What is the treatment for peritonsillar abscess?

Treatment of Peritonsillar Abscess

The primary treatment for peritonsillar abscess is drainage of the abscess (via needle aspiration, incision and drainage, or immediate tonsillectomy) combined with appropriate antibiotic therapy targeting both aerobic and anaerobic bacteria. 1, 2

Diagnosis

• Clinical presentation: Fever, severe sore throat, dysphagia, trismus (limited mouth opening), "hot potato" voice, and unilateral tonsillar swelling with deviation of the uvula to the opposite side 1
• Diagnostic confirmation: Clinical examination is usually sufficient, but ultrasonography or CT scanning can be helpful in confirming diagnosis in uncertain cases 2

Treatment Algorithm

1. Drainage Procedure

Choose one of the following drainage methods:

• Needle aspiration: Gold standard for diagnosis and initial treatment 2

  • Most minimally invasive approach
  • Can be performed in outpatient setting with local anesthesia
  • May need to be repeated if reaccumulation occurs

• Incision and drainage: Alternative when needle aspiration is insufficient 2

  • Creates better drainage pathway
  • Higher success rate for preventing reaccumulation

• Immediate tonsillectomy (quinsy tonsillectomy): Reserved for:

  • Cases with multiple recurrences
  • Failed needle aspiration or incision and drainage
  • Patients with history of recurrent tonsillitis 3

2. Antibiotic Therapy

Peritonsillar abscesses are polymicrobial infections requiring coverage for both group A streptococcus and oral anaerobes 1:

• First-line options:

  • Penicillin plus metronidazole
  • Amoxicillin-clavulanate
  • Clindamycin (good for penicillin-allergic patients)
  • Cephalosporins with anaerobic coverage

• Duration: Typically 10-14 days of antibiotics

3. Supportive Care

• Hydration: Critical component of treatment
• Pain control: NSAIDs and acetaminophen; opioids may be needed for severe pain
• Corticosteroids: Consider adding to reduce inflammation, pain, and trismus 4
  • Dexamethasone or prednisone can significantly reduce symptoms
  • Shown to speed recovery when used alongside drainage procedures

Special Considerations

• Outpatient vs. Inpatient: Most patients can be managed as outpatients 1

  • Consider hospitalization for:
    • Airway concerns
    • Inability to maintain hydration
    • Significant comorbidities
    • Failed outpatient management
    • Extension of infection to deep neck spaces

• Medical management alone: May be considered in select cases 5

  • A protocol using hydration, antibiotics, steroids, and pain control showed success with only 4.1% of patients requiring subsequent drainage
  • However, this approach should be used cautiously and with close follow-up

• Complications to monitor for:

  • Airway obstruction
  • Extension to deep neck spaces
  • Aspiration
  • Sepsis

Follow-up

• Reassess within 24-48 hours to ensure improvement
• Consider interval tonsillectomy (4-6 weeks after resolution) for patients with:
  • History of recurrent tonsillitis
  • Multiple peritonsillar abscesses
  • Complications from the abscess 6

Pitfalls to Avoid

• Delaying drainage: Prompt drainage is essential to prevent complications
• Inadequate antibiotic coverage: Ensure coverage for both aerobic and anaerobic bacteria
• Overlooking deep space extension: Always evaluate for possible extension to parapharyngeal or retropharyngeal spaces
• Neglecting hydration: Dehydration is common due to dysphagia and should be aggressively addressed
• Missing underlying causes: Consider conditions that may predispose to abscess formation (e.g., periodontal disease, smoking) 3

The clinical practice guideline from the American Academy of Otolaryngology-Head and Neck Surgery suggests that a history of more than one peritonsillar abscess may be a modifying factor that favors tonsillectomy 6, indicating that recurrent peritonsillar abscesses should prompt consideration of definitive surgical management.