What is the recommended treatment for peritonsillar abscess in adults?

Treatment of Peritonsillar Abscess in Adults

The recommended treatment for peritonsillar abscess in adults is drainage of the abscess (via needle aspiration, incision and drainage, or immediate tonsillectomy in select cases) combined with appropriate antibiotic therapy covering both aerobic and anaerobic bacteria.

Diagnosis

• Typical presentation includes:

  • Fever
  • Severe throat pain (often unilateral)
  • Dysphagia (difficulty swallowing)
  • Trismus (limited mouth opening)
  • "Hot potato" voice
  • Unilateral peritonsillar swelling with deviation of the uvula to the opposite side
  • Muffled voice

• Diagnostic confirmation:

  • Clinical examination is usually sufficient
  • Needle aspiration serves as both diagnostic and therapeutic
  • Ultrasound or CT scan may be used in uncertain cases

Treatment Algorithm

1. Drainage Procedure (Primary Treatment)

• Needle aspiration - Gold standard first-line approach 1

  • Less invasive than incision and drainage
  • Can be performed in outpatient setting with local anesthesia
  • May need to be repeated if reaccumulation occurs

• Incision and drainage

  • Consider for larger abscesses or when aspiration fails
  • Creates better drainage pathway

• Immediate tonsillectomy

  • Reserved for severe cases or recurrent peritonsillar abscesses
  • May be considered in patients with history of recurrent tonsillitis

2. Antibiotic Therapy

Peritonsillar abscesses are polymicrobial infections involving both aerobic and anaerobic bacteria. Common pathogens include Group A Streptococcus, Staphylococcus aureus, Fusobacterium, and other anaerobes.

First-line antibiotic options:

• Amoxicillin-clavulanate: 875 mg/125 mg orally every 12 hours or 500 mg/125 mg orally every 8 hours 2

  • Provides coverage for both aerobic and anaerobic bacteria
  • Take at the start of a meal to minimize GI intolerance

• Clindamycin: 300-450 mg orally every 6 hours 3

  • Excellent anaerobic coverage
  • Good option for penicillin-allergic patients
  • Monitor for C. difficile-associated diarrhea

• Penicillin plus metronidazole (alternative regimen)

  • Provides coverage for both aerobic and anaerobic pathogens

Duration of therapy:

• 10-14 days of antibiotics is typically recommended

3. Supportive Care

• Pain management

  • NSAIDs or acetaminophen for pain control
  • Throat lozenges or sprays for local relief
  • Narcotic analgesics may be necessary in severe cases

• Hydration

  • Ensure adequate fluid intake
  • IV fluids may be necessary if oral intake is severely limited

• Corticosteroids

  • Single dose of dexamethasone or equivalent
  • Helps reduce inflammation, pain, and trismus
  • Studies show faster symptom resolution with steroids 4, 5

Inpatient vs. Outpatient Management

Most patients can be managed as outpatients after successful drainage 6. Consider inpatient management for:

• Patients with significant trismus or inability to swallow
• Signs of airway compromise
• Significant comorbidities
• Extension of infection to deep neck spaces
• Inability to tolerate oral intake
• Inadequate social support for outpatient management

Medical Management Without Drainage

While drainage is the standard of care, selected patients with small abscesses may be managed with medical therapy alone 7:

• Aggressive hydration
• Broad-spectrum antibiotics
• Corticosteroids
• Close follow-up

This approach may be considered in:

• Very small or early abscesses
• Patients refusing drainage procedures
• Settings where surgical expertise is not immediately available

Complications to Monitor

• Airway obstruction
• Extension to parapharyngeal or retropharyngeal spaces
• Jugular vein thrombosis (Lemierre syndrome)
• Aspiration pneumonia
• Mediastinitis
• Sepsis

Follow-up

• Reassess within 24-48 hours after initial treatment
• Consider repeat drainage if symptoms persist or worsen
• Consider tonsillectomy after resolution for patients with recurrent peritonsillar abscesses or history of recurrent tonsillitis

Pitfalls and Caveats

1. Don't delay drainage - Peritonsillar abscesses can rapidly progress to airway obstruction or spread to deep neck spaces

2. Don't miss deep space extension - Evaluate for extension to parapharyngeal or retropharyngeal spaces, especially if symptoms are severe or patient has limited response to initial therapy

3. Don't forget anaerobic coverage - Peritonsillar abscesses are polymicrobial; ensure antibiotic coverage includes anaerobes

4. Beware of Lemierre syndrome - Consider this rare but serious complication in adolescents and young adults with severe pharyngitis, especially if caused by Fusobacterium necrophorum 8

5. Don't underestimate hydration needs - Patients often have significant dehydration due to reduced oral intake