Peritonsillar Abscess Treatment & Management

• Patients with dehydration require intravenous fluid administration until the inflammation resolves and they are able to resume an adequate oral fluid intake.
• Antipyretics and analgesics are used to alleviate fever and discomfort.
• Oral and parenteral analgesics are an integral part of the management and allow the patient to resume oral intake. Often, the pain relief is so significant from I&D as to allow the patient to resume oral intake with nonnarcotic analgesics.
• Antibiotic therapy should begin after cultures are obtained from the abscess. The use of high-dose intravenous penicillin remains a good choice for the empiric treatment of PTA.
• Alternatively, due to the polymicrobial nature of cultured pus, agents that treat copathogens and resist beta-lactamases also have been recommended as a first choice.
• Cephalexin or other cephalosporins (with or without metronidazole) are likely the best initial option. Alternatives include (1) cefuroxime or cefpodoxime (with or without metronidazole), (2) clindamycin, (3) trovafloxacin, or (4) amoxicillin/clavulanate (if mononucleosis has been ruled out). The patient may be prescribed oral antibiotics once oral intake is tolerated; length of treatment should be 7-10 days.
• The use of steroids has been controversial. In a study by Ozbek, the addition of a single dose of intravenous dexamethasone to parenteral antibiotics has been found to significantly lessen the variables of hours hospitalized, throat pain, fever, and trismus compared with a group of patients who were only treated with parenteral antibiotics.^[5] In addition, the use of steroids in patients presenting with signs and symptoms of mononucleosis has not led to the formation of a peritonsillar abscess.

The management of patients suspected of a PTA should include a referral to an otolaryngologist or a surgeon with experience in the management of this entity. Early referral should be considered if the diagnosis is unclear and is indicated in patients presenting with airway obstruction.

• Discussing the pathophysiology and indications for surgery with the patient is essential.
• Consent should be obtained from the patient or surrogate only after carefully describing potential complications.
• In cases in which airway access may be compromised, an emergent consultation with the anesthesiologist is obtained, and the potential of airway obstruction is discussed.
• If necessary, the anesthesiologist may perform an intubation using a flexible bronchoscope with the patient in the semisupine position.
• A significant potential for airway obstruction exists if the patient's airway access is limited by significant trismus or by edema of the oropharyngeal structures.

Ongoing controversy exists regarding needle aspiration versus I&D as definitive therapeutic modalities. In cooperative patients, procedures may be performed in an examination chair. The supratonsillar fold is anesthetized by either mucosalization or injection of a local anesthetic with epinephrine to reduce bleeding. If injection of a local anesthetic is performed, care should be taken to superficially infiltrate the overlying mucosa and surrounding soft palate.

Needle aspiration

• Needle aspiration can be carried out in children as young as 7 years, especially if conscious sedation is used.
• Needle aspiration may be used both as a diagnostic and as a therapeutic modality because it allows the accurate localization of the abscess cavity.
• The fluid aspirated may be sent for culture and, in some cases, may not need to be followed by an I&D.

Incision and drainage

• Intraoral incision and drainage is performed by incising the mucosa overlying the abscess, usually located in the supratonsillar fold.
• Once the abscess is localized, blunt dissection is carried out to break loculations.
• The opening is left open to drain, and the patient is asked to gargle with a sodium chloride solution, allowing the accumulated material to exit the abscess cavity.
• A successful aspirate or drainage leads to immediate improvement of the patient's symptoms.

Other concerns

• In very young or uncooperative patients or when the abscess is located in an unusual location, the procedure is best performed under general anesthesia.
• Immediate tonsillectomy as part of the management of a PTA also has been a subject of controversy. Many studies have shown the safety of a tonsillectomy in the setting of an acute abscess. Others have shown that immediate or delayed tonsillectomy may not be necessary because of the high rate of success and low rates of recurrence and morbidity associated with intraoral drainage.
• In situations in which the abscess is located in an area difficult to access, a tonsillectomy may be the only way to drain the abscess.

