Quinsy in A&E: Diagnosis, Drainage, and Targeted Antibiotic Therapy

You’re halfway through a busy A&E shift. The board is full, and your next patient is a 30-year-old with a "sore throat". It’s a common complaint, but every so often, it’s the sign of something much more serious that needs your immediate attention. Could this be quinsy (a peritonsillar abscess)?

Let's walk through a classic presentation, break down the key steps in diagnosis and management, and make sure you feel confident the next time a patient with a severe unilateral sore throat comes through the door.

A Case from the Frontline

A 30-year-old man presents to A&E. He tells you he’s felt unwell for three days with a fever and general malaise , but it’s the sore throat that’s really troubling him. It's been getting steadily worse and is now almost unbearable.

You take his observations:

• Blood Pressure: 140/70 mmHg

• Heart Rate: 90 bpm

• Respiratory Rate: 22/min

• Oxygen Sats: 98% on room air

• Temperature: 37.8°C

He looks uncomfortable but is alert and speaking logically. However, you notice his speech is slightly muffled and has a nasal quality—the classic "hot potato voice".

When you examine his throat, you immediately see the problem. There's a striking asymmetry of the palatal arches. The right arch is swollen and pushing downwards, causing the uvula to deviate to the left. This is highly suggestive  of a peritonsillar abscess.

You bleep the on-call ENT registrar, who agrees with your assessment. In a treatment room, they perform an incision and drainage of the swollen arch, aspirating pus thatis sent for culture. The patient is given 8 mg IV dexamethasone  and co-amoxiclav.

After a few hours of observation, he reports a significant improvement. His pain has eased, he can open his mouth wider, and he's able to swallow some water. He is discharged home with a course of oral antibiotics and an appointment at the ENT outpatient clinic for the next day.

At his follow-up, he’s feeling much better. The trismus (jaw tightness) has resolved, and he can eat and drink normally. No further intervention is needed.

What Exactly is Quinsy?

Quinsy (peritonsillar abscess, PTA)  is the most common deep neck space infection we see in A&E. It’s essentially a collection of pus that forms in the space between the tonsil and the pharyngeal muscles.

It typically affects young adults and is a polymicrobial infection, usually involving Group A Streptococcus alongside anaerobic bacteria like Fusobacterium and Prevotella. While it can be a complication of bacterial or even viral tonsillitis, the abscess itself is always a bacterial process. The loose connective tissue in this area provides the perfect environment for pus to accumulate over 1– 3 days, forming a very painful, tense collection.

Spotting the Signs: Quinsy Diagnosis and Treatment

The diagnosis is primarily clinical. You need to know what to look for in the history and examination.

Key Symptoms:

• A severe unilateral sore throat is the hallmark symptom.

• Fever and general malaise.

• Dysphagia (difficulty swallowing) and odynophagia (pain on swallowing), which can be so severe that the patient is drooling.

• Trismus (difficulty opening the mouth) due to irritation of the nearby pterygoid muscles.

• A muffled, nasal-sounding voice, often described as a "hot potato voice", as if they are trying to speak with a hot potato in their mouth.

Key Examination Findings:

• Asymmetrical Palatal Arch: One side will be red, swollen, and bulging downwards and medially.

• Uvula Deviation: The growing abscess pushes the uvula to the opposite, unaffected side.

• The patient may have tender cervical lymphadenopathy.

While most patients present before serious issues develop, an untreated quinsy can be life-threatening. It can spread, leading to deep neck space infection, descending mediastinitis, or Lemierre syndrome. This is why prompt recognition is so vital.

Confirming the Diagnosis

For most cases, the clinical picture is enough. However, in uncertain cases or if you suspect a deeper infection, you have options:

• CT Neck with Contrast: This is the gold standard for visualising deep neck anatomy and confirming an abscess if the diagnosis is unclear.

