Management of Peritonsillar Abscess
The management of peritonsillar abscess in teenagers and adults requires immediate drainage combined with antibiotics targeting group A streptococcus and oral anaerobes, with most patients successfully managed as outpatients. 1
Immediate Treatment Algorithm
Source Control (Drainage) - Essential First Step
Drainage is absolutely essential and antibiotics alone should not be relied upon for treatment success. 1 You have three equivalent drainage options:
- Needle aspiration - simplest approach, can be performed in office/ED 2, 3
- Incision and drainage - traditional surgical approach 4, 3
- Quinsy tonsillectomy (immediate tonsillectomy) - reserved for select cases 3, 5
All three methods yield successful results, and the choice depends on provider experience and patient factors. 3 The key is that pus must be removed from the abscess cavity. 4
Antibiotic Therapy
Initiate empiric antibiotics immediately once diagnosis is made, targeting group A streptococcus and oral anaerobes. 1 Continue antibiotics for 3-5 days after adequate source control has been achieved. 1 Avoid potentially nephrotoxic agents like aminoglycosides. 1
Supportive Care
- Hydration: Provide adequate IV or oral hydration, as volume depletion is common from fever, poor oral intake, and tachypnea 1
- Pain control: Use ibuprofen, acetaminophen, or both for adequate analgesia, which is essential for maintaining oral intake and hydration 1
- Corticosteroids: Consider adjunctive steroids to reduce symptoms and speed recovery 2, 3, 5
Disposition Decision
Outpatient Management (Most Patients)
Most patients can be managed as outpatients with the combination of drainage, antibiotics, steroids, and pain control. 1, 2
Inpatient Admission Required For:
- Severe systemic symptoms 1
- Inability to maintain hydration 1
- Signs of sepsis 1
- Concern for airway obstruction 6
- Risk of aspiration 6, 2
- Extension of infection into deep neck tissues 6, 2
Monitoring and Follow-Up
Monitor all patients for potential complications including airway obstruction, aspiration, or extension into deep neck tissues. 6 These complications, though rare, can be life-threatening and require emergent surgical intervention if inadequately treated. 4
Definitive Treatment Consideration
For patients with recurrent peritonsillar abscess (more than one episode), tonsillectomy should be considered as definitive treatment. 6, 1 This represents a modifying factor that favors tonsillectomy even if standard criteria for recurrent tonsillitis are not met. 1
Note that unilateral tonsillectomy carries a 14% risk of developing contralateral streptococcal tonsillitis and 7% risk of contralateral peritonsillar complications. 1
Critical Pitfalls to Avoid
- Never rely on antibiotics alone without drainage - source control is essential 1
- Don't miss atypical presentations - in older patients without history of recurrent tonsillitis, consider malignancy (lymphoma or squamous cell carcinoma) if tonsillar hypertrophy persists after treatment 7
- Don't underestimate hydration needs - aggressive fluid replacement is crucial 1
- Don't delay treatment - prompt recognition and therapy prevent serious complications 2