Peritonsillar Abscess

NICHOLAS

J.

GALIOTO,
Broadlawns MD,
Medical Center, Des Moines, Iowa

Peritonsillar abscess remains the most common deep infection of the head and neck. The condition occurs
primarily
in young adults, most often during November to December and April to May, coinciding with the highest
incidence of pharyngitis and exudative tonsillitis. A peritonsillar abscess is a polymicrobial infection, but
streptococcal
Group
A
streptococcus
is the predominate organism. Symptoms generally include fever, malaise, sore throat,
dysphagia,
and may include trismus and a mufed voice (also called hot potato voice). Drainage of
otalgia. Physical
ndings
the
abscess, antibiotics, and supportive therapy for maintaining hydration and pain control are the foundation of
treatment. Antibiotics effective against Group A streptococcus and oral anaerobes should be rst-line therapy.
may Steroids
be helpful in reducing symptoms and speeding recovery. To avoid potential serious complications, prompt
recognition
and initiation of therapy is important. Family physicians with appropriate training and experience can
diagnose and treat most patients with peritonsillarAm
abscess.
(
Fam Physician
. 2008;77(2):199-202, 209. Copyright
2008American Academy of Family Physicians.)

a eritonsillar
pathway abscess
for
blood
is
vessels
the
most and
com- nerves.
Perimon deep
tonsillar
infectionabscesses
of
the
form head
in
the
area between
and
neck in
young
the adults,
palatine
despite tonsil and 1its
capsule.
the
widespread use
of
antibiotics
Etiology
for
treating
tonsillitis
and
pharyngitis. This
Patient information:
infection
can
occur
Peritonsillar
in
all
abscess
age
groups,
has
traditionally
but
the been
A handout on peritonsillar
abscess, written by the highest
regarded
incidence
as
is
the
in
end
adultspoint
20
ofto
a40
continuum
years of
author of this article, is age.
1,2
Peritonsillar abscess
that
begins most
as
commonly
acute exudative
tonsillitis,
proprovided on page 209.
occurs during gresses
November
to
cellulitis,
December
and
eventually
forms an
April to
May, which
abscess.
coincidesA
with
recentthe
reviewhighimplicates
Webers
est
glands
incidence
as
playing
rates of
a
streptococcal
key
role
pharyn-in
the
formation
gitis
and
exudative3,4 Peritonsillar
tonsillitis.of
peritonsillar 6,7
abscesses.
This
group of
abscesses
are
to almost
25 always
mucous
rst
20 encountered
salivary
glands are
located
by
inthe
the
family space
physician,
just
superior
and
those to
with the
appro-tonsil in
the
priate training soft and
palate
experience
and
are can
connected
diagnose to
the
surface
7
and
treat of
most the
patients.
tonsil by
Promptrecognia
duct. The
glands clear the
tion
and
initiation
tonsillar of
area
therapy
of
debris
is
and
important
assist with
to
the
avoid potential
digestion
seriouscomplications.
of
food particles
trapped
in
the
tonsillar
crypts. If
Webers
glands become
Anatomy
inamed,
local cellulitis
can
develop.
The
two As
palatine
the
infection
tonsils lie
progresses,
on
the
the
lateralduct
walls to
the
of
the
oropharynx
surface
in of the the depression
tonsil becomes
between progressively
the
anterior
tonsillar morepillar
obstructed
(palatoglossal
from surrounding inamarch) and mation.
the
posterior
The
resulting
tonsillar
tissue
pillar necrosis
(palaand
pus
topharyngeal arch).
formation
The
tonsils
produce
form during
the
classic signs and
symp8
the
last
monthstoms of
of
peritonsillar
gestation
abscess.
and
grow
These
irregu-abscesses
larly, reaching
generally their
formlargest
in size
the at area approxiof
the
soft
palate,
matelyjust
six
above
or
the
seven superior
years of
pole
age. of
The the
tonsilstonsil, in
the
7
begin to
location
gradually
of
involute
Webers
at
glands.puberty,The
and
occurrence
of
5
by
older age peritonsillar
little tonsillar
abscesses
tissue
in remains.
patients
who
have
When healthy,
the
undergone
tonsils do
tonsillectomy
not
projectfurther supports
the
2
beyond
theory
the
that
tonsillar
Webers
pillars glands
medially.
have aEach role
in
the
tonsil has
a
number pathogenesis.
of
crypts
Otheronclinical
itsvariables
surface include
6
and
is
surrounded
signicant
by
aperiodontal
capsulediseasethat
provides
and
smoking.
This article exemplies the AAFP 2008 Annual
Clinical Focus on infectious
disease: prevention, diagnosis, and management.

