Tonsillitis and Peritonsillar Abscess Treatment & Management

Treatment of acute tonsillitis is largely supportive and focuses on maintaining adequate hydration and caloric intake and controlling pain and fever. Inability to maintain adequate oral caloric and fluid intake may require IV hydration, antibiotics, and pain control. IV corticosteroids may be administered to reduce pharyngeal edema.

• Corticosteroids may shorten the duration of fever and pharyngitis in cases of infectious mononucleosis (MN). In severe cases of MN, corticosteroids or gammaglobulin may be helpful. Symptoms of MN may last for several months. Corticosteroids are also indicated for patients with airway obstruction, hemolytic anemia, and cardiac and neurologic disease. Inform patients of complications from steroid use.
• Antibiotics are reserved for secondary bacterial pharyngitis. Because of the risk of a generalized papular rash, avoid ampicillin and related compounds when MN is suspected. Similar reactions from oral penicillin-based antibiotics (eg, cephalexin) have been reported. Therefore, initiate therapy with another antistreptococcal antibiotic such as erythromycin.
• Administer antibiotics if conditions support bacterial etiology, such as the presence of tonsillar exudates, presence of a fever, leukocytosis, contacts who are ill, or contact with a person who has a documented GABHS infection. In many cases, bacterial and viral pharyngitis are clinically indistinguishable. Waiting 1-2 days for throat culture results has not been shown to diminish the usefulness of antibiotic therapy in preventing rheumatic fever.
• GABHS infection obligates antibiotic coverage. Bisno et al stated, in a practice guideline for the diagnosis and management of group A beta-hemolytic Streptococcus pyogenes (GABHS), the desired outcomes of therapy for GABHS pharyngitis are (1) prevention of acute rheumatic fever, (2) prevention of suppurative complications, (3) abatement of clinical symptoms and signs, (4) reduction in transmission of GABHS to close contacts, and (5) minimization of potential adverse effects of inappropriate antimicrobial therapy.^[11]
• Administering oral penicillin for 10 days is the best treatment of acute GABHS pharyngitis.^[12] Intramuscular penicillin (ie, benzathine penicillin G) is required for persons who may not be compliant with a 10-day course of oral therapy. Penicillin is optimal for most patients (barring allergic reactions) because of its proven safety, efficacy, narrow spectrum, and low cost. Other antibiotics proven effective for GABHS pharyngitis are the penicillin congeners, many cephalosporins, macrolides, and clindamycin. Clindamycin may be of particular value because its tissue penetration is considered equivalent for both oral and IV administration. Clindamycin is effective even for organisms that are not rapidly dividing (Eagle effect), which explains its great efficacy for GABHS infection. Vancomycin and rifampin have also been useful. Reduced-frequency dosing is recommended to improve compliance with medication regimens. A consensus on the efficacy of such dosing has not yet been formulated.
• Airway obstruction may require management by placing a nasal airway device, using intravenous corticosteroids, and administering humidified oxygen. Observe the patient in a monitored setting until the airway obstruction is clearly resolving.
• Most acute pharyngitis is self-limited with clinical improvement observed in 3-4 days. Recent clinical practice guidelines state that avoiding antibiotic therapy for this time period is safe and that a delay of up to 9 days from symptom onset to antimicrobial treatment should still prevent the major complication of GABHS (ie, acute rheumatic fever).
• Recurrent tonsillitis may be managed with the same antibiotics as acute GABHS pharyngitis. If the infection recurs shortly after a course of an oral penicillin agent, then consider IM benzathine penicillin G. Clindamycin and amoxicillin/clavulanate have been shown to be effective in eradicating GABHS from the pharynx in persons experiencing repeated bouts of tonsillitis. A 3- to 6-week course of an antibiotic against beta-lactamase–producing organisms (eg, amoxicillin/clavulanate) may allow tonsillectomy to be avoided.
• Carrier state should be treated when the family has a history of rheumatic fever, a history of glomerulonephritis in the carrier, a "ping pong" spread of infection between household contacts of the carrier, familial anxiety regarding the implications of GABHS carriage, infectious outbreak within a closed community such as a school, an outbreak of acute rheumatic fever, or when tonsillectomy may be under consideration to treat the chronic carriage of GABHS.
• Peritonsillar cellulitis may respond to oral antibiotics.
• Antibiotics, either orally or intravenously, are required to treat PTA medically, although most peritonsillar abscesses (PTAs) are refractory to antibiotic therapy alone. Penicillin, its congeners (eg, amoxicillin/clavulanic acid, cephalosporins), and clindamycin are appropriate antibiotics.
• Aetius of Amida, a sixth century Byzantine physician, managed spontaneously draining abscesses with gargles of honey, milk and herbs, or rose extract. In rare cases of spontaneous peritonsillar abscess (PTA) rupture, mouthwashes are still recommended for hygienic reasons. A 10-day course of an oral antibiotic is prescribed.

