An evidence-based review of peritonsillar abscess
EMERGENCY ORL: CONTROVERSIES IN MANAGEMENT
Powell, J. & Wilson, J.A.
Department of Otolaryngology Head and Neck Surgery, Freeman Hospital, Newcastle upon Tyne, UK
Accepted for publication 1 February 2012
Clin. Otolaryngol. 2012, 37, 136–145
Objective of review: We present the current literature
surrounding peritonsillar abscess management highlight-
ing areas of controversy.
Type of review and search strategy: Literature review
using Medline and Embase databases (search terms ‘peri-
tonsillar abscess’, ‘peritonsillar infection’ and ‘quinsy’)
limited to articles published from 1991 to 2011 (English
language).
Results: (i) Investigations: Intraoral ultrasound has a
sensitivity and specificity of between 89–95% and 79–
100%, respectively, for correctly diagnosing peritonsillar
abscess and is underutilised currently. (ii) Medical man-
agement: Steroids can effectively aid recovery, reducing
hospitalisation time and improving symptom relief; how-
ever, further study is needed, especially related to risk
and cost benefit. Penicillin and metronidazole are an
effective combination in 98–99% of cases of peritonsillar
abscess. (iii) Surgical management: Overall, there is no
convincing evidence in favour of either aspiration or inci-
Abscess in the area between the palatine tonsil and its
capsule, peritonsillar abscess or quinsy, is one of the most
common deep neck space infections. English data from
the year 2009 to 2010 saw 7589 finished consultant epi-
sodes attributed to peritonsillar abscess – an increase of
approximately 18% over the last 10 years. A link must be
considered between this increased incidence, and the con-
current trends of fewer tonsillectomy operations being
performed in the United Kingdom (UK), in addition to
the reduced antibiotic prescribing in primary care. Peri-
tonsillar abscess accounted for 11 069 hospital bed days
in 2009–2010, and trends towards early discharge and
outpatient management mean this figure is actually a
12% reduction from 10 years ago (see Fig. 1); however,
peritonsillar abscess still represents a significant resource
cost to ENT departments (http://www.hesonline.nhs.uk
accessed 10th April 2011).
Correspondence: J. Powell, Department of Otolaryngology Head and
Neck Surgery, Freeman Hospital, Newcastle upon Tyne, NE7 7DN, UK.
Fax: (44) 191 223 1246; e-mail: jason.powell@doctors.org.uk
136
sion & drainage. Quinsy tonsillectomy is subject to great
geographical variation, however, is a safe procedure and
reduces overall recovery time when compared with inter-
val tonsillectomy. (iv) Admission: peritonsillar abscess
can be effectively managed as an outpatient in many
cases. (v) Further management: Overall, the recurrence
rate of peritonsillar abscess is poorly defined but esti-
mated as 9–22% based on current evidence. Interval ton-
sillectomy may be indicated in selected groups of patients
at high risk of recurrence.
Conclusions: Peritonsillar abscess is a common condi-
tion with increasing incidence. We demonstrate the
potential for evidence-based modifications in clinical
management. However, lack of national consensus may
mean that this evidence base is not being adequately
exploited in current practice. A national audit of peri-
tonsillar abscess management, in particular looking at
recurrence rates and patient experience with different
management strategies, appears indicated.
Peritonsillar abscess is often described as part of a spec-
trum of disease from tonsillitis, via peritonsillar cellulitis,
culminating in peritonsillar abscess. Most peritonsillar
abscesss resolve with simple medical and surgical manage-
ment. Inadequately treated peritonsillar abscess carries life-
threatening complications – airway obstruction, abscess rup-
ture and aspiration of pus, erosion or septic necrosis causing
carotid sheath haemorrhage and extension of the infection
into the deep neck tissues or posterior mediastinum. Despite
the high incidence of peritonsillar abscess, there is little
local, national or international management consensus,1
culminating in management based mainly on consultant or
trainee preference. We aim to present the literature sur-
rounding peritonsillar abscess management, assess current
UK practice and highlight areas for further study.
Methods
A literature review was undertaken in April 2011 of the
Medline and Embase databases using search terms –
‘peritonsillar abscess’, ‘peritonsillar infection’ and ‘quinsy’,
 2012 Blackwell Publishing Ltd • Clinical Otolaryngology 37, 136–145
 A review of peritonsillar abscess 137

