The contemporary approach to diagnosis and management of

peritonsillar abscessRomaine F. Johnsona and Michael G. Stewartb

Purpose of review

Peritonsillar abscess is a common problem, but some

aspects of diagnosis and management remain

controversial. We review the recent literature on

peritonsillar abscess.

Recent findings

Intraoral ultrasound can be a helpful diagnostic tool for

peritonsillar abscess. For management, needle aspiration,

incision and drainage, and quinsy tonsillectomy all yield

successful results. Recent reviews have still not

established that one treatment is consistently preferred.

A randomized, placebo-controlled trail found that the use

of intravenous steroids seems to reduce many symptoms,

when used along with abscess drainage.

Summary

The use of steroids may be beneficial in the treatment of

peritonsillar abscess, and different techniques for abscess

drainage are still used around the world, with consistently

good results.

Keywords

incision and drainage, intraoral ultrasound, peritonsillar

abscess

Curr Opin Otolaryngol Head Neck Surg 13:157——160. ª 2005 Lippincott Williams& Wilkins.

aDepartment of Otolaryngology-Head and Neck Surgery, University of CincinnatiMedical Center, Cincinnati, Ohio, USA, and bThe Bobby R. Alford Department ofOtorhinolaryngology and Communicative Sciences, Baylor College of Medicine,Houston, Texas, USA

Correspondence to Michael G. Stewart, MD, MPH, Bobby R. Alford Department ofOtorhinolaryngology and Communicative Sciences, Baylor College of Medicine,One Baylor Plaza, NA-102 Houston, TX 77030, USATel: 713 798 7217; fax: 713 798-5078; e-mail: mgstew@bcm.tmc.edu

Current Opinion in Otolaryngology & Head and Neck Surgery 2005,13:157——160

Abbreviation

PTA peritonsillar abscess

ª 2005 Lippincott Williams & Wilkins.1068-9508

IntroductionPeritonsillar abscess (PTA) remains a common clinical en-

tity in otolaryngology. Although it is commonly seen, there

is still debate regarding several aspects of its evaluation and

treatment. In this review, we summarize the results from

articles published in the last 2 years with a focus on stud-

ies since December 2003 that address some of these clin-

ical issues. We also review some milestone articles on the

topic.

PTA occurs near the superior pole of the palatine tonsil,

and arises from either suppuration in the soft tissue due

to adjacent acute tonsillitis, or from obstruction of the

Weber glands at the superior tonsil pole. The exact inci-

dence of PTA is difficult to calculate, but it has been

estimated at 30 cases per 100,000 people per year in

the United States, and has also been estimated to result

in at least $150 million a year in health care expenditures

[1]. The major controversies surrounding PTA include the

best tool for diagnosis, method of acute management, and

indications for tonsillectomy, either urgent or elective.

Management issues are more complicated in pediatric

patients who are too young to tolerate drainage under local

anesthesia. So, since the child will be taken to the oper-

ating room, what procedure should be performed?

MethodsWe performed a literature search usingMEDLINEwith the

search term, ‘peritonsillar abscess,’ which is a medical sub-

ject heading term. Articles were limited to English language

and review articles were excluded. Attention was paid

to articles published in the last 2 years (2002–2004), and

which addressed aspects of the diagnosis and management

of peritonsillar abscess. Articles published before the review

period were included if the authors deemed it of special

interest.

Diagnosis of peritonsillar abscessThe historical gold standard for diagnosis of PTA has been

physical examination. However, as technology has advanced,

other diagnostic techniques have become available. In the

last two years, two articles were published on the use of

ultrasound. In the first article Lyon et al. used intraoral

ultrasound to diagnose and treat a patient with bilateral

abscesses [2]. They performed intraoral ultrasound on

a patient believed to have only a left-sided PTA, but ul-

trasound revealed the contralateral abscess as well. The

patient was treated successfully with needle aspiration

of both abscesses. In another study Blaivas et al. used

157

intraoral ultrasound to help diagnose and guide abscess

drainage by emergency room physicians [3]. They re-

ported five cases of successful diagnosis and drainage,

and one case where ultrasound did not show a PTA. That

patient underwent attempted needle aspiration, which

confirmed that there was no PTA. So in their small series

they reported 100% accuracy using ultrasound. Prior stud-

ies of ultrasound have shown similar good results [4,5].

