Continuing Education Activity

Peritonsillar abscess is the most common deep neck space infection in adolescents and young adults and usually arises as a complication of acute tonsillitis or pharyngitis. Clinical presentation often includes unilateral throat pain, odynophagia, dysphagia, muffled “hot potato” voice, trismus, uvular deviation, and cervical lymphadenopathy; severe cases feature drooling and respiratory distress from upper airway compromise. Diagnosis is often clinical, while point-of-care ultrasonography and contrast-enhanced computed tomography aid confirmation, delineate the extent, and exclude other deep neck infections. Management prioritizes airway assessment, hydration, analgesia, and prompt antimicrobial therapy, with needle aspiration or incision and drainage performed when indicated. Complications, although uncommon, include spread to deep neck spaces, mediastinitis, vascular injury, and septic thrombophlebitis.

Course participants learn to recognize key historical and examination findings that distinguish a peritonsillar abscess from a peritonsillar phlegmon, tonsillitis, a retropharyngeal abscess, epiglottitis, an odontogenic infection, and malignancy. Practical skills include risk stratification for airway compromise, selection of laboratory tests, and appropriate use of ultrasonography or contrast-enhanced computed tomography when diagnostic uncertainty exists. Collaboration with an interprofessional team, primary care clinicians, emergency medicine clinicians, otolaryngology clinicians, nursing staff, radiology, and pharmacy, enhances outcomes through timely airway stabilization, accurate imaging interpretation, safe procedural support, optimized antimicrobial stewardship, and reliable follow-up to confirm hydration, nutrition, and clinical resolution.

Objectives:

• Differentiate peritonsillar abscess from peritonsillar phlegmon, tonsillitis, epiglottitis, and other deep neck space infections using targeted history and physical examination findings.
• Select appropriate diagnostic testing, including rapid group A streptococcus testing and abscess aspirate culture when drainage is performed, to guide antimicrobial therapy and escalation of care.
• Identify indications for hospitalization, intravenous hydration, corticosteroids, and close follow-up to prevent dehydration, treatment failure, and progression to deep neck space infection.
• Collaborate with all members of the interprofessional team including specialists such as otolaryngologists, anesthesiologists, and radiologists to provide efficient, comprehensive, and coordinated care for patients with peritonsillar abscesses.

Introduction

Peritonsillar abscess, historically known as quinsy, is the most common deep neck space infection in adults and children. In children, it accounts for almost 50% of deep neck space infections.[1][2] Peritonsillar abscess is characterized by accumulation of purulent material within the peritonsillar space, a potential space between the fibrous capsule of the palatine tonsil medially (part of the pharyngobasilar fascia), the superior constrictor muscle laterally, the palatopharyngeus muscle posteriorly, the palatoglossus muscle anteriorly, the torus of the Eustachian tube superiorly, and the pyriform sinus of the hypopharynx inferiorly.[3][4][5] Because the peritonsillar space contains loose areolar tissue, infection can spread rapidly, with extension to the adjacent parapharyngeal space, the soft palate, and the base of the tongue if the infection is not recognized and addressed promptly.

Etiology

Although the exact etiology of peritonsillar abscess remains unclear, they most likely form from direct spread of infection into the peritonsillar space. The infection may spread from the minor salivary glands of Weber in the superior tonsillar pole, or from the crypta magna of the tonsil, a large cleft near the superior pole that represents the remnant of the second pharyngeal pouch.[6] An alternative theory implicates capsular necrosis and obstruction of the Weber glands, given that some cases occur even after tonsillectomy.[7] Typically, the infection develops unilaterally after an episode of pharyngitis or tonsillitis, progressing to a peritonsillar phlegmon and abscess. Infrequently, abscesses may be bilateral, such as in mononucleosis.[8]