• Due to the rapid improvement in pain, most patients may be discharged immediately following the procedure if they are able to tolerate oral intake of fluids and bleeding is not apparent.
• Some patients may require admission in the hospital setting for 24-48 hours or until oral intake is properly reestablished and pain is well controlled.
• Intravenous hydration is important because most patients present with significant fluid deficits.
• Continued use of antibiotics in the postoperative period also is important. When the patient is able to take sufficient fluids by mouth, antibiotics may be administered orally for a total length of treatment of 7-10 days.
• Oral analgesics also are important due to the level of discomfort from the ongoing inflammation.

Patients are seen routinely in follow-up in the office setting. Elements to consider at that time are reduction of the amount of pain, defervescence, and ability to comfortably resume oral intake.

During the examination, carefully inspecting the drainage site and ruling out re-accumulation of pus is important; check for improvement in tonsillar appearance, inflammation, and the resolution of cervical lymphadenopathy. In general, unless the patient presents with a history of recurring tonsillitis or recurrent PTA, tonsillectomy is not indicated.

For excellent patient education resources, visit eMedicine's Ear, Nose, and Throat Center. Also, see eMedicine's patient education articles Peritonsillar Abscess, Tonsillitis, and Antibiotics.

• A number of clinical complications may occur if the diagnosis of a PTA is missed or delayed. The severity of the complications depends on the rapidity of progression of the illness as well as the characteristics of the affected fascial spaces. Early management and intervention are important.
• The fascial spaces of the neck are interconnected. Once inflammation exceeds the limits of the peritonsillar space, involvement of the masticator space (with increasing degrees of trismus) occurs. Extension may progress to the submandibular and sublingual spaces within the floor of the mouth (Ludwig angina). At this point, emergent airway control through intubation or tracheotomy is indicated to obviate obstruction from swelling of the base of the tongue. In severe cases, death may occur.
• In patients treated with I&D, evaluating the patency of the opening is important. Premature closure before the cavity has become obliterated is possible, leading to re-accumulation of pus. This may warrant a second I&D procedure or a tonsillectomy.
• Limiting the drainage incision to the mucosa of the soft palate and using blunt dissection within the cavity are important to avoid serious bleeding. The terminal branches of the external carotid artery lie on the posterior aspect of the tonsillar fossa and can be injured easily, particularly in children, in whom they are relatively superficial.
• Bleeding is a potential complication if branches of the external carotid artery are injured or if the external carotid artery itself is injured. The bleeding may occur intraoperatively or in the early postoperative period.
• Intraoperative hemorrhage is an emergency and results from direct injury to terminal branches of the external carotid artery or the external carotid artery itself. Once the patient is stabilized hemodynamically, the tonsillar fossa is reevaluated. The ipsilateral neck also should be prepared and draped in a sterile fashion for access to the proximal external carotid artery. If the hemorrhage is controlled intraorally, the patient's continued stabilization is pursued.^[6]
• If the bleeding appears to be too brisk, and it is not controlled by careful intraoral source identification, an ipsilateral cervicotomy is performed.

  • The sternocleidomastoid muscle is retracted laterally, and the carotid sheath contents are identified. The internal jugular vein; the vagus nerve; and the common, external, and internal carotid arteries are identified.
  • A vascular loop is applied around the external carotid artery to assess temporization of bleeding.
  • The external carotid artery is dissected superiorly, with careful attention to preservation of the external laryngeal, the ansa hypoglossi, and the hypoglossal nerves.
  • These severe life-threatening bleeds may require ligation of the external carotid artery.
• The general approach to postoperative hemorrhage similarly is directed to the identification of the source of bleeding. The patient is brought to the operating room, and the same procedure as described above is followed.

Most patients treated with antibiotics and adequate drainage of their abscess cavity recover within a few days. A small number present with another abscess later, requiring tonsillectomy. If patients continue to report recurring and/or chronic sore throats following proper I&D, a tonsillectomy may be indicated.

Ongoing controversy exists regarding needle aspiration versus I&D as definitive therapeutic modalities.

Immediate tonsillectomy as part of the management of a PTA also has been a subject of controversy. Many studies have demonstrated the safety of a tonsillectomy in the setting of an acute abscess. Others have shown that immediate or delayed tonsillectomy may not be necessary because of the high rate of success and low rates of recurrence and morbidity associated with intraoral drainage. In situations in which the abscess is located in an area difficult to access, a tonsillectomy may be the only way to drain the abscess.