• Recurrent tonsillitis

  • Tonsillectomy is indicated for individuals who have experienced more than 6 episodes of streptococcal pharyngitis (confirmed by positive culture) in 1 year, 3 or more infections of tonsils and/or adenoids per year despite adequate medical therapy, or chronic or recurrent tonsillitis associated with the streptococcal carrier state that has not responded to beta-lactamase–resistant antibiotics. Tonsillectomy may be considered for children when multiple antibiotic allergies or intolerances are seen, for children with periodic fever, aphthous stomatitis, pharyngitis and adenitis (PFAPA), or a history of peritonsillar abscess.^[13]
  • Time missed from school or work and severity of illness (eg, whether hospitalization was required) are important considerations in recommending tonsillectomy.
  • Because adenoid tissue has similar bacteriology to the pharyngeal tonsils and minimal additional morbidity occurs with adenoidectomy if tonsillectomy is already being performed, most surgeons perform adenoidectomy if adenoids are present and inflamed at the time of tonsillectomy. However, this point remains controversial.
  • Recurrent tonsillitis after tonsillectomy is extremely rare. Tonsillectomy reduces the bacterial load of GABHS and may also allow an increase in alpha-Streptococcus, which can be protective against GABHS infection. Recurrent tonsillitis is usually due to regrowth of tonsillar tissue, which is treated by excision.
• Chronic tonsillitis

  • Tonsillectomy with or without adenoidectomy is the treatment of chronic tonsillitis. The details of the technique are reviewed in the article on Tonsillectomy.
  • In cases of chronic tonsillitis, specific technical considerations for tonsillectomy include awareness of a higher intraoperative and perioperative bleeding risk and awareness that dissection may be more difficult because of fibrosis and scarring of the tonsillar capsule. Such considerations may affect instrument selection and discharge decisions.
• Lingual tonsillitis

  • Surgery is rarely required for acute lingual tonsillitis.
  • Surgery is indicated for frequent and disabling episodes of this uncommon malady.
• Tonsillitis in cases of MN: Tonsillar hypertrophy that persists after resolution of MN and causes obstructive airway symptoms may require tonsillectomy.
• Peritonsillar abscess

