Quinsy

Quinsy is the colloquial term for a peritonsillar abscess (Tiefel et al, 2021) and is the most common suppurative complication associated with a sore throat (Dunn et al, 2007). Quinsy is one of the differential diagnoses of acute sore throat (Georgalas and Margaritis, 2023) as well as a potential complication (National Institute for Health and Care Excellence (NICE), 2022) and is distinct from conditions such as tonsillitis and pharyngitis (Georgalas and Margaritis, 2023).

Quinsy is commonly seen in children between 2 and 4 years of age (NICE, 2022), but can also affect people of any age. However, quinsy is also commonly seen in adults aged 20–40 years, and is most common in males, among people who smoke and those taking immunosuppressant drugs (Knipe et al, 2013).

Nurses should be aware that quinsy can be potentially life threatening, as a result of an airway obstruction, and therefore needs to be identified

Common signs of quinsy include:

• swelling in the peritonsillar region
• enlarged and displaced tonsil(s)
• swollen cervical lymph glands on the affected side
• fever
• a muffled voice (sometimes called ’hot potato’ voice)
• a displaced uvula
• trismus (lock jaw, caused by muscle spasm)
• drooling (Knipe et al, 2013; Galioto, 2017; NICE, 2022)

Common symptoms of quinsy include:

• neck pain
• odynophagia (pain on swallowing) (Knipe et al, 2013; NICE, 2022)

People with quinsy can also present as systemically unwell with a fever and general malaise (Galioto, 2017) as well as dehydration.

In quinsy, an abscess (a collection of pus) forms between the tonsils and the wall of the throat. This can happen when a bacterial infection spreads from an infected tonsil to the surrounding area. Patients with quinsy often initially present with tonsillitis, then a significant one-sided sore throat as well as the other signs and symptoms identified above (Tiefel et al, 2021). The bacteria then transfer via the lymph system to the peritonsillar area causing initially cellulitis, and subsequently an immature abscess (phlegmon) develops into a peritonsillar abscess (quinsy).  

It was commonly believed that quinsy form as part of a continuum from streptococcus A throat infection and tonsillitis, although this is uncertain since quinsy occurs throughout the year and streptococcal tonsillitis is seasonal (Klug, 2014). 

Quinsy may also occur after infectious mononucleosis infection (glandular fever) and is also associated with smoking and periodontal disease (Wikstén et al, 2017).  

Quinsy may be suspected if the patient has had a recent acute sore throat or tonsilitis (NICE, 2022) and presents with the signs and symptoms described above. Most patients who present with quinsy look unwell and have a fever.

Diagnosis of quinsy occurs when the nurse will see a grossly swollen tonsil with the uvula deviated from the midline (Galioto, 2017). If there is suspicion that the abscess has spread, for example into the lateral neck space, where the airway and the integrity of the carotid artery may be compromised, then computed tomography or magnetic resonance imaging may be required (Galioto, 2017).

While there may superficially appear to be an argument in favour of treating all respiratory tract infections with antibiotics to prevent quinsy development, such practices would require approximately 1000 people being treated to prevent one quinsy (Winter et al, 2020) and would contribute to increasing antimicrobial resistance (World Health Organisation, 2021).

People identified in primary care as having a quinsy should be referred to hospital, where the management of quinsy relies on a simple clinical triad (NICE, 2018). This includes:

• drainage
• antibiotics
• supportive therapy (Galioto, 2017).

As an acute presentation, a patient presenting with quinsy should be assessed applying the ABCDE (see article: applying ABCDE in emergency care) assessment protocol as occurrence of an airway obstruction, while rare, is a possibility (Galioto, 2017). At the same time, some patients presenting to the emergency department with quinsy will be dehydrated,  because they have odynophagia and a fever and will need intravenous

References

Battaglia A, Burchette R, Bernstein P et al. Comparison of Medical Therapy Alone to Medical Therapy with Surgical Treatment of Peritonsillar Abscess. Otolaryngology Head Neck Surgery. 2017;158(2):280-286. https://doi.org/10.1177/0194599817739277

Dunn N, Lane D, Everitt H, Little P. Use of antibiotics for sore throat and incidence of quinsy. Br J General Practice. 2007;57(534):45-49.

Galioto NJ. Peritonsillar abscess. Am Fam Physician. 2017;95(8):501-506.

Georgalas C, Margaritis E. BMJ Best Practice: Tonsilitis. 2023. https://bestpractice.bmj.com/topics/en-gb/598 (accessed 2 February 2023)

Hardman JC, McCulloch NA, Nankivell P. Do Corticosteroids Improve Outcomes in Peritonsillar Abscess? Laryngoscope. 2015;125: 537-538. https://doi.org/10.1002/lary.24936.

Klug TE. Incidence and microbiology of peritonsillar abscess: the influence of season, age, and gender. Eur J Clin Microbiol Infect Dis. 2014;33(7):1163-1167.

Knipe H, Yu Jin T, Hacking C. Peritonsillar abscess. 2013. https://radiopaedia.org/articles/peritonsillar-abscess?lang=us (accessed 2 February 2023)

Monsees E, Tamma P, Cosgrove S et al. Integrating bedside nurses into antibiotic stewardship: A practical approach. Infect Control Hosp Epidemiol. 2019;40(5),