An ENT's Approach to Peritonsillar Abscesses

Christina Shenvi, MD, PhD and Justin Miller, MD

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The summary below is from an episode of ERcast: Clinical Perspectives

Peritonsillar abscess is a common deep neck infection marked by unilateral sore throat, trismus, muffled voice, and uvular deviation. The hard parts are confirming abscess versus phlegmon, draining safely near the carotid, and deciding who needs imaging, admission, or ENT follow-up.

Peritonsillar Abscess Diagnosis and Management

Classic bedside findings: PTA usually declares itself with severe unilateral sore throat, trismus, muffled “hot potato” voice, trouble handling secretions, and uvular deviation away from the affected side.
Abscess versus phlegmon: Soft-palate bulging with bogginess suggests a drainable fluid collection, but bilateral tonsillitis makes PTA uncommon enough that imaging should usually confirm the diagnosis.
Imaging decision support: Ultrasound can help separate abscess from cellulitis, but performance is operator-dependent; when the exam and POCUS are non-diagnostic, CT with IV contrast is often the practical next step. We get into that imaging judgment in the episode.
Steroid-assisted examination: Dexamethasone 10 mg IV can meaningfully reduce inflammation and trismus, and giving it about an hour before re-exam may turn a poor oral exam into an adequate one.
Drainage safety anatomy: The superior pole is the usual site, and the carotid lies posterolateral only a short distance away, so depth control matters more than enthusiasm during aspiration or incision.
Disposition and follow-up: Airway concern is the key reason to transfer, while stable patients often do well with ED treatment plus antibiotics; adults should still get Otolaryngology follow-up after resolution to exclude occult oropharyngeal carcinoma.

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References:

Chang BA, Thamboo A, Burton MJ, et al. Needle aspiration versus incision and drainage for the treatment of peritonsillar abscess. Cochrane Database Syst Rev. 2016 Dec 23;12(12): CD006287. PMID: 28009937.
Long B, Gottlieb M. Managing Peritonsillar Abscess. Ann Emerg Med. 2023 Jul;82(1):101-107. Epub 2023 Jan 19. PMID: 36669912.
Kim DJ, Burton JE, Hammad A, et al. Test characteristics of ultrasound for the diagnosis of peritonsillar abscess: A systematic review and meta-analysis. Acad Emerg Med. 2023;30(8):859-869. PMID: 36625850

Faculty

Christina Shenvi, MD, PhD
Dr. Christina Shenvi is a Professor of Emergency Medicine at the University of North Carolina at Chapel Hill School. She is fellowship-trained in geriatric emergency medicine and is the creator and host of GEMCAST, a podcast focused on geriatric EM. Dr. Shenvi has served on the Board of Governors for the ACEP Geriatric ED accreditation. A passionate educator, she has received multiple institutional and national teaching awards and co-directs the ACEP Teaching Fellowship. Her academic interests include teaching and learning, deliberate practice, and innovative pedagogy.
Justin Miller, MD