14 000 2.5 findings (such as splenomegaly or lymphadenopathy) sug-

gest the possible diagnosis. A process should be in place
Number of finished consultant episodes/Bed days

12 000 to advise on lifestyle factors, such as alcohol and contact

2 sports, to patients with positive results (leaflet accessible
10 000 at: http://www.ekhuft.nhs.uk/EasySiteWeb/GatewayLink.

Mean length of stay (days)

aspx?alId=82313). A standard monospot test for infective
8000
1.5
mononucleosis adds £4.39* to the cost of our local full
blood count (£2.91*); however, this test has a fairly low
6000 sensitivity, missing up to 20% of cases in adults and even
1
more in children. The ‘gold standard’ test is an Epstein–
4000 Barr virus (EBV) IgM antibody test (>90% sensitivity),
0.5
which costs £6.13*.6 There is insufficient current evidence
2000 to incur the cost of either investigation, as routine, in all
patients with peritonsillar abscess (Grade of recommenda-
0 0
tion D). It should be noted that liver function tests
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 (LFTs) are also required if glandular fever is diagnosed or
– – – – – – – – – –
2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 strongly suspected in the presence of a negative test.
Year *Newcastle upon Tyne Hospitals NHS Trust 2011.
Mean length of stay Finished consultant episodes Bed days

Fig. 1. A graph demonstrating English (HES) data on the fin- I Key points on Baseline investigations
ished consultant episodes, hospital bed days and mean hospital • Clinicians should consider infective mononucleosis
stay for peritonsillar abscess patients between 2000 and 2010.
as an alternative diagnosis or a co-diagnosis in peri-
tonsillar abscess.
from 1991 to present day, in English language. The
• EBV IgM antibody is the preferred test for infective
abstracts of 424 articles were reviewed, and 45 relevant
mononucleosis.
articles identified. Further articles were obtained through
• Tests for infective mononucleosis should be reserved
their bibliographies. Our proposed care pathway based on
for cases were clinical suspicion is high, such as in
these studies is presented in Fig. 2, with areas of contro-
teenagers and young adults and those with general
versy highlighted and discussed in the remainder of the
features that are suggestive of infective mononucleo-
article. Evidence and recommendation levels are included
sis (Grade of recommendation D).
in the text and based on the Scottish Intercollegiate
Guidelines Network grading system [See Table 1 (a, b)].
Pus cultures. In a 2008 survey of 86 UK ENT departments,
Areas of controversy 67% of respondents stated that they routinely sent microbi-
ology cultures of pus obtained from a peritonsillar abscess.
I Baseline investigations
However, the results were actually reviewed in only 28% of
Routine bloods. Routine bloods should be taken includ- cases.7 The rate of positive pus culture in peritonsillar
ing, full blood count, C-reactive protein and urea and abscess has been reported as extremely variable in a num-
electrolytes if dehydration is suspected. ber of fairly small (100–300 patient) prospective and retro-
spective case series (overall evidence level 3), with a range
Infective mononucleosis screening. Infective mononucleosis from <50 to 100%.8–11 Interestingly though, two similarly
can be a differential diagnosis of peritonsillar abscess and sized retrospective studies (overall evidence level 3) found
also a co-existing condition. Several retrospective case ser- that the results of cultures obtained from peritonsillar
ies (overall evidence level 3) indicate a prevalence of co- abscesss did not alter management.12,13 Patients tended to
existent infective mononucleosis in patients diagnosed have improved on initial or subsequent antibiotic choice,
with peritonsillar abscess of 1.5–6%.2–4 The condition based on local guidelines, before the culture was available
should be considered as an alternative diagnosis or co- 24–48 h later. Each pus culture costs £17.71*. Pus cultures
diagnosis specifically in teenagers and young adults should be reserved only for specific indications. Cases
because of high incidence,5 but as infective mononucleo- where cultures may be of benefit include cases of recurrent
sis may occur at any age it must be borne in mind in all, or persistent infection, diabetic or immunocompromised
with investigations ordered if history and examination patients (Grade of recommendation D).12,13

