What is the treatment for a tonsillar abscess?

Treatment of Tonsillar (Peritonsillar) Abscess

The treatment of peritonsillar abscess requires drainage (needle aspiration as first-line), antibiotics effective against Group A streptococcus and oral anaerobes, and supportive care, with most patients managed in the outpatient setting. 1, 2

Immediate Management

Drainage Procedures

• Needle aspiration is the gold standard for both diagnosis and treatment of peritonsillar abscess 3
• Incision and drainage may be required in advanced cases where needle aspiration is inadequate 3
• Drainage combined with antibiotic therapy and hydration are the cornerstones of treatment 2, 4

Antibiotic Selection

• First-line antibiotics must be effective against Group A streptococcus and oral anaerobes 1, 2
• Appropriate antibiotic options include:
  • Penicillin (covers streptococcus) 3
  • Clindamycin (provides excellent anaerobic coverage and is recommended for children with asthma due to increased complication risk) 1
  • Amoxicillin-clavulanate (80 mg/kg/day in three doses, maximum 3 g/day for outpatient management, though anaerobic coverage may not be optimal) 1
  • Cephalosporins or metronidazole as alternatives 3
• Duration: 7-10 days, adjusted based on clinical response 1

Adjunctive Therapy

• Corticosteroids may reduce symptoms and speed recovery 4
• Supportive therapy for hydration and pain control is essential 2

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 5
• Key symptoms warranting closer monitoring include: fever, severe throat pain, dysphagia, trismus, and "hot potato" voice 2

Surgical Considerations: Tonsillectomy

Immediate Tonsillectomy

• Immediate tonsillectomy under general anesthesia can be performed safely and provides dramatic symptom relief within days 6
• This approach ensures adequate drainage, which is critical given the high incidence of anaerobes 6
• May be required in advanced cases not responding to needle aspiration 3
• If proceeding to tonsillectomy, do NOT prescribe perioperative antibiotics (strongly recommended against by the American Academy of Otolaryngology-Head and Neck Surgery) 1

Interval/Elective Tonsillectomy

• Consider tonsillectomy 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, 5
• May be considered for patients whose symptomatic episodes do not diminish in frequency over time 5

Important Clinical Pitfalls

Atypical Presentations

• In patients without history of recurrent tonsillitis, especially older adults, consider malignant etiology (squamous cell carcinoma or lymphoma) 7
• If tonsillar hypertrophy persists after treatment, tonsillectomy with histologic examination should be performed for early diagnosis 7

Complications to Monitor

• Airway obstruction 2
• Aspiration 2
• Extension of infection into deep neck tissues 2
• Prompt recognition and treatment initiation are critical to avoid these potentially serious complications 2

Diagnostic Confirmation

• Clinical diagnosis is usually sufficient based on fever, sore throat, dysphagia, trismus, and "hot potato" voice 2
• Ultrasonography and CT scanning are useful for confirming diagnosis in uncertain cases 3