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Peritonsillar abscess

Medical Professionals

Professional Reference articles are designed for health professionals to use. They are written by UK doctors and based on research evidence, UK and European Guidelines. You may find the Tonsillitis article more useful, or one of our other health articles.

Synonym: quinsy

Peritonsillar abscess is a complication of acute tonsillitis. Tonsillitis is inflammation of the pharyngeal tonsils (see the separate Tonsillitis article)1 . In peritonsillar abscess, there is pus trapped between the tonsillar capsule and the lateral pharyngeal wall2 .

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It usually starts with acute follicular tonsillitis, progresses to peritonsillitis and results in formation of a peritonsillar abscess. It can arise without previous tonsillitis.

An alternative theory suggests involvement of the Weber glands3 . These are a group of salivary glands, immediately above the tonsillar area in the soft palate. They are thought to play a minor role in clearing any trapped debris from the tonsillar area. Tissue necrosis and formation of pus produce an abscess between the tonsillar capsule, lateral pharyngeal wall and supratonsillar space. There is scarring and obstruction of the ducts that drain the glands. They swell and progress to abscess formation.


  • Tonsillitis is predominantly a disease of children. Peritonsillar abscess usually affects teenagers and young adults but can occur in younger children2 . This picture may, however, be changing. One Israeli study found a distinct cohort of people over 40 suffering from peritonsillar abscess who had more severe symptoms and a more prolonged course. Tonsillitis was not always a precursor to the condition or it sometimes occurred despite prior adequate antibiotic therapy. Smoking was thought to be a risk factor4 . An American study reported an incidence of 30 per 100,000 among patients who are 5-59 years of age. It is rare under the age of 55 .

  • It is most common in November to December and April to May, coinciding with the highest incidence of streptococcal pharyngitis and exudative tonsillitis2 .

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Causative organisms

  • Culture nearly always shows a mixed flora. Most common organisms include6 :

    • Streptococcus pyogenes (usually the predominant organism).

    • Staphylococcus aureus.

    • Haemophilus influenzae.

    • Anaerobic organisms including Prevotella spp., and Fusobacterium spp.

  • Peritonsillar abscess can also be a complication of infectious mononucleosis7 .


  • Severe throat pain which may become unilateral.

  • Fever.

  • Drooling of saliva.

  • Foul-smelling breath.

  • Swallowing may be painful.

  • Trismus (difficulty opening the mouth).

  • Altered voice quality ('hot potato voice') due to pharyngeal oedema and trismus.

  • Earache on the affected side.

  • Neck stiffness symptoms.

  • Headache and general malaise.

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  • Examination may be difficult as trismus may make it difficult to open the mouth in up to two thirds of cases.

  • Breath is fetid.

  • There may be drooling and salivation.

  • Look for a temperature.

  • Tender, enlarged ipsilateral cervical lymph nodes.

  • Torticollis may be present.

  • There is unilateral bulging, usually above and lateral to one of the tonsils; occasionally the bulging is inferiorly.

  • There is medial or anterior shift of the affected tonsil and the tonsil may be erythematous, enlarged and covered in exudate.

  • The uvula is displaced away from the lesion.

  • Examine for signs of dehydration.

  • Compromise of the airway is rare.

  • Spontaneous rupture of the abscess into the pharynx can (rarely) occur and can lead to aspiration8 .

Important information

A patient with a suspected peritonsillar abscess should be referred to an ear, nose and throat (ENT) specialist that day9.


  • The diagnosis is clinical.

  • CT scanning is not generally needed but may be used in atypical presentations such as an inferior pole abscess, or if the patient is high risk for a drainage procedure (eg, a bleeding disorder). It may also be helpful to guide drainage in difficult cases.

  • Ultrasound may be helpful in differentiating a peritonsillar abscess from peritonsillitis. It may also help to locate the optimal site for drainage8 .

  • Evidence supporting the use of screening for infectious mononucleosis is equivocal. One study found that only 4% of quinsy patients tested positive for infectious mononucleosis, all of them under the age of 30.



  • Intravenous fluids may be required to correct dehydration.

  • Analgesia should be prescribed.

  • Intravenous antibiotics give higher blood levels than oral therapy and are usually used.

  • Antibiotics need to cover the broad spectrum of Gram-positive, Gram-negative and anaerobic organisms. Amoxicillin with clindamycin or metronidazole are appropriate antibiotics5 .

  • Studies have also shown that the use of single-dose intravenous steroids as well as antibiotics may be beneficial10 . They may help to reduce symptoms and to speed recovery2 .


  • Antibiotics alone are not usually sufficient as treatment. Changes in the microbiology of the causative organisms and their resistance has resulted in surgery being the preferred option in most cases11 .

  • Needle aspiration, incision and drainage and quinsy tonsillectomy are all considered acceptable for the surgical management of acute peritonsillar abscess. An evidence-based review failed to differentiate between them in terms of effectiveness and recurrence rates12 .

  • Ultrasound-guided aspiration is occasionally used if surgery is unsuccessful or the abscess is in a location that is difficult to reach13 .

  • Interval tonsillectomy is usually carried out if there is a background of chronic or recurrent tonsillitis.

  • Some surgeons advocate acute (immediate) tonsillectomy as a treatment for peritonsillar abscess. A case series review found no significant differences in total hospital days, blood loss, operative time, or postoperative complications between immediate tonsillectomy and interval tonsillectomy in the treatment of paediatric peritonsillar abscess14 .

  • Tonsillectomy is discussed in more detail in the separate Tonsillitis article.


