What is the appropriate management of a peritonsillar abscess?

Management of Peritonsillar Abscess

The appropriate management of peritonsillar abscess requires immediate drainage combined with antibiotics effective against group A streptococcus and oral anaerobes, with most patients managed as outpatients unless they have severe systemic symptoms, inability to maintain hydration, or signs of sepsis. 1

Immediate Treatment Priorities

Source Control Through Drainage

• Drainage is essential for treatment success and antibiotics alone without drainage should not be relied upon 1
• Drainage can be accomplished through needle aspiration, incision and drainage, or quinsy tonsillectomy—all yield successful results 2
• Needle aspiration can be performed in the outpatient setting without general anesthesia in most cases, including children 3

Antibiotic Therapy

• Initiate empiric antibiotics immediately once diagnosis is made, targeting group A streptococcus and oral anaerobes 1, 4
• Common organisms include Streptococcus pyogenes (most common), Staphylococcus aureus, and anaerobes 5, 3
• Avoid potentially nephrotoxic antibiotics like aminoglycosides 1
• Consider that Staphylococcus aureus is often resistant to penicillin, while Streptococcus pyogenes remains sensitive 5

Supportive Care

• Provide adequate hydration, as volume depletion is common from fever, poor oral intake, and tachypnea 1
• Use ibuprofen, acetaminophen, or both for adequate pain control, which is essential for maintaining oral intake and hydration 1

Adjunctive Corticosteroid Therapy

• A single high-dose intravenous steroid in addition to antibiotics and drainage significantly reduces symptoms including fever, throat pain, dysphagia, and trismus compared to antibiotics alone 6
• Steroids may help speed recovery and reduce hospital stay 2, 6

Disposition Decision-Making

Outpatient Management (Most Patients)

• Most patients can be managed as outpatients with the combination of drainage, antibiotics, steroids, and pain control 1
• Ensure adequate pain control to maintain oral intake 1, 4

Inpatient Management Indications

• Severe systemic symptoms 1
• Inability to maintain hydration 1
• Signs of sepsis 1
• Concern for airway compromise 4

Follow-Up and Definitive Management

Recurrence Prevention

• After discharge, patients should continue oral antibiotics (resistant to beta-lactamase) for more than 10 days 3
• Close follow-up is recommended, particularly in the first months after the initial episode, as recurrence rates can reach 15-16% 3

Tonsillectomy Considerations

• For patients with a history of more than one peritonsillar abscess, tonsillectomy should be considered as definitive treatment 1
• This represents a modifying factor that favors tonsillectomy even if Paradise criteria for recurrent tonsillitis are not met 1
• Peritonsillar abscess alone is no longer considered a strong indication for tonsillectomy due to relatively low recurrence rates 3

Common Pitfalls to Avoid

• Do not rely on antibiotics alone without drainage—source control is essential 1
• Do not discharge patients without ensuring adequate pain control and ability to maintain oral hydration 1, 4
• Do not use short antibiotic courses—extend oral therapy beyond 10 days to prevent persistent infection masquerading as recurrence 3
• Recognize that some "recurrences" within the first month may actually represent persistent infection requiring longer antibiotic therapy 3
• Be vigilant for potentially serious complications including airway obstruction, aspiration, or extension into deep neck tissues 4