What is the recommended treatment for peritonsillar abscess?

Treatment of Peritonsillar Abscess

The recommended treatment for peritonsillar abscess includes drainage of the abscess, empiric antibiotic therapy effective against group A streptococcus and oral anaerobes, and supportive care for pain control and hydration. 1

Diagnosis and Initial Management

• Diagnosis is typically made based on clinical presentation and examination, with symptoms including fever, sore throat, dysphagia, trismus, and a characteristic "hot potato" voice 2
• Prompt recognition and initiation of therapy are essential to avoid serious complications such as airway obstruction, aspiration, or extension of infection into deep neck tissues 2

Treatment Algorithm

1. Drainage Procedure

• Needle aspiration or incision and drainage are the two main surgical approaches for treating peritonsillar abscess 3
  • Needle aspiration may be associated with higher recurrence rates compared to incision and drainage, though it may be less painful for patients 3
  • A Cochrane review found that incision and drainage may be associated with a lower chance of recurrence than needle aspiration (very low-quality evidence) 3

2. Antibiotic Therapy

• Empiric antibiotic therapy should be initiated immediately once peritonsillar abscess is diagnosed 1
• Antibiotics should be effective against both group A streptococcus and oral anaerobes, as recommended by the Infectious Diseases Society of America 1
• Penicillin combined with metronidazole is an effective antibiotic regimen of choice, targeting both aerobic and anaerobic bacteria commonly found in peritonsillar abscesses 4
• Peritonsillar abscesses are polymicrobial infections, with studies showing a mix of aerobic and anaerobic bacteria (particularly Streptococcus and Bacteroides species) 4

3. Adjunctive Therapy

• Corticosteroids may be beneficial in reducing symptoms and speeding recovery 2
• A single high-dose steroid treatment in addition to antibiotic therapy has shown statistically significant improvement in clinical outcomes compared to antibiotics alone, including reduced hospitalization time, throat pain, fever, and trismus 5
• Supportive care should include adequate hydration and pain control 2

4. Treatment Setting

• Most patients with peritonsillar abscess can be managed in the outpatient setting 2
• Some patients may be successfully treated with an outpatient medical regimen involving hydration, antibiotics, steroids, and pain control, potentially avoiding surgical drainage in select cases 6

Special Considerations

• For patients with a history of more than one peritonsillar abscess, tonsillectomy should be considered as a definitive treatment 1
• While routine bacteriologic studies are generally unnecessary on initial presentation, clinicians should be aware of the polymicrobial nature of these infections and ensure coverage for both aerobic and anaerobic organisms 4

Potential Complications to Monitor

• Airway obstruction
• Aspiration
• Extension of infection into deep neck tissues
• Dehydration due to pain and difficulty swallowing 2, 3