Treatment of Tonsillar Abscess
The recommended treatment for a tonsillar abscess includes drainage of the abscess (via needle aspiration, incision and drainage, or tonsillectomy) combined with appropriate antibiotic therapy targeting Group A streptococcus and oral anaerobes, particularly Fusobacterium necrophorum. 1
Diagnosis and Clinical Presentation
Tonsillar abscess (peritonsillar abscess) typically presents with:
- Progressively worsening odynophagia (painful swallowing)
- Ipsilateral swelling of the soft palate
- Trismus (difficulty opening mouth)
- "Hot potato" voice
- Fever
- Tonsillar exudate
- Asymmetric tonsillar enlargement 1, 2
Treatment Algorithm
Step 1: Drainage Procedure
One of the following drainage methods should be performed:
- Needle aspiration (gold standard for diagnosis and initial treatment) 3
- Incision and drainage (for larger abscesses or when aspiration is insufficient)
- Acute tonsillectomy (reserved for specific cases, such as recurrent peritonsillar abscess) 1
Step 2: Antibiotic Therapy
Initiate empiric antibiotic therapy immediately after drainage:
First-line regimen:
- Amoxicillin-clavulanate 1
For penicillin-allergic patients:
- Clindamycin (10-20 mg/kg/day in 3 divided doses for children; 300-450 mg 3 times daily for adults) 1, 3
Alternative options:
- Cephalosporins (if no immediate hypersensitivity to penicillin)
- Metronidazole (in combination with another antibiotic for gram-positive coverage) 3
Step 3: Supportive Care
- Pain management with ibuprofen, acetaminophen, or both 4
- Maintain hydration 2
- Single intraoperative dose of intravenous dexamethasone if surgical intervention is performed 4
Special Considerations
Indications for Tonsillectomy
- History of more than one peritonsillar abscess 1
- Recurrent tonsillitis meeting specific criteria:
- ≥7 episodes in the past year, or
- ≥5 episodes per year in the past 2 years, or
- ≥3 episodes per year in the past 3 years 4
Monitoring and Complications
Close monitoring for 24-48 hours after drainage is necessary to watch for potential complications:
- Airway obstruction
- Extension to parapharyngeal space (occurs in approximately 52% of cases) 5
- Bacteremia
- Lemierre's syndrome (jugular vein thrombosis)
- Mediastinitis 1
If no improvement within 48 hours, consider:
- Alternative drainage approach
- CT imaging to rule out parapharyngeal extension
- Broader antibiotic coverage 1
Important Clinical Pearls
Microbiology: Tonsillar abscesses are polymicrobial infections. While Group A streptococcus has been traditionally considered the primary pathogen, recent evidence suggests Fusobacterium necrophorum is prevalent in up to 58% of cases and may cause more severe infections with higher inflammatory markers 5.
Risk factors: Smoking is associated with increased risk of peritonsillar abscess across all age groups 5.
Atypical presentations: In rare cases, particularly in older patients without a history of recurrent tonsillitis, a peritonsillar abscess may be the presenting sign of a malignancy such as lymphoma or squamous cell carcinoma 6.
Parapharyngeal extension: Always evaluate for possible extension to the parapharyngeal space, which requires more aggressive management 5.