Treatment of Peritonsillar Abscess
The recommended treatment for peritonsillar abscess requires immediate drainage combined with antibiotics effective against group A streptococcus and oral anaerobes, with most patients manageable as outpatients using needle aspiration, antibiotics, hydration, steroids, and pain control. 1, 2
Immediate Management Algorithm
Step 1: Source Control Through Drainage
- Drainage is essential and antibiotics alone should not be relied upon 1
- Needle aspiration is the gold standard for both diagnosis and treatment 3, 4
- Initial success rates are 87-90% with needle aspiration, comparable to incision and drainage 4
- If needle aspiration fails, proceed to incision and drainage 3
Step 2: Antibiotic Therapy
First-line antibiotic selection:
- Penicillin remains first-line therapy (IV: 2-4 million units every 4-6 hours for hospitalized patients; pediatric: 100,000 units/kg/day divided) 5
- Amoxicillin-clavulanate for outpatient management (80 mg/kg/day in three doses, max 3 g/day) 5
- For penicillin allergy: Clindamycin is the drug of choice (600-900 mg IV every 6-8 hours for adults; 10-13 mg/kg/dose every 8 hours IV for pediatrics) 5
- For non-severe penicillin reactions: cephalosporins (cefdinir, cefuroxime, or cefpodoxime) with <10% cross-reactivity 5
- Duration: 3-5 days after adequate source control, with extension if no improvement 6, 1
- Avoid nephrotoxic aminoglycosides 1
Step 3: Supportive Care
- Adequate hydration is critical due to volume depletion from fever, poor oral intake, and tachypnea 1
- Pain control with ibuprofen, acetaminophen, or both to maintain oral intake 1
- Corticosteroids reduce symptoms and speed recovery 2, 7
Disposition Decision
Outpatient management is appropriate for most patients 1, 8, 4
Admit patients with:
- Severe systemic symptoms 1
- Inability to maintain hydration 1
- Signs of sepsis 1
- Need for rehydration and IV antibiotics 4
Special Considerations
High-Risk Populations
- Children with asthma require aggressive initial management with clindamycin due to increased complication risk 5
Tonsillectomy Indications
- Consider tonsillectomy for patients with more than one peritonsillar abscess, even without meeting standard recurrent tonsillitis criteria 1, 5
- Do NOT prescribe perioperative antibiotics if proceeding to tonsillectomy 5
- Unilateral tonsillectomy carries 14% risk of contralateral streptococcal tonsillitis and 7% risk of contralateral peritonsillar complications 1
Common Pitfalls to Avoid
- Never rely on antibiotics alone without drainage - source control is essential for treatment success 1
- Avoid delaying treatment, as prompt recognition prevents serious complications including airway obstruction, aspiration, or deep neck space extension 2
- Don't automatically hospitalize all patients - outpatient protocols with drainage, antibiotics, steroids, and pain control have 95.9% success rates 8
- Ensure adequate anaerobic coverage in antibiotic selection, as these are polymicrobial infections 2