History

Symptoms of peritonsillar abscess usually begin 3-5 days prior to evaluation.

Fever
Malaise
Headache
Neck pain
Throat pain markedly more severe on the affected side and occasionally referred to the ipsilateral ear
Dysphagia
Change in voice
Otalgia
Odynophagia

Physical

Physical findings of peritonsillar abscess include the following:

Mild/moderate distress
Fever
Tachycardia
Dehydration
Drooling, salivation, trouble handling oral secretions
Trismus resulting from pain from inflammation and spasm of masticator muscles
Hot potato/muffled voice
Rancid or fetor breath
Cervical lymphadenitis in the anterior chain
Asymmetric tonsillar hypertrophy
Localized fluctuance
Inferior and medial displacement of the tonsil
Contralateral deviation of the uvula
Erythema of the tonsil
Exudates on the tonsil

Causes

Peritonsillar abscesses are usually polymicrobial. A prospective study carried out to elucidate significant pathogens involved in peritonsillar abscesses demonstrated that the most prominent aerobic pathogen was Streptococcus pyogenes. Other aerobic pathogens isolated included Staphylococcus aureus,Neisseria species, and Corynebacterium species. In the same study, the most common anaerobic species found was Fusobacterium necrophorum, an obligate, anaerobic, Gram-negative rod. Other Fusobacterium species and Prevotella species were also isolated. A literature review demonstrated that the Streptococcus milleri group, a facultative anaerobic group of bacteria, is also commonly associated with peritonsillar infection. Though these studies are European publications, studies within the United States have demonstrated similar results.^{[5, 13, 4, 14, 15]}

The aforementioned literature review by Klug et al reported that the most prevalent bacteria in peritonsillar abscess are viridans group streptococci (25%), beta-hemolytic streptococci (20%), Fusobacterium necrophorum (13%), Staphylococcus aureus (11%), Prevotella species (10%), and Bacteroides species (9%).^[11]

Differential Diagnoses

Johnson RF. Emergency department visits, hospitalizations, and readmissions of patients with a peritonsillar abscess. Laryngoscope. 2017 Oct. 127 Suppl 5:S1-S9. [QxMD MEDLINE Link].
Johnson RF, Stewart MG, Wright CC. An evidence-based review of the treatment of peritonsillar abscess. Otolaryngol Head Neck Surg. 2003 Mar. 128(3):332-43. [QxMD MEDLINE Link].
Herzon FS, Martin AD. Medical and surgical treatment of peritonsillar, retropharyngeal, and parapharyngeal abscesses. Curr Infect Dis Rep. 2006 May. 8(3):196-202. [QxMD MEDLINE Link].
Steyer TE. Peritonsillar abscess: diagnosis and treatment. Am Fam Physician. 2002 Jan 1. 65(1):93-6. [QxMD MEDLINE Link].
Galioto NJ. Peritonsillar abscess. Am Fam Physician. 2008 Jan 15. 77(2):199-202. [QxMD MEDLINE Link].
Vieira F, Allen SM, Stocks RM, Thompson JW. Deep neck infection. Otolaryngol Clin North Am. 2008 Jun. 41(3):459-83, vii. [QxMD MEDLINE Link].
Klug TE, Rusan M, Fuursted K, Ovesen T. Peritonsillar Abscess: Complication of Acute Tonsillitis or Weber's Glands Infection?. Otolaryngol Head Neck Surg. 2016 Mar 29. [QxMD MEDLINE Link].
Lepelletier D, Pinaud V, Le Conte P, et al. Is there an association between prior anti-inflammatory drug exposure and occurrence of peritonsillar abscess (PTA)? A national multicenter prospective observational case-control study. Eur J Clin Microbiol Infect Dis. 2017 Jan. 36 (1):57-63. [QxMD MEDLINE Link].
Johnson RF, Stewart MG. The contemporary approach to diagnosis and management of peritonsillar abscess. Curr Opin Otolaryngol Head Neck Surg. 2005 Jun. 13(3):157-60. [QxMD MEDLINE Link].
Qureshi HA, Ference EH, Tan BK, et al. National Trends in Retropharyngeal Abscess among Adult Inpatients with Peritonsillar Abscess. Otolaryngol Head Neck Surg. 2015 Jan 20. [QxMD MEDLINE Link].
Klug TE, Greve T, Hentze M. Complications of peritonsillar abscess. Ann Clin Microbiol Antimicrob. 2020 Jul 30. 19 (1):32. [QxMD MEDLINE Link]. [Full Text].
Herzon FS. Harris P. Mosher Award thesis. Peritonsillar abscess: incidence, current management practices, and a proposal for treatment guidelines. Laryngoscope. 1995 Aug. 105(8 Pt 3 Suppl 74):1-17. [QxMD MEDLINE Link].
Sakae FA, Imamura R, Sennes LU, Araujo Filho BC, Tsuji DH. [Microbiology of peritonsillar abscesses]. Rev Bras Otorrinolaringol (Engl Ed). 2006 Mar-Apr. 72(2):247-51. [QxMD MEDLINE Link].
Klug TE, Henriksen JJ, Fuursted K, Ovesen T. Significant pathogens in peritonsillar abscesses. Eur J Clin Microbiol Infect Dis. 2011 May. 30(5):619-27. [QxMD MEDLINE Link].
Powell EL, Powell J, Samuel JR, Wilson JA. A review of the pathogenesis of adult peritonsillar abscess: time for a re-evaluation. J Antimicrob Chemother. 2013 Sep. 68(9):1941-50. [QxMD MEDLINE Link].
Powell J, Wilson JA. An evidence-based review of peritonsillar abscess. Clin Otolaryngol. 2012 Apr. 37(2):136-45. [QxMD MEDLINE Link].
Huang Z, Vintzileos W, Gordish-Dressman H, Bandarkar A, Reilly BK. Pediatric peritonsillar abscess: Outcomes and cost savings from using transcervical ultrasound. Laryngoscope. 2017 Jan 16. [QxMD MEDLINE Link].
Lyon M, Blaivas M. Intraoral ultrasound in the diagnosis and treatment of suspected peritonsillar abscess in the emergency department. Acad Emerg Med. 2005 Jan. 12(1):85-8. [QxMD MEDLINE Link].
Costantino TG, Satz WA, Dehnkamp W, Goett H. Randomized trial comparing intraoral ultrasound to landmark-based needle aspiration in patients with suspected peritonsillar abscess. Acad Emerg Med. 2012 Jun. 19(6):626-31. [QxMD MEDLINE Link].
Rahn R, Hutten-Czapski P. Quinsy (peritonsillar abscess). Can J Rural Med. 2009 Winter. 14(1):25-6. [QxMD MEDLINE Link].
Bovo R, Barillari MR, Martini A. Hospital discharge survey on 4,199 peritonsillar abscesses in the Veneto region: what is the risk of recurrence and complications without tonsillectomy?. Eur Arch Otorhinolaryngol. 2015 Jan 11. [QxMD MEDLINE Link].
Chau JK, Seikaly HR, Harris JR, Villa-Roel C, Brick C, Rowe BH. Corticosteroids in peritonsillar abscess treatment: a blinded placebo-controlled clinical trial. Laryngoscope. 2014 Jan. 124 (1):97-103. [QxMD MEDLINE Link].
Lee YJ, Jeong YM, Lee HS, Hwang SH. The Efficacy of Corticosteroids in the Treatment of Peritonsillar Abscess: A Meta-Analysis. Clin Exp Otorhinolaryngol. 2016 Jun. 9 (2):89-97. [QxMD MEDLINE Link]. [Full Text].
Losanoff JE, Missavage AE. Neglected peritonsillar abscess resulting in necrotizing soft tissue infection of the neck and chest wall. Int J Clin Pract. 2005 Dec. 59(12):1476-8. [QxMD MEDLINE Link].
Mizuno K, Takeuchi M, Kishimoto Y, Omori K, Kawakami K. Risk Factors for Recurrence of Peritonsillar Abscess. Laryngoscope. 2022 Aug 27. [QxMD MEDLINE Link].
Chen MM, Roman SA, Sosa JA, Judson BL. Safety of Adult Tonsillectomy: A Population-Level Analysis of 5968 Patients. JAMA Otolaryngol Head Neck Surg. 2014 Jan 30. [QxMD MEDLINE Link].
Melville NA. Adult tonsillectomy shown to be safe, with few complications. Medscape Medical News. 2014 Feb 4. [Full Text].

