Treatment of Peritonsillar Abscess
The primary treatment for peritonsillar abscess is drainage (via needle aspiration, incision and drainage, or immediate abscess tonsillectomy) combined with antibiotics effective against Group A streptococcus and oral anaerobes. 1, 2
Drainage Procedures
Drainage is the cornerstone of treatment and must be performed promptly to prevent complications such as airway obstruction or deep neck space extension. 2
Drainage Options:
- Needle aspiration is effective as initial outpatient treatment in 85-90% of uncomplicated cases 3
- Incision and drainage is appropriate for larger abscesses or failed aspiration 2
- Immediate abscess tonsillectomy is safe, effective, and removes the abscess completely while improving trismus and dysphagia 4, 5
When to Consider Immediate Tonsillectomy:
- Recurrent peritonsillar abscess (more than one episode) warrants consideration for tonsillectomy, even without meeting standard frequency criteria for recurrent throat infections 1
- Failed response to aspiration or incision and drainage 4
Antibiotic Therapy
First-Line Antibiotics:
Antibiotics must cover Group A streptococcus and oral anaerobes as peritonsillar abscesses are polymicrobial infections. 1, 2
Specific Regimens:
For patients requiring parenteral therapy:
- Intravenous penicillin remains an excellent first-line choice after drainage, with efficacy equivalent to broad-spectrum antibiotics 6
- Broad-spectrum coverage (e.g., ampicillin-sulbactam) can be considered but shows no superior outcomes compared to penicillin alone 6
For outpatient oral therapy:
- Amoxicillin-clavulanate 80 mg/kg/day in three divided doses (maximum 3 g/day), though it may not provide optimal anaerobic coverage 1
- Clindamycin is the drug of choice for patients with severe penicillin hypersensitivity, as it provides necessary anaerobic coverage without cross-reactivity 1
- Clindamycin is particularly recommended for children with peritonsillar abscess and asthma history due to increased complication risk 1
Duration:
- 7-10 days of antibiotic therapy, adjusted based on clinical response 1
Critical Caveat:
Do NOT prescribe perioperative antibiotics if the patient proceeds to tonsillectomy - this is strongly recommended against by the American Academy of Otolaryngology-Head and Neck Surgery. 1
Supportive Care
- Maintain hydration 2
- Provide adequate pain control 2
- Corticosteroids may reduce symptoms and speed recovery 2
Outpatient vs. Inpatient Management
Most patients can be managed in the outpatient setting with needle aspiration, oral antibiotics, and supportive care. 2, 3 Hospitalization is reserved for patients with:
- Airway compromise
- Inability to maintain oral hydration
- Failed outpatient management
- Severe systemic toxicity 2