Do all peritonsillar abscesses require drainage?

Do All Peritonsillar Abscesses Require Drainage?

Yes, drainage is the cornerstone of treatment for peritonsillar abscess and should be performed in virtually all cases, with needle aspiration being the gold standard approach. 1

Primary Treatment Approach

Drainage combined with antibiotic therapy and supportive care are the essential components of peritonsillar abscess management. 2 The infection will not resolve with antibiotics alone in most cases, and an undrained abscess can expand into adjacent spaces and progress to life-threatening complications including airway obstruction, aspiration, or extension into deep neck tissues. 2

Drainage Method Selection

• Needle aspiration is the gold standard for both diagnosis and treatment of peritonsillar abscess 1
• Needle aspiration can be performed in the outpatient setting by appropriately trained family physicians 2
• Incision and drainage is an alternative approach, though evidence comparing the two methods shows conflicting results 3

Evidence on Drainage Necessity

The available research consistently supports drainage as mandatory treatment:

• A Cochrane review found very low-quality evidence suggesting incision and drainage may have lower recurrence rates (RR 3.74,95% CI 1.63-8.59) compared to needle aspiration, though needle aspiration appears less painful 3
• Three-point puncture and aspiration has shown success rates comparable to incision and drainage, with recurrence rates around 19% 4
• Catheter or needle drainage is specifically identified as the drainage method of choice for peritonsillar abscesses 5

Clinical Decision-Making Algorithm

All patients with confirmed peritonsillar abscess should undergo drainage. The specific approach depends on:

1. First-line approach: Needle aspiration in the outpatient setting for most patients 1
2. Consider incision and drainage if:
   • Needle aspiration fails 1
   • Multiple recurrences occur 4
   • Patient has history of recurrent tonsillitis with mixed aerobic/anaerobic flora (not Streptococcus pyogenes) 4
3. Consider immediate tonsillectomy in advanced cases or selected patients with recurrent disease 5, 1

Adjunctive Therapy

After drainage is performed:

• Initiate antibiotics effective against group A streptococcus and oral anaerobes (penicillin, clindamycin, cephalosporins, or metronidazole) 2, 1
• Corticosteroids may reduce symptoms and speed recovery 2
• Provide supportive care for hydration and pain control 2

Important Caveat

Testing for Streptococcus pyogenes in the aspirate may guide prognosis: presence of this organism is associated with favorable outcomes with puncture and antibiotics, while mixed aerobic/anaerobic flora without S. pyogenes may warrant more aggressive surgical intervention. 4