What is the treatment for a throat abscess?

Treatment of Throat Abscess

Throat abscesses require immediate drainage combined with antibiotic therapy—drainage is essential and antibiotics alone are insufficient for treatment success. 1

Immediate Management

Source Control (Drainage)

• Drainage is the cornerstone of treatment and must be performed promptly—antibiotics without drainage should not be relied upon 1
• Three accepted drainage methods exist for peritonsillar abscess: needle aspiration, incision and drainage, or immediate tonsillectomy (quinsy tonsillectomy) 2, 3
• Immediate tonsillectomy provides definitive treatment by draining the abscess, eliminating occult inferior pole or contralateral abscesses, and preventing future recurrence 4, 5
• For parapharyngeal abscesses associated with peritonsillar abscess, initial transoral aspiration should be performed for evacuation and bacteriologic examination 6

Antibiotic Therapy

• Empiric antibiotics effective against group A streptococcus AND oral anaerobes must be initiated immediately upon diagnosis 1, 2
• Intravenous amoxicillin-clavulanic acid is recommended as first-line therapy 6
• For penicillin-allergic patients, clindamycin is recommended (not macrolides) due to the high frequency of Fusobacterium necrophorum, which is recovered from 23-58% of peritonsillar abscesses 3
• Duration: 5-7 days of intravenous antibiotics 6

Supportive Care

• Adequate hydration is essential as volume depletion is common from fever, poor oral intake, and tachypnea 1
• Pain control with ibuprofen, acetaminophen, or both is critical for maintaining oral intake and hydration 1
• Corticosteroids combined with antibiotics may reduce symptoms and speed recovery 2, 6

Disposition Decision Algorithm

Outpatient Management (Most Patients)

Most patients can be managed as outpatients with drainage, antibiotics, steroids, and pain control 1, 2

Inpatient Management Required If:

• Severe systemic symptoms present 1
• Inability to maintain hydration 1
• Signs of sepsis 1
• Concern for deeper or necrotizing infection 7
• Poor adherence to therapy anticipated 7
• Severely immunocompromised patient 7

Special Considerations

Recurrent Abscesses

For patients with a history of more than one peritonsillar abscess, tonsillectomy should be performed as definitive treatment 7, 1

Parapharyngeal Extension

• 52% of parapharyngeal abscesses have concomitant peritonsillar abscess—combined tonsillectomy and intrapharyngeal incision is recommended when peritonsillar abscess is present or suspected 3
• Non-complicated parapharyngeal abscesses require first-line medical management with IV antibiotics and steroids, with follow-up CT scan 6
• Surgical drainage via cervical incision or immediate tonsillectomy is indicated for complicated cases 6

Bacteriology Considerations

• Fusobacterium necrophorum is the most prevalent pathogen (23-58% of cases) and is associated with significantly higher inflammatory markers than other bacteria 3
• Group A streptococcus is recovered in only ~20% of cases 3
• Cultures should include selective F. necrophorum agar plates 3
• Blood cultures should be obtained as bacteremia occurs in 22% of cases 3

Critical Pitfalls to Avoid

• Never rely on antibiotics alone without drainage—this approach fails to achieve source control 1
• Do not use macrolides in penicillin-allergic patients—use clindamycin instead due to F. necrophorum prevalence 3
• Do not miss concomitant parapharyngeal abscess—maintain high index of suspicion given 52% co-occurrence rate 3
• Watch for life-threatening complications: airway obstruction, aspiration, Lemierre syndrome (septic thrombophlebitis of internal jugular vein), necrotizing fasciitis, mediastinitis 2, 3
• Patients with progressive sore throat despite antibiotics should raise suspicion for abscess formation 4