What is the recommended treatment for peritonsillar abscess?

Treatment for Peritonsillar Abscess

The recommended treatment for peritonsillar abscess is drainage of the abscess (via needle aspiration, incision and drainage, or immediate tonsillectomy) combined with appropriate antibiotic therapy targeting both aerobic and anaerobic bacteria. This approach addresses both the source control and antimicrobial aspects necessary for effective treatment.

Diagnosis

• Clinical presentation typically includes:
  • Fever
  • Severe sore throat (often unilateral)
  • Dysphagia (difficulty swallowing)
  • Trismus (limited mouth opening)
  • "Hot potato" voice
  • Unilateral peritonsillar swelling with deviation of the uvula to the opposite side
  • Possible drooling and muffled voice

Treatment Algorithm

1. Source Control Options

• Needle aspiration:

  • First-line approach for most patients 1
  • Gold standard for both diagnosis and treatment 2
  • Can be performed in outpatient setting with appropriate training
  • May need to be repeated in approximately 10% of cases 3

• Incision and drainage:

  • Alternative when needle aspiration is unsuccessful or for larger abscesses
  • Creates better drainage but is more invasive

• Immediate tonsillectomy:

  • Reserved for advanced cases or when other methods fail 2
  • May be considered in patients with history of recurrent tonsillitis

2. Antimicrobial Therapy

• First-line antibiotics (polymicrobial coverage needed):

  • Penicillin plus metronidazole
  • Amoxicillin-clavulanate (covers both aerobes and anaerobes) 4
  • Clindamycin (good option for penicillin-allergic patients) 5

• Duration: 10-14 days of antibiotic therapy

3. Adjunctive Treatments

• Corticosteroids:

  • Help reduce inflammation, pain, and trismus 6
  • Single dose of dexamethasone or equivalent

• Supportive care:

  • IV or oral hydration based on severity
  • Adequate pain control (NSAIDs, acetaminophen)
  • Warm salt water gargles

Special Considerations

Outpatient vs. Inpatient Management

• Most patients can be managed as outpatients 1
• Indications for hospitalization:
  • Inability to maintain oral hydration
  • Significant respiratory distress or concern for airway compromise
  • Immunocompromised status
  • Failed outpatient management
  • Extension of infection to deep neck spaces

Medical Management Alone

Some evidence suggests that selected patients with small peritonsillar abscesses may be managed with medical therapy alone (antibiotics, steroids, hydration, pain control) without drainage procedures 7. However, this approach should be reserved for:

• Small, well-defined abscesses
• Patients without significant trismus or respiratory symptoms
• Settings with close follow-up capability

Follow-up Considerations

• Interval tonsillectomy (4-6 weeks after resolution) should be considered for:
  • History of recurrent tonsillitis
  • Previous peritonsillar abscess
  • Patients with complications

Potential Complications

• Airway obstruction (medical emergency)
• Extension to parapharyngeal or retropharyngeal spaces
• Jugular vein thrombosis
• Mediastinitis
• Aspiration pneumonia

Prompt recognition and appropriate treatment are essential to prevent these potentially life-threatening complications. The combination of effective drainage and appropriate antibiotic therapy remains the cornerstone of management for peritonsillar abscess.