What is the treatment for a tonsillar abscess?

Treatment for Tonsillar Abscess

The treatment for a tonsillar abscess consists of drainage of the abscess (either by needle aspiration, incision and drainage, or tonsillectomy) combined with antibiotic therapy effective against both aerobic and anaerobic bacteria.

Diagnosis and Clinical Presentation

• Tonsillar abscess (peritonsillar abscess or quinsy) is the most common deep infection of the head and neck, typically occurring as a complication of acute tonsillitis 1
• Characteristic symptoms include:
  • Fever
  • Severe sore throat (odynodysphagia)
  • Dysphagia (difficulty swallowing)
  • Trismus (limited mouth opening)
  • "Hot potato" voice (muffled voice quality)
  • Unilateral swelling of the soft palate 1, 2

Treatment Approach

1. Drainage of the Abscess

• Drainage is the cornerstone of treatment and should be performed promptly to avoid complications 1
• Three main drainage options:
  • Needle aspiration - less invasive option that may be appropriate for initial management 3
  • Incision and drainage under local anesthesia - creates an opening to allow continued drainage 2
  • Tonsillectomy (immediate or "hot" tonsillectomy) - may be considered in severe cases or when malignancy is suspected 2, 4

2. Antibiotic Therapy

• Peritonsillar abscesses are polymicrobial infections, commonly involving:

  • Group A Streptococcus (Streptococcus pyogenes)
  • Staphylococcus aureus
  • Anaerobic bacteria 1, 3, 5

• First-line antibiotic regimen:

  • Penicillin plus metronidazole - targets both aerobic and anaerobic bacteria 3
  • Alternative: Clindamycin as monotherapy if first-line treatment fails or in penicillin-allergic patients 3

• Antibiotic therapy should be administered for 7-10 days 1

3. Supportive Care

• Pain management with appropriate analgesics 1
• Hydration support 1
• Corticosteroids may help reduce symptoms and speed recovery 1

Special Considerations

Recurrent Peritonsillar Abscess

• History of more than one peritonsillar abscess may be a modifying factor favoring tonsillectomy 6
• The Infectious Diseases Society of America notes that tonsillectomy may be considered for patients whose symptomatic episodes do not diminish in frequency over time 6

Atypical Presentations

• Peritonsillar abscess in older adults without a history of recurrent tonsillitis should raise suspicion for possible malignancy (squamous cell carcinoma or lymphoma) 4
• Consider tonsillectomy with histological examination in these cases 4

Complications to Watch For

• Airway obstruction
• Aspiration
• Extension of infection into deep neck tissues 1

Outpatient vs. Inpatient Management

• Most patients with peritonsillar abscess can be managed in the outpatient setting after successful drainage and initiation of antibiotics 1
• Consider inpatient management for:
  • Patients with significant trismus or inability to swallow
  • Signs of systemic toxicity
  • Concern for extension beyond the peritonsillar space 1

Antibiotic Resistance Considerations

• Streptococcus pyogenes generally remains sensitive to penicillin
• Staphylococcus aureus often shows resistance to penicillin, requiring coverage with cloxacillin or other anti-staphylococcal agents 5
• Ciprofloxacin and ceftazidime may be effective against both common pathogens 5