Downloaded from the American Family Physician Web site at www.aafp.org/afp. Copyright 2008 American Academy of Family Physicians. For the private,
noncommercial
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PeritonsillarAbscess

ClinicalManifestations
SORT:KEYRECOMMENDATIONSFORPRACTICE

Patients
with peritonsillar abscess
appearill
and
present
with
fever,
malaise,
sore
throat,
Evidence
Clinical recommendation
rating
References
dysphagia,
or
otalgia.
The
throat pain is
markedly more severe on
the
affected
side
and
is
Treatment for peritonsillar abscess shouldC
1, 3, 6, 12
often
referred
to
the
ear
on
the
same
side.
Physinclude drainage and antibiotic therapy.
ical
examination usuallyreveals
trismus,
with
Initial empiric antibiotic therapy for
C
the
patienthaving
difculty
opening
his
or
her
peritonsillar abscess should include
8, 13, 14
antimicrobials effective against Group A
mouth because
of
pain from inammation
9
streptococcus and oral anaerobes.
and
spasm of
masticator
muscles.
Swallowing
Steroids may be useful in reducing is
symptoms
B also
17
highly painful,
resulting
in
pooling
of
and in speeding recovery in patients with
9
saliva or
drooling.
Patients
often speak in
a
peritonsillar abscess.
mufed
voice (also called hot potato voice).
Markedly
tender cervical
lymphadenitis may
A = consistent, good-quality patient-oriented evidence; B = inconsistent
or limitedquality patient-oriented evidence; C = consensus,
evidence, usual
bedisease-oriented
palpated
on
the
affected
side. Inspection
practice, expert opinion, or case series. For information about the SORT evidence
of
the
oropharynx
reveals
tense
swelling
and
rating system, see page 131 or http://www.aafp.org/afpsort.xml.
erythema
of
the
anterior
tonsillar
pillar and
the
soft
palate overlying
the
infected
tonsil.
The
tonsil is
generally
displaced
inferiorly
and
medially
with contralateral deviation
of
the
uvula(FigureThe
1).
most common
symptoms and
physical
ndings
are
summarized in
Table
Potential
.1
complications of
peritonsillar
abscess
Table
are .2Death
outlined
can
in
occur
from
airway
obstruction,
aspiration,
or
Soft palate
hemorrhage
from
erosion
or
septic
necrosis
swelling
into
the
carotid sheath.
Diagnosis

Tonsil

The
diagnosis
of
peritonsillar abscess
is
often made on
the
basis of
a
thorough
history
and
physical
examination. Differential
diagnosis
includes
infectious
mononucleosis,
lymphoma,
peritonsillar cellulitis,
and
retromolar
or
retropharyngeal
abscess.
Patients
often present
with peritonsillar cellulitis
with
Figure1. Patientwithrightperitonsillarabscess.
the
potential
to
progress
to
abscess
formation.
In
peritonsillar cellulitis,
the
area between
the
tonsil
and
its
capsule
is
edematous
and
eryTable1.CommonSymptomsandPhysicalFindingsin
thematous, but
pus
has
not 1 yet
formed.
PatientswithPeritonsillarAbscess
On
occasions
when the
diagnosis
of
peritonsillar
abscess
is
in
question,
the
presence
Symptoms
Physicalndings
of swollen
pus
on
needle aspiration
or
radiologic
testFever
Erythematous,
soft palate
with
uvula
deviation
ing
to
contralateral
may
help
conrm
the
diagnosis.
TransMalaise
side and enlarged tonsil
cutaneousor intraoral ultrasonography
Severe sore throat
Trismus
(worse on one side)
also
can
be
helpful in
identifying
an
abscess
Drooling
Dysphagia
and
in
distinguishing peritonsillar abscess
1,6
Mufed voice (hot potato voice)
Otalgia (ipsilateral)
from peritonsillar cellulitis.
If
spread of
the
Rancid or fetor breath infection
beyond
the
peritonsillar space or
Cervical lymphadenitis
complications involving
the
lateral neck space
are
suspected,
computed
tomography (CT)
or
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PeritonsillarAbscess
Table2.ComplicationsofPeritonsillarAbscess
Table3.CommonOrganismsAssociated
withPeritonsillarAbscess
Airway obstruction
Anaerobicbacteria
Aerobicbacteria
Aspiration pneumonitis or lung abscess secondary to
peritonsillar abscess rupture
Fusobacterium
Group A streptococcus
Death secondary to hemorrhage from erosion or septic
Peptostreptococcus
Staphylococcus aureus
necrosis into carotid sheath
Pigmented Prevotella
Haemophilus inuenzae
Extension of the infection into the tissues of the deep neck
or posterior mediastinum
Information from references 8 and 14.
Poststreptococcal sequelae (e.g., glomerulonephritis, rheumatic
fever) when infection is caused by Group A streptococcus

