Is drainage necessary for peritonsillar abscess?

Management of Peritonsillar Abscess

Yes, drainage is necessary for peritonsillar abscess and should be performed as the primary treatment. Drainage, along with antibiotic therapy and supportive care, forms the cornerstone of treatment for peritonsillar abscess 1.

Diagnosis and Evaluation

• Peritonsillar abscess is characterized by:

  • Fever, severe sore throat
  • Dysphagia and odynophagia (pain on swallowing)
  • Trismus (limited mouth opening)
  • "Hot potato" voice
  • Unilateral peritonsillar swelling with deviation of the uvula

• While CT scan can confirm deep neck abscesses, diagnosis is usually made clinically 1, 2

• Intraoral ultrasound can be a helpful diagnostic tool when available 3

Treatment Approach

Drainage Options

Two main drainage methods exist:

1. Needle Aspiration

   • Less painful procedure 4
   • Can be performed in outpatient setting
   • Higher recurrence rate compared to incision and drainage 4
   • Success rate of 85% reported in some studies 5

2. Incision and Drainage

   • Lower recurrence rate than needle aspiration 4
   • May be more painful during the procedure 4
   • More definitive drainage

Timing of Drainage

• Timing should be based on the presence and severity of sepsis 6
• For patients with sepsis, severe sepsis, septic shock, or immunosuppression, emergent drainage is required 7
• In the absence of these factors, drainage should ideally be performed within 24 hours 7

Antibiotic Therapy

• Peritonsillar abscesses are polymicrobial infections
• Antibiotics should be effective against Group A streptococcus and oral anaerobes 1
• Common regimens include:
  • Clindamycin 300-450 mg PO TID + ciprofloxacin 500 mg PO BID 7
  • Metronidazole 500 mg PO TID + ciprofloxacin 500 mg PO BID 7
  • Broad-spectrum IV antibiotics for severe cases 7

Adjunctive Therapy

• Corticosteroids may reduce symptoms and speed recovery 1, 3
• Adequate hydration and pain control are essential 1
• Most patients can be managed in the outpatient setting 1, 5

Special Considerations

• Young, fit patients without signs of sepsis may have drainage performed in an ambulatory setting 6
• Patients with severe trismus, young age, or non-cooperation may not be candidates for needle aspiration 5
• Approximately 12% of patients may require hospitalization despite outpatient drainage attempts 5

Follow-up

• Follow-up should be scheduled within 48-72 hours to assess:
  • Response to treatment
  • Adequacy of drainage
  • Need for additional interventions 7

Potential Complications

• Airway obstruction
• Aspiration
• Extension of infection into deep neck tissues 1
• Recurrence (higher with needle aspiration) 4

In conclusion, while both needle aspiration and incision and drainage are effective treatment options for peritonsillar abscess, the evidence suggests that some form of drainage is necessary for proper management of this condition. The choice between needle aspiration and incision and drainage may depend on provider experience, patient factors, and local practice patterns.