 2012 Blackwell Publishing Ltd • Clinical Otolaryngology 37, 136–145

138 J. Powell & J.A. Wilson

Patient identified with suspected peritonsillar abscess Examination:

• Airway
• Oral cavity
• Lymph nodes
• Abdominal
Assessment by ENT • Signs of dehydration & sepsis
History • Basic observations
Clinical examination • Suitability for theatre

Urgent senior I. Baseline investigations:

ENT and Signs of Airway No Signs of Airway • Bloods – FBC, CRP,
anesthetic compromise compromise U&E
review (i.e. low sats, • Only in specific
stridor) scenarios:
o Pus culture
o IM screen/EBV
IgM antibody
Suspicion of infective Abscess confined (LFT’s)
Confirmed infective spread beyond the to peritonsillar
spread beyond the peritonsillar space space
peritonsillar space

III. Surgical management:

• Intraoral US • Needle aspiration
• I&D
II. Imaging:
• CT/MR scan head and • Quinsy tonsillectomy
neck

Key Pus confirmed No pus

Areas of controversy are in shaded

boxes and are discussed further in Re-collection of
the text. pus
Continuous line - IV. Medical management:
Evidence supports • Antibiotics as per local protocol
routine practice
• Analgesia
Dashed line – • Consider IV rehydration
further evidence • Steroids
needed (not
recommended for
routine practice)

Progressive V. Admission v discharge:

disease
Admit to ENT • Monitor clinically and consider current
and co-morbid state
Improving
disease

VI. Interval
Discharge: tonsillectomy
• Complete course of (if no quinsy
antibiotics tonsillectomy)

Fig. 2. Proposed care pathway for peritonsillar abscess.

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 A review of peritonsillar abscess 139

Table 1. Taken from the Scottish Intercollegiate Guidelines Network (SIGN) evidence level and recommendation grading guidelines
(http://www.sign.ac.uk/guidelines/fulltext/50/annexb.html accessed 10th April 2011)
Ratings (a) Levels of evidence

1++ High-quality meta-analyses, systematic reviews of RCTs or RCTs with a very low risk of bias
1+ Well-conducted meta-analyses, systematic reviews or RCTs with a low risk of bias
1) Meta-analyses, systematic reviews or RCTs with a high risk of bias
2++ High-quality systematic reviews of case–control or cohort studies. High-quality case control
or cohort studies with a very low risk of confounding or bias and a high
probability that the relationship is causal
2+ Well-conducted case–control or cohort studies with a low risk of confounding or
bias and a moderate probability that the relationship is causal
2) Case–control or cohort studies with a high risk of confounding or bias and
a significant risk that the relationship is not causal
3 Non-analytic studies, for example case reports, case series
4 Expert opinion

(b) Grades of recommendation

A At least one meta-analysis, systematic review or RCT rated as 1++, and directly applicable to
the target population; or
A body of evidence consisting principally of studies rated as 1+, directly applicable
to the target population and demonstrating overall consistency of results
B A body of evidence including studies rated as 2++, directly applicable to the target
population and demonstrating overall consistency of results; or
Extrapolated evidence from studies rated as 1++ or 1+
C A body of evidence including studies rated as 2+, directly applicable to the target
population and demonstrating overall consistency of results; or
Extrapolated evidence from studies rated as 2++
D Evidence level 3 or 4; or
Extrapolated evidence from studies rated as 2+

who is disproportionately unwell compared with the

I Key points on Baseline investigations
• Routine pus culture is not recommended in periton-
sillar abscess because it is an expensive test that rarely
alters management (Grade of recommendation D).
• Culture is indicated in patients at risk of resistant
organisms, for example those with recurrent or per-
sistent infection, diabetes or immunocompromise.
• Cultures should never be sent if there is no inten-
tion to check the findings.
physical findings, consistently unwell despite standard
clinical treatment or has physical findings of a deep neck
space infection. CT scanning can accurately diagnose
peritonsillar abscess (sensitivity, 100%; specificity, 75%),
while identifying infective spread beyond the peritonsillar
space.14 MRI has the advantages of improved soft tissue
detail and allowing assessment for the carotid sheath
without the associated radiation of a CT. However, MRI
takes longer, tends to be more expensive and has greater
problems of availability compared with CT scanning.