Epidemiology

Peritonsillar abscesses are most common in young adults, with a peak incidence between 15 and 35 years of age.[9][10][11] Girls are affected more often than boys in patients younger than 14 years, and males are affected more often than females in patients older than 14 years.[9] The overall incidence of peritonsillar abscess in individuals aged 5 to 59 years is 14 to 30 cases per 100 000 per year, although it is as high as 167 per 100 000 in adolescents.[12] Peritonsillar abscesses are uncommon in children younger than 5 years, who are more susceptible to retropharyngeal abscess.[13][14]

Pathophysiology

Peritonsillar abscesses are typically polymicrobial, although viral infections such as the Epstein-Barr virus can also cause abscess formation.[15][16] Rarely, peritonsillar abscesses may occur in the absence of prior sore throat.[7][17] The organisms most frequently isolated from cultured peritonsillar abscesses include Streptococcus pyogenes (group A streptococcus), Streptococcus anginosus, group A β-hemolytic Staphylococcus aureus (including methicillin-resistant strains), and a variety of respiratory anaerobes such as Fusobacterium, Prevotella, Veillonella, and Haemophilus species. Usually, both aerobic and anaerobic organisms are present. However, Fusobacterium necrophorum is the most common organism in patients aged 15 to 24 years, while Streptococcus pyogenes is more common in other age groups.[9][18][19][20][21]

History and Physical

Patients typically present with unilateral throat pain, although bilateral pain may occur. Odynophagia and dysphagia are generally present, and with severe pain, patients may be unable to tolerate salivary secretions and may drool. Some patients also note ipsilateral otalgia. Constitutional symptoms, such as fever, chills, malaise, and body aches, may be present.[4]

Pharyngitis, with or without upper respiratory symptoms, usually precedes abscess development by 3 to 5 days. If a patient presents with unilateral throat pain of fewer than 3 to 5 days' duration, the infection is unlikely to have progressed from the phlegmon stage to a true abscess. As the abscess enlarges, patients may develop a muffled, hypernasal hot potato voice due to edema and dysfunction of the soft palate.[22] Neck pain often arises from accompanying cervical lymphadenitis. Trismus, ranging in severity, occurs in nearly all cases due to inflammation of the pterygoid muscles adjacent to the superior constrictor muscle.[2][23] Trismus can make physical examination and treatment of the abscess particularly challenging if severe.

Physical examination characteristically demonstrates indurated peritonsillar swelling, erythema, medialization of the ipsilateral tonsil, and deviation of the base of the uvula away from the affected side, the latter found in roughly half of cases. (See Image. A Right-Sided Peritonsilar Abscess).[1][24][25][26][27] Additionally, patients almost universally present with cervical lymphadenopathy in the jugulodigastric region. Torticollis may be observed with the head tilted to the affected side.

Peritonsillar abscesses in children exhibit clinical features similar to those in adults; however, conducting an accurate physical examination can be challenging due to anatomical differences and patient age.[1] In patients with acute respiratory distress characterized by anxiety, drooling, tripoding (leaning forward with the head in a sniffing position), and labored breathing, emergency airway stabilization should be prioritized before evaluation for peritonsillar abscess. Please see StatPearls' companion resource, "Pediatric and Neonatal Resuscitation," for further information.

Evaluation

Laboratory Investigations  [28]

Laboratory testing can help to identify the pathogen and guide therapy:

• Complete blood count with differential: Typically shows leukocytosis with a neutrophil predominance, although this finding is nonspecific.
• Basic metabolic panel: Indicated in patients with poor oral intake or clinical signs of dehydration.
• Group A streptococci testing: Rapid antigen detection is preferred; throat culture or molecular assays are acceptable alternatives.
• Abscess aspirate analysis: If a needle aspiration or incision and drainage of the abscess is performed, Gram stain, aerobic and anaerobic cultures, and susceptibility testing can guide antimicrobial therapy, particularly in immunocompromised patients or those with complicated or extensive infection.

