Management of Peritonsillar Abscess: Outpatient Approach
Peritonsillar abscess can be effectively managed on an outpatient basis in carefully selected patients who are immunocompetent, without signs of sepsis, and able to maintain oral hydration.
Patient Selection for Outpatient Management
- Outpatient management is appropriate for patients without systemic inflammatory response syndrome (SIRS), altered mental status, or hemodynamic instability 1
- Contraindications to outpatient management include:
Diagnostic Approach
- Clinical diagnosis is usually sufficient for typical peritonsillar abscesses 2
- Key clinical findings include fever, sore throat, dysphagia, trismus, and a "hot potato" voice 1
- Imaging (CT or intraoral ultrasound) may be considered for atypical presentations or suspected complications 2, 6
Outpatient Treatment Protocol
Drainage Procedure
- Needle aspiration is an effective first-line drainage technique for outpatient management 4, 7
- Incision and drainage is an alternative approach with similar efficacy 7
- The procedure should be performed by clinicians with appropriate training and experience 1
Antimicrobial Therapy
- Oral antibiotics should be started immediately after drainage 3, 7
- Select antibiotics effective against group A streptococcus and oral anaerobes 1
- Common regimens include:
- Amoxicillin-clavulanate
- Clindamycin (for penicillin-allergic patients)
- Penicillin plus metronidazole
- Duration of therapy is typically 5-7 days 3, 1
Adjunctive Treatments
- Corticosteroids can reduce symptoms and speed recovery 6, 1
- Adequate pain control with analgesics is essential 3
- Ensure proper hydration 3, 7
Follow-up and Monitoring
- Patients should be followed closely within 24-48 hours to assess response to treatment 3
- Treatment failure requiring hospitalization occurs in approximately 4-12% of outpatient cases 3, 4
- Signs of treatment failure include:
- Worsening symptoms despite 24-48 hours of therapy
- Inability to maintain oral hydration
- Development of complications (airway obstruction, extension of infection) 1
Potential Complications
- Airway obstruction
- Extension to deep neck spaces
- Aspiration
- Recurrence 1
Cost and Resource Considerations
- Outpatient management significantly reduces healthcare costs compared to inpatient treatment 4, 7
- Success rates of 85-96% have been reported with outpatient management protocols 3, 4
Special Considerations
- Younger patients and those with severe trismus may require inpatient management 4
- Patients with recurrent peritonsillar abscesses may benefit from interval tonsillectomy 1
The evidence strongly supports that properly selected patients with peritonsillar abscess can be safely and effectively managed as outpatients, resulting in similar outcomes to inpatient management while significantly reducing healthcare costs.