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with recurrent infections may require tonsillectomy, in the urgent setting, this surgical procedure has largely been replaced by I&D. More recently, needle aspiration, even less invasive than a traditional I&D, has shown comparable outcomes with I&D and may be associated with less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.

What If There Is Definitive Abscess?

A retrospective study assessed outcomes among 214 emergency eepartment (ED) patients who underwent CT imaging demonstrating a definitive peritonsillar abscess at one of three EDs. Overall, the mean abscess size was 2.0 cm. The study found treatment failure (defined as return visit with need for surgical treatment within 30 days), was similar between groups treated with medical therapy (8.0 percent) or surgical therapy (7.9 percent).

As expected in non-randomized data, there were some differences between groups. Individuals selected for medical treatment alone were, on average, older, less likely to be febrile, and had smaller abscess size (1.69 cm versus 2.32 cm). In a secondary analysis of outcomes based on abscess size, there was no difference in treatment failure between medical therapy (5.3 percent) and surgical treatment (5.0 percent); however, in those with an abscess >2.0 cm, there was a non-significant trend towards treatment failure in the medical therapy alone group (13.3 percent vs 9.2 percent). Interestingly, when the definition of treatment failure included return ED visits for pain without subsequent surgical intervention, the failure rate in the surgical group jumped to 18.4 percent, making medical treatment alone appear more appealing.¹

In most patients, the initial treatment of peritonsillar abscess is perfect for informed, shared decision making. The evidence clearly demonstrates that 5 to 15 percent of patients with peritonsillar abscess will have treatment failure/recurrence, regardless of whether the abscess was drained on the initial visit. Patients should receive counseling that regardless of initial treatment approach, there is a decent chance they may need a subsequent procedure and that drainage is more painful. While initial drainage is certainly necessary in ill-appearing patients and probably preferable for large abscesses, in others, an initial approach of antibiotics and steroids is in line with the best available evidence.

DR. WESTAFER (@LWESTAFER) is an assistant professor in the departments of emergency medicine and healthcare delivery and population science at UMass Chan Medical School, Baystate, and co-host of FOAMcast.

References

1. Urban MJ, Masliah J, Heyd C, Patel TR, Nielsen T. Peritonsillar abscess size as a predictor of medical therapy success. Ann Otol Rhinol Laryngol. 2022;131(2):211-218.
2. Zebolsky AL, Dewey J, Swayze EJ, Moffatt S, Sullivan CD. Empiric treatment for peritonsillar abscess: A single-center experience with medical therapy alone. Am J Otolaryngol. 2021;42(4):102954.
3. Battaglia A, Burchette R, Hussman J, Silver MA, Martin P, Bernstein P. Comparison of medical therapy alone to medical therapy with surgical treatment of peritonsillar abscess. Otolaryngol Head Neck Surg. 2018;158(2):280-–286.
4. Souza DLS, Cabrera D, Gilani WI, et al. Comparison of medical versus surgical management of peritonsillar abscess: A retrospective observational study. Laryngoscope. 2016;126(7):15291534.
5. Kim DJ, Burton JE, Hammad A, et al. Test characteristics of ultrasound for the diagnosis of peritonsillar abscess: A systematic review and meta-analysis. Acad Emerg Med. 2023;30(8):859–869.
6. Johnson RF. Emergency department visits, hospitalizations, and readmissions of patients with a peritonsillar abscess. Laryngoscope. 2017;127 Suppl 5:S1–S9.