What is the management and treatment approach for a patient with a peritonsillar abscess?

Management of Peritonsillar Abscess

Peritonsillar abscess requires immediate drainage combined with antibiotics effective against group A streptococcus and oral anaerobes—antibiotics alone without drainage should not be relied upon. 1

Immediate Treatment Approach

Source Control (Drainage)

• Drainage is essential for treatment success and must be performed promptly 1
• Two primary drainage options exist:
  • Needle aspiration: Less invasive, may be associated with lower procedural pain 2
  • Incision and drainage: May have lower recurrence rates (RR 0.27,95% CI 0.12-0.61 favoring incision and drainage) 2
• The choice between needle aspiration versus incision and drainage remains debated, though very low-quality evidence suggests incision and drainage may reduce recurrence 2
• Family physicians with appropriate training can perform drainage procedures 3

Antibiotic Therapy

• Initiate empiric antibiotics immediately upon diagnosis, targeting group A streptococcus and oral anaerobes 1, 3
• First-line regimen: Amoxicillin-clavulanic acid is recommended as it covers both aerobic and anaerobic pathogens 4, 5
• Alternative regimen: Penicillin plus metronidazole for anaerobic coverage 5
• Avoid aminoglycosides due to nephrotoxicity risk 1
• If initial treatment fails, consider clindamycin for broader anaerobic coverage 5
• Duration: Typically 3-5 days after adequate source control, though specific duration for peritonsillar abscess is not explicitly stated in guidelines 6

Supportive Care

• Provide adequate hydration, as volume depletion is common from fever, poor oral intake, and tachypnea 1
• Pain control with ibuprofen, acetaminophen, or both is essential for maintaining oral intake and hydration 1
• Corticosteroids may help reduce symptoms and speed recovery 3

Disposition Decision

Outpatient Management (Most Patients)

• Most patients can be managed as outpatients with drainage, antibiotics, steroids, and pain control 1
• Ensure patient can maintain oral hydration 4
• Arrange follow-up within 24 hours 4

Inpatient Management (Selected Patients)

• Admit patients with:
  • Severe systemic symptoms 1
  • Inability to maintain hydration 1
  • Signs of sepsis 1
  • Airway compromise concerns 3

Long-Term Considerations

Tonsillectomy Indications

• For patients with history of more than one peritonsillar abscess, tonsillectomy should be considered as definitive treatment 1
• This represents a modifying factor favoring tonsillectomy even if Paradise criteria for recurrent tonsillitis are not met 1
• Note: Unilateral tonsillectomy carries 14% risk of contralateral streptococcal tonsillitis and 7% risk of contralateral peritonsillar complications 1

Common Pitfalls to Avoid

• Do not rely on antibiotics alone without drainage—source control is mandatory 1
• Avoid using penicillin V alone, as Staphylococcus aureus (commonly isolated) is resistant to it 7
• Do not delay treatment, as complications include airway obstruction, aspiration, or deep neck space infection 3
• Ensure adequate anaerobic coverage, as anaerobes play an important role in pathogenesis 5
• Monitor for treatment failure requiring repeat intervention, which occurs more frequently with needle aspiration 2