Treatment of Peritonsillar Abscess
Peritonsillar abscess requires immediate drainage combined with antibiotics—drainage is essential and antibiotics alone are insufficient for treatment success. 1
Immediate Management
The cornerstone of treatment involves three simultaneous interventions:
Drainage is mandatory for source control and antibiotics alone should not be relied upon for treatment 1. Needle aspiration remains the gold standard for both diagnosis and treatment 2, with success rates of 85% when combined with oral antibiotics 3.
Initiate empiric antibiotics immediately upon diagnosis, targeting group A streptococcus and oral anaerobes 1, 4. First-line options include penicillin (effective against Streptococcus pyogenes), though cloxacillin or clindamycin should be added for Staphylococcus aureus coverage, as all S. aureus isolates show penicillin resistance 5. Alternative regimens include cephalosporins, metronidazole, or ciprofloxacin 2, 5.
Provide adequate hydration as volume depletion is common from fever, poor oral intake, and tachypnea 1. Use ibuprofen, acetaminophen, or both for pain control, which is essential for maintaining oral intake 1.
Drainage Technique Selection
Needle aspiration is the preferred initial approach for most patients, avoiding hospitalization in 88% of cases and achieving resolution without further therapy in 85% 3.
Incision and drainage or immediate tonsillectomy may be required in advanced cases or when needle aspiration fails 2.
Disposition Decision
Most patients can be managed as outpatients with the combination of drainage, antibiotics, steroids, and pain control 1, 4.
Admit patients who have:
- Severe systemic symptoms or signs of sepsis 1
- Inability to maintain hydration 1
- Severe trismus preventing drainage 3
- Young age or noncooperation 3
Adjunctive Therapy
- Consider corticosteroids as they may reduce symptoms and speed recovery 4, 6. Intravenous steroids used alongside abscess drainage have been shown to reduce multiple symptoms in randomized controlled trials 6.
Follow-up and Definitive Management
Tonsillectomy should be considered for patients with a history of more than one peritonsillar abscess, as this represents definitive treatment even if Paradise criteria for recurrent tonsillitis are not met 1.
Follow-up periods of 4 months to 3 years show recurrence rates of only 12% with appropriate initial management 3.
Critical Pitfall
The most common error is attempting antibiotic therapy without drainage—this approach fails because source control through drainage is essential for treatment success 1. Promptly recognizing the infection and initiating combined therapy prevents potentially serious complications including airway obstruction, aspiration, or extension into deep neck tissues 4.