Medical Care
The areas to be addressed in patients with peritonsillar abscess (PTA) include hydration, analgesia, and antibiotics. The mode of delivery (intravenous vs oral) depends on the patient's ability to tolerate oral intake and on the decision to treat the patient as an inpatient or outpatient.
Hospitalization may be needed, especially in young children. However, adults and older children with uncomplicated peritonsillar abscess may be managed as outpatients after drainage if they can take oral medications and hydration. [16, 17]
Medical treatment alone may be a safe and effective alternative to surgical drainage for the empiric treatment of peritonsillar abscess [28] ; however, careful patient selection is likely to optimize treatment outcomes.
The initial evaluation of a patient with peritonsillar abscess is the degree of upper airway obstruction. An anxious, ill-appearing child with drooling and posturing must be monitored continuously. When present, airway obstruction may require immediate airway management. Therefore, equipment for intubation cricothyroidotomy or tracheotomy should be available. Supportive therapy to ensure adequate hydration and analgesia should be provided.
Surgical Care
Three drainage procedures are needle aspiration, incision and drainage, and tonsillectomy.
Needle aspiration is performed as follows:
-
This procedure is indicated either as the definitive drainage procedure or to confirm the presence of pus prior to incision and drainage. Ultrasonography may be used to guide the aspiration.
-
The procedure can be done using topical anesthesia. After the identified area of fluctuance is numbed with topical anesthesia (in 90% of cases, this is the superior-medial aspect of the tonsil), an 18-gauge spinal needle is inserted, and pus is aspirated with a 10-mL syringe.
-
Some authorities recommend 3-point aspiration, with the first site being superior and medial and the other 2 sites progressively 0.5-1 cm more inferior and lateral.
-
Complications include respiratory distress, aspiration, and hemorrhage.
-
The success rate of needle aspiration exceeds 90%. Similar success rates were found in randomized trials that compared needle aspiration to incision and drainage (each above 92%). [29, 30] A meta-analysis showed needle aspiration was 94% successful in treating peritonsillar abscess (range, 85-100%). [31]
-
Repeat aspiration may be required in 4-10% of individuals. If symptoms do not resolve with needle aspiration, the patient may either undergo a second needle aspiration or one of the other 2 drainage procedures.
-
Needle aspiration may be performed by a well-trained clinician (usually an otolaryngologist).
-
Contraindications to performing needle aspiration in the outpatient setting are (1) uncertain diagnosis, (2) uncooperative child, (3) very young child, (4) anticipation of airway management problems, and (5) bleeding diathesis.
Incision and drainage is performed as follows:
-
The procedure achieves wider drainage than with needle aspiration.
-
It is more painful than needle aspiration.
-
The procedure requires an otorhinolaryngologist to perform it.
-
Contraindications to performing incision and drainage in the outpatient setting are (1) uncertain diagnosis, (2) uncooperative child, (3) very young child, and (4) anticipation of airway management problems.
Tonsillectomy is performed as follows:
-
When performed in the acute stages of a peritonsillar abscess, the procedure is also known as an abscess tonsillectomy, quinsy tonsillectomy, cold tonsillectomy, and tonsillectomy à chaud. When performed after an interval of several weeks, this procedure is known as interval tonsillectomy.
-
Tonsillectomy is preferred by some authorities because it is definitive therapy, may decrease the overall duration of inpatient stay if interval tonsillectomy is to be performed at a later date, and carries no increased morbidity over interval tonsillectomy.
-
Performed if abscess fails to resolve with other drainage techniques.
-
Tonsillectomy is preferred in those with a previous history of recurrent pharyngitis or previous episodes of peritonsillar abscess.
-
The downsides to this procedure are that it must be performed in the operating room, which leads to increased costs and time delays, and that intubating the patient may prove difficult.
-
Only an otorhinolaryngologist should perform tonsillectomy.
Consultations
Consult an otorhinolaryngology in all cases for follow-up care.
Directly involve an ear, nose, and throat (ENT) physician in the following cases:
-
All children with an unclear diagnosis
-
Anyone undergoing incision and drainage in the emergency department
-
All patients (very young, uncooperative) who require abscess tonsillectomy in the operating room
Diet and Activity
Diet
When airway compromise is a concern, the patient should be restricted to nothing by mouth (NPO). Otherwise, diet should consist of fluids and a soft diet as tolerated.
Activity
Permit activity as tolerated.
-
Examination of the oropharynx demonstrates unilateral swelling and erythema of the left tonsil with deviation of the uvula to the contralateral side. Courtesy of Michael Altieri, MD, Medifor, Inc. Used with permission.
-
CT scan with contrast demonstrates a 2-cm low-attenuation mass with a minimally enhancing wall in the right peritonsillar region. Associated edema, ipsilateral jugulodigastric lymphadenopathy, compression of the internal jugular vein, and deviation of the airway are present.
