Treatments: Peritonsillar Abscess

A peritonsillar abscess is usually treated by draining the pus, along with antibiotics and supportive care. Tonsil removal is considered in selected situations, such as abscesses that keep coming back.

Overview

A peritonsillar abscess (sometimes called "quinsy") is a pocket of pus that collects beside one of the tonsils, usually as a complication of a severe throat or tonsil infection. It typically causes a severe one-sided sore throat, painful swallowing, a muffled voice, and difficulty opening the mouth. More about the condition itself is on the peritonsillar abscess page.

Treatment has three parts that are usually carried out together: draining the pus, antibiotics, and supportive care (pain relief and fluids). Most people can be treated without being admitted to the hospital, though some need a short hospital stay.

1. Draining the abscess

Getting the pus out is the most important step. There are three main ways to do this, and the treating physician (often an ear, nose, and throat specialist) chooses based on the individual situation:

• Needle aspiration – A numbing medicine is applied, and a needle is used to draw out the pus. It may need to be repeated.

• Incision and drainage – After numbing, a small cut is made over the swelling and the pocket is opened so the pus can drain out. More detail is on the incision and drainage of peritonsillar abscess page.

• Tonsillectomy during the infection ("abscess tonsillectomy" or "hot tonsillectomy") – The tonsil is surgically removed while the infection is still active. This is generally reserved for people who have complications, when other drainage methods have not worked, or for young children who cannot cooperate with an awake procedure.

Needle aspiration and incision and drainage work about equally well, and both can usually be done while the patient is awake, using local numbing medicine. General anesthesia (being fully asleep) may be needed for young children or for people who cannot tolerate an awake procedure. Any pus removed may be sent to the lab to identify the bacteria.

2. Antibiotics

Peritonsillar abscesses are caused by a mix of bacteria, so antibiotics are given along with drainage. The antibiotics chosen cover the usual bacteria (including strep and bacteria normally found in the mouth that grow without oxygen). Common choices are a penicillin-type antibiotic (often combined with a medicine that blocks bacterial resistance), or clindamycin for people allergic to penicillin. A typical course lasts about 7 to 14 days, depending on how severe the infection is and how well it responds.

A penicillin allergy is important information for the care team. Many people who believe they are allergic to penicillin are not truly allergic, so reviewing exactly what reaction occurred can be worthwhile.

3. Supportive care

• Pain control with medicines directed by the treating physician

• Staying hydrated by drinking enough fluids; some people need fluids through a vein (IV) if swallowing is too painful

• Corticosteroids (steroids) are added in some cases to reduce swelling and pain and to speed recovery

Warning signs that need urgent care

The following symptoms call for emergency care right away:

• Difficulty breathing or noisy breathing

• Trouble swallowing saliva, or drooling

• Inability to open the mouth at all

• A rapidly swelling neck, high fever with shaking chills, or feeling very unwell

• Heavy bleeding from the throat

These can be signs of a serious complication, such as the infection spreading into the neck or chest, or blockage of the airway. Prompt treatment helps prevent these rare but dangerous problems.

Recurrent peritonsillar abscesses

After proper drainage and antibiotics, a peritonsillar abscess comes back only rarely. Because of this, routine removal of the tonsils after a single abscess is generally not recommended once the infection has settled.

Tonsillectomy (surgical removal of the tonsils) may be considered when:

• There has been more than one peritonsillar abscess (recurrent abscesses)

• There is also a history of repeated tonsil infections that meet the criteria for tonsil surgery

• The abscess involved complications, or earlier drainage attempts did not work

• Abscesses are present on both sides at the same time

For recurrent abscesses, removing the tonsils is the most definitive way to prevent future abscesses, and the chance of an abscess returning afterward is very low. However, tonsillectomy carries its own risks, most importantly bleeding after surgery and a sometimes longer recovery, so the decision is made together with the surgeon, weighing how often abscesses have happened against the risks of surgery.

The timing of tonsillectomy (for example, removing the tonsils during the acute infection versus waiting several weeks until it has healed, called "interval" tonsillectomy) is decided case by case. Some guidelines advise against routinely planning a delayed interval tonsillectomy once an abscess has resolved, because it may offer no added benefit. This is a topic to discuss with an ENT specialist.

Questions to discuss with the treating physician

• Which drainage method fits the situation, and will the procedure be done awake?

• Which antibiotic is being prescribed, and for how long?

• Which symptoms mean an urgent return visit is needed?

• Given the person's history, is tonsil removal worth considering?

More on related topics: tonsil and/or adenoid problems, pharyngitis, and tonsils and adenoids in the Learning Center.