What is the recommended treatment for peritonsillar abscess?

Treatment of Peritonsillar Abscess

The treatment of peritonsillar abscess requires three simultaneous interventions: drainage of the abscess (via needle aspiration or incision and drainage), empiric antibiotics targeting group A streptococcus and oral anaerobes, and supportive care for hydration and pain control. 1, 2

Immediate Management Algorithm

1. Drainage Procedure

• Needle aspiration is the preferred initial drainage method for most peritonsillar abscesses, as it is less painful than incision and drainage, though it carries a higher recurrence risk (RR 3.74) 3
• Incision and drainage should be considered for patients who fail needle aspiration or when recurrence is a significant concern 3
• Both drainage methods are effective when combined with appropriate antibiotic therapy 4

2. Antibiotic Therapy

• Initiate empiric antibiotics immediately upon diagnosis targeting group A streptococcus and oral anaerobes 1, 2
• The recommended regimen is penicillin plus metronidazole, as peritonsillar abscesses are polymicrobial with significant anaerobic involvement 2, 5
• Bacteriologic cultures are unnecessary on initial presentation in routine cases 5

3. Adjunctive Corticosteroid Therapy

• A single high-dose intravenous corticosteroid should be administered prior to antibiotic therapy to reduce fever, throat pain, dysphagia, and trismus more rapidly than antibiotics alone (p < 0.01) 6
• This significantly shortens hospitalization time and accelerates symptom resolution 6, 4

4. Supportive Care

• Maintain adequate hydration, as dehydration requiring hospitalization can occur 3
• Provide appropriate pain control to facilitate oral intake 2

Special Considerations

Recurrent Disease

• Tonsillectomy should be performed for patients with more than one peritonsillar abscess as definitive treatment 1
• Immediate tonsillectomy has a limited but useful role in selected cases of acute peritonsillar abscess 4

Common Pitfalls to Avoid

• Failing to cover anaerobic organisms—these account for 50% of isolates and are critical to treatment success 5
• Delaying drainage in favor of antibiotics alone—drainage is essential and should not be deferred 1, 2
• Underestimating airway compromise risk—promptly recognize and treat to avoid serious complications including airway obstruction and deep neck space extension 2

Outpatient vs. Inpatient Management

• Most patients can be managed in the outpatient setting after drainage and initiation of therapy 2
• Hospitalization is indicated for patients with severe trismus, dehydration, airway concerns, or inability to tolerate oral intake 2, 3