This document discusses several types of pharyngeal abscesses including peritonsillar abscess (quinsy), parapharyngeal abscess, and retropharyngeal abscess. It covers the epidemiology, bacteriology, clinical features, investigations, treatment, and complications of each. Peritonsillar abscess typically presents with sore throat, odynophagia, and trismus. Needle aspiration or incision and drainage along with IV antibiotics are the main treatments. Parapharyngeal and retropharyngeal abscesses can spread infection to deep neck spaces and sometimes require surgical drainage. Complications of pharyngeal abscesses include mediastinitis, deep neck infections, and Lemierre

1. Acute & chronic pharyngeal abscess
Peritonsillar abscess(quinsy)
Peritonsillar abscess is a collection of pus between the capsule of tonsil usually upper pole, & the
superior constrictormuscles of the pharynx.
Epidemiology
It usually arises as a complications of tonsillitis but also de novo in the absence of a history of
previous recurrent tonsillitis.
It may happen at any age but majority is in young adults between 20 & 39 years of age which is
surprising in view of the fact that the incidence of tonsillitis peaks in childhood, suggesting the
aetiology must be more complex.
Passy suggested that PTA may be abscess of weber’s gland, which is minor salivary gland located in
the supratonsillar space.
Bacteriology
The presence of anaerobic organisms & usual beta-haemolytic streptococcus . it may arise as a
consequence of dental abscess or third molar extraction. Methicillin-resistance staphylococcus
aureus has been identified in a PTA.
Clinical features
The main feature of the history is the progressive ,unilateral, sore throat over 3 to 4 days,
odynophagia, dysphagia for solids &eventually liquid, drooling of saliva, trismus, unilateral
otalgia,headache, fever & unilateral lymphadenopathy.
The patient often develops a plumy voice secondary to oropharyngeal swelling.
On examination : limited mouth opening(trismus) is virtual pathognomic,
The tonsil is displaced medially,
Jugulodiagastric nodes are tender & enlarged.
Bilateral quinsy may be occur in infectious mononucleosis
Differential diagnosis
1) Infectious; peritonsillar cellulitis, parapharyngeal abscess, upper third molar abscess &
coexistent infectious mononucleosis.
2) Inflammatory; Kawasaki disease presenting as PTA. Treatment is aspirin & intravenous
gammaglobulin.
3) Vascular ; post traumatic internal carotid artery pseudoaneursym can cause catastrophic
confusion.

2. 4) Benign lymphoepithelial cyst;
5) Neoplastic ; large tonsil tumour with lateral extracapsular spread such as SCC, lymphoma,
rhambdomyosarcoma.
6) Peritonsillar space tumours; minor salivary gland tumours.
7) Anterior pillar mucosal tumour for example SCC.
Investigation
Investigation is not mandatory in clear cut cases,
1)Needle aspiration of pus is often curative & may be also provide useful bacteriology in
recurrent or nonresponsive quinsy. Help clarify the difference between peritonsillar cellulittis & PTA.
2) Routine screening for IM in all patients with PTA.
3) Dental radiography or OPG to known to dental pathology.
4) CT sanning has been used to know the suspected spread to
parapharyngeal,retropharyngeal spread.
5) MRI or MRA; angiography may be suitable for suspected vascular anomalies.
Treatment
1)Admission to the hospital with intravenous antibiotic
2)Intravenous benzylpenicillin which deals most relevant anaerobic as well as streptococcal infection
is the treatment of choice.
3) The use of steroids as an adjunctive treatment ( a single dose steroid in addition to antibiotic)
reduces throat pain, time in hospital, fever & trismus.
4) Needle aspiration is the most common treatment in the UK. Or I/D under Local spray.
5) In a paediatric population in which needle aspiration or I/D requires G/A abscess tonsillectomy
may be the treatment of choice.( abscess tonsillectomy with poor reputation in UK but is practice in
Germany).
6. Elective tonsillectomy after recurrent quinsy is recommended. Abscess recurrence is rare after the
age of 40 therfore elective tonsillectomy is not warranted.
Complications
Deep neck space infections & mediastinitis.
Necrotizing fasciitis following PTA can be treated broad-spectum antibiotic, abscess tonsillectomy &
large scale debridement of necrotic tissue.