  • Treatment of peritonsillar abscesses (PTAs) includes aspiration and incision and drainage (I&D).
  • Aetius recommended incision if an abscess did not spontaneously drain.
  • When peritonsillar abscess (PTA) is suspected, aspiration with a needle may be attempted to confirm the diagnosis and to remove some of the purulence.
    • The area of the peritonsillar abscess (PTA) is first anesthetized by infiltration with local anesthetic or by spray or sponge application of topical anesthesia (eg, Americaine, benzocaine). Sedation may be helpful; administer sedation only in a facility that is appropriately staffed and equipped.
    • An 18-gauge needle on a 1 mL tuberculin syringe is placed into the pointing area, taking care not to penetrate the pharyngeal mucosa more than 1 inch in order to prevent injury to the vessels and nerves of the parapharyngeal space. Bending a sheathed needle at 2 points may prevent deeper injury during aspiration.^[14]
    • If attempt at aspiration from 3 different peritonsillar sites does not locate the abscess, treat the patient with oral or IV antibiotics. If symptoms persist after 24-48 hours of therapy, CT scanning with contrast may be performed.
  • Once purulence is detected, complete aspiration may be attempted. In the author's experience, limited aspiration is best, provided that sufficient material is available for Gram stain and cultures with antibiotic sensitivities. Not all patients need microbiologic evaluation. For those who are immunosuppressed or who have developed a peritonsillar abscess (PTA) after several days of appropriate antibiotic therapy, send aspirated material for Gram stain, culture, and sensitivity tests.
  • After needle aspiration, incision and drainage may be performed using a knife.
    • The handle of a knife with an attached No 15 blade is taped 1 inch from the tip to prevent deep penetration through the mucosa. A gentle curvilinear incision, not more than half an inch deep, is fashioned along the perimeter of the tonsillar capsule and through the point from which pus was evacuated. A widely tipped blunt clamp (eg, Kelly clamp) is used to widely open the loculated pockets of purulence. A sponge-covered finger to break loculations is ideal. Rinsing with half-strength hydrogen peroxide solution aids hemostasis.
    • When the patient is dehydrated and uncomfortable, this well-intentioned procedure is not greeted with enthusiasm from the patient. Sedation, hydration, analgesia, and anesthesia (at the least, topical or local) are important.
    • Using the nondominant hand, the physician grasps the tongue with a sponge and observes the posterior oropharynx. In patients with severe trismus, a tongue blade may be used to depress the midportion of the tongue. Magnifying and illuminating loupes, such as the LumiView, are the best sources of light. A headlight or mirror is also effective. Arranging the instruments in order of use on a tray adjacent to the physician's dominant hand facilitates rapid accomplishment of this procedure. In experienced hands, this procedure should take fewer than 3 minutes from aspiration to rinsing with peroxide.
    • Some adults and most children require deeper levels of sedation or general anesthesia for safe and adequate aspiration or drainage. An institution with a carefully designed policy for incision and drainage of peritonsillar abscess (PTA) with conscious sedation, including appropriate indications, staff, and criteria, may offer sedation to children.
    • After the procedure, the patient is observed in accordance with sedation and anesthetic protocols. Hospitalization for adults and for older children is rarely required. The patient is discharged with a prescription for an oral antibiotic (10-d course of therapy), a prescription for an oral narcotic for pain control (taking care to avoid antiplatelet agents), and instructions to maintain hydration and control fever. Antibiotic therapy may be altered after cultures return. A follow-up office visit or telephone call is made in 2-4 weeks after the procedure to confirm symptomatic resolution.
  • Tonsillectomy is indicated for peritonsillar abscess (PTA) associated with chronic or recurrent tonsillitis or for exposure of the abscess in unusual cases. Newer techniques and technologies offer improved recovery and reduced complications from surgery.^[15] Acute tonsillectomy is generally regarded as a safe and effective treatment of peritonsillar abscess (PTA). Some physicians advocate immediate tonsillectomy for younger patients with peritonsillar abscess (PTA). Removing hot tonsils (ie, those that are acutely infected) carries the expectation of higher intraoperative blood loss and a higher risk of immediate and delayed posttonsillectomy hemorrhage.
  • The term quinsy tonsillectomy refers to tonsillectomy performed to treat peritonsillar abscess (PTA). Bilateral tonsillectomy is usually performed in these cases, and the abscessed tonsil is usually easier to remove during surgery than the inflamed contralateral tonsil. The abscessed tonsil is easier to remove because the abscess partially dissects the tonsil from the pharyngeal musculature.
  • During surgery, if the abscess cannot be located in the usual superior lateral region of the tonsillar fossa, then careful exploration with needle aspiration may locate the collection, allowing for wide exposure and drainage. Tonsillectomy may be required for exposure in such cases. A CT scan with contrast may be indicated.
  • Fleshy or pale, granular tonsillar tissue may indicate a neoplasm. Immuno-histopathologic examination is indicated in such cases.

Consultations with infectious-disease, hematologic, and pediatric subspecialists are valuable in selected cases.

• Hydration is important, and the oral route is usually adequate.
• Intravenous fluids may be required for severe dehydration.
• Hyperalimentation is rarely necessary.

• Adequate rest for adults and children with tonsillitis accelerates recovery.
• In order to reduce risk of splenic rupture in persons diagnosed with systemic mononucleosis (MN), patients must be cautioned against activities that may cause abdominal injury.