What is the treatment for a paratonsillar abscess?

Treatment of Peritonsillar Abscess

The treatment of peritonsillar abscess requires drainage (needle aspiration or incision and drainage), antibiotics targeting group A streptococcus and anaerobes (preferably penicillin G plus metronidazole), and supportive care with hydration and pain control, with most patients managed successfully in the outpatient setting. 1, 2

Immediate Management Approach

Drainage Procedures

• Abscess drainage is essential and should be performed via needle aspiration or incision and drainage 2
• Needle aspiration is the preferred initial drainage method for peritonsillar abscess and can be performed in the outpatient setting 3
• Internal incision is the most common surgical approach, though tonsillectomy may be performed concurrently in select cases 4

Antibiotic Therapy

• First-line antibiotic therapy should be penicillin G plus metronidazole, which provides coverage against group A streptococcus and oral anaerobes 1, 4, 2
• This regimen is superior to cefuroxime-based therapy, as cefuroxime-treated patients had longer hospitalizations (4.5 vs 3.0 days), more complications (50% vs 18%), and higher rates of abscess recurrence requiring re-operation (44% vs 3%) 4
• For patients with risk factors for complications (high CRP, prior antibiotic use, severe presentation), consider broader coverage such as piperacillin-tazobactam 4

Supportive Care

• Ensure adequate hydration, as patients often have difficulty swallowing 2
• Provide aggressive pain control to facilitate oral intake 2
• Corticosteroids should be considered as they reduce symptoms and speed recovery 3, 2

Monitoring and Complications

Warning Signs Requiring Escalation

• Monitor closely for airway obstruction, aspiration, or extension into deep neck tissues 1, 2
• Patients with systemic toxicity, severe symptoms, drooling, or neck swelling should be considered for inpatient management 1, 5
• Males and patients over 40 years are at higher risk for complications (overall mortality 10% in complicated cases) 6

Common Complications to Watch For

• Descending mediastinitis, parapharyngeal/retropharyngeal abscess extension, necrotizing fasciitis, and Lemierre's syndrome are the most serious complications 6
• Complications can develop despite appropriate antibiotic therapy and drainage 6

Definitive Management Considerations

Tonsillectomy Indications

• Patients with more than one peritonsillar abscess should be considered for tonsillectomy as definitive treatment 7, 1, 5
• The guideline threshold changed from "history of peritonsillar abscess" to ">1 peritonsillar abscess" as a modifying factor favoring tonsillectomy 7
• Immediate tonsillectomy at the time of abscess presentation has a limited but useful role in select cases 3

Outpatient vs Inpatient Decision-Making

Outpatient Management Criteria

• Most patients can be managed successfully in the outpatient setting with drainage, antibiotics, steroids, and pain control 8, 2
• An outpatient medical protocol (without drainage) showed 95.9% success rate, though this approach is less established 8

Inpatient Management Criteria

• Admit patients with signs of systemic toxicity, airway compromise, inability to maintain hydration, or high-risk features 5
• Patients requiring intensive care, external incision, or those with elevated inflammatory markers warrant inpatient management 4