What is the treatment for a peritonsillar abscess?

Treatment of Peritonsillar Abscess

Peritonsillar abscess requires immediate drainage combined with antibiotics targeting group A streptococcus and oral anaerobes—antibiotics alone without drainage should not be relied upon. 1

Immediate Management Algorithm

Step 1: Stabilization and Supportive Care

• Provide adequate hydration as volume depletion is common from fever, poor oral intake, and tachypnea 1
• Administer pain control with ibuprofen, acetaminophen, or both, which is essential for maintaining oral intake and hydration 1
• Monitor for airway obstruction, aspiration, or extension into deep neck tissues as these are potentially serious complications 2, 3

Step 2: Source Control Through Drainage

Drainage is essential for treatment success and must be performed—this is the cornerstone of management alongside antibiotics 1. Multiple drainage techniques are effective:

• Needle aspiration, incision and drainage, or immediate tonsillectomy all yield successful results 4
• The choice depends on provider experience, patient factors, and clinical setting 3
• Immediate tonsillectomy provides complete drainage, dramatic symptom relief within days, and avoids a second procedure if tonsillectomy is ultimately indicated 5, 6

Step 3: Antibiotic Therapy

Initiate empiric antibiotics immediately once diagnosis is made 1:

• Antibiotics must be effective against group A streptococcus and oral anaerobes 1, 2, 3
• The most frequently isolated organisms are gram-positive bacteria (Streptococcus pyogenes) and anaerobes (Bacteroides spp. and Fusobacterium nucleatum) 6

Step 4: Adjunctive Corticosteroid Therapy

• Corticosteroids may reduce symptoms and speed recovery when used alongside drainage 3, 4

Disposition Decision

Outpatient Management (Most Patients)

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

Inpatient Admission Required For:

• Severe systemic symptoms 1
• Inability to maintain hydration 1
• Signs of sepsis 1

Definitive Treatment Considerations

For patients with a history of more than one peritonsillar abscess, tonsillectomy should be considered as definitive treatment 1, 2. This represents a modifying factor that favors tonsillectomy even if Paradise criteria for recurrent tonsillitis are not met 1.

Immediate Tonsillectomy Advantages:

• Safe procedure with minimal complications (3.6% postoperative bleeding rate, no anesthetic complications in large series) 6, 7
• Provides complete drainage and prompt symptom relief 5
• Shortens total hospitalization time and avoids second convalescent period 7
• Mean hospital stay of 3.4 days with only 29% requiring morphine pump analgesia 6

Important Caveat for Unilateral Tonsillectomy:

If only unilateral tonsillectomy is performed, 14.2% may develop contralateral streptococcal tonsillitis and 7.1% may develop contralateral peritonsillar complications requiring readmission 6. This supports bilateral tonsillectomy when the surgical approach is chosen.

Bacteriology Considerations

High incidence of anaerobes suggests that sufficient drainage is required to treat this disease effectively 5. This reinforces why antibiotics alone are inadequate—the polymicrobial nature with anaerobic involvement necessitates physical drainage for treatment success 3.