An important aspect of intraoral ultrasound is that it still

requires a cooperative patient, and very young children are

often unable to cooperate with the examination. Within

the review period there were no articles published that

examined the best methods for diagnosing PTA in young

children. Historically, the CT scan is the best choice

for diagnosing suspected PTA in young uncooperative

patients [6].

ManagementMost of the debate surrounding PTA centers on its manage-

ment [7]. The choices are needle aspiration, or incision

and drainage under either local anesthesia or general an-

esthesia, or abscess drainage with simultaneous tonsillec-

tomy (‘quinsy tonsillectomy’). As with diagnosis, the

decision making can be more complex in an uncooperative

young child, because general anesthesia may be needed

for any method of treatment.

One group performed a survey on the management of PTA

by otolaryngologists in the United Kingdom [8]. Sixty per-

cent of respondents used needle aspiration as the primary

means of treating PTA, and 25% used incision and drain-

age. If needle aspiration failed, then the majority (52%)

would perform incision and drainage. Interestingly, 68%

of respondents admitted every PTA patient to the hospi-

tal, and 26% admitted at least 60% of PTA patients; so a

total of 94% of British respondents treated most or all of

their patients as inpatients, which is likely a much higher

rate than in the United States. Physicians in the U.K. also

commonly used intravenous antibiotics initially, although

the mean number of doses was not specified.

The survey noted that management strategy differed de-

pending on volume of cases. Physicians who saw the largest

number of patients with PTA tended to use needle aspira-

tion more frequently. Additionally, there were geographic

differences: Physicians in England performed incision and

drainage more frequently than those in Scotland. Finally,

the authors did not attempt to compare treatment effi-

cacy or outcome in their report, but only reported which

treatments were used.

A retrospective review from Singapore reported on 185

patients with peritonsillar infection; 151 had abscess

and 34 cellulitis [9•]. Most patients (66%) were treated

with incision and drainage, which was successful. The

other patients (34%) had needle aspiration; in 26 patients,

purulence was identified and drained. However, in this se-

ries 16 of 26 (62%) patients treated with initial needle

aspiration had persistent symptoms and subsequently re-

quired incision and drainage, which in each case was ulti-

mately successful. That failure rate of 62% after needle

aspiration is the highest reported in the literature. In their

series, all patients were admitted at least overnight for

intravenous antibiotics. The overall rate of recurrent PTA

was 7.6%; they did not analyze their data for risk factors

predicting recurrent PTA.

In another article, a German group published their results

for PTA treatment [10]. They performed quinsy tonsil-

lectomy exclusively and looked both retrospectively and

prospectively at their data, specifically at outcomes of

treatment. Although there have been consistent reports

in the past of the success of the quinsy tonsillectomy tech-

nique, the recent study did confirm some findings. For

example, quinsy tonsillectomy was well tolerated, and

the complication rate was very low in their series. In addi-

tion, they found that the prevalence of PTA after recurrent

tonsillitis was low (11%).

The use of steroids as adjunctive therapy for pharyngitis

and tonsillitis has been reported as safe and effective,

and has become more commonplace in recent years. Al-

though there have been few studies that have addressed

the use of steroids in PTA, it seems that the use of ste-

roids in PTA has also been increasing. Recently, Ozbek

et al. studied the use of steroids for PTA in a randomized

trial [11]. Patients received either intramuscular steroids

or placebo, along with abscess drainage by needle aspira-

tion and intravenous antibiotics which were continued at

least 2 days and until the patient improved. All patients

were hospitalized, so the results of treatment could be

easily documented; specific outcomes assessed included

hours hospitalized, throat pain, time to oral intake, fever,

and trismus. The authors found a statistically significant

difference favoring the use of steroids for several out-

comes. For example, at 12 h 70% of the steroid group were

able to swallow water without pain, whereas only 18% of

the placebo group could; similar large differences were

noted in the presence of fever at 24 h (28% and 86%),

and other outcomes. The steroid group also did not have

any increased frequency of complications.