the
development of
similar to
that
of

peritonsillar abscess,
its
treatment
is
a
peritonsillar abscess,
excluding
the
need for
surgical
drainage.
The
main procedures
for
the
drainage
of
peritonsillar
abscess
are
needle aspiration,
incision
and
drainage,
and
immediate
tonsillectomy. Drainage
using any
of
these
methods
combined
with antibiotic
therapy
will
result
Area of abscess
in
resolution
of
the
peritonsillar abscess
in
more than
6
percent
of
90
cases. The
acute
surgical
management of
Right tonsil
peritonsillar abscess
has
evolved
over time from routine
immediate
tonsillectomy to
increased
use
of
incision
and
11
drainage
or Immediate
needle
aspiration.
abscess
tonsilUvula
lectomy
has
not
been
proven to
be
any
more effective
than
needle aspiration
or
incision
and
drainage,
and
it
is
consid12
ered to
be
Several
less
cost-effective.
studiescomparing
needle aspiration
with incision
and
drainage
have found
no
signicant
statistical
differences
in 11,12 outcomes.
Although
it
is
not
routinely
performed
for
the
treatment of
peritonsillar abscess,
immediate
tonsillectomy
should be
considered
for
patients
who
have strong indications
for
tonsillectomy, including
those who
have
symptoms
of
sleep apnea, a
history of
recurrent
tonsillitis
(four or
more infections
per
year despite
adequate
medical
therapy),
or
a
recurrent
or
nonresolving peri6
tonsillar Initialabscess.
empiric
antibiotic
therapy
Figure2. Computedtomographyofarightperitonsillar
abscess.
should include
antimicrobials effective
against
Group
13
A
streptococcus and
oral
Theanaerobes.
most commagnetic
resonance mon
imaging
organisms (MRI)
associated
is
indicated.
with peritonsillar
CT
can abscess
are
distinguishbetweenperitonsillarcellulitisandperitonsillar
listed Although
in
Table .38,14
peritonsillar abscesses
are
abscess,
as
well
as
demonstrate
polymicrobial the
infections,
spread of
severalthe
infection
studieshave shown
to
any
contiguous
intravenous
spaces
penicillin
in(Figure
the
2). alone
deep toneck beregionas
clinically
effective
MRI
has
the
advantage
as
broader-spectrum
of
improved
antibiotics,
soft-tissue
provided
denition
the
abscess
12,14
over CT
without
exposure
to has
radiation.
been adequately
Additionally,
In
these
drained.
MRI
studies,
inadis
superior
to
equateclinical
CT
in
response
detecting following
complications
24from hours
deepof
antibiotic
neck infections
therapy
such
played
as a internal
signicant jugular
roleveinin thrombosis
the
decision
to
use
or
erosion
of
thebroad-spectrum
abscess
into
antibiotics.
the
carotid
Several
sheath. otherDisadvanstudieshave
tages of
MRI
include
reported
longer
that scanning
more than times,
50
higher
percentcost, of
culture results
10
lack
of
availability, demonstrated
and
the
the
potential
presence
for
of
claustrophobia.
beta-lactamase
producing
anaerobes,
leading
many physicians
to
use
broader8,14,15
Treatment
spectrum
antibiotics
as
rst-line
Tabletherapy.
4
16
Drainage
of
the
abscess,
antibiotics,
shows suggested
and
supportive
antimicrobial
ther- regimens.
apy
to
maintain Although
hydration steroids
and
painhave
control
been
are used
the to fountreat edema and
dation of
treatment
forinammation
peritonsillar
in abscess.
other otolaryngologic
Because
diseases,
their
peritonsillar cellulitis
role
in represents
the
treatment
a
transitional
of
peritonsillar
stage in abscess
has
not

January 15, 2008

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201
American Family Physician

PeritonsillarAbscess
Table4.AntimicrobialRegimensfor
PeritonsillarAbscess
Intravenoustherapy

