What is the treatment for a tonsillar abscess?

Treatment of Tonsillar (Peritonsillar) Abscess

The treatment of peritonsillar abscess requires drainage (needle aspiration, incision and drainage, or immediate tonsillectomy), antibiotics effective against Group A streptococcus and oral anaerobes, and supportive care for hydration and pain control. 1, 2

Immediate Management

Drainage Procedures

• Drainage is essential and should be performed promptly to relieve symptoms and prevent complications such as airway obstruction or extension into deep neck tissues 2, 3
• Needle aspiration or incision and drainage are the preferred initial drainage methods for most peritonsillar abscesses 3
• Immediate tonsillectomy under general anesthesia is a safe and effective alternative that provides complete drainage, dramatic symptom relief within days, and avoids a second procedure 4, 5
• Immediate tonsillectomy should be strongly considered as it shortens total hospitalization time and eliminates the need for a second convalescent period 5

Antibiotic Therapy

• First-line antibiotics must be effective against Group A streptococcus and oral anaerobes 1, 2
• Clindamycin is recommended for aggressive initial management, particularly in children with asthma due to increased risk of complications 1
• Amoxicillin-clavulanate (80 mg/kg/day in three doses, maximum 3 g/day) can be considered for outpatient management, though it provides suboptimal anaerobic coverage 1
• Duration of antibiotic therapy is typically 7-10 days, adjusted based on clinical response 1
• The high incidence of anaerobes in these infections underscores the importance of adequate drainage and appropriate antibiotic coverage 4

Supportive Care

• Maintain adequate hydration 2
• Provide pain control 2
• Corticosteroids (single intraoperative dose of dexamethasone) may reduce symptoms and speed recovery 6, 3

Inpatient vs. Outpatient Management

• Most patients can be managed in the outpatient setting 2
• Patients with signs of systemic toxicity or severe symptoms should be considered for inpatient management 7

Surgical Considerations for Tonsillectomy

Indications for Interval or Immediate Tonsillectomy

• Tonsillectomy should be considered in patients with a history of more than one peritonsillar abscess, even if they don't meet standard frequency criteria for recurrent throat infections 1, 7
• Consider tonsillectomy in patients whose symptomatic episodes do not diminish in frequency over time 7

Important Caveat

• If the patient proceeds to tonsillectomy, perioperative antibiotics should NOT be prescribed, as this is strongly recommended against by the American Academy of Otolaryngology-Head and Neck Surgery 1

Diagnostic Considerations

• Diagnosis is typically made clinically based on fever, sore throat, dysphagia, trismus, and "hot potato" voice 2
• Ultrasonography can verify the presence of an abscess in approximately 90% of cases when clinical examination is insufficient due to trismus or lack of cooperation 8
• CT scan can confirm deep neck abscesses but has accuracy limitations 3

Common Pitfalls

• Failing to provide adequate drainage—medical therapy alone may be insufficient for true abscess formation 3
• Using antibiotics without anaerobic coverage, given the polymicrobial nature of these infections 2, 4
• Delaying treatment, which increases risk of serious complications including airway obstruction and deep neck space extension 2