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Quinsy (Phlegmonous Tonsillitis)

Overview

Quinsy, also known as peritonsillar abscess or phlegmonous tonsillitis, is a collection of pus that forms in the tissues surrounding the tonsil. It usually develops as a complication of acute tonsillitis, most often caused by Streptococcus pyogenes (group A strep). The condition is characterized by severe throat pain, swelling, and difficulty opening the mouth.

Who is affected? Quinsy can occur at any age but is most common in adolescents and young adults (15–30 years). It is slightly more prevalent in males than females (approximately 1.2 : 1).

Prevalence – In the United States, peritonsillar abscess accounts for roughly 2 % of all emergency‑department visits for sore throat each year, translating to about 45,000 cases annually (CDC, 2022). Worldwide incidence varies with socioeconomic status and access to primary care, ranging from 10–45 cases per 100,000 population per year (WHO, 2021).

Symptoms

Symptoms develop over 3–10 days after an initial bout of tonsillitis. The classic clinical picture includes:

• Severe unilateral throat pain – usually on one side, worsening when swallowing or talking.
• Fever – temperature often >38 °C (100.4 °F); may be accompanied by chills.
• Trismus (lockjaw) – difficulty opening the mouth due to spasm of the jaw‑closing muscles.
• “Hot potato” voice – muffled, nasal‑quality speech.
• Ear pain referred from the affected side.
• Swelling of the soft palate and uvula – the uvula may be displaced toward the opposite side.
• Visible bulge – a soft, fluctuant mass behind the tonsil that may be seen on examination.
• Difficulty swallowing (dysphagia) – can lead to reduced oral intake and dehydration.
• Neck stiffness or tenderness – especially along the sternocleidomastoid.
• General malaise, fatigue, and loss of appetite.

Less common but noteworthy signs include drooling, significant weight loss (if the illness is prolonged), and cyanosis of the tongue or lips, which may indicate impending airway obstruction.

Causes and Risk Factors

Primary cause

Quinsy is most often a sequela of untreated or partially treated acute bacterial tonsillitis. The infection spreads from the tonsillar crypts into the peritonsillar space, where the tissue architecture allows pus to accumulate.

Common pathogens

• Streptococcus pyogenes (group A streptococcus) – ≈ 70 % of isolates.
• Staphylococcus aureus (including MRSA in some regions).
• Anaerobic bacteria such as Fusobacterium and Prevotella spp.
• Mixed aerobic‑anaerobic flora in up to 30 % of cases.

Risk factors

• Recent or recurrent acute tonsillitis (especially if antibiotics were not completed).
• Smoking or exposure to second‑hand smoke – irritates the mucosa and impairs local immunity.
• Immunosuppression (HIV, diabetes mellitus, chemotherapy, corticosteroid use).
• Chronic tonsillar hypertrophy or enlarged tonsils.
• Living in crowded conditions (e.g., schools, dormitories) – higher transmission of streptococcal infections.
• Poor oral hygiene.

Diagnosis

Timely diagnosis is essential to prevent airway compromise and spread of infection.

Clinical examination

• Inspection of the oral cavity for unilateral tonsillar swelling, uvular deviation, and a fluctuating bulge.
• Palpation of the peritonsillar area – a “soft” and tender mass that may shift with gentle pressure.
• Assessment of trismus and range of mouth opening (< 2 cm suggests significant involvement).

Imaging (when needed)

• Contrast‑enhanced CT scan of the neck – gold standard for delineating abscess size, rule‑out deep neck space infection, and identify airway narrowing.
• Ultrasound – bedside, radiation‑free; useful in children or when CT is unavailable.

Laboratory tests

• Complete blood count (CBC) – typically shows leukocytosis with neutrophil predominance.
• CRP and ESR – elevated, reflecting acute inflammation.
• Throat culture or rapid antigen detection test (RADT) for strep – performed before antibiotics or after drainage to guide therapy.
• Blood cultures – reserved for patients with systemic signs of sepsis.

Differential diagnosis

Conditions that can mimic quinsy include:

• Tonsillar cellulitis
• Retropharyngeal abscess
• Peritonsillar hematoma
• Lymphoma or other neoplastic lesions of the oropharynx

Treatment Options

Management combines antimicrobial therapy, drainage of the abscess, and supportive care.

Antibiotics

Empiric broad‑spectrum coverage is recommended until culture results are available.

First‑line Regimen	Notes
Penicillin V 500 mg PO q6h + Clindamycin 300 mg PO q6h	Covers group A strep and anaerobes; clindamycin added for beta‑lactam allergy or suspected anaerobic infection.
Amoxicillin‑clavulanate 875/125 mg PO q12h	Alternative for non‑allergic patients; provides broader gram‑negative coverage.
IV ceftriaxone 1–2 g q24h + metronidazole 500 mg PO q8h	For patients unable to tolerate oral meds or with severe infection.