Ultrasound scanning. It can be difficult clinically to differ-

II Imaging
CT ⁄ MR imaging. While imaging is required in advanced
parapharyngeal infection, imaging is not routinely per-
formed in the UK in uncomplicated peritonsillar abscess,
in contrast to some other countries with alternative
healthcare systems. Should there be clinical suspicion of
infective spread beyond the peritonsillar space, a CT or
MRI of the head and neck is required, based on local
protocol. Examples of these cases may include a patient
entiate peritonsillar abscess from cellulitis.15 Unnecessary
aspirations or incisions should be avoided as they are
painful and carry risks including damage to the carotid
artery.16,17 Ultrasound imaging has been studied as an
alternative to cross-sectional peritonsillar abscess imaging
for diagnosis and as an aid to drainage. Standard transcu-
taneous ultrasound of the head and neck to visualise
the suspected peritonsillar abscess has been shown in
limited studies to be of little help in diagnosis or

 2012 Blackwell Publishing Ltd • Clinical Otolaryngology 37, 136–145

140 J. Powell & J.A. Wilson
management.18,19 However, three small-scale studies (col-
lective cohort of 70 patients) using the presence of pus
on drainage to asses intraoral ultrasound accuracy have
shown a diagnostic sensitivity of 89–95% and specificity
of 79–100% (overall evidence level 3).14,19,20 It can aid
the efficacy and safety of aspiration by localisation of pus
and its relations to the carotid artery (overall evidence
level 3).21,22 However, intraoral ultrasound relies on spe-
cially trained personnel, also some patients are intolerant
because of trismus. In addition, imaging resources are
often restricted at the time of initial presentation and the
resource cost must also be considered, the intraoral probe
itself costs £8000–£10 000. However, reduction in the cost
of bed days and repeated, failed procedures might make
it cost-effective. Patient experience has not been
addressed in the literature but should also be considered
– given the choice, how many otolaryngoloigists would
elect to have a junior doctor stabbing blindly at a pain-
fully swollen palate? On the other hand, the evidence for
the benefit of intraoral ultrasound is limited. Further
research is needed to quantify its impact on management
and costs. Current evidence is, however, supportive
(Grade of recommendation D).
II Key points on Imaging
• CT and MR imaging should be reserved for diag-
nosing infection spread beyond the peritonsillar
space.
• Intraoral ultrasound when available, without delay-
ing treatment, could be utilised to confirm diagno-
sis, expedite drainage or discharge home patients
without peritonsillar abscess (Grade of recommenda-
tion D).
• Further research is required to assess the cost-effec-
tiveness of intraoral ultrasound scanning.
III Surgical management
In a national survey of peritonsillar abscess management,
60% of respondents favoured first-line needle aspiration,
25% incision and drainage, 1% abscess tonsillectomy and
5% intravenous antibiotics alone.1 There was wide prac-
tice variation according to the caseload and the geograph-
ical location of the ENT department,1 highlighting a
