Peritonsillar Abscess: Signs, Symptoms, and Treatment
Clinical Presentation
Peritonsillar abscess presents with a characteristic constellation of symptoms that should prompt immediate evaluation and treatment. 1
Key Signs and Symptoms
- Severe sore throat with unilateral tonsillar swelling and deviation of the uvula away from the affected side 1
- Trismus (difficulty opening the mouth due to pterygoid muscle spasm) 1, 2
- "Hot potato" voice (muffled speech quality) 1, 2
- Odynophagia (painful swallowing) with drooling 1, 2
- Fever and malaise 1, 2
- Cervical lymphadenopathy 2
The most commonly reported symptom is pharyngalgia, followed by trismus, odynophagia, fever, hot potato voice, malaise, and cervical lymphadenopathy in descending order of frequency. 2
Treatment Approach
Drainage combined with antibiotics is essential—antibiotics alone without drainage should not be relied upon for treatment success. 3
Immediate Management
- Provide adequate hydration as volume depletion is common from fever, poor oral intake, and tachypnea 3
- Initiate empiric antibiotic therapy immediately upon diagnosis, targeting group A streptococcus and oral anaerobes 3, 1
- Ensure adequate pain control with ibuprofen, acetaminophen, or both to maintain oral intake and hydration 3
Drainage Procedures
Needle aspiration or incision and drainage are both acceptable first-line drainage methods, though very low-quality evidence suggests incision and drainage may have lower recurrence rates (RR 3.74 for needle aspiration recurrence, 95% CI 1.63-8.59). 4 The choice depends on clinician experience and patient factors. 1, 5
Antibiotic Selection
First-line antibiotics must cover group A streptococcus and oral anaerobes. 3, 1
- Clindamycin IV is indicated for serious infections caused by susceptible streptococci, staphylococci, and anaerobes, particularly in penicillin-allergic patients 6
- Duration: 3-5 days after adequate source control 3
- Avoid nephrotoxic antibiotics like aminoglycosides 3
The bacterial etiology includes viridans group streptococci (25%), beta-hemolytic streptococci (20%), F. necrophorum (13%), S. aureus (11%), Prevotella species (10%), and Bacteroides species (9%). 7
Inpatient vs. Outpatient Management
Most patients can be managed as outpatients with drainage, antibiotics, steroids, and pain control. 3, 1
Admit patients with:
Corticosteroid Use
Corticosteroids may reduce symptoms and speed recovery, though this represents adjunctive therapy. 5
Complications and Red Flags
Over 10% of PTA cases develop complications, with mortality rates up to 10% in complicated cases. 7, 2
High-Risk Populations
- Males (constitute 70% of complicated cases) 7
- Patients >40 years of age (49% of complicated cases) 7, 2
- Patients with comorbid conditions have increased risk of complications 2
Serious Complications to Monitor
- Descending mediastinitis (most frequently reported complication) 7
- Para- and retropharyngeal abscess 7
- Necrotizing fasciitis 7
- Lemierre's syndrome 7
- Airway obstruction 1
- Extension into deep neck tissues 1, 2
59% of complications are diagnosed simultaneously with PTA, while 36% develop after treatment initiation, emphasizing the need for vigilant monitoring. 7
Long-Term Considerations
For patients with a history of more than one peritonsillar abscess, tonsillectomy should be considered as definitive treatment. 8, 3 This represents a modifying factor that favors tonsillectomy even when Paradise criteria for recurrent tonsillitis are not met. 8
Common Pitfalls
- Delaying drainage while relying on antibiotics alone leads to treatment failure 3
- Inadequate hydration management worsens outcomes 3
- Failure to recognize complications early, particularly in males and older patients 7, 2
- Insufficient pain control prevents adequate oral intake and prolongs recovery 3
- Using oral antibiotics when IV therapy is indicated in patients with systemic illness, though in uncomplicated cases without comorbidities, oral antibiotics appear equivalent to IV 2