What is the treatment for tonsillitis versus peritonsillar abscess?

Treatment of Tonsillitis vs Peritonsillar Abscess

Tonsillitis requires antibiotics targeting Group A streptococcus with consideration for tonsillectomy only in specific circumstances, while peritonsillar abscess demands immediate drainage (needle aspiration or incision) plus antibiotics covering both streptococcus and anaerobes, with tonsillectomy strongly favored after more than one episode. 1, 2

Acute Tonsillitis Management

Medical Treatment

• Antibiotic therapy should target Group A streptococcus as the primary pathogen 2
• Treatment duration is typically 7-10 days, adjusted based on clinical response 2
• Monitor for development of complications including peritonsillar abscess, which occurs at higher rates (3.7%) in patients with recurrent acute tonsillitis 3

Surgical Considerations for Tonsillitis

• Tonsillectomy is NOT routinely indicated for uncomplicated tonsillitis 3
• Consider tonsillectomy only when modifying factors are present, including: 3
  • Multiple antibiotic allergies/intolerance
  • PFAPA syndrome (periodic fever, aphthous stomatitis, pharyngitis, adenitis)
  • History of >1 peritonsillar abscess
• Even when meeting strict Paradise criteria for recurrent infections, benefits of tonsillectomy are modest and time-limited, with natural resolution occurring in many cases during watchful waiting 3

Peritonsillar Abscess Management

Immediate Treatment Algorithm

1. Drainage is mandatory - perform needle aspiration or incision and drainage 1, 4

   • Abscess tonsillectomy (immediate tonsillectomy) is safe and effective, providing definitive treatment with immediate relief of trismus and dysphagia 4
   • If needle aspiration fails to achieve clinical improvement, proceed to abscess tonsillectomy 4

2. Antibiotic therapy must cover both Group A streptococcus AND anaerobes 1, 2

   • Clindamycin is recommended, particularly in children with asthma due to increased complication risk 2
   • Amoxicillin-clavulanate (80 mg/kg/day in three doses, maximum 3 g/day) is an alternative for outpatient management, though anaerobic coverage may be suboptimal 2
   • Duration: 7-10 days based on clinical response 2

Critical Monitoring

• Watch for life-threatening complications: airway obstruction, aspiration, or extension into deep neck tissues causing descending mediastinitis 1, 5
• Peritonsillar abscess can progress to septic multi-organ failure despite aggressive treatment 5
• Drooling, neck tenderness, or swelling indicate potential spread requiring urgent intervention 1

Definitive Surgical Management

• Tonsillectomy is strongly recommended for patients with history of >1 peritonsillar abscess, even if they don't meet standard frequency criteria for recurrent infections 3, 1, 2
• This represents a modifying factor that shifts the risk-benefit balance toward surgery 3
• The recurrence rate is highest in peritonsillar abscess patients (5.4%) compared to other indications 3

Important Caveat

• Do NOT prescribe perioperative antibiotics if the patient proceeds to tonsillectomy - this is strongly recommended against by current guidelines 2

Key Diagnostic Distinction

Clinical differentiation matters: Peritonsillitis (cellulitis without abscess formation) requires only antibiotics, while true peritonsillar abscess requires drainage 6. Ultrasound can enhance diagnostic accuracy (91% sensitivity, 80% specificity) and reduce unnecessary surgical drainage 6.

Special Populations

• Atypical presentations (elderly patients without history of recurrent tonsillitis) should raise suspicion for underlying malignancy, including lymphoma or squamous cell carcinoma 7
• Inadequate initial antibiotic treatment of streptococcal tonsillitis can lead to both suppurative (peritonsillar abscess) and post-infectious complications (reactive arthritis) 8