3. Best clinical practice
Clinically trismus is pathognomic of PTA.
Investigation is usually not indicated.
Antibiotic is needed to cover anaerobic & Beta-haemolytic streptococcus for their pathogens.
Treatment involves hospital admission & I/V antibiotic
Progressing to needle aspiration, incision & drainage or abscess tonsillectomy.
Mediastinitis & necrotizing fasciitis occasionally arise.
Parapharyngeal abscess
The parapharyngeal space lies on the either side of the nasopharynx & oropharynx.
It is bounded laterally by the parotid gland, parotid fascia & medial pterygoid muscle.
Medially it is bounded by superior constrictor separating it from the pharynx.
Superiorly it is limited by the skull base.
Inferiorly by the fascia covering surrounding the submandibular gland.
Posteriorly the parapharyngeal space communicates with the retropharyngeal space.
Parapharyngeal space contains cartotid sheath with internal carotid artery, internal jugular vein,
vagus,some lymph nodes, last four cranial nerve,
Infection from parapharyngeal space can spread to the other deep spaces of the neck, peritonsillar
space, retropharyngeal space & submandibular spaces.
Epidemiology
The most common cause are tonsillitis, PTA, or dental infection.
Bacteriology
Gram-negative aerobic organism,(klebsiella pneumonae)
Streptococcus viridians
Pseudomonas aeroginosa
Streptococcus pyogenes.
Clinical features
Clinical features are similar to PTA except that the maximum swelling in the pharynx is more
inferiorly placed & behind the tonsil with less oedema of the palate.

4. In addition , there is the tender, firm but fluctuant swelling of the abscess to be felt in the neck
rather than lymphadenopathy.
Occasionally parapharyngeal abscess can present as torticolis of the neck.
Differential diagnosis
Infection : PTA & TB
Neoplastic : primary tumours of the parapharyngeal space including deep lobe parotid tumours,
local spread of tonsillar carcinoma, lymphoma.
Vascular : pseudoaneurysms.
Investigation
Plain x-ray soft tissue of the neck( lateral view)
CT scanning of the neck.
Treatment
Admission to hospital for I/V antibiotic (cefuroxime in children.) aspiration of pus for microbiology at
the early stage might facilitate appropriate treatment.
Progressing to external surgical drainage through the neck if there is no response or resolution
within 48hours or there is evidence of airway compromise.
Complications include carotid sheath vessel thrombosis, necrotizing fasciitis, and mediastinitis.
Retropharyngeal abscess
The retropharyngeal space lies immediately behind the posterior pharyngeal wall.
Epidemiology
Retropharyngeal abscess most commonly occur in children under 6 years of age, with peak incidence
between three & five years, due to suppurating retropharyngeal node following a URT infection.
In adults & children it may occur secondary to foreign body penetration(fish bone ) or due to spread
cervical spine TB. Abscess can develop before or after the removal of a pharyngeal foreign body.
Bacteriology
The commonest pathogens streptococcus viridians, staphlycoccus aureus, Klebsiella pneumonae,
E.coli, Enterobacter spp.,provetella, salmonella spp., MRSA.
Tuberculous abscesses are traditionally associated with cervical spine disease in adult, but have also
been described in young children in absence of neck disease.
Clinical features
In young children neck stiffness associated with fever, irritability,dysphagia, airways obstruction.

5. On examination ; the posterior pharyngeal wall bulges forward. The diagnosis of RPA in infant &
young children is easily overlooked.
In adult, there may be few symptoms & little to find on examination . Previous TB contact,
pharyngeal trauma by fish bone or chicken bone, dental bone intravenous drugs abuser must be
sought. There may be posterior wall bulging. There is nothing to feel in the neck unless the abscess is
huge.
Differtial diagnosis
Naspharyngeal carcinoma
Lipoma
Malignant schwannoma
Sarcoidosis
Aberrant internal carotid artery
Pseudoaneurysm
Kawasaki disease
Haematoma
Acute epiglottitis is the most important differential diagnosis in children.
Invstigation
In adult plain x-ray lateral view show loss of curvature of the cervical spine with soft tissue bulge in
front of it as well as bone destruction.
Transoral needle biopsy may be sufficient to obtain diagnostic material for microbiological
confirmationof TB.
Treatment
Surgical drainage is the norms in paediatric RPA.
Retropharyngeal abscess respond to intravenous antibiotic. Abscess recurrence may happen even
after surgical drainage.
Surgical drainage of adult post-traumatic abscesses may require endoscopy to remove the foreign
body as well as drainage. Occasionally abscess does not develop until after removal of the foreign
body.
Surgical drainage of Tubercular abscess is not usually necessary, occasionally exploration is required
to obtain biopsy material in order to diagnosis. This can be cervical incision , in front of carotid
sheath, with anti TB triple drugs regimen for 15months.

6. Complication:
mediastinitis, otorrhoea, spinal epidural abscess, lemierre syndrome, acute suppurative thyroiditis,
meningitis, 12th nerve palsy.
Lemierre syndrome: A severe systemic fusobacterial infection secondary to oropharyngeal infection
or mastoiditis resulting in internal jugular vein thrombophlebitis, septicaemia with septic emboli.

7. Complication:
mediastinitis, otorrhoea, spinal epidural abscess, lemierre syndrome, acute suppurative thyroiditis,
meningitis, 12th nerve palsy.
Lemierre syndrome: A severe systemic fusobacterial infection secondary to oropharyngeal infection
or mastoiditis resulting in internal jugular vein thrombophlebitis, septicaemia with septic emboli.