How do you treat a peritonsillar abscess?

Treatment of Peritonsillar Abscess

The standard treatment for peritonsillar abscess involves drainage of the abscess (via needle aspiration, incision and drainage, or immediate tonsillectomy) combined with appropriate antibiotic therapy covering both aerobic and anaerobic bacteria.

Diagnosis

• Typical presentation includes:

  • Fever
  • Severe sore throat (often unilateral)
  • Dysphagia
  • Trismus (limited mouth opening)
  • "Hot potato" voice
  • Unilateral peritonsillar swelling with deviation of the uvula to the opposite side

• Diagnostic confirmation:

  • Clinical examination is usually sufficient
  • CT scan or ultrasound may be used in uncertain cases

Treatment Algorithm

1. Drainage Procedure Options

• Needle aspiration:

  • Gold standard for initial management 1
  • Advantages: Quick, less invasive, can be performed in outpatient setting
  • Technique: After topical anesthesia, aspirate the most fluctuant point of the abscess

• Incision and drainage:

  • Alternative to needle aspiration
  • May be preferred for larger or multiloculated abscesses

• Immediate tonsillectomy:

  • Reserved for selected cases with recurrent peritonsillar abscesses 2
  • Consider when history of >1 peritonsillar abscess 3

2. Antibiotic Therapy

• First-line regimen:

  • Penicillin plus metronidazole 4
  • Alternatives: Clindamycin or amoxicillin-clavulanate

• Duration:

  • 10-14 days of oral antibiotics following drainage

• Rationale:

  • Peritonsillar abscesses are polymicrobial infections
  • Need coverage for both Group A streptococcus and oral anaerobes 5

3. Adjunctive Therapy

• Corticosteroids:

  • Reduces inflammation, pain, and speeds recovery 2
  • Typical regimen: Dexamethasone 10mg IV or oral prednisone

• Hydration and pain control:

  • IV fluids if unable to maintain oral hydration
  • Adequate analgesia (NSAIDs, acetaminophen)

Special Considerations

Outpatient vs. Inpatient Management

• Most patients can be managed as outpatients 5
• Indications for hospitalization:
  • Inability to maintain oral hydration
  • Respiratory distress or concern for airway compromise
  • Severe systemic symptoms
  • Failed outpatient management

Medical Management Without Drainage

• Some evidence supports outpatient medical treatment without drainage in select cases 6
• Components include:
  • Hydration
  • Antibiotics
  • Steroids
  • Pain control
• However, drainage remains the standard of care for most patients

Follow-up

• 24-48 hour follow-up to ensure clinical improvement
• Consider interval tonsillectomy for patients with:
  • History of recurrent peritonsillar abscess (>1 episode) 3
  • Recurrent tonsillitis meeting criteria for tonsillectomy

Potential Complications

• Airway obstruction
• Extension to deep neck spaces
• Aspiration
• Jugular vein thrombosis
• Mediastinitis

Prevention of Recurrence

• Consider tonsillectomy for patients with:
  • Multiple episodes of peritonsillar abscess
  • Recurrent tonsillitis meeting criteria for tonsillectomy

By following this approach, most peritonsillar abscesses can be effectively managed with good outcomes and minimal complications.