What is the treatment for draining a palatine tonsillar abscess?

Treatment of Palatine Tonsillar (Peritonsillar) Abscess

Incision and drainage is the preferred initial treatment for peritonsillar abscess, as it provides more definitive drainage with lower recurrence rates compared to needle aspiration alone. 1, 2

Primary Treatment Approach

Immediate surgical drainage is the cornerstone of treatment, with the specific technique depending on clinical factors and local expertise:

Incision and Drainage (Preferred Method)

• Provides superior outcomes with significantly lower recurrence rates (10% repetition rate) compared to needle aspiration (46.3% repetition rate) 2
• Reduces hospital length of stay (median 2 days vs 3 days for needle aspiration) 2
• Decreases need for repeat procedures under general anesthesia (4% vs 14% for needle aspiration) 2
• Can be performed under local anesthesia in most cases 2

Needle Aspiration (Alternative)

• May be considered as initial treatment, particularly for diagnostic purposes or in select patients 3, 1
• Associated with higher recurrence risk (RR 3.74,95% CI 1.63-8.59) compared to incision and drainage 1
• May cause less procedural pain than incision and drainage 1
• Best reserved for patients with favorable prognostic factors, particularly when Streptococcus pyogenes is isolated 3

Timing and Setting

• Perform drainage promptly once diagnosis is established 4
• Most procedures can be done under local anesthesia in the outpatient or emergency department setting 5, 2
• Patients with systemic signs of sepsis, severe sepsis, immunosuppression, or diabetes require emergent drainage 4

Immediate (Abscess) Tonsillectomy

Consider immediate tonsillectomy as a definitive treatment option, particularly in specific clinical scenarios:

• Highly effective and safe with low complication rates (3.6% postoperative bleeding) 6

• Advantages include: complete removal of infection source, resolution of trismus and dysphagia, and prevention of recurrence 5, 6

• Particularly indicated when:

  • Mixed aerobic/anaerobic flora (not S. pyogenes) is present 3
  • History of recurrent tonsillitis exists 3
  • Needle aspiration or incision drainage fails 5, 6
  • Contralateral tonsil pathology is present 6

• Unilateral tonsillectomy carries risks: 14.2% developed contralateral streptococcal tonsillitis and 7.1% required readmission for contralateral peritonsillar complications 6

Adjunctive Antibiotic Therapy

• Broad-spectrum antibiotics covering Gram-positive, Gram-negative, and anaerobic bacteria should be administered alongside drainage 4
• Most common organisms are Streptococcus pyogenes, other streptococci, Bacteroides spp., and Fusobacterium nucleatum 6

Common Pitfalls to Avoid

• Inadequate drainage is a major risk factor for recurrence—ensure complete evacuation of purulent material 4
• Needle aspiration alone may be insufficient in many cases, leading to treatment failure and need for repeat intervention 1, 2
• Delaying drainage in patients with systemic signs can lead to progression and complications 4
• Performing unilateral tonsillectomy may leave patients at risk for contralateral complications 6

Post-Drainage Management

• No specific recommendation exists for wound packing after drainage based on available evidence 4
• Monitor for complications including bleeding, recurrence, and need for additional intervention 6, 1
• Hospital admission duration typically ranges 2-4 days depending on clinical response 2