Most emergency physicians recall hearing something along the lines of “the solution to pollution is dilution,” and “the answer to pus is a scalpel,” or “if there’s pus, let it out,” at some point during their training. Source control through drainage by any number of methods depending on the location and size — needle aspiration, incision and drainage (I&D), or loop-drainage — is a key principle in abscess management. Historically, the treatment of patients with peritonsillar abscesses has been no different.

Over time, however, the treatment of peritonsillar abscess has become increasingly less invasive. Initially, tonsillectomy (called quinsy tonsillectomy in this case) was once typical care for peritonsillar abscess. Although some individuals with recurrent infections may require tonsillectomy, in the urgent setting, this surgical procedure has largely been replaced by I&D. More recently, needle aspiration, even less invasive than a traditional I&D, has shown comparable outcomes with I&D and may be associated with less discomfort. However, a significant amount of recent observational data has challenged the necessity of any surgical treatment for many patients with peritonsillar abscess.^1–4 Lately, many have questioned the need for initial surgical treatment. Medical therapy, generally consisting of an antibiotic (either clindamycin, amoxicillin/clavulanate, or ampicillin/sulbactam) and steroids, is increasingly embraced for this disease.

Why the shift? Needle aspiration and I&D not only take additional physician time and resources, but also are associated with increased morbidity, pain, and missed days of work.³ Additionally, the occurrence of “dry taps” is frustrating for clinicians and patients. It is not infrequent, occurring in up to 50 percent of cases, that an aspiration or I&D attempt fails to obtain pus. It can be difficult to clinically differentiate where patients fall on the spectrum of peritonsillar abscess versus phlegmon. Even the addition of point-of-care intra-oral ultrasound is imperfect, with a sensitivity of approximately 91 percent (95% CI: 82%–95%) and a specificity of 75 percent (95% CI: 63%–84%).⁵

A study from an integrated health care delivery system compared outcomes from 12 centers that had adopted medical treatment as first-line with seven sites that continued with surgical drainage. Consistent with prior studies, similar failure and complication rates occurred in patients treated with medical and surgical therapy. However, the medical treatment group had a reduced number of opioid prescriptions, missed days of work, and fewer sore throat days.³ In this study, not all patients received imaging, and some might argue that these patients could have had peritonsillar cellulitis rather than frank abscess.