# Peritonsillar Abscess (Quinsy) Drainage

## Overview

This module describes how to drain a peritonsillar abscess (quinsy).

## Indications

1. Peritonsillar abscess > 1 cm in size

## Contraindications

1. Underlying or suspected oral cavity malignancy

2. Vascular malformations

3. An uncooperative patient

## Patient information and consent

Always verify your patient’s identity and obtain informed consent before proceeding.

### How do I explain this procedure?

“You have an infection with pus, called an abscess, in your throat next to your tonsil. This must be opened to allow the pus inside to run out, otherwise it will not heal, even with antibiotics.”

### What can my patient expect?

“I will spray the area to numb it. Then I will make a small cut and clean out the pus. Keeping your mouth wide open will be difficult and painful but I can't open this abscess quickly and properly without your cooperation.”

### What is my patient’s role?

“Let me know if you have any allergies, a heart condition, or a bleeding tendency, or use blood thinners. Fearing blood or needles is normal, but tell me if you have fainted from it. Keep as still as possible and keep your mouth open wide. If you feel like gagging, try to swallow but don't close your mouth. If you feel strange sensations like tingling or severe pain, tell me immediately.”

## Preparation

Ensure that resuscitation equipment is available in case of airway compromise.

### Documentation

1. Patient notes

### Equipment

1. Non-sterile gloves

2. Alcohol-based hand rub

3. Sharps container
   Sharps container

   If a sharps container is not within arm's length, use a kidney dish or other hard container to temporarily hold used sharps and to carry them to the sharps container for disposal.

4. 10% topical local anaesthetic spray

5. A large-bore needle (20-18 G) and syringe for aspiration

6. No. 11 blade
   No. 11 blade

   Wrap strapping around the blade so that only 1 cm of the tip is protruding. This prevents deep penetration.

   and scalpel handle for drainage

7. A kidney dish or receiver to spit into

8. A cup or container of saline

9. A metal or disposable spatula

10. Wall suction with suction catheter if available

## Site & Positioning

The patient should be seated in front of you with the mouth open. If possible, have them seated with the

head and back against a wall

head and back against a wall

Do not extend the neck to avoid aspiration of pus.

. A

good light source

good light source

If this is not available, an overhead light can be used and angled correctly or an assistant can hold a torch for you.

such as a headlamp is essential. Patients will have trismus because of pain. Using two tongue depressors, apply downward pressure on the tongue to resist the trismus during examination, and then during the procedure.

## Procedure

Follow medical asepsis with non-sterile gloves.

1. Perform hand hygiene.

2. Spray the peritonsillar area well with local anaesthetic.

3. Using a needle and syringe, attempt to aspirate pus from the point of maximum fluctuance. Penetrate to a depth of 1 cm.

4. If large volume of pus is aspirated, decide whether to proceed with incision (see Troubleshooting). Incise using the scalpel blade at the point of maximum fluctuance, or at the junction of the line of the anterior pillar and a line drawn across the base of the uvula.

5. Use suction to clear pus, and allow the patient to spit into the kidney dish or receiver.

6. Advise the patient to gargle with saline to rinse out the rest of the pus.

7. Dispose of medical waste safely.

8. Record completion of the procedure in patient notes.

## Troubleshooting

The abscess is smaller than 1 cm or I am unsure if surgical management is indicated.

Give the patient a stat dose of intravenous corticosteroids (dexamethasone 0.2 mg/kg in children and 0.1 mg/kg-0.2 mg/kg in adults), commence intravenous antibiotics and analgesia and review in 24 hours.

I am unsure if routine antibiotics are indicated.

All patients should receive routine antibiotics. Penicillin G (IV) or Penicillin VK (oral) are first line antibiotics. If unavailable, use co-amoxiclav. Consider macrolides in patients with penicillin allergies (erythromycin or clindamycin).

I was unable to drain any pus, either by aspiration or by incision.

If no pus is aspirated, one additional attempt should be performed (1 cm superior and 1 cm lateral to the initial puncture site). If unsuccessful, consider peritonsillar cellulitis without abscess. Admit the patient for IV antibiotics, give a stat dose of intravenous dexamethasone (0.2mg/kg in children and 0.1mg/kg in adults) and review again in 24 hours.

The patient is uncooperative.

Consult with a senior for drainage under anaesthesia or referral to an ENT specialist. Do not sedate the patient due to risk of aspiration and airway compromise.

I am unsure if my patient requires admission.

Signs of sepsis warrant immediate admission. If the patient is unable to tolerate oral fluids, or there is concern regarding the airway

(“kissing” tonsils)

(“kissing” tonsils)

"Kissing tonsils" refer to severely enlarged tonsils, which touch each other as the patient breathes.

, the patient requires admission for observation, IV antibiotics, and IV fluids.

I am unsure if aspiration or incision and drainage is more appropriate.

Low-quality evidence suggests that incision and drainage reduces the risk of recurrence, and that needle aspiration is less painful. Always attempt aspiration first, which may be sufficient, and the subsequent decision to incise and drain is at the healthcare provider’s discretion.

## Risks

1. Bleeding

2. Aspiration of abscess contents with pneumonia or lung abscess

3. Sepsis

4. Airway compromise (e.g. from excessive bleeding or laryngeal oedema)

5. Sharps injury to healthcare personnel.

## References

1. Gupta G, McDowell R. Peritonsillar abscess. [Updated 2021 July 21]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan. Available from: https://www.ncbi.nlm.nih.gov/books/NBK519520/

2. Galioto NJ. Peritonsillar Abscess. Am Fam Physician. 2017 Apr 15;95(8):501-506. PMID: 28409615. https://www.aafp.org/afp/2017/0415/p501.html

3. Chang BA, Thamboo A, Burton MJ, Diamond C, Nunez, DA. Needle aspiration versus incision and drainage for the treatment of peritonsillar abscess. The Cochrane database of systematic reviews. 2016;12(12), CD006287. https://doi.org/10.1002/14651858.CD006287.pub4

4. Prescott CAJ. Practical skills in ENT. In: Handbook of ENT: Diseases and Disorders of the Ear, Nose and Throat. 4th ed. Southern Africa: Oxford University Press; 2009: 197-198.