Peritonsillar Abscess

 

Am Fam Physician. 2017 Apr 15;95(8):501-506.

Patient information: See related handout on peritonsillar abscess, written by the author of this article.

Author disclosure: No relevant financial affiliation.

Peritonsillar abscess is the most common deep infection of the head and neck, occurring primarily in young adults. Diagnosis is usually made on the basis of clinical presentation and examination. Symptoms and findings generally include fever, sore throat, dysphagia, trismus, and a “hot potato” voice. Drainage of the abscess, antibiotic therapy, and supportive therapy for maintaining hydration and pain control are the cornerstones of treatment. Most patients can be managed in the outpatient setting. Peritonsillar abscesses are polymicrobial infections, and antibiotics effective against group A streptococcus and oral anaerobes should be first-line therapy. Corticosteroids may be helpful in reducing symptoms and speeding recovery. Promptly recognizing the infection and initiating therapy are important to avoid potentially serious complications, such as airway obstruction, aspiration, or extension of infection into deep neck tissues. Patients with peritonsillar abscess are usually first encountered in the primary care outpatient setting or in the emergency department. Family physicians with appropriate training and experience can diagnose and treat most patients with peritonsillar abscess.

Peritonsillar abscess is the most common deep infection of the head and neck, with an annual incidence of 30 cases per 100,000 persons in the United States.13 This infection can occur in all age groups, but the highest incidence occurs in adults 20 to 40 years of age.1,2 Peritonsillar abscess is most commonly a complication of streptococcal tonsillitis; however, a definitive correlation between the two conditions has not been documented.4

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SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingReferences

Some type of drainage procedure is appropriate treatment for most patients who present with a peritonsillar abscess.

C

6, 7, 13

Broad-spectrum antibiotics effective against group A streptococcus and oral anaerobes should be considered first line after drainage of the abscess, although some evidence suggests that penicillin alone may be sufficient.

C

9, 12, 17, 18

Corticosteroids may be useful in reducing symptoms and speeding recovery in patients with peritonsillar abscess.

B

3, 15, 26


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to http://www.aafp.org/afpsort.

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingReferences

Some type of drainage procedure is appropriate treatment for most patients who present with a peritonsillar abscess.

C

6, 7, 13

Broad-spectrum antibiotics effective against group A streptococcus and oral anaerobes should be considered first line after drainage of the abscess, although some evidence suggests that penicillin alone may be sufficient.

C

9, 12, 17, 18

Corticosteroids may be useful in reducing symptoms and speeding recovery in patients with peritonsillar abscess.

B

3, 15, 26


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to http://www.aafp.org/afpsort.

Anatomy

The two palatine tonsils lie on the lateral walls of the oropharynx in the depression between the anterior tonsillar pillar (palatoglossal arch) and the posterior tonsillar pillar (palatopharyngeal arch). The tonsils are formed during the last months of gestation and grow irregularly, reaching their largest size by the time a child is six to seven years of age. The tonsils typically begin to involute gradually at puberty, and after 65 years of age, little tonsillar tissue remains.5 Each tonsil has a number of crypts on its surface and is surrounded by a capsule between it and the adjacent constrictor muscle through which blood vessels and nerves pass. Peritonsillar abscess is a localized infection where pus accumulates between the fibrous capsule of the tonsil and the superior pharyngeal constrictor muscle.6,7

Etiology

Peritonsillar abscess has traditionally been regarded as the last stage of a continuum that begins as an acute exudative tonsillitis, which progresses to a cellulitis and eventually abscess formation. However, this assumes a close association between peritonsillar abscess and streptococcal tonsillitis. Because the occurrence of peritonsillar abscess

The Author

NICHOLAS J. GALIOTO, MD, is associate director of the Family Medicine Residency Program and director of the Transitional Year Residency Program at Broadlawns Medical Center, Des Moines, Iowa.

Address correspondence to Nicholas J. Galioto, MD, Broadlawns Medical Center, 1801 Hickman Rd., Des Moines, IA 50314 (e-mail: ngalioto@broadlawns.org). Reprints are not available from the author.

Author disclosure: No relevant financial affiliation.

REFERENCES

show all references

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