  • The abscess can spread to the deeper neck tissues and can result in necrotising fasciitis15 . Other complications can include retropharyngeal abscess, laryngeal oedema leading to airway compromise, rarely pneumonia or lung abscess following aspiration of a ruptured abscess, and sepsis5 .

  • Airway compromise is rare.

  • Recurrence of peritonsillar abscess can occur.

  • Haemorrhage may follow tonsillectomy.

  • Erosion into major blood vessels or extension to the mediastinum may be fatal16 .


  • The rate of recurrence is poorly defined but is around 9-22%17 .

  • Recurrence can follow tonsillectomy but is rare18 .


  • A Cochrane review found that the benefits of treating sore throats with antibiotics was moderate and that many patients would need to be treated to prevent one case of quinsy19 . The number needed to treat (NNT) was estimated by a Canadian study as being about 3020 .

  • A fall of 50% in the prescribing of antibiotics to children in English general practice has not been accompanied by an increase in hospital admissions for peritonsillar abscess21 .

  • The guidance regarding antibiotics and sore throat is further discussed in the separate Sore Throat and Tonsillitis articles.

Further reading and references

  1. Sidell D, Shapiro NL; Acute tonsillitis. Infect Disord Drug Targets. 2012 Aug;12(4):271-6.
  2. Galioto NJ; Peritonsillar abscess. Am Fam Physician. 2008 Jan 15;77(2):199-202.
  3. Klug TE, Rusan M, Fuursted K, et al; Peritonsillar Abscess: Complication of Acute Tonsillitis or Weber's Glands Infection? Otolaryngol Head Neck Surg. 2016 Aug;155(2):199-207. doi: 10.1177/0194599816639551. Epub 2016 Mar 29.
  4. Marom T, Cinamon U, Itskoviz D, et al; Changing trends of peritonsillar abscess. Am J Otolaryngol. 2010 May-Jun;31(3):162-7. Epub 2009 Apr 23.
  5. Gupta G, McDowell RH; Peritonsillar Abscess
  6. Mazur E, Czerwinska E, Korona-Glowniak I, et al; Epidemiology, clinical history and microbiology of peritonsillar abscess. Eur J Clin Microbiol Infect Dis. 2015 Mar;34(3):549-54. doi: 10.1007/s10096-014-2260-2. Epub 2014 Oct 17.
  7. Ryan C, Dutta C, Simo R; Role of screening for infectious mononucleosis in patients admitted with isolated, unilateral peritonsillar abscess. J Laryngol Otol. 2004 May;118(5):362-5.
  8. Galioto NJ; Peritonsillar Abscess. Am Fam Physician. 2017 Apr 15;95(8):501-506.
  9. Sort throat - acute; NICE CKS, January 2020 (UK access only)
  10. Chau JK, Seikaly HR, Harris JR, et al; Corticosteroids in peritonsillar abscess treatment: a blinded placebo-controlled clinical trial. Laryngoscope. 2014 Jan;124(1):97-103. doi: 10.1002/lary.24283. Epub 2013 Jul 9.
  11. Wu V, Manojlovic Kolarski M, Kandel CE, et al; Current trend of antibiotic prescription and management for peritonsillar abscess: A cross-sectional study. Laryngoscope Investig Otolaryngol. 2021 Mar 11;6(2):183-187. doi: 10.1002/lio2.538. eCollection 2021 Apr.
  12. Lin YY, Lee JC; Bilateral peritonsillar abscesses complicating acute tonsillitis. CMAJ. 2011 Aug 9;183(11):1276-9. doi: 10.1503/cmaj.100066. Epub 2011 May 16.
  13. Costantino TG, Satz WA, Dehnkamp W, et al; Randomized trial comparing intraoral ultrasound to landmark-based needle aspiration in patients with suspected peritonsillar abscess. Acad Emerg Med. 2012 Jun;19(6):626-31. doi: 10.1111/j.1553-2712.2012.01380.x.
  14. Simon LM, Matijasec JW, Perry AP, et al; Pediatric peritonsillar abscess: Quinsy ie versus interval tonsillectomy. Int J Pediatr Otorhinolaryngol. 2013 Aug;77(8):1355-8. doi: 10.1016/j.ijporl.2013.05.034. Epub 2013 Jun 28.
  15. Losanoff JE, Missavage AE; Neglected peritonsillar abscess resulting in necrotizing soft tissue infection of the neck and chest wall. Int J Clin Pract. 2005 Dec;59(12):1476-8.
  16. Brook I; Microbiology and management of peritonsillar, retropharyngeal, and parapharyngeal abscesses. J Oral Maxillofac Surg. 2004 Dec;62(12):1545-50.
  17. Powell J, Wilson JA; An evidence-based review of peritonsillar abscess. Clin Otolaryngol. 2012 Apr;37(2):136-45. doi: 10.1111/j.1749-4486.2012.02452.x.
  18. Farmer SE, Khatwa MA, Zeitoun HM; Peritonsillar abscess after tonsillectomy: a review of the literature. Ann R Coll Surg Engl. 2011 Jul;93(5):353-5. doi: 10.1308/003588411X579793.
  19. Spinks A, Glasziou PP, Del Mar CB; Antibiotics for treatment of sore throat in children and adults. Cochrane Database Syst Rev. 2021 Dec 9 ;11:CD000023.
  20. Worrall G; Acute sore throat. Can Fam Physician. 2011 Jul;57(7):791-4.
  21. Sharland M, Kendall H, Yeates D, et al; Antibiotic prescribing in general practice and hospital admissions for peritonsillar abscess, mastoiditis, and rheumatic fever in children: time trend analysis. BMJ. 2005 Aug 6;331(7512):328-9. Epub 2005 Jun 20.

Article history

The information on this page is written and peer reviewed by qualified clinicians.

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