University of Iowa Carver College of Medicine in Iowa City. Dr. Galioto

Ampicillin/sulbactam (Unasyn) 3 g every six hours
received his medical degree from Creighton University in Omaha, Neb., and
Penicillin G 10 million units every six hours plus
completed a family medicine residency at Broadlawns Medical Center.
metronidazole (Flagyl) 500 mg every six hours
Address correspondence to Nicholas J. Galioto, MD, Broadlawns MediIf allergic to penicillin, clindamycin (Cleocin) 900 mg
cal Center, 1801 Hickman Rd., Des Moines, IA 53104 (e-mail: ngalioto@
every eight hours
broadlawns.org). Reprints are not available from the author.
Oraltherapy
Author disclosure: Nothing to disclose.
Amoxicillin/clavulanic acid (Augmentin) 875 mg twice daily
Penicillin VK 500 mg four times daily plus metronidazole
500 mg four times daily
REFERENCES
Clindamycin 600 mg twice daily or 300 mg four times daily1. Steyer TE. Peritonsillar abscess: diagnosis and treatment [Published corInformation from reference 16.

rection appears in
Am Fam Physician
. 2002;66(1):30].Am Fam Physician. 2002;65(1):93-96.
2. Khayr W, Taepke J. Management of peritonsillar abscess: needle aspiration versus incision and drainage versus tonsillectomy.
Am J Ther
.
2005;12(4):344-350.

been extensively studied.

A
recent study reported
that
3. Belleza WG, Kalman S. Otolaryngologic emergencies in the outpatient
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(methylprednisolone [Depo-Medrol]2
to
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mg
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4. Bisno AL, Gerber MA, Gwaltney JM, Kaplan EL, Schwartz RH, for the
Infectious
Diseases Society
of America. Practice guidelines for the diagup
to
250
mg)
intravenously plus
antibiotics
responded
A streptococcal pharyngitis. Infectious
much more quicklyto
treatment
than nosis
28 and management
patients of group
who
Diseases Society of America.
Clin Infect Dis
. 2002;35(2):113-125.
received
antibiotics 17plus
The placebo.
use
of 5. Berkovitz
steroids
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in
the
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of
peritonsillar abscess
appears
helpNY: Churchill
Anatomical Basis of Clinical
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speed recovery,
but
additional
studiesare
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before
Martin AD. Medical and surgical treatment of peritonsillar,
making
a
recommendation 6,17 for 6. Herzon
their FS,routineuse.
retropharyngeal, and parapharyngeal abscesses.
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treat2006;8(3):196-202.
ing
peritonsillar abscess
or
when 7. complications
or of peritonsillar
ques- abscess.
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an
otolaryngologist
should
8. Brook
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diagnosis
has I. Microbiology
been established,
geal, and parapharyngeal abscesses.
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formedin
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9. Nwe TT, Singh B. Management of pain in peritonsillar abscess.
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gol Otol. 2000;114(10):765-767.
Ghorayeb
BY, Stiernberg
well
suited for
the
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who PW,has
had
appro-CM. Contemporary management
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space infections.
.
priate training.
The
patientshould be
observed
a Otolaryngol
few Head Neck Surg
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hours after aspiration
to
ensure he 11. or
she
can
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Johnson RF, Stewart MG, Wright CG. An evidence-based review of
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the treatment
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.
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should occur in
24 Oral
to antibiotics
36
hours.
are2003;128(3):332-343.
con12. Herzon FS, Harris P. Mosher Award thesis. Peritonsillar abscess: incitinued for
10
days.
dence, current management practices, and a proposal for treatment
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can
be
Laryngoscope
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treated
in
an
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may
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DA, Bhattacharyya N, Siegel NS, Salman SD. Selection of antibiotare
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pain control and 14. Kieff
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The
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developing
a
secondperitonsillar
Head
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. 1999;120(1):57-61.
11,12
abscess
is
approximately10
Up
to
to 15.30
15
percent.
Ozbek C, perAygenc
E, Unsal E, Ozdem C. Peritonsillar abscess: a comparison of outpatient
IM clindamycin
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critefollowing needle aspiration.
Ear Nose Throat
. 2005;84(6):366-368.
J
12
ria
for
tonsillectomy.
This
operation
may be
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16. Fairbanks DN, ed. Pocket Guide to Antimicrobial Therapy in Otolarynimmediately or
delayed
until the
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hasSurgery.
resolved.
gologyHead and Neck
12th ed. Alexandria, Va.: American
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roids in the treatment of peritonsillar abscess.

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NICHOLAS J. GALIOTO, MD, is associate director of the Family Medicine
2004;118(6):439-442.
Residency Program and director of the Transitional Year Residency
Program for Broadlawns Medical Center in Des Moines, Iowa. He
has aJR. ED considerations in the diagnosis and treatment of peri18.also
Roberts,
clinical teaching appointment in the Department of Family Medicine
atabscess.
the Emerg Med News.
tonsillar
2001;23(3):6,9-10.

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