Media Gallery

Right peritonsillar abscess. The soft palate, which is erythematous and edematous, is displaced anteriorly. The patient has a "hot potato–sounding" voice.
Pus is aspirated through a wide-bore needle from the right peritonsillar abscess. An additional incision will be made to drain any other pus pockets.

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Author

Jorge Flores, MD Resident Physician, Department of Emergency Medicine, Kings County Hospital Center, SUNY Downstate Medical Center

Jorge Flores, MD is a member of the following medical societies: American College of Emergency Physicians, Society for Academic Emergency Medicine, Emergency Medicine Residents' Association

Disclosure: Nothing to disclose.

Coauthor(s)

Audrey J Tan, DO Staff Physician, Department of Emergency Medicine, State University of New York Downstate Medical Center, Kings County Hospital Center

Audrey J Tan, DO is a member of the following medical societies: American College of Emergency Physicians, American Medical Association

Disclosure: Nothing to disclose.

Ninfa Mehta, MD, MPH Clinical Assistant Professor, Ultrasound Fellowship Director, Department of Emergency Medicine, Kings County Hospital, State University of New York Downstate Medical Center

Ninfa Mehta, MD, MPH is a member of the following medical societies: American College of Emergency Physicians, American Medical Association, American Medical Student Association/Foundation, Society for Academic Emergency Medicine, American Association of Physicians of Indian Origin

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Chief Editor

Jeter (Jay) Pritchard Taylor, III, MD Assistant Professor, Department of Surgery, University of South Carolina School of Medicine; Attending Physician / Clinical Instructor, Compliance Officer, Department of Emergency Medicine, Prisma Health Richland Hospital

Jeter (Jay) Pritchard Taylor, III, MD is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, Columbia Medical Society, Society for Academic Emergency Medicine, South Carolina College of Emergency Physicians, South Carolina Medical Association

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Employed contractor - Chief Editor for Medscape.

Additional Contributors

Michael Glick, DMD Dean, University of Buffalo School of Dental Medicine

Michael Glick, DMD is a member of the following medical societies: American Academy of Oral Medicine, American Dental Association

Disclosure: Nothing to disclose.

Acknowledgements

Mazen J El-Sayed, MD Resident Physician, Department of Emergency Medicine, University of Maryland Medical Center

Disclosure: Nothing to disclose.

Mark W Fourre, MD Associate Clinical Professor, Department of Surgery, University of Vermont School of Medicine; Program Director, Department of Emergency Medicine, Maine Medical Center

Disclosure: Nothing to disclose.

A Antoine Kazzi, MD Deputy Chief of Staff, American University of Beirut Medical Center; Associate Professor, Department of Emergency Medicine, American University of Beirut, Lebanon

A Antoine Kazzi, MD is a member of the following medical societies: American Academy of Emergency Medicine

Disclosure: Nothing to disclose.