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Peritonsillar abscess

Sir, reading BDJ letters on Unexpected quinsy (BDJ 2007; 203: 227) reminded me of a recent event.

A 61-year-old male was referred from his GP to investigate a pain of ostensibly dental origin down the right side of the throat. The pain had started a week earlier, and made swallowing very painful. The GP has prescribed co-amoxiclav, which had had no effect on the pain.

On examination, there was no swelling but it was clear that the patient was in moderate to severe discomfort. There was a reddened area around the soft palate, extending down the fauces, to the retromolar area of the right mandible. This appeared to extend down the lingual side of the mandible. There appeared to be no areas of suspicion from a dental point of view, however, I requested a minimal DPT view of the right sextant and advised the patient to continue with the co-amoxiclav in the meantime. I did advise him and his wife of the potential for throat involvement and to be wary of stridor.

The DPT was inconclusive, and nothing abnormal could be detected. On contacting the patient, I was told that he was comfortable and that the pain was lessening. I advised him to remain vigilant, and to return in seven days for review, or sooner should it recur.

Two days later, I was contacted by the on-call A&E doctor, requesting my opinion. The patient had turned up in severe pain from the same area, but the doctor was at a loss to explain it. No stridor, but the same area was now swollen as well as reddened.

I saw the patient, and noticed that the residual tonsillor tissue on the lateral border of the tongue was reddened and that the rest of the right side of the fauces was slightly swollen without pointing. It was soft and quite fluctuant to touch, rather than the firm swelling one may see with cellulitis. I decided to drain the area, but on incision gained no pus at all, merely normal bleeding.

Because of the fact that he was obviously in considerable distress and having problems with drinking fluids I referred him directly to Raigmore Hospital in Inverness, with the differential diagnosis of 'Quinsy'. This was confirmed by ENT surgeons, and successfully treated with IV antibiotics.

It is interesting to note that the ENT surgeons initially refused to believe that it was a dentist who had diagnosed the problem and kept asking the patient for the name of the referring 'doctor'.

This episode highlights the fact that 'quinsy', or peritonsillor abscess, is not just a potential problem of the young, with active tonsils, but can recur in the mature patient via the residual tonsillor tissue in the fauces and lingual regions. It can arise de novo and can present as a problem with moderate to severe pain, with swelling, fever, malaise and headache, along with hoarseness described as 'hot potato voice'. The jugulodigastric nodes may be involved, but this case was entirely localised to the area of infection. The diagnosis can be easily dismissed as a simple 'sort throat', but if the symptoms persist or recur, then peritonsillar abscess should be considered as a potential diagnosis.

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Monks, D. Peritonsillar abscess. Br Dent J 203, 559 (2007).

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