx spreads to the soft tissues. Infection is virtually always unilateral and is located between the tonsil and the superior pharyngeal constrictor muscle. It usually involves multiple bacteria. Streptococcus and Staphylococcus are the most frequent aerobic pathogens, whereas Bacteroides species is the predominant anaerobic pathogen.
Symptoms include gradual onset of severe unilateral sore throat, dysphagia, fever, otalgia, and asymmetric cervical adenopathy. Trismus, "hot potato" voice (speaking as if a hot object was in the mouth), a toxic appearance (eg, poor or absent eye contact, failure to recognize parents, irritability, inability to be consoled or distracted, fever, anxiety), drooling, severe halitosis, tonsillar erythema, and exudates are common. Abscess and cellulitis both have swelling above the affected tonsil, but with abscess there is more of a discrete bulge, with deviation of the soft palate and uvula and pronounced trismus.
Peritonsillar cellulitis is recognized in patients with severe sore throat who have trismus, "hot potato" voice, and uvular deviation. All such patients require needle aspiration of the tonsillar mass and cultures. Aspiration of pus differentiates abscess from cellulitis. Point-of-care ultrasonography can be used for diagnosis and to determine the optimal location for aspiration or incision and drainage.
CT of the neck can help confirm the diagnosis when the physical examination is difficult or the diagnosis is in doubt, particularly when the condition must be differentiated from a parapharyngeal infection or other deep neck infection.
Cellulitis subsides, usually within 48 hours, with hydration and high-dose penicillin (eg, 2 million units IV every 4 hours or 1 g orally 4 times a day); alternative drugs include a 1st-generation cephalosporin or clindamycin. Culture-directed antibiotics are then prescribed for 10 days.
Abscesses are incised and drained in the emergency department using thorough local anesthesia and sometimes procedural sedation; many clinicians believe needle aspiration alone provides adequate drainage. Ultrasound guidance is frequently used. Although most patients can be treated as outpatients, some need brief hospitalization for parenteral antibiotics, IV hydration, and airway monitoring. Rarely, an immediate tonsillectomy is done, particularly in a young or uncooperative patient who has other indications for elective tonsillectomy (eg, history of frequently recurrent tonsillitis or obstructive sleep apnea). Otherwise, elective tonsillectomy is done 4 to 6 weeks later to prevent abscess recurrence.
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