Drainage of a Peritonsillar Abscess

Essentials

• Peritonsillar abscess is the most common deep infection of the head and neck and usually a complication of acute tonsillitis. It always warrants immediate therapy.
• The condition can also be managed in primary health care. Refer to an ENT clinic for treatment:
  • a paediatric patient
  • a severely ill patient
  • a patient with difficulty in breathing
  • a patient with bilateral abscess
  • a patient with a large abscess (pharynx is obstructed or suspected deep neck abscess (e.g. a parapharyngeal abscess Parapharyngeal and Retropharyngeal Abscesses - Etiology and Treatment), the symptom of which is a clear unilateral swelling of the neck
  • if the abscess cannot be drained
  • if trismus does not alleviate
  • if there is suspicion of another cause for symptoms (e.g. malignancy in an elderly patient with excessive consumption of alcohol and tobacco).

Instruments

• An ENT examination chair, a headlight, a nurse positioned at the back of the patient to support the patient's head
• Equipment for local anaesthesia (10% xylocaine spray, 2 ml syringe, 1% lidocaine-adrenaline and a long 25 Gauge needle)
• Tongue blade, long 18 Gauge needle and 10 ml or 20 ml syringe, No. 11 scalpel blade, angulated or haemostatic forceps
• Suction equipment
• I.v. rehydration kit if the patient is dehydrated

Procedure

1. If necessary the patient is administered i.v. fluids and analgesics before the procedure.
2. While the patient is placed in sitting upright position and keeps his/her mouth as open as possible, depress the tongue with tongue depressor. Hypopharynx and larynx are inspected with a mirror to exclude lower oedema and bulging of the tissues and possible airway obstruction.
3. The most prominent area of the mucous membrane overlying the abscess is sprayed with topical anaesthetic.
4. 1-2 ml of local anaesthetic is infiltrated under the palatoglossal arch at the location of the abscess, first right under the mucous membrane and then deeper. Try to localize the abscess by aspirating from three locations (picture 1).
5. The abscess can be emptied by draining the pus with the anaesthetic needle or with a larger needle. The patient should come for a check up next day and the procedure can be repeated. If healing is clearly not progressing, an incision can be performed (see point 6) Needle Aspiration Versus Incision and Drainage for the Treatment of Peritonsillar Abscess.
6. If the abcess is not sufficiently emptied by needle aspiration, a larger incision is needed. Under local anaesthesia make a 1-1.5 cm incision in the mucous membrane parallel to the palatal arch at the site with the largest bulge.
7. Dissect along the capsule of the tonsil with haemostatic or angulated forceps until the abscess cavity is found. Spread the forceps only when in the abscess cavity. You should find your way to the back of the tonsil around its edge and not get mixed up in the tonsillar tissue. Work in sagittal plane and avoid proceeding too far laterally (carotid artery).
8. Remove all pus with a rigid catheter for oral suction (metallic or plastic) and take a sample for bacterial culture if needed.
9. The patient should sit leaning forward and rinse the mouth with cool mouth wash until bleeding stops.
10. Give a sufficient dose of analgesics (e.g. ibuprofen 600 mg × 3 as necessary).
11. Antimicrobial therapy: Either oral or parenteral penicillin V according to the severity of the disease (1 million IU 3 times daily for 10 days). In a large share of abscesses, there are anaerobic bacteria involved, but there is no evidence on the benefit of the use of broader-spectrum antimicrobial drugs in an adult patient whose abscess has been initially drained. If the patient cannot take penicillin, either a cephalosporin or amoxicillin or, in the case of allergy, clindamycin may be used. If the abscess is not found through aspiration or incision, or if it is not adequately drained, metronidazole (400 mg 3 times daily for 7 days) may be added to the treatment.
12. Depending on the patient's work, sick leave is usually needed for a few days or a week.
13. The patient should come for a follow-up visit 1 to 2 days after the incision if symptoms persist. The abscess cavity is opened with angular forceps (local anaesthesia) and drained. If necessary, the procedure is repeated after 2 days.

Tonsillectomy

• Peritonsillar abscess is an indication for tonsillectomy if the patient has had recurrent episodes of tonsillitis or the abscess recurs.
• In children, tonsillectomy is usually performed immediately (in the "hot" phase).