What is the treatment for a paratonsillar abscess?

Treatment for Peritonsillar Abscess

The standard treatment for peritonsillar abscess includes drainage of the abscess (via needle aspiration, incision and drainage, or immediate tonsillectomy in select cases), appropriate antibiotic therapy covering Group A streptococcus and oral anaerobes, and supportive care for pain management and hydration. 1

Diagnosis

• Clinical presentation typically includes:
  • Fever
  • Severe sore throat (often unilateral)
  • Dysphagia (difficulty swallowing)
  • Trismus (limited mouth opening)
  • "Hot potato" voice (muffled speech)
  • Unilateral peritonsillar swelling with deviation of the uvula to the opposite side
  • Tender cervical lymphadenopathy

Treatment Algorithm

1. Drainage Procedure

• Needle aspiration: First-line drainage procedure 2

  • Aspirate at three points in the area of maximum fluctuance 3
  • Repeat aspiration may be necessary in approximately 10% of cases 3

• Incision and drainage: Consider when needle aspiration fails or for larger abscesses 2

• Immediate tonsillectomy: Reserved for advanced cases or when other drainage methods fail 2

2. Antibiotic Therapy

• First-line antibiotics (covering Group A streptococcus and oral anaerobes):

  • Penicillin plus metronidazole
  • Clindamycin
  • Amoxicillin-clavulanate
  • Cephalosporins with anaerobic coverage 2

• For severe infections or immunocompromised patients:

  • Consider broader coverage with vancomycin plus either piperacillin-tazobactam, a carbapenem, or ceftriaxone plus metronidazole 4

• Route of administration:

  • Initial IV antibiotics for hospitalized patients
  • Transition to oral antibiotics for outpatient management once clinically improving

3. Adjunctive Therapy

• Corticosteroids: A single high-dose steroid treatment can significantly improve clinical outcomes including:

  • Reduced throat pain
  • Faster resolution of fever
  • Reduced trismus
  • Shorter hospitalization 5

• Supportive care:

  • Adequate hydration
  • Pain management
  • Pharyngeal douches 3

Hospitalization Criteria

• Severe symptoms
• Inability to maintain oral hydration
• Respiratory distress or concern for airway compromise
• Significant comorbidities
• Failure of outpatient management
• Extension of infection into deep neck tissues

Follow-up Considerations

• Interval tonsillectomy: Consider only when there is:
  • History of recurrent tonsillitis
  • Previous peritonsillar abscess 3
  • Multiple (>1) peritonsillar abscesses 6

Potential Complications

• Airway obstruction
• Aspiration
• Extension of infection into deep neck tissues
• Sepsis
• Rarely, jugular vein thrombosis (Lemierre syndrome)

Special Considerations

• Peritonsillar abscesses are polymicrobial infections, but Group A streptococcus is the predominant organism 7
• Seasonal incidence peaks during November-December and April-May, coinciding with highest incidence of streptococcal pharyngitis 7
• Most patients can be managed in the outpatient setting after successful drainage and initiation of antibiotics 1
• Fusobacterium necrophorum should be considered in adolescents and young adults with severe pharyngitis, as it can lead to Lemierre syndrome in rare cases 6

Family physicians with appropriate training and experience can diagnose and treat most patients with peritonsillar abscess, but prompt recognition and treatment are essential to avoid serious complications.