Radiological Imaging

Imaging is not strictly necessary when a peritonsillar abscess is clinically apparent based on history and physical examination findings; however, results from a 2025 study by Voruz et al compared clinical and radiographic diagnoses of peritonsillar abscesses and reported substantially higher diagnostic accuracy with contrast-enhanced CT, even when performed by an otolaryngologist.[29] The study findings demonstrated that imaging should be used when available, especially if a specialist is not available. Imaging is also particularly useful because it can characterize the size and location of the infection, distinguish peritonsillar abscess from tonsillitis, peritonsillar phlegmon, parapharyngeal abscess, or retropharyngeal abscess, and identify complications.

• Ultrasonography: Point-of-care ultrasonography (POCUS) is recommended as a first-line imaging modality for peritonsillar abscess. POCUS can confirm an abscess, delineate the carotid artery, guide real-time drainage, and verify reduction of the fluid collection. Two different approaches are used: intraoral ultrasonography with an intracavitary transducer (sensitivity, 90% to 100%) and extraoral ultrasonography via a transcervical or submandibular route with a linear transducer (sensitivity, 80% to 91%). Specificity for both approaches ranges from 79% to 100%.[30][31][32][33][34]
• Computed tomography: Contrast-enhanced computed tomography (CECT) of the neck is the gold standard for diagnosing a peritonsillar abscess or other deep neck space infection. CECT should be performed if POCUS is nondiagnostic, another deep neck space infection is suspected, or the clinical evaluation is equivocal. CECT has 76% to 96% sensitivity, 75% to 81% specificity, and typically differentiates a drainable abscess from a phlegmon by showing rim enhancement in the former. (See Image. Peritonsillar Abscess, Computed Tomography).[29][35] However, this imaging modality has disadvantages, including radiation exposure, longer diagnostic time, and higher cost than POCUS.

Treatment / Management

The management of a peritonsillar abscess is determined by clinical examination, disease severity, and ultrasonography or CECT.[1]

Airway Stabilization

The initial step in evaluating a suspected peritonsillar abscess is to assess for severe upper airway obstruction, which may present with ill appearance, drooling, tripoding, or respiratory distress. In such cases, immediate airway stabilization is required and should precede further diagnostic evaluation.[9][36][37]

Medical Management

• Pain control: If the patient has trismus, anti-inflammatory medications like ketorolac or ibuprofen can provide analgesia. Opioids may be necessary for severe pain.
• Antibiotics: Once the diagnosis is confirmed clinically or radiographically, prompt initiation of antibiotic therapy is essential. Treatment may be administered intravenously (IV), intramuscularly, or orally (PO), depending on severity and patient status. Recommended regimens include clindamycin (450 mg PO three times daily or 600-900 mg IV three times daily), ampicillin-sulbactam (3 g IV four times daily), amoxicillin-clavulanic acid (875 mg PO twice daily), or a combination of metronidazole (400-500 mg PO or IV 4 times daily) with ceftriaxone (1 g IV twice daily) or cefdinir (300 mg PO twice daily), providing coverage against Streptococcus pyogenes, oral anaerobes, and other common oropharyngeal pathogens.[38] If methicillin-resistant Staphylococcus aureus is suspected, metronidazole with vancomycin (1 g IV twice daily) or linezolid (600 mg PO twice daily) should be used instead.[26] Oral antibiotics should be started once the patient can tolerate oral intake.
• Intravenous fluids: Intravenous fluids are typically necessary because most patients with peritonsillar abscesses will present with dehydration due to reduced oral intake from odynophagia.[26][39]
• Corticosteroids: Corticosteroids such as dexamethasone (8-10 mg IV three times daily) or methylprednisolone (2-3 mg/kg IV) reduce pain and shorten recovery time compared with placebo.[40] Corticosteroids are also indicated if there is any concern for airway patency.

