Abscesses round the tonsils are quite common, and follow tonsillitis. The patient, who is usually a child, has a tense swelling above and behind one of his tonsils, displacing it downwards and forwards. Non-operative treatment is almost always successful, and is much safer than draining it, which is a heroic procedure and is seldom necessary, because much of the swelling is inflammatory oedema.
PERITONSILLAR ABSCESSES For the general method see Section 5.2.
NON-OPERATIVE TREATMENT. Admit the patient, and give him intramuscular benzyl penicillin, or ampicillin, or intravenous chloramphenicol (2.9). He will also need intravenous fluids and morphine or pethidine. He should respond within 24 hours and his abscess will probably burst spontaneously, or the inflammation will subside sufficiently to make drainage much easier.
INCISION. In the unlikely event that he fails to respond to non-operative treatment, sit him upright in a chair with his head supported, and a gag in his mouth. Get a very good headlight.
Spray his pharynx with a local anaesthetic solution, such as 4% lignocaine. If he cannot open his mouth wide enough, you may have to give him a general anaesthetic, intubate him, and place him on his side with his head as low as possible. If intubation is impossible, give him ketamine and keep his head down.
Use a guarded scalpel to incise the abscess over its most prominent part, as in Fig. 5-6. Divide only the mucosa, then use sinus forceps to find pus by Hilton's method (5-3).
CAUTION ! (1) Don't let him inhale pus. (2) Have suction instantly available.
If severe bleeding follows and you cannot control it, try firm compression through his mouth with a tightly rolled swab, or tight mattress sutures. Tying his external carotid artery is a heroic last resort (3.3), and means that you have put your knife too deep.