Abstract
Peritonsillar abscess, commonly known as quinsy, is an acute collection of pus between the tonsillar capsule and the surrounding pharyngeal muscles. It usually develops as a complication of acute tonsillitis and is one of the most common deep infections of the head and neck. Patients typically present with severe unilateral throat pain, fever, odynophagia, dysphagia, trismus, muffled “hot potato” voice, and uvular deviation. Management requires prompt recognition, adequate analgesia, hydration, antibiotics, and drainage where appropriate. This case highlights the importance of distinguishing uncomplicated tonsillitis from quinsy, identifying airway red flags, and escalating urgently when swallowing, hydration, or breathing are compromised.
Introduction
Acute sore throat is a common presentation in primary care and emergency ENT practice. Most cases are viral or uncomplicated bacterial tonsillitis and improve with supportive
treatment. However, a small proportion progress to peritonsillar cellulitis or abscess formation. Quinsy is clinically important because symptoms may worsen rapidly and can lead to dehydration, airway compromise, aspiration, or spread of infection into deeper neck spaces. Classic findings include unilateral tonsillar swelling, soft palate bulging, deviation of the uvula away from the affected side, trismus, and a muffled voice. On oral examination the appearances of the oropharynx can vary and be asymmetrical so a quinsy can me basked. Appearances of tonsils- (figure1: Tonsil sizes grade 1-4). This case illustrates the assessment and management of suspected quinsy, with emphasis on early ENT referral, airway assessment, drainage of pus, and clear safetynet advice.
Figure 1
Case Presentation
Clinical History
A 28-year-old patient presented with a 4-day history of worsening sore throat, fever, and difficulty swallowing. Symptoms began as a generalised sore throat with malaise and enlarged tonsils. Over the next 48 hours, the pain became predominantly right-sided and severe.
The patient reported difficulty opening their mouth, pain radiating to the right ear, and increasing difficulty swallowing fluids. Their voice had become muffled, and family members described it as sounding “thick” or “hot potato-like. ” The patient had taken simple analgesia with limited benefit and had reduced oral intake due to pain.
There was no rash, neck stiffness, stridor, drooling at rest, or known immunosuppression. The patient had a previous history of recurrent tonsillitis but no previous quinsy or tonsillectomy.
Examination
The patient appeared uncomfortable and febrile but was alert and able to speak in full sentences. There was no stridor or respiratory distress. Hydration was reduced, with dry mucous membranes and reduced oral intake reported.
Examination of the oropharynx was limited by trismus. The right tonsillar region appeared swollen and erythematous, with bulging of the right soft palate. The uvula was displaced towards the left side. There was tender right-sided upper cervical lymphadenopathy. Flexible nasendoscopy was considered because of the severity of symptoms, but there were no signs of supraglottic swelling or airway compromise. The clinical findings were consistent with a right-sided peritonsillar abscess (quinsy).
Investigation findings
The diagnosis of quinsy is usually clinical, based on history and examination. In this case, the combination of unilateral severe throat pain, trismus, muffled voice, soft palate swelling, and uvular deviation strongly supported the diagnosis.( figure 2- quinsy)
Needle aspiration was performed under local anaesthetic and confirmed the diagnosis by yielding purulent material. A sample was sent for microbiology culture and sensitivity.
Routine imaging was not required because the abscess was clinically apparent and there were no signs of deep neck space infection. CT imaging would be considered if the diagnosis were uncertain, if there was concern about parapharyngeal or retropharyngeal extension, or if the patient had severe neck swelling, airway symptoms, sepsis, or failure to improve after treatment. Ultrasound may also assist diagnosis in selected cases.
Figure 2
Management
Initial management focused on airway assessment, pain control, hydration, antibiotics, and drainage. The patient was given appropriate analgesia and intravenous fluids due to poor oral intake.
Needle aspiration of the abscess was performed, followed by clinical improvement in throat pressure and swallowing discomfort. Depending on local practice and abscess size, incision and drainage may also be used. Both needle aspiration and incision and drainage are accepted methods of abscess drainage.
Antibiotic treatment was started to cover common aerobic and anaerobic organisms, in line with local antimicrobial guidance. The patient was observed after drainage to ensure they could swallow fluids and had no progression of swelling or airway symptoms.
A single dose of corticosteroid was considered to reduce inflammation and improve pain and swallowing, depending on local protocol and patient suitability. The patient was discharged only once pain was controlled, oral intake had improved, and there were no airway concerns.
Safety-net advice was provided. The patient was advised to seek urgent medical attention if they developed breathing difficulty, drooling, inability to swallow fluids, increasing neck swelling, worsening trismus, persistent fever, rigors, confusion, or recurrent severe throat pain.
Follow-up was arranged to confirm recovery and discuss recurrent tonsillitis history. Interval tonsillectomy may be considered in selected patients with recurrent tonsillitis or recurrent quinsy.
Discussion
This case demonstrates the importance of recognising quinsy as a complication of acute tonsillitis rather than treating it as a simple sore throat. The progression from generalised tonsillitis to severe unilateral pain, trismus, muffled voice, and uvular deviation is a key diagnostic pattern.
Trismus is particularly significant because it reflects irritation of the pterygoid muscles and surrounding tissues. Referred otalgia may occur due to shared glossopharyngeal nerve
pathways. Reduced oral intake can quickly lead to dehydration, especially when swallowing is painful.
The most important early step is airway assessment. Most patients with quinsy do not have airway obstruction, but clinicians must look for red flags such as stridor, drooling, respiratory distress, inability to lie flat, rapidly progressive swelling, or signs of sepsis. These features require urgent senior ENT and anaesthetic involvement.
Drainage is central to treatment when pus has collected. Antibiotics alone may be insufficient once a mature abscess has formed. Needle aspiration can be diagnostic and therapeutic, while incision and drainage may be required if aspiration is unsuccessful or if pus reaccumulates. Quinsy can usually be managed effectively with prompt treatment, but delayed recognition increases the risk of complications, including dehydration, airway compromise, aspiration, and spread to deep neck spaces. Clear safetynetting and follow-up are therefore essential. In some very rare cases ths can lead to a parapharyngeal abscess or collection, leading to more serious complications.
Conclusion
Peritonsillar abscess should be suspected in any patient with worsening unilateral sore throat, fever, trismus, muffled voice, dysphagia, soft palate swelling, or uvular deviation.
This case highlights the importance of early recognition, airway assessment, adequate analgesia, hydration, antibiotic therapy, and drainage of pus where appropriate. While uncomplicated tonsillitis is common and often self-limiting, quinsy requires prompt escalation and ENT involvement.
For clinicians in primary care, urgent care, and ENT settings, the key learning point is that unilateral severe throat pain with trismus is a red-flag presentation. Early diagnosis and treatment can rapidly improve symptoms and prevent serious complications.
