What is the recommended treatment for a tonsil abscess in a teenager?

Treatment of Peritonsillar Abscess in Teenagers

A peritonsillar abscess in a teenager requires immediate drainage (either needle aspiration or incision and drainage) combined with antibiotics effective against Group A Streptococcus and oral anaerobes, with consideration for tonsillectomy based on recurrence history. 1

Immediate Management

Drainage Procedure

• Drainage is the cornerstone of treatment and should be performed promptly to avoid complications such as airway obstruction, aspiration, or extension into deep neck tissues 1
• Needle aspiration is typically attempted first as it may be less painful procedurally, though incision and drainage may have lower recurrence rates (RR 3.74 for needle aspiration recurrence compared to incision and drainage) 2
• In children who are cooperative, fine needle aspiration allows prompt diagnosis and treatment 3
• If needle aspiration fails or the abscess recurs, incision and drainage should be performed 2

Antibiotic Therapy

• Antibiotics effective against Group A Streptococcus and oral anaerobes should be first-line therapy 1
• Amoxicillin-clavulanate is an appropriate choice given its coverage of both aerobic and anaerobic organisms 4
  • For teenagers (≥40 kg): 875 mg/125 mg every 12 hours for more severe infections 4
  • Alternative: 500 mg/125 mg every 8 hours 4
• Clindamycin is an alternative option, particularly in penicillin-allergic patients 5
• Intravenous antibiotics should be used initially in clinically unstable patients or those with respiratory compromise 5

Supportive Care

• Maintain hydration, as dehydration requiring hospitalization can occur 1, 2
• Provide adequate pain control with acetaminophen or ibuprofen 6, 1
• Corticosteroids may help reduce symptoms and speed recovery 1

Surgical Considerations for Tonsillectomy

Indications for Immediate Tonsillectomy (Quinsy Tonsillectomy)

• Immediate tonsillectomy should be considered in select cases as it drains the abscess, eliminates potential for occult inferior pole or contralateral abscess, and spares a future hospitalization 3, 7
• This approach has low morbidity and no significantly greater complication rate than elective tonsillectomy 7
• Consider immediate tonsillectomy for respiratory compromise or unresponsiveness to medical treatment 5

Indications for Interval Tonsillectomy

• History of more than one peritonsillar abscess is a modifying factor that favors tonsillectomy 8
• The updated 2019 AAO-HNS guideline changed the threshold from "history of peritonsillar abscess" to ">1 peritonsillar abscess" 8
• Tonsillectomy may also be considered based on frequency and severity of illness and the patient's response to treatment 8

Clinical Pearls and Pitfalls

Key Diagnostic Features

• Look for fever, severe sore throat, dysphagia, trismus, and "hot potato" voice 1
• Physical examination typically shows asymmetric tonsillar hypertrophy, peritonsillar fullness, uvular deviation to the opposite side, and tonsillar erythema 1, 3, 5
• Progressive sore throat despite antibiotics should raise suspicion 3

Common Pitfalls to Avoid

• Do not delay drainage in favor of antibiotics alone, as drainage is essential for treatment 1
• Be vigilant for airway compromise, which may require emergency intubation 5
• Recognize that isolated intratonsillar abscess (without peritonsillar component) may respond to IV antibiotics alone in clinically stable children 5
• Do not perform tonsillectomy solely to reduce frequency of throat infections unless the patient meets established Paradise criteria (≥7 episodes in past year, ≥5 episodes per year for 2 years, or ≥3 episodes per year for 3 years with proper documentation) 8, 6

Follow-up

• Most patients can be managed in the outpatient setting 1
• Monitor for recurrence, which occurs more frequently after needle aspiration than incision and drainage 2
• Reassess need for interval tonsillectomy if a second peritonsillar abscess occurs 8