BILATERAL PERITONSILLAR
AIBSCESSES AND QUINSY
TONSILLECTOMY
Randall E. Dalton, MD, Esrafil Abedi, MD, and Aristides Sismanis, MD, FACS
Richmond, Virginia
Two patients presented with history, symp-
toms, and clinical findings suggesting unilat-
eral peritonsillar abscesses. At the time of
quinsy tonsillectomy, the patients were found
to have pus present in the contralateral
peritonsillar spaces. These findings prompted
a review of the literature to determine the
actual frequency of bilateral peritonsillar
abscesses and to reassess the approach to
treatment of patients presenting with periton-
sillar abscesses.
Peritonsillar abscess frequently develops
following the onset of acute tonsillitis, and it is
possible that this process occurs bilaterally
with the developmental stages of the absces-
ses being different on each side. Intensive
antibiotic treatment, incision and drainage of
the obvious abscess probably suppresses the
development of and masks the presence of
the abscess on the opposite side.
Quinsy tonsillectomy has been indicated
previously for patients not responding to in-
travenous antibiotic treatment and incision
and drainage of their peritonsillar abscess.
The possibility of a subclinical contralateral
peritonsillar abscess being present is an ad-
ditional indication for proceeding with a
Presented at the 89th Annual Convention and Scientific As-
sembly of the National Medical Association, Montreal,
Canada, August 1, 1984. Requests for reprints should be
addressed to Dr. Randall E. Dalton, Department of
Otolaryngology, Medical College of Virginia, Virginia
Commonwealth University, Richmond, VA 23298.
JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 77, NO. 10, 1985
quinsy tonsillectomy, especially in patients
who remain febrile after apparent satisfactory
drainage of the clinically evident abscess.
Peritonsillar abscess develops as the most fre-
quent complication of acute tonsillitis when the
infection spreads from the crypts to the loose al-
veolar peritonsillar tissues.' Early, adequate drain-
age of the abscess to prevent serious complica-
tions always has been recognized as being impor-
tant. The methods of accomplishing this drainage,
however, have been varied, and the appropriate
approach to the definitive treatment of peritonsil-
lar abscess continues to generate controversy.
The authors' experience with two patients with
bilateral peritonsillar abscesses prompted a review
of the literature to determine the actual frequency
of this clinical entity and to reassess the approach
to treatment of patients with peritonsillar absces-
ses. Both patients presented with history, symp-
toms, and clinical findings suggestive of unilateral
peritonsillar abscesses, and at the time of quinsy
tonsillectomy pus was found in the contralateral
peritonsillar spaces.
CASE REPORTS
Case I. T.B. is a seven-year-old black girl who
was referred from pediatrics to the clinic to be
evaluated for a possible left peritonsillar abscess.
807
PERITONSILLAR ABSCESS
She had onset of a sore throat ten days prior to
presentation and was being treated with oral
penicillin. Despite that treatment, the sore throat
persisted and worsened. Her appetite was poor,
but she was having no trouble swallowing and no
breathing difficulty. The child's mother denied any
history of frequent sore throats or tonsillitis in the
past.
Pertinent findings of the physical examination
were: oral temperature of 99.60 F, pulse 104 beats
per minute, respiratory rate 20 per minute, and
blood pressure 100/40 mmHg. General inspection
revealed a well-developed, well-nourished black
female child in no apparent acute distress. Her
voice was normal; she exhibited no drooling or
trismus. On pharyngeal examination she was
noted to have 31/2+ enlarged, exudative tonsils.
There was erythema, bulging and fullness of the
left anterior tonsillar pillar and soft palate. The
uvula was edematous but in the midline. White
blood count was 12,500 mm3 with 71 segmented
neutrophils, 27 lymphocytes, and 2 monocytes.
Treatment was initiated with intravenous (IV)
antibiotics, hydration, humidified mist, saline
gargles, and IV dexamethasone. On the following
morning the peritonsillar edema had decreased,
making the marked left anterior tonsillar pillar
bulging more apparent.
A quinsy tonsillectomy was carried out under
general anesthesia. Nine mL of pus was drained
from the left peritonsillar space and an unsus-
pected 3 mL of pus was encountered in the right
peritonsillar space. Estimated blood loss for the
procedure was 60 mL. The postoperative course
was benign and unremarkable.
Case 2. J.O. is a 19-year-old black man who
presented to our clinic with a history of onset of a
sore throat of one week's duration. He had been
seen initially in a local emergency room and was
treated with oral penicillin V, 500 mg, four times
daily. Despite that treatment, his sore throat prog-
ressed to the point where he was unable to swal-
low solids. He was seen by a local physician and
had what was described as incision and drainage of
a right peritonsillar abscess and received an
intramuscular penicillin injection. He presented at
the clinic three days after the incision and drainage
procedure, unable to swallow even liquids. He
denied any history of frequent sore throats in the
past.
808 JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 77, NO. 10, 1985
Physical examination revealed a well-
developed, well-nourished, young, black man in
obvious discomfort, with a "hot potato" voice,
drooling saliva, and demonstrating a moderate
amount of trismus. Oral temperature was 100.20 F,
pulse 100 beats per minute, respiratory rate 24 per
minute, and blood pressure 124/80 mmHg.
Pharyngeal examination revealed bilateral
erythematous tonsils with bulging of the right
anterior pillar and soft palate with displacement of
the uvula to the left of midline. His white blood
count was elevated to 21,000 mm3.
Eight mL of pus was drained from the right
peritonsillar space in the clinic. The trismus im-
proved but the patient continued to be febrile. The
trismus recurred and again pus was drained from
the right side of the incision and drainage site.
When trismus and dysphagia again recurred, he
was subjected to a quinsy tonsillectomy, at which
time unsuspected pus was encountered in the left
peritonsillar space. Operative estimated blood loss
was 100 mL. The postoperative course was unre-
markable.
HISTORICAL PERSPECTIVES
Quinsy is an old English word that described
any throat infection until about 1800 when the
term began to be more specific for peritonsillar
abscess. Incision and drainage was considered a
method of treatment of this entity during the 14th
century. In 1859, Chassaignac,2 a French surgeon,
performed the first complete "abscess tonsillec-
tomy."
Prior to antibiotics there were many fatalities
secondary to peritonsillar abscess, attesting to the
inadequacy of incision and drainage alone as
treatment. Records reveal 226 deaths in England
in 1875 with the cause indicated as "quinsy."
Later it was recommended that tonsillectomy
be used routinely for the adequate drainage of
peritonsillar abscesses. Between 1890 and 1930
European and American surgeons continued to
debate the merits of incision and drainage vs par-
tial or complete tonsillectomy. During this period
of time only two articles appeared in the American
literature in favor of "quinsy tonsillectomy."