Johnson et al. performed an evidence-based review of the

literature on PTA, which reviewed many of these issues

[7]. The review asked three specific clinical questions:

‘Are steroids beneficial in the treatment of PTA?’, ‘What

is the most effective method of acute management?’,

and ‘Which patients would benefit from tonsillectomy

to prevent recurrences of PTA?’ The review did not ad-

dress the diagnosis of PTA. English language articles pub-

lished from 1966 to 2001 were retrieved using a systematic

158 General otolaryngology

literature search. Articles were graded and assigned an ev-

idence level according to the quality of the evidence, us-

ing the method of Sackett [12]. Summary evidence tables

were created and an overall evidence grade of recommen-

dation was assigned for each of the clinical questions.

The review found no evidence on the use of steroids.

Regarding the best method of management, the review

found grade C evidence that either needle aspiration

or incision and drainage are effective initial treatments.

Compiling the data from multiple studies, incision and

drainage had a slightly higher success rate than needle as-

piration (94% vs. 92%), but incision and drainage are more

painful. Furthermore, the number needed to treat was 48

patients. In other words, it would take 48 patients treated

by incision and drainage to prevent one failure treated by

needle aspiration. Based on those findings, the authors

concluded that needle aspiration was probably the best

initial treatment, with incision and drainage performed

if needle aspiration fails.

Other studies of interest included a study by Ono et al. onthe airway management of patients with PTA [13]. The

authors concluded that awake fiberoptic bronchoscopy

was the method of choice for intubating PTA patients if

there was significant pharyngeal edema, or if the patient

was having airway distress. However, most patients in

their series could be intubated orally using a standard

technique.

Another recent study suggested that infectious mononu-

cleosis somehow plays a role in PTA [14]. In their study,

they screened a large number of patients who presented

with unilateral PTA and found a 6% incidence of infec-

tious mononucleosis. Although we cannot make assump-

tions about cause and effect based on cross-sectional

data, it is still an interesting finding. The authors recom-

mended that routine screening of all patients with PTA

might be beneficial, because the complications of infec-

tious mononucleosis could perhaps be recognized and

treated earlier.

Recommendations for interval tonsillectomyThe recurrence rate of PTA and the indications for elec-

tive interval tonsillectomy to prevent future PTA recur-

rence have not been clearly defined by well-designed

prospective studies. In the Johnson review [7•], two levelII (retrospective cohort) studies were identified that

addressed the risk of recurrent PTA. Both studies were

small, and they reported conflicting results: One showed

an increased rate of recurrent PTA in patients who also

had recurrent tonsillitis, and the other study showed no

difference in recurrent PTA based on a prior history of ton-

sillitis. Calculation of a true recurrence rate can be diffi-

cult because of issues surrounding follow-up and data

reporting, however the reported prevalence of recurrent

PTA, in all patients, is usually around 10%. Based on these

findings and the rest of the evidence, Johnson et al. recom-

mended that routine elective tonsillectomy, or quinsy ton-

sillectomy, for patients who present with their first PTA

was unnecessary. While not supported or contraindicated

by the available evidence, if a patient was a candidate for

elective tonsillectomy for other reasons, then it seems ra-

tional to perform a quinsy tonsillectomy for treatment, or

to proceed with planned elective tonsillectomy after suc-

cessful abscess drainage.

Pediatric patientsThe management of patients that are too young to undergo

drainage under local anesthesia is not well defined. The

primary issue is to whether to perform quinsy tonsillectomy

on all cases regardless of a prior history of tonsillitis or

PTA. At first this may seem excessive, if considered from

the perspective of prevention of recurrence. Needle aspi-

ration or incision and drainage can be performed under

general anesthesia, and the outcomes should be equiv-

alent to those under local anesthesia, which is highly

successful. However, the complication rate of quinsy ton-

sillectomy is low, the literature supports its use as defin-

itive treatment, and one can make the argument that if

a young child is being taken to the operating room, then

the surgeon should perform the most definitive proce-

dure, which is quinsy tonsillectomy. Therefore, quinsy ton-

sillectomy perhaps makes the most sense for children that

require a general anesthetic. Indeed, based on that logic,

quinsy tonsillectomy may be the treatment of choice for

any patient undergoing general anesthesia for treatment.

