Treatment of Tonsillar Abscess
The recommended treatment for a tonsillar abscess includes drainage of the abscess (via needle aspiration, incision and drainage, or immediate tonsillectomy) combined with appropriate antibiotic therapy targeting both Group A streptococcus and oral anaerobes. 1
Diagnosis
Clinical presentation typically includes:
- Fever
- Severe sore throat
- Dysphagia (difficulty swallowing)
- Trismus (limited mouth opening)
- "Hot potato" voice
- Unilateral tonsillar swelling with deviation of the uvula
- Tender cervical lymphadenopathy
Diagnostic confirmation may include:
- Ultrasonography
- CT scanning (in complex cases)
Treatment Algorithm
1. Drainage Procedure
One of the following drainage procedures must be performed:
Needle aspiration: Gold standard for initial management 2
- Advantages: Can be performed in outpatient setting, less invasive
- Success rate: Approximately 87% 3
Incision and drainage: Alternative approach
- Advantages: May provide more complete drainage
- Success rate: Approximately 90% 3
Immediate tonsillectomy: Reserved for advanced cases or recurrent abscesses 2
- Consider for patients with history of >1 peritonsillar abscess 4
2. Antibiotic Therapy
Peritonsillar abscesses are polymicrobial infections, requiring antibiotics effective against both Group A streptococcus and oral anaerobes 1.
First-line options:
- Penicillin (IV or oral after initial improvement)
Alternative options (for penicillin allergy or treatment failure):
- Clindamycin: 300-450 mg orally three times daily for 10 days 6
- Cephalosporins (cefdinir, cefuroxime, cefpodoxime) 6
- Amoxicillin-clavulanate (for treatment failures) 6
3. Supportive Care
Pain management:
- NSAIDs or acetaminophen for pain control
- Warm salt water gargles
- Adequate hydration
Corticosteroids:
- May help reduce symptoms and speed recovery 1
Special Considerations
Outpatient vs. Inpatient Management
Most patients can be managed as outpatients 1, but hospitalization is indicated for:
- Inability to maintain oral hydration
- Respiratory distress or airway concerns
- Significant comorbidities
- Treatment failure
- Extension of infection into deep neck tissues
Complications to Monitor
- Airway obstruction
- Aspiration
- Extension of infection into deep neck spaces
- Dehydration
Follow-up
- Follow-up within 24-48 hours to assess response to therapy
- Consider tonsillectomy after resolution for patients with recurrent peritonsillar abscesses (history of >1 episode) 4
Microbiology Considerations
Common pathogens include:
- Streptococcus pyogenes (most common) 7
- Staphylococcus aureus 7
- Anaerobic bacteria
- Other organisms: Haemophilus influenzae, Pseudomonas aeruginosa, Escherichia coli 7
Local resistance patterns should be considered when selecting antibiotics, as Staphylococcus aureus may be resistant to penicillin while Streptococcus pyogenes typically remains sensitive 7.