distinct lack of evidence-based practice. When assessing
the evidence for different surgical interventions in peri-
tonsillar abscess, a problem is that there is no standardi-
sation of definitions for what constitutes a re-collection,
persistent or recurrent disease, making comparison
between studies difficult.
Needle aspiration. The introduction of a large bore (i.e.
21G) needle into the suspected peritonsillar abscess to
aspirate pus was first described by King in 196123 and
provides a simple technique for treatment of a peritonsil-
lar abscess, which can be carried out by junior members
of staff with appropriate training and supervision. Aspira-
tion has been criticised as only removing pus from one
area of the abscess. Two randomised trials24,25 with a
combined cohort of 112 patients found that with aspira-
tion, re-collection or failed resolution occurs in  10% of
patients at 1–2 days. However, these studies fail to iden-
tify the criteria for re-aspiration (overall level of evidence
1-). One study has looked specifically at pain post-aspira-
tion or incision and drainage. Nwe et al. looked at the
objective measures of pain in 75 peritonsillar abscess
patients treated by needle aspiration or incision and
drainage. There was an improvement in the mean upper-
to-lower incisor distance 15 min after treatment in 38%
of the aspiration group compared with 100% in the inci-
sion and drainage group. In addition, 2 h after the initial
treatment 8% of patients in the aspiration group and
92% in the incision and drainage group were able to
swallow water.26 This limited study seems to demonstrate
that incision and drainage may resolve pain faster than
aspiration (evidence level 3).
Incision and drainage. Incision and drainage of a periton-
sillar abscess, first described in the 14th century by Guy de
Chauliac, is still used by half of UK otolaryngologists as a
secondary treatment in non-resolving peritonsillar
abscesss.1 Proponents favour the ability to clear pus from
the entire abscess cavity, but others consider it to be a more
painful procedure for the patient. Incision and drainage
early re-collection ⁄ failed resolution rate appears compara-
ble with needle aspiration (10%; evidence level 1-).25,27
Quinsy tonsillectomy. Chassaignac reported the first quinsy
(‘hot’) tonsillectomy in 1859. The approach exploits the
dissection plane opened by pus, which later fibroses mak-
ing interval tonsillectomy more difficult.27 However, gen-
eral anaesthesia for a quinsy tonsillectomy in the presence
of acute airway suppuration may make intubation more
difficult. In addition, as previously demonstrated, 1.5–6%
of patients with peritonsillar abscess will have a coexistent
infective mononucleosis, which may result in acute liver
inflammation and more risky general anaesthesia, and
investigations for this may delay the operation and make
quinsy tonsillectomy not a favourable option for some
patients. However, one limited study looking specifically
at general anaesthesia in 50 adult patients with peritonsil-
lar abscess found no anaesthesia complications and
showed that trismus resolved during induction in 77.4%
 2012 Blackwell Publishing Ltd • Clinical Otolaryngology 37, 136–145

