What is the recommended treatment for peritonsillar abscess?

Treatment of Peritonsillar Abscess

The recommended treatment for peritonsillar abscess includes drainage of the abscess (via needle aspiration, incision and drainage, or quinsy tonsillectomy), antibiotic therapy effective against group A streptococcus and oral anaerobes, corticosteroids, and supportive care for pain control and hydration. 1

Diagnosis

• Peritonsillar abscess is the most common deep infection of the head and neck, occurring primarily in young adults 1
• Diagnosis is typically made based on clinical presentation and examination, with symptoms including:
  • Fever
  • Severe sore throat
  • Dysphagia (difficulty swallowing)
  • Trismus (limited mouth opening)
  • "Hot potato" voice
  • Unilateral peritonsillar swelling with deviation of the uvula 1
• In cases where the diagnosis is uncertain, intraoral ultrasound can be a helpful diagnostic tool 2

Treatment Approach

Drainage Options

• Drainage of the abscess is a cornerstone of treatment and can be performed using one of three methods:
  • Needle aspiration - often preferred as first-line approach 3
  • Incision and drainage 1
  • Quinsy tonsillectomy (immediate tonsillectomy) - reserved for selected cases 3

Antibiotic Therapy

• Empiric antibiotic therapy should be initiated once peritonsillar abscess is diagnosed 4
• Antibiotics should be effective against group A streptococcus and oral anaerobes, as peritonsillar abscesses are typically polymicrobial infections 1
• Antibiotic therapy should be started promptly in the emergency department or outpatient setting 4

Corticosteroids

• A single high-dose steroid treatment has been shown to be effective in relieving symptoms such as fever, throat pain, dysphagia, and trismus 5
• Studies have demonstrated that adding corticosteroids to antibiotic therapy results in statistically significant improvement in clinical outcomes compared to antibiotics alone 5
• Corticosteroids reduce morbidity and speed recovery in patients with peritonsillar abscess 2, 3

Supportive Care

• Hydration is essential for patients with peritonsillar abscess 1, 3
• Adequate pain control should be provided to improve patient comfort and facilitate oral intake 1

Outpatient vs. Inpatient Management

• Most patients with peritonsillar abscess can be managed in the outpatient setting 1
• An outpatient medical treatment protocol involving hydration, antibiotics, steroids, and pain control has been shown to be effective, with only 4.1% of patients subsequently requiring needle aspiration or incision and drainage 6
• Inpatient management may be necessary for patients with:
  • Severe symptoms
  • Inability to maintain oral hydration
  • Significant comorbidities
  • Complications such as airway compromise or extension of infection 1

Special Considerations

• For patients with history of more than one peritonsillar abscess, tonsillectomy should be considered as a definitive treatment 4
• Prompt recognition and treatment are crucial to avoid potentially serious complications such as:
  • Airway obstruction
  • Aspiration
  • Extension of infection into deep neck tissues 1

Treatment Algorithm

1. Confirm diagnosis through clinical examination (and imaging if necessary)
2. Perform drainage procedure (needle aspiration preferred as first-line) 3
3. Initiate antibiotic therapy effective against group A streptococcus and oral anaerobes 1
4. Administer single-dose corticosteroid 5
5. Provide adequate hydration and pain control 1
6. Consider outpatient management for stable patients 6, 1
7. Monitor for resolution of symptoms and potential complications
8. Consider tonsillectomy for recurrent cases (history of >1 peritonsillar abscess) 4