What is the treatment approach for a patient with a peritonsillar abscess, considering potential complications and the need for prompt medical attention?

Treatment of Peritonsillar Abscess

Immediate drainage of the abscess combined with antibiotics effective against group A streptococcus and oral anaerobes is the definitive treatment for peritonsillar abscess, with most patients manageable in the outpatient setting. 1

Diagnosis and Initial Assessment

Clinical diagnosis is typically sufficient based on the characteristic presentation of severe pharyngalgia, trismus, odynophagia, fever, "hot potato" voice, and unilateral peritonsillar swelling with uvular deviation 2, 1.

• Imaging is not routinely required for typical presentations 3, 1
• Consider imaging (CT or intraoral ultrasound) only for atypical presentations, suspected deep space extension, or diagnostic uncertainty 4
• Do not delay treatment waiting for imaging if clinical diagnosis is clear 3

Drainage Procedures: The Cornerstone of Treatment

Abscess drainage must be performed promptly - this is non-negotiable for successful treatment 3, 1. Three drainage options exist:

Needle Aspiration vs. Incision and Drainage

• Incision and drainage appears superior to needle aspiration with lower recurrence rates (RR 3.74 for needle aspiration recurrence, 95% CI 1.63-8.59) 5
• Needle aspiration may cause less procedural pain but has higher treatment failure rates 5, 4
• Both techniques yield successful results in experienced hands, and the choice depends on provider training and patient factors 4
• Incision and drainage should be preferred when feasible given the lower recurrence risk 5

Immediate Tonsillectomy (Quinsy Tonsillectomy)

• Reserved for specific indications: recurrent peritonsillar abscess, inability to adequately drain the abscess, or suspected malignancy 3, 4
• Not routinely recommended as first-line treatment 4

Antibiotic Therapy

Antibiotics must cover group A streptococcus and oral anaerobes as these are polymicrobial infections 1.

• Streptococcus species are the most common pathogens isolated 2
• Oral antibiotics are as effective as intravenous antibiotics in patients without complications or comorbidities 2
• Intravenous antibiotics are indicated for patients with systemic toxicity, inability to tolerate oral intake, immunocompromise, or significant comorbidities 2, 1

Adjunctive Corticosteroid Therapy

Consider adding corticosteroids to reduce symptoms and speed recovery 1, 4.

• Intravenous steroids have been shown to reduce multiple symptoms when combined with abscess drainage 4
• This represents beneficial adjunctive therapy, not a replacement for drainage 4

Supportive Care

• Pain control and hydration maintenance are essential 1
• Monitor for ability to maintain oral intake 1
• Dehydration requiring hospitalization can occur, particularly after incision and drainage 5

Outpatient vs. Inpatient Management

Most patients can be managed in the outpatient setting 3, 1.

Indications for Hospital Admission:

• Inability to maintain oral hydration 1
• Airway compromise or concern for airway obstruction 1
• Suspected deep neck space extension 1
• Immunocompromised state or significant comorbidities 2
• Failed outpatient management 1

Monitoring for Complications

Prompt recognition and treatment prevent serious complications 1.

Life-Threatening Complications to Monitor:

• Airway obstruction - the most immediately dangerous complication 1
• Deep neck space infection - extension into parapharyngeal, retropharyngeal, or mediastinal spaces 2, 1
• Aspiration 1
• Sepsis (rare but possible) 2

Complication Risk Factors:

• Over 10% of patients develop complications, most commonly extension into deep neck spaces 2
• Comorbid conditions significantly increase complication risk 2
• Delayed treatment increases risk of serious complications 3, 1

Follow-Up and Recurrence

• Close follow-up is essential to monitor treatment response 3
• Recurrence rates vary by drainage technique, with needle aspiration having higher rates 5
• Patients with recurrent peritonsillar abscess should be considered for interval tonsillectomy 3, 4

Common Pitfalls to Avoid

• Do not treat with antibiotics alone without drainage - this will fail 3, 1
• Do not delay drainage for imaging in typical presentations 3
• Do not discharge patients who cannot maintain oral hydration 1
• Do not miss signs of airway compromise or deep space extension - these require immediate escalation of care 1
• Do not assume intravenous antibiotics are always necessary - oral antibiotics work well in uncomplicated cases 2