From the Guidelines
The diagnosis and treatment of a peritonsillar abscess (PTA) involves immediate empiric antibiotic therapy, typically with penicillin or clindamycin, along with drainage of the abscess, which can be achieved through needle aspiration or incision and drainage. The recommended approach is to start empiric antibiotic therapy immediately, typically with penicillin (such as amoxicillin-clavulanate 875/125 mg twice daily) or clindamycin (300-450 mg four times daily) for penicillin-allergic patients, for 10-14 days 1. Patients should also take pain medications like acetaminophen or ibuprofen and use warm salt water gargles to reduce discomfort. Hospitalization may be necessary for severe cases, especially if there's difficulty swallowing, breathing problems, or signs of spreading infection. Prompt treatment is essential as untreated abscesses can lead to serious complications including airway obstruction, spread of infection to deep neck spaces, or even sepsis. The abscess forms as a complication of tonsillitis when bacteria penetrate the tonsillar tissue and create a pocket of infection, commonly caused by streptococcal or anaerobic bacteria. Complete resolution typically occurs within 1-2 weeks with appropriate treatment. Ultrasound imaging can be used to evaluate and drain the abscess, as outlined in the emergency ultrasound imaging criteria compendium by the American College of Emergency Physicians 1. Key considerations in the management of PTA include:
- Prompt initiation of empiric antibiotic therapy
- Drainage of the abscess through needle aspiration or incision and drainage
- Pain management with medications like acetaminophen or ibuprofen
- Use of warm salt water gargles to reduce discomfort
- Consideration for hospitalization in severe cases.
From the Research
Diagnosis of Peritonsillar Abscess (PTA)
- The diagnosis of PTA is primarily based on clinical presentation, including symptoms such as fever, throat pain, and trismus 2.
- Ultrasonography and computed tomographic scanning can be useful in confirming a diagnosis 2.
- Needle aspiration remains the gold standard for diagnosis and treatment of peritonsillar abscess 2.
- Fine-needle aspiration can also be used to obtain pus and confirm the diagnosis of abscess or peritonsillar cellulitis 3.
Treatment of Peritonsillar Abscess (PTA)
- Several treatment guidelines have been described, including needle aspiration, incision and drainage, or abscess tonsillectomy 4.
- Immediate abscess tonsillectomy is considered a safe and effective treatment for PTA, with advantages including removal of the abscess and amelioration of trismus and dysphagia 4.
- Needle aspiration as the initial and only treatment can be performed in some cases, but may require subsequent abscess tonsillectomy if there is no clinical improvement 4.
- Puncture-drainage, intravenous antibiotics, and a single dose of steroids can also be used to treat PTA, with a mean length of hospital stay of 3 days and a recurrence rate of 5% 3.
- Incision and drainage may be associated with a lower chance of recurrence than needle aspiration, although the evidence is of very low quality 5.
- Antibiotic therapy, including penicillin, clindamycin, cephalosporins, or metronidazole, is also an important part of the treatment of PTA 2.
- In some cases, treatment with antibiotics and needle aspiration without surgical intervention may be possible, as seen in the case of an intratonsillar abscess 6.
Comparison of Treatment Options
- The effectiveness of needle aspiration versus incision and drainage for the treatment of PTA has not been clearly demonstrated and remains an area of debate 5.
- The choice of treatment may depend on the individual case and the clinical judgment of the healthcare provider, taking into account factors such as the severity of symptoms, the presence of complications, and the patient's overall health status 4, 3, 2, 5, 6.