What are the symptoms and treatment of a peritonsillar abscess?

Peritonsillar Abscess: Symptoms and Treatment

A peritonsillar abscess presents with fever, severe throat pain, dysphagia, trismus, and a characteristic "hot potato" voice, requiring prompt drainage, appropriate antibiotic therapy targeting group A streptococcus and oral anaerobes, and supportive care for optimal outcomes. 1

Symptoms of Peritonsillar Abscess

• Fever is a common presenting symptom due to the inflammatory response to the infection 1
• Severe sore throat/throat pain, typically worse on the affected side 1, 2
• Dysphagia (difficulty swallowing) due to inflammation and mass effect 1
• Trismus (limited mouth opening) caused by inflammation of muscles adjacent to the infection 1, 2
• "Hot potato" voice - a muffled voice quality resulting from swelling and altered articulation 1
• Unilateral tonsillar enlargement with displacement of the uvula to the contralateral side 2
• Drooling may occur in severe cases due to difficulty managing oral secretions 3
• Neck tenderness or swelling may be present, indicating potential spread of infection 3

Diagnosis

• Clinical presentation and physical examination are usually sufficient for diagnosis in most cases 1
• Imaging may be used to confirm diagnosis in uncertain cases:
  • Ultrasonography is useful for confirming the presence of an abscess and is increasingly used as a point-of-care diagnostic tool 2, 4
  • CT scanning can help differentiate between peritonsillar cellulitis and abscess, and identify potential complications 2, 5
• Needle aspiration remains the gold standard for both diagnosis and initial treatment 2

Treatment Approach

Drainage Options

• Needle aspiration is the first-line approach for drainage and is both diagnostic and therapeutic 2
• Incision and drainage may be necessary for more advanced or loculated abscesses 5
• Immediate tonsillectomy (quinsy tonsillectomy) may be considered in selected cases, particularly for recurrent episodes 5, 6

Antibiotic Therapy

• Empiric antibiotic therapy should be initiated immediately after diagnosis 6, 1
• Antibiotics should target both group A streptococcus and oral anaerobes, as peritonsillar abscesses are typically polymicrobial infections 1
• Appropriate antibiotic options include:
  • Penicillin (traditional first-line therapy) 2
  • Clindamycin (especially for penicillin-allergic patients or when anaerobic coverage is emphasized) 2
  • Cephalosporins (good broad-spectrum coverage) 2
  • Metronidazole (often combined with other antibiotics for anaerobic coverage) 2

Adjunctive Therapy

• Corticosteroids may help reduce symptoms and speed recovery 5, 4
• Adequate hydration is essential for recovery 5
• Pain control with appropriate analgesics is a cornerstone of management 1

Special Considerations

• Most patients can be managed in the outpatient setting after successful drainage 1
• Patients with history of more than one peritonsillar abscess should be considered for tonsillectomy as definitive treatment 6
• Atypical presentations, especially in older adults without history of recurrent tonsillitis, should raise suspicion for potential malignancy (including lymphoma or squamous cell carcinoma) 7
• Potential complications requiring vigilance include airway obstruction, aspiration, or extension of infection into deep neck tissues 1

Treatment Algorithm

1. Confirm diagnosis through clinical examination and imaging if necessary
2. Perform drainage via needle aspiration, incision and drainage, or immediate tonsillectomy based on severity and recurrence
3. Initiate appropriate antibiotic therapy targeting group A streptococcus and anaerobes
4. Provide supportive care including hydration and pain management
5. Consider corticosteroids to reduce symptoms
6. Monitor for potential complications
7. Consider tonsillectomy for patients with recurrent episodes 6, 1, 5