Baum3 presented his enthusiastic and comprehen-
sive paper in 1926 and Holinger's4 report in favor
of acute abscess tonsillectomy was given in 1921.
Although Virtanen5 reported, in the European
literature, 3,000 cases of quinsy tonsillectomy
without incidence in 1949, it was not until the
1960s that American surgeons "discovered" that
immediate tonsillectomy was a practical and safe
way to completely drain the pus of a peritonsillar
abscess. In 1960 Volk and Brandow6 described
their "acute tonsillectomy" results and pointed
out that "if the surgery could be done safely prior
to antibiotics, certainly, there should be no worry
if the patient is covered with good blood levels of
penicillin."
DISCUSSION
There continues to be an ongoing debate in this
country about the ultimate, appropriate treatment
of the patient with a peritonsillar abscess. A basic
surgical tenet is that pus must be drained and there
is little disagreement with this teaching, but the
method of drainage has been the issue of debate.
Pathophysiology
The term peritonsillitis has been used to en-
compass both peritonsillar cellulitis and abscess,
which are stages in the same disease spectrum.7
Exudative tonsillitis can lead to peritonsillar
erythema and edema (peritonsillar cellulitis) and
subsequent formation of microabscesses within
the tonsillar crypts. This can progress to coales-
cence of pus within the tonsillar capsule, suppura-
tion outside of the capsule in the peritonsillar
space, and finally, spontaneous rupture or exten-
sion of the abscess.
The individual's systemic response to infection,
antibiotics, or surgical intervention may, of
course, interrupt the progression of this disease at
any stage. The amount of time involved in the
progression from one stage to another in the for-
mation of a frank abscess is highly variable and is
surely dependent on many factors. As tonsillitis is
an infection that in most instances involves both
tonsils, it is probable that progression to peritonsil-
lar abscess also occurs bilaterally, with the devel-
JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 77, NO. 10, 1985
PERITONSILLAR ABSCESS
opmental stages of the abscesses being different
on each side.8 With this scheme in mind, it is easy
to imagine bilateral peritonsillar abscesses occur-
ring fairly frequently. Adequate antibiotic treat-
ment and incision and drainage of the obvious
abscess probably suppresses the development and
masks the presence of the abscess on the opposite
side.
Potential complications of an untreated (or in-
adequately treated) peritonsillar abscess includes
airway compromise from epiglottis and/or
laryngeal edema, parapharyngeal abscess, re-
tropharyngeal space and mediastinal extension,
jugular vein thrombophlebitis, and sepsis. Intra-
cranial complications include cavernous sinus
thrombosis, brain abscesses, meningitis, and os-
teomyelitis of the sella turcica. Spontaneous rup-
ture of the abscess can result in aspiration
pneumonia and lung abscess.
Diagnosis
The diagnosis of peritonsillar abscess is made
on the basis of the history and physical findings.
Typically the patient is a young adult (there is no
evidence of male predominance, contrary to pre-
vious reports in the literature), aged 15 to 30
years. The patient usually has had a sore throat for
three to ten days and already has been started on
oral antibiotics. Progressive odynophagia, dys-
phagia, and ear pain prompt the individual to seek
relief. The patient appears ill, is noted to be feb-
rile, with trismus, oral pooling of saliva and drool-
ing. There is a muffled "hot potato" voice and
pharyngeal examination reveals bulging of an
anterior tonsillar pillar and soft palate with uvula
displacement contralaterally. Complete blood
count will demonstrate a leukocytosis.
Treatment
Treatment of peritonsillar abscess consists of
systemic antibiotics that cover group A
B3-hemolytic streptococci, the most common of-
fending organism,' and drainage of pus from the
abscess cavity. The methods favored for accom-
plishing evacuation of the pus are incision and
drainage or an immediate tonsillectomy.
The site usually used for incision and drainage
is located at the midpoint of a line drawn from the
809
PERITONSILLAR ABSCESS

