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. Home intravenous therapy under the supervision of qualified home health providers or the independent oral intake ability of patients ensures hydration. Intravenous corticosteroids may be administered to reduce pharyngeal edema.

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.

Tonsillectomy is indicated for individuals who have experienced more than 6 episodes of streptococcal pharyngitis (confirmed by positive culture) in 1 year, 5 episodes in 2 consecutive years, or 3 or more infections of tonsils and/or adenoids per year for 3 years in a row despite adequate medical therapy, or chronic or recurrent tonsillitis associated with the streptococcal carrier state that has not responded to beta-lactamase–resistant antibiotics.

Tonsillitis and its complications are frequently encountered. Antibiotics cure most patients with bacterial tonsillitis, and surgery usually cures patients with infections and complications that are refractory to medical management. Better understanding of the immunology of tonsillitis, actively tracking patterns of bacterial and viral pathogenicity and resistance, and exploring novel technologies for tonsillectomy allow physicians to continue to build on their long experience with these conditions.

Consider transfer of patient care when tonsillitis or its complications cannot be managed safely and expediently. Ensure airway protection for transfer. Ensure that appropriately trained personnel accompany the patient during transfer. Children younger than 3 years may require transfer because of the special care needed during tonsillitis or its complications. Patients with syndromic diagnoses (eg, trisomy 21) and patients with hematologic problems may benefit from transfer to facilities that have the availability of subspecialist care.

Discharge of the patient from the hospital occurs after the patient and caregivers can demonstrate compliance with oral pain medication and antibiotics. To confirm clinical improvement, follow-up care by telephone contact or physical examination may be useful in 2-4 weeks after the acute episode. Follow-up throat swabs and cultures are usually not necessary, unless family or personal history of rheumatic fever exists, significant recurrent tonsillitis is evident, or family members continue to reinfect each other.

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

A study by Battaglia et al indicated that medical therapy alone for uncomplicated peritonsillar abscess presenting in the emergency department is equally as effective as medical treatment plus surgery but is also associated with less pain and opioid use and fewer days off from work. This was particularly true in patients presenting without trismus. Medical treatment included the use of intravenous (IV) fluids, weight-appropriate IV ceftriaxone, clindamycin, and dexamethasone, with the patients subsequently discharged on clindamycin for 10 days. Surgical treatment consisted of drainage. ^[17]

Corticosteroids may shorten the duration of fever and pharyngitis in cases of infectious mononucleosis (MN). In severe cases of MN, corticosteroids or gamma globulin 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 infectious mononucleosis (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 a 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 group A beta-hemolytic Streptococcus pyogenes (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

GABHS infection obligates antibiotic coverage. Bisno et al stated in practice guidelines for the diagnosis and management of GABHS that the desired outcomes of therapy for GABHS pharyngitis are the prevention of acute rheumatic fever, the prevention of suppurative complications, the abatement of clinical symptoms and signs, the reduction in transmission of GABHS to close contacts, and the minimization of potential adverse effects of inappropriate antimicrobial therapy. ^[18]

Administering oral penicillin for 10 days is the best treatment of acute GABHS pharyngitis. ^[19] 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.

Most cases of acute pharyngitis are self-limited, with clinical improvement observed in 3-4 days. Clinical practice guidelines state that avoiding antibiotic therapy for this time period is safe and 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 abscess

Peritonsillar cellulitis may respond to oral antibiotics. Antibiotics, either orally or intravenously, are required to treat peritonsillar abscess (PTA) medically, although most PTAs are refractory to antibiotic therapy alone. Penicillin, its congeners (eg, amoxicillin/clavulanic acid, cephalosporins), and clindamycin are appropriate antibiotics. In rare cases of spontaneous PTA rupture, mouthwashes are still recommended for hygienic reasons. A 10-day course of an oral antibiotic is prescribed.

Beta-lactamase resistance

Beta-lactamase resistance of streptococcal species may now be observed in up to a third of community-based streptococcal infections. This resistance is probably due to the presence of copathogens that are beta-lactamase–producing organisms, such as H influenzae and Moraxella catarrhalis. These organisms are able to degrade the beta-lactam ring of penicillin and make an otherwise sensitive GABHS act resistant to beta-lactam antibiotics. In one study, erythromycin did not inhibit nearly half of S pyogenes isolates. The limited precision of many throat swabs may reduce the usefulness of these samples.

