Approach to the diagnosis and treatment of peritonsillar abscess in the emergency department

IV: intravenous; US: ultrasound; OR: operating room.
* Maintenance of the airway is the mainstay of treatment. In patients with signs of total or near-total airway obstruction; airway control necessarily precedes diagnostic evaluation. If available, activate a critical airway team consisting of an anesthesiologist, emergency and/or critical care specialist, and an otolaryngologist to assist with securing the airway. Refer to UpToDate content on upper airway obstruction and management of the difficulty airway.
¶ For suggested antibiotic regimens, refer to UpToDate topics on peritonsillar abscess. Patients with peritonsillar cellulitis and patients with improvement after drainage of a peritonsillar abscess may be discharged home if they are well hydrated, have no airway compromise, and can tolerate oral intake including oral antibiotics. Otherwise, hospitalization is warranted.
Δ Intraoral or submandibular ultrasound has significantly better sensitivity for distinguishing peritonsillar abscess from peritonsillar cellulitis than physical examination alone and improves the success of needle aspiration. Needle aspiration should be performed by a properly trained and experienced physician, typically an otolaryngologist. However, if US is equivocal or not available, then patients without airway compromise may undergo a trial of IV antibiotics and hospital observation instead of needle aspiration.