Peritonsillar Abscess Treatment & Management

In cases of peritonsillar abscess (PTA), when incision and drainage (I&D) is performed, it leads to immediate improvement of the patient's symptoms. Needle aspiration may be used as a diagnostic modality and as a therapeutic one, because it allows the accurate localization of the abscess cavity. The aspirated fluid may be sent for culture, and in some cases, I&D may not be necessary. If patients continue to report recurring and/or chronic sore throats after proper I&D, a tonsillectomy may be indicated.

Intraoral drainage has a high rate of success, with low morbidity and a low rate of recurrence. Normally, unless the patient presents with recurrent tonsillitis or recurrent PTA, tonsillectomy is not indicated; however, in situations where the abscess is located in an area difficult to access, a tonsillectomy may be the only way to drain the abscess.

Patients with PTAs who are dehydrated require intravenous (IV) fluid administration until the inflammation resolves and they are able to resume 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 from I&D is so significant that the patient is able to resume oral intake with nonnarcotic analgesics.

Antibiotic therapy should begin after cultures are obtained from the abscess. High-dose IV penicillin remains a good choice for empiric treatment of PTA. Alternatively, because of the polymicrobial nature of cultured pus, agents that treat copathogens and resist beta-lactamases also have been recommended as a first choice. Cephalexin or another cephalosporin (with or without metronidazole) is likely the best initial option. Alternatives include the following:

• Cefuroxime or cefpodoxime (with or without metronidazole)
• Clindamycin
• Amoxicillin-clavulanate (if mononucleosis has been ruled out)

Oral antibiotics may be prescribed once the patient is able to tolerate oral intake; treatment should be continued for 7-10 days.

The use of steroids has been controversial. In a study by Ozbek, the addition of a single dose of IV dexamethasone to parenteral antibiotics significantly lessened the variables of hours hospitalized, throat pain, fever, and trismus in comparison with treatment involving only parenteral antibiotics. ^[13] In addition, the use of steroids in patients presenting with signs and symptoms of mononucleosis has not led to the formation of a PTA.

Management of a patient with a suspected 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 who present with airway obstruction.

Preparation for surgery

Discussing the pathophysiology and indications for surgery with the patient is essential. Informed consent should be obtained from the patient or surrogate only after the potential complications have been carefully described.

In cases in which airway access may be compromised, an emergency 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.

Procedural details

There continues to be controversy regarding the relative merits of needle aspiration and I&D as definitive therapeutic modalities. With 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 accurate localization of the abscess cavity. The fluid aspirated may be sent for culture, and in some cases, needle aspiration may not have to be followed by I&D.

Incision and drainage

Intraoral I&D 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. Successful aspiration or drainage leads to immediate improvement of the patient's symptoms.

Other concerns

With very young or uncooperative patients or patients whose abscess is 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 the low recurrence rate and morbidity associated with intraoral drainage. When the abscess is located in an area that is difficult to access, a tonsillectomy may be the only way to drain it.

A systematic review and meta-analysis by Tsikopoulos et al found no significant differences in clinical poutcomes between immediate and delayed tonsillectomy for PTA. ^[14]

Smoking is often more common among patients with peritonsillar abscess and is often associated with more complications. ^[15]

Because of the rapid alleviation of pain commonly achieved with surgical treatment, most patients may be discharged immediately after 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.

IV hydration is important because most patients present with significant fluid deficits. Continued use of antibiotics in the postoperative period is important as well. When the patient is able to take sufficient fluids by mouth, antibiotics may be administered orally for 7-10 days. Because of the level of discomfort from the ongoing inflammation, administration of oral analgesics is also helpful.

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 reaccumulation 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 for preventing 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 the external carotid artery or terminal branches thereof. Once the patient is stabilized hemodynamically, the tonsillar fossa is reevaluated. The ipsilateral neck also should be prepared and draped in a sterile fashion to provide access to the proximal external carotid artery. If the hemorrhage is controlled intraorally, the patient's continued stabilization is pursued. ^[16]

If the bleeding appears to be too brisk, and it is not controlled by careful intraoral source identification, an ipsilateral cervicotomy is performed, as follows.

The sternocleidomastoid is retracted laterally, and the carotid sheath contents are identified. The internal jugular vein, the vagus nerve, and the carotid arteries (common, external, and internal) 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 preserving the external laryngeal, the ansa hypoglossi, and the hypoglossal nerves. Ligation of the external carotid artery may prove necessary.

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.

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, it is important to inspect the drainage site carefully and to rule out reaccumulation of pus. Assessment should include checking 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.