Tonsillectomy is indicated for individuals who have experienced more than 6 episodes of streptococcal pharyngitis (confirmed by positive culture) in 1 year, 5 episodes in 2 consecutive years or 3 or more infections for 3 years in a row, 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, as well as for children with periodic fever, aphthous stomatitis, pharyngitis and adenitis (PFAPA), or a history of peritonsillar abscess. ^[20]

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 palatine tonsils and because minimal additional morbidity occurs with adenoidectomy if tonsillectomy is already being performed, most surgeons perform an 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 group A beta-hemolytic Streptococcus pyogenes (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.

Tonsillectomy with or without adenoidectomy is the treatment for chronic tonsillitis. 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.

Surgery is rarely required for acute lingual tonsillitis, but surgery is indicated for frequent and disabling episodes of this uncommon malady. Tonsillar hypertrophy that persists after resolution of mononucleosis and causes obstructive airway symptoms may necessitate tonsillectomy.

A literature review by Morad et al indicated that in the short-term (< 12 mo), children with recurrent throat infections who undergo tonsillectomy/adenotonsillectomy demonstrate greater reductions in sore throat days, clinician contacts, diagnosed group A streptococcal infections, and school absences than do such children treated with watchful waiting. However, quality-of-life scores did not significantly differ between the two groups, and the evidence was not strong enough to determine whether the greater tonsillectomy/adenotonsillectomy-associated benefits would persist in the longer term. ^{[21, 22]}

A study by Wang et al indicated that tonsillectomy increases the risk of deep neck infections. Using a health insurance research database search, the investigators found patients to be at 1.71-fold greater risk of deep neck infection after undergoing tonsillectomy. ^[23]

A retrospective cohort study of 61,430 patients who underwent tonsillectomy indicates that the use of intravenous steroids on the day of surgery increases the incidence of posttonsillectomy bleeding in children, but not in adults. In the study, Suzuki et al found that the rate of reoperation for bleeding was 1.2% for children aged 15 years or younger who received intravenous steroids, versus 0.5% for patients in the same age group who did not. Among patients older than 15 years, however, the reoperation rate was not significantly higher in the steroid patients than in the controls (1.7% vs. 1.4%). ^{[24, 25]}

A retrospective study by Spektor et al indicated that the risk of postoperative bleeding in children undergoing tonsillectomy is increased when the surgery is performed on a child with recurrent tonsillitis (4.5 times increased risk), on a child with attention deficit hyperactivity disorder (8.7 times increased risk), or on an older child (twice the bleeding risk in children aged 11 years or above). ^[26]

Similarly, a study by Kshirsagar et al indicated that in children undergoing outpatient tonsillectomy with or without adenoidectomy, the risk of immediate postoperative bleeding is increased by older age (age between 9 and 18 years) and obesity, with the latter making the likelihood of hemorrhage about 2.3 times greater. ^[27]

A literature review by De Luca Canto et al indicated that respiratory compromise is the most frequent complication occurring in children (9.4%) following adenotonsillectomy, with secondary hemorrhage being the second most frequent (2.6%). The investigators also found that in children who undergo adenotonsillectomy, the risk of respiratory complications is 4.9 times higher in those who have obstructive sleep apnea than in children who do not, but the risk of postoperative bleeding is lower. ^{[28, 29]}

A retrospective study by McLean et al of tonsillectomy in adults found that 11.9% of patients in the report who underwent the surgery experienced postoperative hemorrhage. However, the study did not find such bleeding to be associated with the use of nonsteroidal anti-inflammatory drugs (NSAIDs), with the hemorrhage rate for patients in whom postoperative NSAIDs were prescribed and that for individuals in whom they were not prescribed being nonsignificantly different, at 12.6% and 11.7%, respectively (although the investigators admitted that a higher-powered study would be needed to better establish this). ^[30]

A prospective, multicenter, observational study by Tomkinson et al of 17,480 tonsillectomies and adenotonsillectomies found that 1.5% of all patients went back to the operating room for tonsillar hemorrhage control, with 0.7% suffering a primary hemorrhage and 0.8% experiencing a secondary hemorrhage. ^[31]

A study by Galindo Torres et al of tonsillectomy in adults found bleeding to be the complication that recurred the most (5.21% of tonsillectomies). Bleeding risk did not seem to have a statistically significant association with whether the tonsillar pillars were sutured or not or with surgical indication. Tonsillitis was the most frequent indication for surgery (74.85%). ^[32]

Peritonsillar abscess

Treatment of peritonsillar abscess (PTA) includes aspiration and incision and drainage (I&D). The term quinsy tonsillectomy refers to tonsillectomy performed to treat 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.

