Treatment 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 Protocol
The cornerstone of treatment involves three simultaneous interventions:
- Drainage is essential and must be performed as source control; antibiotics without drainage are inadequate 1
- Empiric antibiotic therapy should target group A streptococcus and oral anaerobes, initiated immediately upon diagnosis 1, 2
- Adequate hydration is critical, as volume depletion commonly occurs from fever, poor oral intake, and tachypnea 1
Drainage Options
All three surgical approaches yield successful results, and the choice depends on provider experience and patient factors:
- Needle aspiration, incision and drainage, or quinsy tonsillectomy all demonstrate consistently good outcomes 3
- No single drainage technique has been established as consistently superior 3
- Family physicians with appropriate training can diagnose and treat most patients 2
Antibiotic Selection
First-line antibiotics must cover group A streptococcus and oral anaerobes 1, 2:
- Clindamycin is an excellent choice given its anaerobic and streptococcal coverage 4
- For adults: 300-450 mg every 6 hours for severe infections 4
- For pediatric patients able to swallow capsules: 16-20 mg/kg/day divided into 3-4 doses for severe infections 4
- Treatment should continue for at least 10 days in streptococcal infections 4
Adjunctive Steroid Therapy
A single high-dose intravenous steroid significantly improves symptoms and speeds recovery:
- Steroids reduce fever, throat pain, dysphagia, and trismus more effectively than antibiotics alone 5
- Single-dose IV dexamethasone or equivalent should be administered 3, 5
- This intervention shows statistically significant improvement in clinical outcomes (p < 0.01) 5
Pain Management
- Adequate pain control is essential for maintaining oral intake and hydration 1, 6
- Ibuprofen, acetaminophen, or both should be used 7
- Good pain control is a critical component of the outpatient medical protocol 6
Disposition Decision
Most patients can be managed as outpatients with the combination of drainage, antibiotics, steroids, and pain control 1, 6:
- An outpatient medical protocol (hydration, antibiotics, steroids, pain control) shows only 4.1% treatment failure requiring subsequent drainage 6
- Admit patients with: severe systemic symptoms, inability to maintain hydration, or signs of sepsis 1
- Patients with airway compromise or extension into deep neck tissues require immediate hospitalization 2
Medical Management Alone Consideration
Recent evidence suggests medical intervention alone may be viable in highly selected cases:
- Meta-analysis shows no statistically significant difference in treatment failure between medical management alone (5.7%) versus surgical drainage (5.5%) 8
- However, this contradicts guideline recommendations that drainage is essential 1
- Given the low risk of drainage procedures and guideline emphasis on source control, drainage should remain standard practice rather than relying on antibiotics alone 1
Tonsillectomy Considerations
For patients with history of more than one peritonsillar abscess, tonsillectomy should be considered as definitive treatment 1:
- This represents a modifying factor that favors tonsillectomy even if Paradise criteria for recurrent tonsillitis are not met 7
- A single peritonsillar abscess does not mandate tonsillectomy, but recurrence changes the risk-benefit calculation 7
Common Pitfalls to Avoid
- Never rely on antibiotics alone without drainage—source control is essential for treatment success 1
- Do not underestimate hydration needs; volume depletion is common and must be addressed aggressively 1
- Failure to use steroids misses an opportunity for significant symptom improvement 5
- Missing signs of airway compromise or deep space extension can lead to life-threatening complications 2