Surgical Management

Determining whether to perform surgical intervention for a peritonsillar abscess should be individualized. In some settings, procedural drainage is performed early, whereas in others, initial medical management is more common. There is no statistically significant difference in outcomes after medical or surgical management for abscesses of any size. However, abscesses larger than 2 cm in diameter are less likely to resolve with medical treatment alone. Findings from a 2022 study by Urban et al demonstrated a noninsignificant trend toward higher success rates with surgical drainage for abscesses larger than 2 cm compared with medical management. However, both medical and surgical management of peritonsillar abscesses had lower success rates for infections larger than 2 cm.[41] 

Peritonsillar abscesses are most often located at the superior pole of the affected tonsil. Occasionally, injecting local anesthetic in preparation for procedural drainage may cause some purulent material to escape from the puncture site, helping localize the infection. However, obtaining adequate local anesthesia of the abscess cavity is very challenging, and blunt disruption of loculations is very uncomfortable for the patient.

Needle Aspiration

• Anesthesia: The tonsil, the anterior tonsillar pillar, the ipsilateral base of tongue, and the ipsilateral soft palate are sprayed with a topical anesthetic (eg, benzocaine). If unavailable, viscous lidocaine may be applied directly using a tongue depressor.
• Patient positioning: The patient should be positioned upright in the bed or a chair. The patient should be allowed to hold the laryngoscope blade or a tongue depressor to improve comfort, and a suction catheter should be provided to help clear secretions. This will also free the clinician's nondominant hand for the procedure. Applying a topical anesthetic to the tongue will help reduce gagging during the procedure.
• Aspiration: An 18-gauge spinal needle is typically used with a 10-mL syringe. The plastic sheath on the needle may be left in place, with the distal 1 to 1.5 cm cut off, to create a guard that reduces the risk of carotid artery injury. In adults, the internal carotid artery lies 20 to 25 mm deep to the tonsillar fossa, but this distance is shorter in children (8-9 mm), especially in those with craniofacial conditions such as velocardiofacial syndrome.[42][43] The needle is inserted into the peritonsillar space, and purulent material is aspirated until no further return is obtained. The most common location for successful aspiration is medial to the superior pole of the tonsil.

In children or when the abscess is in an anatomically challenging location, the procedure may need to be performed under general anesthesia or conscious sedation.[1][27]

Incision and Drainage

Limited evidence indicates that incision and drainage may be associated with a lower recurrence risk than needle aspiration.[27][44] Patient positioning and anesthesia are performed identically for incision and drainage as they are for needle aspiration. Needle aspiration is frequently performed before incision and drainage to localize the abscess definitively.

• Incision: An approximately 1 cm curvilinear incision is made through the anterior tonsillar pillar overlying the point of maximal fluctuance and following the curve of the tonsil. The incision is typically along the medial aspect of the superior pole of the tonsil. The incision should be quite superficial to prevent damage to blood vessels running within or deep to the tonsillar fossa. If a significant amount of purulent material is released, it should be suctioned quickly to prevent the patient from gagging or aspirating.
• Disruption of loculations: A curved Kelly clamp is inserted through the incision and gently spread to break up loculations, keeping the curve parallel to the tonsil. Most patients find this painful despite topical and local anesthesia. A Yankauer or Goodhill suction can be inserted into the incision to evacuate any remaining purulent material. (See Image. Instruments for Peritonsillar Abscess Management).
• Drainage: The patient is instructed to apply external pressure (milk the abscess) with their own hand. This approach improves tolerance and reduces the likelihood of gagging or accidental biting. Additionally, the patient is asked to gargle with saline to help debride accumulated material within the abscess cavity.

After drainage, patients often report reduced discomfort; however, inflammation and edema may persist for several days, leading to continued pain, a hypernasal voice, and trismus.

Tonsillectomy

In children with a history of peritonsillar abscess or obstructive sleep apnea presenting with a peritonsillar abscess, a tonsillectomy to remove the abscess (quinsy tonsillectomy) may be required.[1] Quinsy tonsillectomy may also be indicated if the abscess is intratonsillar or located at the inferior pole of the tonsil and not easily accessed.[45] Tonsillectomy with a peritonsillar abscess may be more challenging than a standard tonsillectomy due to inflammation and potentially increased bleeding; alternatively, it may be facilitated by dissection of the tonsil from the surrounding musculature.

