What is the treatment for peritonsillar abscess?

Treatment of Peritonsillar Abscess

Peritonsillar abscess requires both drainage (via needle aspiration or incision and drainage) and empiric antibiotic therapy targeting group A streptococcus and oral anaerobes, initiated as soon as the diagnosis is confirmed. 1

Immediate Management Approach

Drainage Procedure

• Perform drainage as the primary intervention using either needle aspiration or incision and drainage 1
• Needle aspiration may be attempted first, though incision and drainage appears to have lower recurrence rates (RR 3.74 for recurrence with needle aspiration versus incision and drainage) 2
• Needle aspiration causes less procedural pain but may require repeat intervention more frequently 2
• If needle aspiration fails or abscess recurs, proceed to incision and drainage 2

Antibiotic Therapy

• Initiate empiric antibiotics immediately upon diagnosis targeting group A streptococcus and oral anaerobes 1
• The most common organisms isolated are Streptococcus pyogenes and Staphylococcus aureus, with anaerobes (particularly Bacteroides species) frequently present 3, 4
• Recommended antibiotic regimen: Penicillin plus metronidazole to cover both aerobic streptococci and anaerobes 3
• Alternative consideration: If Staphylococcus aureus is suspected (all isolates in one study were penicillin-resistant), add cloxacillin or use broader coverage with ciprofloxacin or ceftazidime 4
• Mixed aerobic-anaerobic flora is present in approximately 50% of cases, making anaerobic coverage essential 3

Supportive Care Components

Adjunctive Measures

• Provide adequate hydration, as volume depletion is common from fever, poor oral intake, and tachypnea 5
• Administer intravenous steroids as adjunctive therapy, which reduces symptoms when combined with abscess drainage 6
• Ensure effective pain control to facilitate oral intake and recovery 7

Outpatient versus Inpatient Management

• Most patients can be managed as outpatients with the combination of drainage, antibiotics, steroids, and pain control 7
• Only 4.1% of patients in one outpatient protocol required subsequent intervention 7
• Admit patients with: severe systemic symptoms, inability to maintain hydration, or signs of sepsis 5

Follow-up and Definitive Treatment

Monitoring for Recurrence

• Recurrence rates are higher with needle aspiration alone (approximately 3-4 times higher than incision and drainage) 2
• Close clinical follow-up is essential, particularly in the first 48-72 hours 7

Tonsillectomy Consideration

• For patients with more than one peritonsillar abscess, recommend tonsillectomy as definitive treatment to prevent recurrence 1
• Quinsy tonsillectomy (immediate tonsillectomy) is an option but not routinely necessary for first-time presentations 6

Common Pitfalls to Avoid

• Do not rely on antibiotics alone without drainage - source control through drainage is essential for treatment success 5
• Do not assume penicillin alone is adequate - anaerobic coverage is necessary given the polymicrobial nature of these infections 3
• Do not overlook Staphylococcus aureus - all isolates may be penicillin-resistant, requiring anti-staphylococcal coverage 4
• Routine cultures are not necessary on initial presentation unless the patient fails to respond to empiric therapy 3