Duration: 10–14 days, with at least 48 h of IV therapy if the patient was initially hospitalized.

Drainage Procedures

• Incision and drainage (I&D) – performed under local anesthesia; a small horizontal or vertical cut is made into the bulge and pus is expressed.
• Aspiration – needle aspiration with a syringe; less invasive, often used when the abscess is small (< 2 cm) or in children.
• Quinsy tonsillectomy (also called “quinsy tonsillectomy”) – immediate tonsil removal during the acute phase; considered when I&D fails, the abscess recurs, or airway obstruction is imminent.

Post‑drainage, a small cottonoid dressing may be placed to keep the tract open for continued egress of pus.

Supportive Care

• Hydration – encourage oral fluids; if unable, IV fluids may be required.
• Pain control – acetaminophen or ibuprofen (unless contraindicated).
• Salt‑water gargles (warm saline) 3–4 times daily to reduce discomfort.
• Rest and a soft‑diet (soups, smoothies, yogurt) to ease swallowing.

Hospital Admission Criteria

Patients should be admitted if they present with any of the following:

• Airway compromise or stridor.
• Severe trismus limiting oral intake.
• Systemic toxicity (hypotension, tachycardia, altered mental status).
• Immunocompromised status.
• Failure of outpatient I&D or inability to attend follow‑up.

Living with Quinsy (phlegmonous tonsillitis)

Daily management tips

• Complete the full antibiotic course even if you feel better after a few days.
• Keep a pain‑log and report worsening pain or new fever to your clinician.
• Maintain good oral hygiene – brush teeth twice daily and use an alcohol‑free mouthwash.
• Stay hydrated; aim for 2–3 L of clear fluids per day.
• Consume soft, non‑spicy foods for the first 5–7 days (e.g., mashed potatoes, oatmeal, smoothies).
• Perform warm saline gargles after meals to soothe the throat.
• Avoid smoking and alcohol until fully recovered.
• Schedule a follow‑up appointment 48–72 hours after drainage to ensure resolution.

Return to normal activities

Most patients can resume work or school within 5–7 days if pain is controlled and they can tolerate oral intake. However, avoid strenuous exercise and heavy lifting for at least 2 weeks to reduce the risk of re‑bleeding from the drainage site.

Prevention

• Prompt treatment of sore throats – see a healthcare professional within 48 h of symptom onset, especially if fever, swollen lymph nodes, or exudates are present.
• Complete the prescribed antibiotic regimen for streptococcal tonsillitis.
• Practice **hand hygiene**: wash hands with soap for ≥20 seconds or use an alcohol‑based sanitizer.
• Avoid sharing utensils, drinks, or toothbrushes.
• Quit smoking and limit exposure to second‑hand smoke.
• Maintain regular dental check‑ups and good oral care.
• Consider **tonsillectomy** for patients with recurrent tonsillitis (> 5 episodes per year) or a history of repeated quinsy, as recommended by ENT specialists.

Complications

If left untreated or inadequately managed, quinsy can lead to serious, potentially life‑threatening complications:

• Airway obstruction – swelling can compromise the oropharyngeal airway, necessitating emergent intubation or tracheostomy.
• Spread of infection – to adjacent deep neck spaces (parapharyngeal, retropharyngeal) leading to necrotizing fasciitis or mediastinitis.
• Septicemia – systemic infection with fever, hypotension, and organ dysfunction.
• Internal jugular vein thrombosis (Lemierre’s syndrome) – rare but associated with high morbidity.
• Chronic sinusitis or otitis media – due to contiguous spread.
• Scarring of the palatal tissue – can cause persistent dysphagia or altered speech.

Early drainage and appropriate antibiotics reduce the risk of these outcomes dramatically (Cleveland Clinic, 2023).

When to Seek Emergency Care

References

• Mayo Clinic. “Peritonsillar Abscess.” Updated 2023. https://www.mayoclinic.org
• CDC. “Strep Throat & Complications.” 2022. https://www.cdc.gov
• NIH National Institute of Allergy and Infectious Diseases. “Peritonsillar Abscess.” 2021. https://www.niaid.nih.gov
• World Health Organization. “Acute Respiratory Infections – Global Burden.” 2021. https://www.who.int
• Cleveland Clinic. “Peritonsillar Abscess (Quinsy) Treatment.” 2023. https://my.clevelandclinic.org
• American Academy of Otolaryngology–Head and Neck Surgery. Clinical Practice Guideline: Tonsillitis and Peritonsillar Abscess. 2022.

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