What is the recommended management for a peritonsillar abscess?

Management of Peritonsillar Abscess

Peritonsillar abscess requires immediate drainage combined with antibiotics—antibiotics alone without drainage should not be relied upon for treatment success. 1

Immediate Management Priorities

Source Control Through Drainage

• Drainage is essential and must be performed promptly as the cornerstone of treatment, with antibiotics serving as adjunctive therapy rather than standalone treatment 1, 2
• Needle aspiration remains the gold standard for both diagnosis and treatment of peritonsillar abscess 3
• Alternative drainage methods include incision and drainage or quinsy tonsillectomy, all of which yield successful results with no single technique consistently superior 4
• Family physicians with appropriate training can diagnose and treat most patients with peritonsillar abscess in the outpatient or emergency department setting 2

Hydration Management

• Provide adequate hydration immediately, as volume depletion is common from fever, poor oral intake, and tachypnea 1
• Maintaining hydration is a cornerstone of supportive therapy alongside drainage and antibiotics 2

Antibiotic Therapy

Empiric Coverage

• Initiate empiric antibiotics immediately once diagnosis is made, targeting group A streptococcus and oral anaerobes 1, 2
• First-line antibiotic options include penicillin, clindamycin, cephalosporins, or metronidazole 3
• The infection is polymicrobial in nature, requiring coverage of both aerobic and anaerobic bacteria 2, 3

Important Microbiological Considerations

• Streptococcus pyogenes and Staphylococcus aureus are the most commonly isolated organisms 5
• Critical caveat: While Streptococcus pyogenes remains sensitive to penicillin, Staphylococcus aureus shows resistance to penicillin, necessitating consideration of cloxacillin, ciprofloxacin, or ceftazidime for broader coverage 5
• Other organisms may include Haemophilus influenzae, Pseudomonas aeruginosa, Escherichia coli, and Enterococcus species 5

Adjunctive Corticosteroid Therapy

• A single high-dose intravenous steroid should be administered in addition to antibiotics and drainage to reduce symptoms and speed recovery 1, 6
• Steroids significantly reduce fever, throat pain, dysphagia, trismus, and hospitalization time compared to antibiotics alone (p < 0.01) 6
• This represents a statistically significant improvement in clinical outcomes when steroids are used prior to antibiotic therapy 6
• Multiple studies confirm that corticosteroids are helpful in reducing symptoms and accelerating recovery 2, 4

Disposition Decision-Making

Outpatient Management Criteria

• Most patients can be managed as outpatients with the combination of drainage, antibiotics, steroids, and pain control 1
• Patients suitable for outpatient management are those without severe systemic symptoms, able to maintain hydration, and without signs of sepsis 1

Inpatient Admission Criteria

• Admit patients with severe systemic symptoms 1
• Admit patients with inability to maintain hydration 1
• Admit patients with signs of sepsis 1
• Hospitalization allows rigorous assessment of clinical course and response to therapy 6

Definitive Management for Recurrent Disease

• For patients with a history of more than one peritonsillar abscess, tonsillectomy should be considered as definitive treatment 1
• This prevents future recurrences in patients with repeated episodes 1

Critical Complications to Avoid

• Promptly recognizing the infection and initiating therapy prevents potentially serious complications including airway obstruction, aspiration, or extension of infection into deep neck tissues 2
• In advanced cases where initial management fails, incision and drainage or immediate tonsillectomy may be required 3