What is the treatment for peritonsillar abscess?

Treatment of Peritonsillar Abscess

The primary treatment for peritonsillar abscess is drainage of the abscess (through needle aspiration, incision and drainage, or immediate tonsillectomy in select cases) followed by appropriate antibiotic therapy covering both group A streptococcus and oral anaerobes. 1

Diagnosis

• Clinical presentation typically includes:

  • Fever
  • Severe sore throat (often unilateral)
  • Dysphagia
  • Trismus (limited mouth opening)
  • "Hot potato" voice
  • Unilateral peritonsillar swelling and deviation of the uvula to the opposite side

• Intraoral ultrasound can be a helpful diagnostic tool when the diagnosis is uncertain 2

Treatment Algorithm

1. Drainage Procedure (choose one)

• Needle aspiration:

  • Gold standard for initial management 3
  • Less invasive, can be performed in outpatient setting
  • Requires local anesthesia
  • May need repeated aspirations

• Incision and drainage:

  • Alternative to needle aspiration
  • Creates better drainage
  • Requires local anesthesia

• Immediate tonsillectomy (quinsy tonsillectomy):

  • Reserved for specific situations:
    • Recurrent peritonsillar abscess (>1 previous episode)
    • Bilateral peritonsillar abscesses
    • Cases where drainage is difficult
    • History of recurrent tonsillitis meeting criteria 1

2. Antibiotic Therapy

• First-line regimen: Penicillin plus metronidazole 4

  • Covers both aerobic (primarily Streptococcus pyogenes) and anaerobic bacteria
  • This combination is effective in 98% of patients 4

• Alternative regimens (for penicillin-allergic patients):

  • Clindamycin (covers both aerobes and anaerobes)
  • Cephalosporins (if non-anaphylactic penicillin allergy)
  • Ciprofloxacin plus metronidazole 5, 3

• Antibiotics should be administered promptly, ideally within 8 hours of presentation 6

3. Adjunctive Therapy

• Corticosteroids:

  • May reduce symptoms and speed recovery 2
  • Consider a short course of systemic steroids

• Supportive care:

  • Adequate hydration
  • Pain control with analgesics
  • Antipyretics for fever

Follow-up

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

Considerations for Tonsillectomy

• 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
  • Patients with history of >1 peritonsillar abscess 1

Complications to Monitor

• Airway obstruction
• Aspiration
• Extension of infection into deep neck tissues
• Dehydration due to dysphagia

Pitfalls to Avoid

• Failure to distinguish peritonsillar abscess from peritonsillar cellulitis
• Delaying drainage when indicated
• Using penicillin alone without anaerobic coverage (32% of cases have penicillin-resistant organisms) 4
• Discharging patients without ensuring adequate oral intake and follow-up plan

Most patients with peritonsillar abscess can be managed in the outpatient setting with appropriate drainage, antibiotics, and close follow-up 7.