Treatment of Tonsillar (Peritonsillar) Abscess
The treatment of peritonsillar abscess requires drainage (needle aspiration, incision and drainage, or immediate tonsillectomy), combined with antibiotics effective against Group A streptococcus and oral anaerobes, with most patients manageable in the outpatient setting unless systemic toxicity is present. 1, 2
Immediate Management
Drainage Procedures
- Abscess drainage is mandatory and represents the cornerstone of treatment 2, 3
- Needle aspiration or incision and drainage are the preferred drainage methods for peritonsillar abscess 3
- Immediate tonsillectomy under general anesthesia is a safe alternative that provides complete drainage, dramatic symptom relief within days, and avoids a second procedure 4
- Immediate tonsillectomy can be performed safely without significant complications and may shorten total hospitalization time 5
Antibiotic Therapy
- First-line antibiotics must be effective against Group A streptococcus and oral anaerobes 1, 2
- Peritonsillar abscesses are polymicrobial infections with high incidence of anaerobes, requiring coverage for both streptococci and anaerobic bacteria 2, 4
- Antibiotic therapy should accompany drainage procedures in all cases 3
Adjunctive Therapy
- Corticosteroids may reduce symptoms and speed recovery 2
- Supportive therapy for hydration and pain control is essential 2
Inpatient vs Outpatient Decision
- Most patients can be managed in the outpatient setting 2
- Patients with systemic toxicity or severe symptoms require inpatient management 6
- Signs warranting hospitalization include airway compromise, inability to maintain hydration, or extension into deep neck tissues 2
Indications for Tonsillectomy
Immediate Tonsillectomy
- Consider immediate tonsillectomy as the primary drainage procedure, particularly if tonsillectomy is already indicated 4, 5
- This approach provides definitive treatment, complete drainage, and avoids a second convalescent period 5
Interval Tonsillectomy
- Tonsillectomy should be considered in patients with a history of more than one peritonsillar abscess 6, 1
- A history of recurrent peritonsillar abscess is a modifying factor favoring tonsillectomy even without meeting standard frequency criteria for recurrent throat infections 1
- Tonsillectomy may be considered for patients whose symptomatic episodes do not diminish in frequency over time 6
Common Pitfalls
- Failing to drain the abscess: Medical therapy alone is insufficient for peritonsillar abscess; drainage is mandatory 2, 3
- Inadequate antibiotic coverage: Ensure coverage for both streptococci and anaerobes, as these are polymicrobial infections 2, 4
- Missing airway compromise: Promptly recognize signs of airway obstruction, aspiration risk, or deep neck space extension to avoid serious complications 2
- Diagnostic uncertainty: When clinical examination is limited by trismus or poor cooperation, ultrasonography can verify abscess presence in approximately 90% of cases 7