of patients.28 These risks and benefits must be discussed
with anaesthetic colleagues prior to a procedure. Quinsy
tonsillectomy can offer several advantages over other man-
agement options, by allowing full evacuation of the
abscess cavity, effectively relieving symptoms and identify-
ing any further spread of infection beyond the peritonsil-
lar space. The procedure also removes the need for patient
co-operation, particularly important in children who may
not allow awake examination or drainage of an abscess.
Children with peritonsillar abscess can be successfully
managed with quinsy tonsillectomy and have short overall
hospital stays.29
There are a number of variably sized prospective and
retrospective case series that have reported operative com-
plications in quinsy tonsillectomy. Post-tonsillectomy
haemorrhage rates in quinsy tonsillectomy vary widely
from 0 to 13%, with surgical haemostasis required in
0–6% (overall evidence level 3).30–33 An outlying study34
had much higher rates for unexplained reasons. The 2003–
2004 national prospective UK tonsillectomy audit of
33 921 patients found post-tonsillectomy haemorrhage in
3.5%, while 0.9% returned to theatre.35 Comparison of the
post-tonsillectomy haemorrhage rates of quinsy versus elec-
tive tonsillectomy in age- and gender-matched groups
shows no statistically significant difference.30,32 These lar-
ger scale, higher evidence studies show better correlation
of results and highlight again the need for large-scale audit
data on peritonsillar abscess. In a review of 661 patients,32
post-elective tonsillectomy haemorrhage occurred in
11.6% and haemorrhages requiring surgery in 5.5%, with
8% and 2.6%, respectively, for quinsy tonsillectomy in age-
matched participants. Windfuhr30 found post-tonsillec-
tomy haemorrhage in 2.8% of elective and 2.9% of quinsy
tonsillectomies (overall evidence level 3). Thus, quinsy ton-
sillectomy as a procedure carries no greater risk of post-
tonsillectomy haemorrhage than routine tonsillectomy,
and it is merely the population undergoing the procedure
who are more at risk (overall recommendation grade D).
Quinsy tonsillectomy can potentially also save time and
money over an initial acute admission with aspira-
tion ⁄ incision and drainage followed by an interval tonsil-
lectomy at a later date (cost of a second admission). Two
prospective randomised studies (combined n > 100) have
addressed this time-saving (overall evidence level 1-). Fa-
gan et al27 in South Africa found no statistically signifi-
cant difference in total hospital stay for patients treated
with quinsy tonsillectomy, compared with aspiration and
interval tonsillectomy. However, when comparing the
number of days off work, there was a statistically signifi-
cant reduction in favour of quinsy tonsillectomy. In a
military population, quinsy tonsillectomy carried a signif-
icantly shorter hospital stay (2–5 days less) than incision
 2012 Blackwell Publishing Ltd • Clinical Otolaryngology 37, 136–145
A review of peritonsillar abscess 141
and drainage plus interval tonsillectomy.36 Both studies
suffer from problems with lack of generalisablity to a cur-
rent UK population, being undertaken almost 25 years
ago when longer inpatient stays prevailed.
The general anaesthesia and operative risks must be
weighed against success rates from aspiration or incision
and drainage; the age and co-operation of the patient and
ongoing need for later definitive treatment (see interval
tonsillectomy section). Factors such as patient choice and
quality of life remain ignored by current literature.
Another key area that is not addressed in the literature is
the availability of resources to perform a quinsy tonsillec-
tomy at presentation (a procedure that would require an
emergency operating slot, a hospital bed pre- and post-
operatively and an available surgeon and anaesthetist).
Current competition for surgical resources may make
quinsy tonsillectomy unavailable to many, but the proce-
dure should be considered in certain situations, in partic-
ular where inpatient stay is already advised (see admission
versus outpatient management section).
III Key points on Surgical management
• Until more robust evidence is forthcoming to com-
pare re-collection ⁄ failed resolution rates between
aspiration and incision and drainage (which are
comparable at 10% based on current evidence),
clinician experience and patient choice should pre-
vail (Grade of recommendation B).
• Some evidence suggests incision and drainage may
resolve pain faster than aspiration (Grade of recom-
mendation D).
• Quinsy tonsillectomy has a clear role for those
intolerant of an awake procedure (such as children)
and in patients with persistent peritonsillar abscess
who could benefit in overall reduced recovery time
compared to an interval tonsillectomy (Grade of rec-
ommendation B). However, operative risk and avail-
ability of resources must also be considered.
• The evidence is lacking and more is needed on the
topic of surgical management, in particular patients’
views on procedures and the effects on quality of life.
IV Medical management
Analgesia and rehydration. Pain relief is vital in the man-
agement of peritonsillar abscess, and analgesia should be
titrated to symptomatic relief following local guidelines.
Intravenous fluid resuscitation may also be needed in