• Point-of-Care Ultrasound (POCUS): Using an intraoral or submandibular probe, intraoral POCUS is a fantastic tool in A&E. It can quickly differentiate between cellulitis (inflammation without pus) and a drainable abscess, guiding your management right at the bedside. Studies show it has good sensitivity and specificity, and A&E doctors can become proficient with minimal training.

Management in A&E: A Two-Pronged Approach

Management revolves around two key principles: draining the pus and treating the infection.

1. Drainage: The Main Event

Getting the pus out provides immediate relief. The two main techniques are equally effective:

• Needle Aspiration of Quinsy: This is often the first-line approach. It's less invasive, less painful than a full incision, and can be both diagnostic (confirming the presence of pus) and therapeutic.

• Incision and Drainage (I&D) of Quinsy: A small incision is made over the abscess to allow the pus to drain freely.

The choice between needle aspiration and incision and drainageoften comes down to local ENT preference and the clinician's experience.

2. Medications: The Supporting Cast

• Antibiotic Therapy for Quinsy: All patients need antibiotics. According to BNF and local trust guidelines, a 10-day course is typical.

  • First-line: Phenoxymethylpenicillin or co-amoxiclav are common choices.

  • Penicillin Allergy: Clindamycin is a suitable alternative.

  • Metronidazole? Interestingly, evidence suggests that adding metronidazole to penicillin-based therapy provides no additional benefit, so it's not routinely required.

• Corticosteroids: A single dose of a corticosteroid, such as dexamethasone, is recommended as adjunct therapy. It significantly reduces pain and swelling, speeding up recovery and helping the patient return to normal eating and drinking much sooner.

To Admit or Not to Admit?

The majority of patients (around 80%) with an uncomplicated quinsy can be managed safely as outpatients, provided they have follow-up arranged with ENT within 24– 48 hours.

Consider admission if the patient:

• Has signs of sepsis or airway compromise.

• Has significant comorbidities.

• Is unable to tolerate oral fluids, leading to dehydration.

• Has clinical features consistent with a deep neck space infection.

Most patients won't require a second drainage procedure. If their symptoms are improving at follow-up, they simply complete their course of antibiotics.

Key Takeaways for Your Next A&E Shift

• Think Quinsy: When a patient presents with a severe unilateral sore throat, fever, and trismus, quinsy  should be high on your differential list.

• Look for the Signs: The classic triad is a bulging palatal arch, deviation of the uvula to the contralateral side, and a "hot potato voice".

• Drainage is Key: Needle aspiration and I&D are both effective. Needle aspiration is simpler and less painful.

• Treat Effectively: The standard medical therapy is a penicillin-based antibiotic (or clindamycin if allergic) plus a single dose of dexamethasone.

• Discharge Safely: Most patients can go home but MUST have reliable ENT follow-up arranged within 24– 48 hours.

Mastering A&E presentations like this is a core skill for any junior doctor. By knowing what to look for and how to act, you can provide rapid, effective relief and prevent life-threatening complications.

References

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

• Steyer TE. Peritonsillar Abscess: Diagnosis and Treatment. Am Fam Physician. 2002;65(1):93-96.

• Moen CM, Paramjothy K, Williamson A, et al. A Systematic Review of the Role of Penicillin Versus Penicillin Plus Metronidazole in the Management of Peritonsillar Abscess. J Laryngol Otol. 2023;137(1):15-21.

• Hur K, Zhou S, Kysh L. Adjunct Steroids in the Treatment of Peritonsillar Abscess: A Systematic Review. Laryngoscope. 2018;128(1):72-77.

• Chang BA, Thamboo A, Burton MJ, Diamond C, Nunez DA. Needle aspiration versus incision and drainage for the treatment of peritonsillar abscess. Cochrane Database Syst Rev. 2016;12(12):CD006287.

• Forner D, Curry DE, Hancock K, et al. Medical Intervention Alone vs Surgical Drainage for Treatment of Peritonsillar Abscess: A Systematic Review and Meta-Analysis. Otolaryngol Head Neck Surg. 2020;163(4):645-653.