1. Spray the superior pole with topical anesthesia. Inject local anesthesia with epinephrine. Aspirate with 10 or 20 cc syringe and 18 or 20 gauge needle.
   
   
2. Organisms

   10-15% are penicillin resistant

   Aerobes: Streptococcus, M. Catarrhalis

   H. influenzai, Staphylococcus

   Anaerobes: Bacteroides, Peptocci, Fusobacteria

   Peptostreptococci

Antibiotics

Pen V.K. 500 mg P.O. qid and

Flagyl 500 mg P.O. q 8 hrs. (both for 7-10 days) or

Ceftin 500 mg P.O. bid

if PCN Allergic ––––>Erythromycin 500 mg P.O. qid

Clindamycin 600 mg IV drip, followed by clindamycin 300 mg p.o. q 6 h is an alternative to the above and is a second line drug if the above fails.

Overview of Peritonsillar Abscess

No one really knows why a tonsillar abscess develops. The best theory I know is the following: there is a small gland in the soft palate mucosa near the superior pole of the tonsil called Weber's gland. This occasionally becomes infected and when it does spreads into the peritonsillar space. When this occurs a peritonsillar infection develops. Peritonsillar abscess presents as would any bad bacterial pharyngitis. Ultimately, the patient becomes increasingly ill. Difficulty swallowing and even pain while speaking is common as the abscess progresses. The pain is greater on the infected side. On physical examination it may look like tonsillitis, but on careful examination, one will see that the uvula is edematous, the soft palate and superior pole of the tonsil are swollen and the tonsil is protruding into the pharynx. The uvula in the late stages, deviates away from the abscess.

Once the diagnosis is suspected, treatment should be instituted. Given the 10-15 % incidence of penicillin resistent organisms, one is obliged to treat with more than a first generation penicillin.

My own opinion is to treat with penicillin and flagyl or with clindamycin. Most Otolaryngologists would feel that all peritonsillar abscesses should be needle aspirated or incised and drained as a minimum. A number of primary care physicians who see these in an earlier state might not agree. If the tonsil is not particularly swollen and protuberant, but the diagnosis is suspect, antibiotic treatment is appropriate. Once an abscess forms, antibiotics alone will not cure the illness and some form of drainage is required. The easiest is needle aspiration. This is performed by anesthetizing the superior pole of the tonsil or the bottom of the soft palate, just above the tonsil. Spray first with a topical anesthetic such as: Cetacaine, then make a 1cc mucosal injection of lidocaine and adrenaline. An 18 or 20 gauge needle, preferably on a 20cc syringe is then inserted near the superior tonsillar pole and the abscess contents aspirated. When an abscess exists, it is not uncommon to aspirate 5-30 cc's of pus. The aspirate should be sent for culture and sensitivity.

Many of these patients are already alimenting poorly and it is our current practice to insert an intravenous line, administer 1-2 liters of Lactated Ringers and as long as one has IV access to administer the first dosage of antibiotics intravenously.

Assuming that the abscess is not advanced, assuming the patient is having no difficulty with respiration and assuming the patient is swallowing sufficiently well to take their medicine, they can be sent home. If pus reaccumlates it can be reaspirated once or twice.

ENT referral can be made for incision and drainage; however this combined with the already existing discomfort, creates sufficient dysphagia and discomfort that the patient often requires hospitalization. Given concerns about recurrent peritonsillar abscesses and given that performing a tonsillectomy in the acute phase is easy and safe, it is our current recommendation that if the patient is sick enough to be admitted they should be brought to the operating room and both tonsils resected.

If PTA is successfully managed as an outpatient, the literature reports a 5-15% recurrence rate. Most recommend a prophylactic tonsillectomy. Certainly, if the peritonsillar abscess becomes recurrent, a tonsillectomy is indicated.