What is the recommended management for peritonsillar infection?

Management of Peritonsillar Abscess

Incision and drainage is the primary intervention for first-time peritonsillar abscess, with antibiotics effective against both aerobic and anaerobic bacteria, while tonsillectomy should be reserved for recurrent cases. 1

Diagnosis

• Typical clinical presentation includes:
  • Fever
  • Severe sore throat
  • Dysphagia (difficulty swallowing)
  • Trismus (limited mouth opening)
  • "Hot potato" voice
  • Unilateral peritonsillar swelling and deviation of the uvula

Treatment Algorithm

1. Initial Management

• Drainage procedure (first-line intervention):
  • Needle aspiration
  • Incision and drainage
  • Both are equally effective for first-time peritonsillar abscess 1

2. Antibiotic Therapy

• Empiric antibiotic regimen (polymicrobial infection):
  • Penicillin plus metronidazole is the recommended first-line combination 2, 3
    • Penicillin (e.g., phenoxymethylpenicillin 4.5 million units daily)
    • Metronidazole (1500 mg daily)
  • Alternative for penicillin-allergic patients:
    • Clindamycin (as a single agent covering both aerobic and anaerobic bacteria) 3

3. Adjunctive Therapy

• Corticosteroids to reduce inflammation and speed recovery 4
• Pain management with appropriate analgesics
• Hydration support

4. Follow-up

• Clinical reassessment within 24-48 hours to ensure:
  • Resolution of fever
  • Improvement in pain and trismus
  • Improved ability to swallow 1

5. Indications for Tonsillectomy

• Immediate tonsillectomy should be considered for:

  • Recurrent peritonsillar abscess (history of >1 episode)
  • Bilateral peritonsillar abscesses
  • Cases where drainage is difficult 1

• Delayed tonsillectomy should be considered for patients with:

  • History of recurrent throat infections meeting criteria:
    • ≥7 episodes in the past year, or
    • ≥5 episodes per year for 2 years, or
    • ≥3 episodes per year for 3 years 1

Special Considerations

Outpatient vs. Inpatient Management

• Most patients can be managed as outpatients 4, 5
• Consider inpatient management for:
  • Signs of airway compromise
  • Inability to maintain oral hydration
  • Significant comorbidities
  • Extension of infection into deep neck tissues

Potential Complications

• Airway obstruction
• Aspiration
• Extension of infection into deep neck spaces
• Mediastinitis

Pitfalls to Avoid

• Failing to recognize potential airway compromise requiring immediate intervention
• Inadequate drainage of the abscess cavity
• Using antibiotics alone without drainage for a confirmed abscess
• Neglecting anaerobic coverage in antibiotic selection
• Delaying follow-up assessment to confirm clinical improvement

While some studies suggest that medical management alone with antibiotics, hydration, steroids, and pain control may be effective in certain populations 5, the standard of care remains drainage of the abscess combined with appropriate antibiotic therapy to prevent potentially serious complications.