ConclusionBased on the available evidence, a reasonable approach for

the diagnosis of PTA is to use physical examination as the

primary diagnostic technique. If there is doubt on the

physical examination, intraoral ultrasound is an option al-

though it requires a cooperative patient, and CT scan is

another diagnostic option. Attempted needle aspiration

can be both diagnostic and therapeutic in skilled hands,

so if alternative diagnostic methods such as ultrasound

are not available, attempted needle aspiration can be used

as a diagnostic tool as well.

In the patient with PTA, if acute management outside of

the OR is attempted, it appears as if needle aspiration may

be slightly more advantageous due to its high efficacy, low

cost, and patient tolerance. Incision and drainage is an ef-

fective and inexpensive option, although it is slightly more

painful. If general anesthesia is required because of the

patient’s age or lack of cooperation, then quinsy tonsillec-

tomy should be considered, although aspiration or incision

and drainage are also options.

Diagnosis and management of peritonsillar abscess Johnson and Stewart 159

When considering the role of elective tonsillectomy, there

is no clear evidence that routine tonsillectomy is indicated

to prevent future PTA. If a patient has had multiple recur-

rent episodes of PTA, or has other clear indications for

tonsillectomy (such as sleep-disordered breathing) then

elective tonsillectomy should be strongly considered. In

addition, quinsy tonsillectomy might be the best initial

treatment in such a patient.

While there are many studies on PTA, most are uncon-

trolled, and/or they do not compare any treatment or di-

agnostic options, so choosing the optimal methods for

diagnosis and treatment is controversial. However, it is

also clear that several techniques are highly effective for

the diagnosis and management of this common problem,

so the clinician has several good options from which to

choose.

References and recommended readingPapers of particular interest, published within the annual period of review, havebeen highlighted as:• of special interest•• of outstanding interest

1 Herzon FS, Harris P. Mosher Award thesis. Peritonsillar abscess: incidence,current management practices, and a proposal for treatment guidelines.Laryngoscope 1995; 105:1——17.

2 Lyon M, Glisson P, Blaivas M. Bilateral peritonsillar abscess diagnosed on thebasis of intraoral sonography. J Ultrasound Med 2003; 22:993——996.

3 Blaivas M, Theodoro D, Duggal S. Ultrasound-guided drainage of peritonsillarabscess by the emergency physician. Am J Emerg Med 2003; 21:155——158.

4 Scott PM, Loftus WK, Kew J, et al. Diagnosis of peritonsillar infections: a pro-spective study of ultrasound, computerized tomography and clinical diagno-sis. J Laryngol Otol 1999; 113:229——232.

5 Haeggstrom A, Gustafsson O, Engquist S, et al. Intraoral ultrasonography inthe diagnosis of peritonsillar abscess. Otolaryngol Head Neck Surg 1993;108:243——247.

6 Friedman NR, Mitchell RB, Pereira KD, et al. Peritonsillar abscess in earlychildhood. Presentation and management. Arch Otolaryngol Head Neck Surg1997; 123:630——632.

7 Johnson RF, Stewart MG, Wright CC. An evidence-based review of the treat-ment of peritonsillar abscess. Otolaryngol Head Neck Surg 2003; 128:332——343.

8 Mehanna HM, Al-Bahnasawi L, White A. National audit of the management ofperitonsillar abscess. Postgrad Med J 2002; 78:545——548.

•9 Ong YK, Goh YH, Lee YL. Peritonsillar infections: local experience. Singapore

Med J 2004; 45:105——109.This case series and review of the literature provides a balanced discussion con-cerning the different options for treatment.

10 Dunne AA, Granger O, Folz BJ, et al. Peritonsillar abscess——critical analysis ofabscess tonsillectomy. Clin Otolaryngol 2003; 28:420——424.

11 Ozbek C, Aygenc E, Tuna EU, et al. Use of steroids in the treatment of peri-tonsillar abscess. J Laryngol Otol 2004; 118:439——442.

12 Sackett DL SS, Richardson WS. Evidence-based medicine: how to practiceand teach EBM, 2nd ed. Edinbourgh: Wolfe Publishing; 2000.

13 Ono K, Hirayama C, Ishii K, et al. Emergency airway management of patientswith peritonsillar abscess. J Anesth 2004; 18:55——58.

14 Ryan C, Dutta C, Simo R. Role of screening for infectious mononucleosis inpatients admitted with isolated, unilateral peritonsillar abscess. J LaryngolOtol 2004; 118:362——365.

160 General otolaryngology