When 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 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 but should be administered only in a facility that is appropriately staffed and equipped.

Tonsillectomy is indicated for 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. ^[33] Acute tonsillectomy is generally regarded as a safe and effective treatment of PTA. Some physicians advocate immediate tonsillectomy for younger patients with 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 post-tonsillectomy hemorrhage.

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. Immunohistopathologic examination is indicated in such cases.

Aspiration

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. ^[34] If attempt at aspiration from 3 different peritonsillar sites does not locate the abscess, the patient should be treated 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. Sufficient material should be 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 PTA after several days of appropriate antibiotic therapy, aspirated material should be sent for Gram stain, culture, and sensitivity tests.

Incision and drainage

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. There may be a role for intravenous dexamethasone in reducing pain after drainage. ^[35] 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 PTA with conscious sedation, including appropriate indications, staff, and criteria, may offer sedation to children.

Exposure of the posterior oropharynx for aspiration and incision and drainage is achieved by using the nondominant hand to grasp the tongue with a sponge while the patient opens his or her mouth. 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.

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-day 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.

A retrospective study by Windfuhr and Zurawski indicated that incisional drainage as a first-line treatment for peritonsillar abscess decreases the hemorrhage rate from that associated with abscess tonsillectomy (0.3% vs 5.1%, respectively) and significantly reduces inpatient treatment days (4 vs 7 days, respectively). The study involved 775 patients, including 443 who underwent abscess tonsillectomy and 332 who were treated with incisional drainage. ^[36]

Coronavirus disease 2019 (COVID-19) considerations

Bann et al compiled a set of recommendations for best pediatric otolaryngology practices with regard to the coronavirus disease 2019 (COVID-19) pandemic. These included the following for procedures involving the oral cavity, oropharynx, nasal cavity, or nasopharynx ^[37] :

• Whenever possible, defer procedures involving the nasal cavity, nasopharynx, oral cavity, or oropharynx, as these pose a high risk for COVID-19 owing to the high viral burden in these locations
• Whenever possible, preoperative COVID-19 testing should be administered to patients and caregivers prior to surgical intervention
• Employment of enhanced personal protective equipment (PPE), with a strong recommendation for the use of a powered air-purifying respirator (PAPR), should be undertaken with any patient with unknown, suspected, or positive COVID-19 status
• Limit the use of powered instrumentation, including microdebriders, to reduce aerosol generation

With regard to audiologic evaluation and otologic surgery, the recommendations include the following ^[37] :

• Perform routine newborn hearing screening and early intervention as indicated in the Joint Committee on Infant Hearing (JCIH) recommendations
• Defer tympanostomy tube placement for unilateral otitis media with effusion
• Although it should be prioritized, intervention for bilateral otitis media with effusion and hearing loss may be deferred based on the availability of COVID-19 testing
• Surgery involving the middle ear and mastoid, owing to their continuity with the upper aerodigestive tract, should be considered high risk for COVID-19 transmission
• Whenever possible, defer mastoidectomy, but if the surgery is required, employ enhanced PPE and avoid the use of high-speed drills
• Employment of a PAPR is strongly recommended when, in patients with unknown, suspected, or positive COVID-19 status, high-speed drills are required for otologic procedures

With regard to head and neck surgery and deep neck space infections, the recommendations include the following ^[37] :

• Defer surgical excision of benign neck masses
• A multidisciplinary tumor board should decide the most appropriate treatment modality for pediatric patients with solid tumors of the head and neck, including thyroid cancer, with the availability of local resources taken into account
• Prior to surgical intervention, medical management of infectious conditions should, whenever possible, be attempted; on admission, patients and caregivers should be tested for COVID-19 and strictly quarantined pending test results

With regard to craniomaxillofacial trauma, the guidelines include the following ^[37] :

• When urgent or emergent bedside procedures, including closure of facial lacerations, are required, patients should be presumed positive for COVID-19, even if they are asymptomatic; carry out procedures in a negative-pressure room using enhanced PPE
• Employ closed-reduction techniques, when possible, until preoperative COVID-19 testing is available
• Avoid the use of high-speed drills, to reduce aerosol formation
• When urgent or emergent surgical intervention is required, patients should be presumed positive for COVID-19, even if they are asymptomatic

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, patients must be cautioned against activities that may cause abdominal injury.

Avoidance of contact with individuals who are ill or patients who are immunocompromised is useful.

The use of the antipneumococcal vaccine may help to prevent acute tonsillitis; however, to date, experience is insufficient to determine whether prevention is likely to occur.