those unable to take sufficient oral intake or with clinical
or biochemical signs of dehydration.
142 J. Powell & J.A. Wilson
Antibiotic treatment. While surgical intervention may
remove the majority of pus in peritonsillar abscess, antibi-
otics are usually recommended to clear the remaining and
disseminated infection. Only one study (evidence level 3)
supports medical management alone, demonstrating that
only 4% of 98 patients eventually required drainage.37
A survey of 302 UK consultants took place in 2009,38
and the survey asked about their preference for antibiotic
prescribing in throat infections. The study highlighted
that the majority (44%) prefer a combination of benzyl-
penicillin and metronidazole for the inpatient manage-
ment of peritonsillar abscess, continuing treatment for
1 week in most (60%). In penicillin allergy, the majority
(44%) would choose clarithromycin.
The choice of penicillin and metronidazole appears to
be sensible as this combination has been shown in two
studies, containing a cumulative total of 172 patients, to
be effective in between 98% and 99% of cases of periton-
sillar abscesss, based on aspiration culture (overall evi-
dence level 3),13,39 although a retrospective study of 103
patients found penicillin alone did not lengthen the hos-
pital stay (evidence level 3).40 However, with the demon-
strated polymicrobial infection,11,41 and the variable rates
of penicillin resistance reported (overall evidence level
3),11,39,42 a combination antibiotic approach would seem
sensible (Grade of recommendation D).
Route of administration is another area of controversy,
not directly investigated in recent literature. One small,
randomised study of 27 patients by Sexton et al.43 in
1987 demonstrated that oral antibiotics are as effective as
IV antibiotics in managing peritonsillar abscess, with no
difference in morbidity, recovery time or recurrence (evi-
dence level 1-); however, further studies are required.
It should be noted that amoxicillin is contraindicated
because of the risk of maculopapular rash if infective
mononucleosis is present.
IV Key points on Medical management
• Current best evidence supports the combination of
penicillin and metronidazole in peritonsillar abscess
(Grade of recommendation D); however, this should
be in conjunction with local guidelines.
• Further study would be of value into the antibiotic
type and administration route in peritonsillar abscess.
Steroids. Only one study addresses the use of steroids, a
double-blinded randomised placebo-controlled study from
Turkey of 62 patients (evidence level 1+).44 The groups
received steroid treatment or a placebo, in addition to treat-
ment with aspiration and intravenous antibiotics. Statisti-
cally significant (P < 0.01) improvements in analgesia were
achieved with a single dose of intravenous methylpredniso-
lone, and 70% of patients were able to swallow after 12 h in
the steroid group compared with only 18% in the placebo
group. Hospital stay was also reduced with steroids, with
84% of patients in the steroid group discharged at 4 days
compared with only 22% in the placebo group. Therefore, a
grade-B recommendation may be given for the use of ste-
roids in peritonsillar abscess; however, further studies are
needed to assess whether these results are reproducible.
IV Key points on Medical management
• Steroids can be effectively used to aid recovery in
peritonsillar abscess; however, more evidence is
needed (Grade of recommendation B).
V Admission versus outpatient management
A 2002 UK peritonsillar abscess audit showed that 94% of
patients are managed as inpatients, with a median inpa-
tient stay of 2 days.1 This UK management is in stark con-
trast to other countries, such as the United States where
most peritonsillar abscesss are managed as outpatients.45
Studies (n < 100) support outpatient management; how-
ever, these were single cohort observational studies, with
no clear outcome measures and no comparison with inpa-
tient management. These studies cite low readmission
(2%) and absent complications as evidence of effective
outpatient management (evidence level 3).25,26,37 In the
UK, a prospective study of 46 patients showed successful
outpatient management with a readmission rate of 5%
and, importantly, high levels of patient satisfaction (evi-
dence level 3).46
Limited evidence indicates that peritonsillar abscess can
be effectively managed as an outpatient (Grade of recom-
mendation D). A change from inpatient to mainly outpa-
tient management would represent a significant reduction
in costs and increase in bed availability within ENT depart-
ments. However, a suitable system needs to be in place for
the identification of less well patients – for example those
with clinical or biochemical dehydration, airway compro-
mise (kissing tonsils) or inability to manage oral intake and
medications such as antibiotics. Comorbidity, immuno-
compromise and age >40 years are further risk factors for
the complications of peritonsillar abscess.47 Short-term
monitoring bays, patient information protocols and if
required follow-up systems, all need to be set up within the
department before outpatient management can successfully
be implemented.46
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 A review of peritonsillar abscess 143