9~~~~~~~~~~~~

-, iA-Anterior
U.P-Upper Pole
M-M idport ion
L.P-Lower Pole
P-Posterior
Figure 1. Possible abscess sites within the
peritonsillar space

UPPER POLE RMIDPORTION

I ~~~~~~~BILATERAL

LOWER POLE MULTILOCULATED

Figure 2. Possible locations of peritonsillar abscess

second upper molar tooth, on the involved side, to CONCLUSIONS

the base of the uvula. Unfortunately this approach
is only successful in draining pus that is located
behind the upper pole of the tonsil. That is the
situation 60 to 70 percent of the time but in the
remaining situations the pus persists.9 The abscess
may be located in the midportion, lower pole, or
posteriorly, as well as in the upper-pole area.
There is also the possibility of multiloculation and
bilateral peritonsillar abscesses in addition to the
other sites (Figures 1 and 2).
Tonsillectomy, which involves excision of the
entire medial wall of the abscess cavity, -always
accomplishes adequate and dependent drainage.
Throughout the literature, those who favor
tonsillectomy, either immediately or scheduled in
the future, cite the need to prevent a recurrent
abscess. Those who favor only incision and drain-
age will state that the recurrence rate has not been
determined and imply that it is low and insignifi-
cant.
From several series,10-22 the authors have de-
termined that the reported frequency of recurrent
peritonsillar abscess is 5.9 to 22.7 percent (Table
1). The incidences were determined prospectively
or retrospectively, depending on the particular
series. The length of time in following patients for

810 JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 77, NO. 10, 1985
 PERITONSILLAR ABSCESS

TABLE 1. INCIDENCE OF RECURRENT PERITONSILLAR ABSCESS

No. of
Patients No. of
with Recurrent
Source Abscess Abscesses* Percentage
Bonding'° 317 35 11
Nielsen and Greisen" 44 10 22.7
Schecter, et al12 36 8 22.2
Holt and Tinsley'3 29 2 6.9
McCurdy'4 68 4 5.9
Templer, et all5 119 14 11.7
Lee, et all6 29 4 13.7
Brandow17 156 12 7.6
Holt18 67 5 7.5
Herbild and Bonding19 161 35 22
Muller20 152 20 13.1
Harma, et al2l 153 10 6.5
Beeden and Evans22 111 18 16.2
*Incidence determined prospectively or retrospectively

TABLE 2. INCIDENCE OF BILATERAL PERITONSILLAR ABSCESSES*

No.- of
Quinsy No. of
Tonsillec- Bilateral
Source tomies Abscesses Percentage
Yung and Cantrell9 50 4 8
Maisel' 45 1 2.2
Sumner24 114 4 3.5
Bateman, et a18 120 13 10.8
Beeden and Evans22 100 6 6
Lee, et al16 29 7** 24.1
Bonding10 317 10 3.1
Templer, et al'5 119 3 2.5
Brandow'7 156 3 1.9
Leek25 15 3 20
Trzcinski26 50 1 2
*Unsuspected contralateral abscesses found at quinsy tonsillectomy
**Plus two additional patients who had undergone incision and drainage of an
abscess contralateral to the abscess found during surgery

recurrence varied widely. These figures are, of
course, also skewed by the fact that patients
treated after their first peritonsillar abscess with
immediate or interval tonsillectomy had only a
rare opportunity of developing a recurrent
abscess.
Although there are only two papers in the En-
glish language literature that specifically address
the subject of bilateral peritonsillar abscesses,8'23
their occurrence was recognized in several of the
series reporting quinsy tonsillectomies. The au-
thors have determined that the incidence of bilat-
eral peritonsillar abscesses, with the unsuspected
contralateral abscess being discovered at quinsy
tonsillectomy, as determined from these series, is
from 1.9 to 24.1 percent (Table 2). The cases of all

JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 77, NO. 10, 1985 811
PERITONSILLAR ABSCESS
of the series were combined and resulted in an
incidence of 4.9 percent (55/1,115). 1,8-10,15-17,22,24-26
The advantages of immediate tonsillectomy in
the treatment of peritonsillar abscess are that total
evacuation of pus is assured, an unsuspected con-
tralateral abscess may be revealed, and there is
prompt relief of trismus and pain. Furthermore, it
is a one-stage curative operation that is technically
simple to perform, especially on the involved side,
as the dissection is partially completed by the
abscess.
In contrast, the disadvantages of incision and
drainage are that it is a very unpleasant, awkward
procedure for both surgeon and patient; the drain-
age of pus is often incomplete and the patient's
symptoms subside slowly. If an interval tonsillec-
tomy is planned, there is the need for an additional
period of discomfort and convalescence, and the
procedure is technically more difficult after fibro-
sis of the tonsillar bed has been allowed to de-
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1. Maisel RH. Peritonsillar abscess: Tonsil antibiotic
levels in patients treated by acute abscess surgery. Laryn-
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2. Chassagnac E. Traite pratique de la suppuration et
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3. Baum HL. The radical cure of peritonsillar abscess.
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4. Holinger J. The removal of tonsils in the presence of
a peritonsillar abscess. Ann Otol Rhinol Laryngol 1921;
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5. Virtanen VS. Tonsillectomy as treatment of acute
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ACTA Otolaryngol [Suppl] (Stockh) 1949; 80:1.
6. Volk BM, Brandon EC. Bilateral tonsillectomy for
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7. Fried MP, Forrest JL. Peritonsillitis: Evaluation of
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10. Bonding P. Tonsillectomy a chaud. J Laryngol Otol
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812 JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 77, NO. 10, 1985
velop. Also, the risk of recurrent symptoms from
the tonsils remains until tonsillectomy.
Modem anesthetic techniques have contributed
to making immediate quinsy tonsillectomy a safe,
reliable, and economical method of treatment for
peritonsillar abscess.2024 Experience has proven
that the feared complications of sepsis, excessive
bleeding, and airway obstruction that could occur
when operating during the acute stage are more
theoretical than real.11
Quinsy tonsillectomy previously has been indi-
cated for patients not responding to intravenous
antibiotic treatment and incision and drainage of
their peritonsillar abscess, to assure that the pus is
completely drained. The possibility of a subclini-
cal contralateral peritonsillar abscess being pres-
ent is an additional indication for proceeding with
a quinsy tonsillectomy, especially in patients who
remain febrile after apparent satisfactory drainage
of the clinically evident abscess.
14. McCurdy JA Jr. Peritonsillar abscess: A comparison
of treatment by immediate tonsillectomy and interval tonsil-
lectomy. Arch Otolaryngol 1977; 103:414-415.
15. Templer JW, Hollinger LD, Wood RP II, et al. Im-
mediate tonsillectomy for the treatment of peritonsillar
abscess. Am J Surg 1977; 134:596-598.
16. Lee KJ, Traxler JH, Smith HW, Kelly JH. Tonsillec-
tomy: Treatment of peritonsillar abscess. Trans Am Acad
Ophthalmol Otolaryngol 1973; 77:417-423.
17. Brandow EC Jr. Immediate tonsillectomy for
peritonsillar abscess. Trans Am Acad Ophthalmol
Otolaryngol 1973; 77:412-416.
18. Holt GR. The management of peritonsillar absces-
ses in military medicine. Mili Med 1982; 147:851-855.
19. Herbild 0, Bonding P. Peritonsillar abscess: Recur-
rence rate and treatment. Arch Otolaryngol 1981; 107:540-
542.
20. Muller SP. Peritonsillar abscess: A prospective
study of pathogens, treatment, and morbidity. Ear Nose
Throat J 1978; 57:439-444.
21. Harma RA, Juola E, Rnoppi P, Vartiainen E. Abscess
tonsillectomy a tiede. Acta Otolaryngol [Suppl] (Stockh)
1979; 360:67-69.
22. Beeden AG, Evans JN. Quinsy tonsillectomy-A
further report. J Laryngol Otol 1970; 84:443-448.
23. Brook I, Shah K. Bilateral peritonsillar abscess: An
unusual presentation. South Med J 1981; 74:514-515.
24. Sumner E. Quinsy tonsillectomy: A safe procedure.
Anesthesia 1973; 28:558-561.
25. Leek JH. Stat tonsillectomy for peritonsillar
abscess. Minn Med 1980; 63:699-700.
26. Trzcinski WK. Peritonsillar abscess: A rationale for
treatment. Northwest Med 1973; 72:139-141.