Management of Peritonsillar Abscess
Peritonsillar abscess should be treated with drainage of the abscess (via needle aspiration, incision and drainage, or immediate tonsillectomy) combined with appropriate antibiotic therapy targeting group A streptococcus and oral anaerobes. 1
Clinical Presentation and Diagnosis
Peritonsillar abscess is the most common deep infection of the head and neck, occurring primarily in young adults. Diagnosis is typically based on clinical presentation and examination, characterized by:
- Fever
- Severe sore throat
- Dysphagia (difficulty swallowing)
- Trismus (limited mouth opening)
- "Hot potato" voice
- Unilateral peritonsillar swelling with deviation of the uvula to the opposite side
Management Algorithm
1. Drainage Procedures
Three main approaches for drainage exist:
Needle aspiration: First-line approach for most uncomplicated peritonsillar abscesses
- Simple, can be performed in outpatient setting
- Studies show 82% of patients achieve complete resolution with needle aspiration plus antibiotics 2
- May need to be repeated if reaccumulation occurs
Incision and drainage: Alternative when needle aspiration is unsuccessful
- Provides more definitive drainage
- May be preferred for larger or multiloculated abscesses
Immediate tonsillectomy: Reserved for specific cases
- Consider for recurrent peritonsillar abscess (history of >1 peritonsillar abscess) 3
- May be appropriate for bilateral peritonsillar abscesses or when drainage is difficult
2. Antibiotic Therapy
First-line: Penicillin remains an excellent choice for most cases 4
- Intravenous penicillin has been shown to be as effective as broader-spectrum antibiotics
- Can switch to oral therapy once clinical improvement occurs
Alternative options (for penicillin allergy or treatment failure):
- Clindamycin
- Amoxicillin-clavulanate
- Ampicillin-sulbactam
Duration: Typically 7-10 days of total antibiotic therapy
3. Adjunctive Therapy
Corticosteroids: Single high-dose steroid treatment has been shown to:
- Reduce symptoms (throat pain, trismus, fever)
- Speed recovery
- Reduce hospitalization time 5
Supportive care:
- Adequate hydration
- Pain control with appropriate analgesics
- Oral rinses for comfort
Treatment Setting
- Most patients can be managed in the outpatient setting after successful drainage 1
- Hospitalization criteria:
- Inability to maintain oral hydration
- Significant comorbidities
- Concern for airway compromise
- Extension of infection to deep neck spaces
- Failed outpatient management
Complications to Monitor
- Airway obstruction (emergency)
- Extension to deep neck spaces
- Aspiration
- Sepsis
- Recurrence
Special Considerations
Recurrent peritonsillar abscess: Consider tonsillectomy after resolution of acute infection, particularly with history of >1 peritonsillar abscess 3
Pediatric patients: Same principles apply, but may require more careful monitoring and consideration of the airway
Failed initial management: Consider CT imaging to evaluate for:
- Inadequate drainage
- Extension to other deep neck spaces
- Alternative diagnosis
Follow-up
- Clinical reassessment within 24-48 hours after initial treatment
- Ensure resolution of fever, improvement in pain, trismus, and ability to swallow
- Complete the full course of antibiotics even if symptoms improve rapidly
By promptly recognizing peritonsillar abscess and initiating appropriate drainage and antibiotic therapy, serious complications can be avoided and most patients will recover completely.