V Key points on Admission versus outpatient
management
• Current evidence suggests peritonsillar abscess can
be effectively managed as an outpatient, provided
that a suitable management protocol is in place,
supported by an appropriate administrative and clin-
ical setup with the hospital (Grade of recommenda-
tion D).
• Inpatient management is still required for more
severe sepsis, dehydration, airway compromise, com-
orbidity or age >40 years.
VI Interval tonsillectomy
In 2000, only 15% or UK ENT surgeons advised tonsil-
lectomy after a single quinsy – 83% advised interval
tonsillectomy in those with a history of tonsillitis.49
Overall peritonsillar abscess recurrence is between 9%
and 22%, with variability in follow-up period, age, sex
and technique of drainage between the studies (overall
evidence level 3).9,42,48–50 Therefore, the number needed
to treat would be approximately 5–10 patients. Higher
recurrence rates of peritonsillar abscess were found in
some9,15,51 but not all42 reports of people with prior ton-
sillitis and in patients <40 years of age48,51 (overall evi-
dence level 3). Interval tonsillectomy is thus indicated in

Table 2. A table highlighting potential areas of further research as demonstrated by this review
Key areas of further study required regarding peritonsillar abscess

Area of study Outcome measures Justification Suggested study type

Disease course and Symptoms experienced,
quality of life impact on quality
of life.
Quinsy tonsillectomy Hospital stay, cost,
patient satisfaction,
quality of life.
Aspiration versus Patient satisfaction,
incision and drainage success rate, recurrence
rate, hospital stay.
Intraoral ultrasound Management change,
diagnostic accuracy,
cost, feasibility of
ENT operator.
Steroids Symptom improvement,
hospital stay .
Antibiotic route Pathogen treated, clinical
and type improvement.
Little is known of the
course of the disease
pre- and post-quinsy,
knowledge of this would
guide management, in
particular the need or
not for tonsillectomies
in this group.
Financial implications,
patient satisfaction,
quality of life issues,
opportunity costs.
No convincing evidence
of best practice,
patient satisfaction,
quality of life issues,
opportunity costs.
Aware of its accuracy but
little evidence as to any
management change
produced by its use or
the subsequent
cost-effectiveness.
Only one study with a
small cohort, needs
replicating.
Limited evidence of the
effectiveness of
antibiotic management
regimes, potential for
none inpatient
management.
National audit of quality
of life and symptom
prevalence ⁄ severity.
Prospective study.
Retrospective study.
Qualitative studies.
National audit of
management.
Cost-based analysis.
Qualitative studies.
National audit of
management.
Qualitative study.
Prospective study.
Qualitative study.
Prospective study.
Randomised controlled
trial (RCT).
Prospective study.
Randomised controlled
trial (RCT).

 2012 Blackwell Publishing Ltd • Clinical Otolaryngology 37, 136–145

144 J. Powell & J.A. Wilson
patients at high risk of recurrent peritonsillar abscess,
those with a history of prior tonsillitis and <40 years of
age, if a quinsy tonsillectomy is not undertaken for what-
ever reason, bearing in mind the risk of needlessly per-
forming a potentially more demanding dissection (overall
recommendation grade D).27 In addition, further quality
evidence is needed on the rates of recurrence in quinsy to
allow better-informed decision-making regarding tonsil-
lectomy.
VI Key points on Interval tonsillectomy
• Tonsillectomy for peritonsillar abscess should be
aimed at those patients at high risk or recurrence,
such as those with previous tonsillitis, aged
<40 years (Grade of recommendation D).
• Interval tonsillectomy may provide a more difficult
dissection than quinsy tonsillectomy and result in an
overall longer recovery time. However, interval ton-
sillectomy allows a more planned operation without
the patient being acutely unwell.
Conclusions
Peritonsillar abscess is an increasingly common condi-
tion, with many thousands of sufferers per annum in
the UK. Nonetheless, good quality, comparative evi-
dence is lacking for many aspects of management. Most
evidence is level 3. The inevitable result is persisting
variation in practice. This will become increasingly
problematic for our patients as secondary ENT provi-
sion becomes more fragmented among general units
and true specialist expertise becomes more remote. Sig-
nificantly, more good quality, patient-centred data is
required (see Table 2). Meanwhile, an interim indicative
treatment algorithm for peritonsillar abscess based on
the current best evidence available with the discussion
of key areas of controversy is shown (Fig. 2).
Conflict of interest
None to decleare.
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