Differential Diagnosis

In addition to peritonsillar abscess, patients who present with unilateral or bilateral sore throat, upper airway obstruction, or pharyngeal swelling should be evaluated for peritonsillar phlegmon, tonsillitis, pharyngitis, parapharyngeal abscess, retropharyngeal abscess, epiglottitis, ondontogenic infections of the molars, and tonsillar or nasopharyngeal neoplasms. Examples of tonsillar neoplasms include cysts and squamous cell carcinoma, while nasopharyngeal neoplasms that may distort the soft palate include nasopharyngeal carcinoma, juvenile nasopharyngeal angiofibroma (found only in boys), and lymphoma.

Prognosis

The prognosis for peritonsillar abscesses is generally favorable; however, delayed treatment and airway compromise can be fatal. Most patients recover within 4 to 7 days following prompt drainage and antibiotic therapy. Recurrence occurs in approximately 1% to 5% of cases, and tonsillectomy is typically offered after the second acute infection resolves, to reduce the risk of a future episode.[46][47]

Complications

Peritonsillar abscesses require prompt medical evaluation for several reasons, including the potential to progress to upper airway obstruction and respiratory distress, especially in children, due to pharyngeal edema. A spontaneously ruptured abscess can also cause aspiration pneumonia.[48] Suppuration of cervical lymph nodes ipsilateral to the abscess may occur, as can involvement of the sublingual or submandibular space in the floor of the mouth (Ludwig angina), causing a potential airway emergency. The infection may also spread through the superior constrictor muscle and into the parapharyngeal space or other deep neck spaces, allowing inferior expansion and mediastinitis, which may be fatal. Due to the proximity of the internal carotid artery, pseudoaneurysm or arterial rupture may occur.[49] 

The internal jugular vein is at risk for suppurative thrombophlebitis (Lemierre syndrome), which can release septic emboli to the lungs, brain, and the rest of the body, potentially resulting in septicemia, shock, and death.[48][50][51] While extremely rare, necrotizing fasciitis has been reported as a sequela of peritonsillar abscess.[52][53] Although complications from peritonsillar abscesses are uncommon, when they arise, mortality may approach 10%.[37]

Deterrence and Patient Education

Patients discharged following treatment for peritonsillar infection should be counseled to seek prompt medical reassessment if they develop any of the following: dyspnea, progressive throat or neck pain, trismus, tonsillar enlargement, fever, neck stiffness, or bleeding from the throat. Outpatients should be reassessed within 24 to 36 hours. Patients discharged after hospitalization should be reassessed within several days to ensure adequacy of oral hydration and nutrition.

Although no studies have specifically examined the effectiveness of strategies to prevent peritonsillar abscess, smoking and alcohol consumption have been identified as risk factors. Patients with recurrent peritonsillar abscesses are more likely to have further episodes, suggesting that tonsillectomy may be effective in preventing recurrence. However, peritonsillar abscesses have been reported following tonsillectomy.[54][55][56] Lastly, because bacterial pharyngitis or tonsillitis frequently precedes peritonsillar infection, and more than 5 episodes of tonsillitis have been associated with an increased risk of peritonsillar abscess, appropriate antibiotic therapy reduces the risk of progression to abscess.[57]

Enhancing Healthcare Team Outcomes

Peritonsillar abscess management requires an interdisciplinary team, including primary care and emergency medicine clinicians as well as an otolaryngologist if surgical intervention is needed. Posttreatment follow-up is essential to ensure complete recovery and the ability to tolerate an oral diet. Patients with recurrent peritonsillar abscesses should be referred to an otolaryngologist for consideration of tonsillectomy.[58][59]

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Disclosure: Dharshana Krishnaprasadh declares no relevant financial relationships with ineligible companies.

Disclosure: Marc Hohman declares no relevant financial relationships with ineligible companies.

Disclosure: Rachel McDowell declares no relevant financial relationships with ineligible companies.