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Acta Otorrinolaringol Esp. 2012;63(3):212---217

www.elsevier.es/otorrino

ORIGINAL ARTICLE

Peritonsillar Infections: Prospective Study of 100 Consecutive

Cases
Mara Costales-Marcos, Fernando Lpez-lvarez, Faustino N
nez-Batalla,
Carla Moreno-Galindo, Csar lvarez Marcos, Jos Luis Llorente-Pends
Servicio de Otorrinolaringologa, Hospital Universitario Central de Asturias, Oviedo, Principado de Asturias, Spain
Received 25 October 2011; accepted 2 January 2012

KEYWORDS
Peritonsillar
infection;
Abscess;
Cellulitis;
Tonsillitis

Abstract
Introduction: Peritonsillar infection is the most frequent complication of acute tonsillitis. Peritonsillar infections are collections of purulent material, usually located between the tonsillar
capsule and the superior constrictor of the pharynx. Peritonsillar infection can be divided into
abscess and cellulitis.
Material and methods: We prospectively analysed the clinical data from 100 patients with peritonsillar infection from 2008 to 2010. The diagnosis of abscess or peritonsillar cellulitis was
primarily based on obtaining pus through ne-needle aspiration.
Results: Seventy-seven percent of patients had no history of recurrent tonsillitis and 55% were
receiving antibiotic treatment. Sixty-two cases were peritonsillar abscess and the rest were
cellulitis. Trismus, uvular deviation and anterior pillar bulging were statistically associated with
peritonsillar abscess (P<.005). All patients were admitted to hospital and treated with puncturedrainage, intravenous antibiotics (amoxicillin/clavulanate in 83% of cases) and a single dose of
steroids. All patients were discharged on oral antibiotic therapy. The mean length of hospital
stay was 3 days and the recurrence rate was 5%.
Conclusions: Due to the absence of clinical practice guidelines, there are different therapeutic
protocols. According to our experience, puncture-aspiration and administration of intravenous
antibiotics is a safe, effective way to treat these patients. To determine the efcacy and safety
of outpatient management, controlled studies would be needed.
2011 Elsevier Espaa, S.L. All rights reserved.

Please cite this article as: Costales-Marcos M, et al. Infecciones periamigdalinas: estudio prospectivo de 100 casos consecutivos.
Acta Otorrinolaringol Esp. 2012;63:212---7.
Corresponding author.
E-mail address: Costi2@hotmail.com (M. Costales-Marcos).

2173-5735/$ see front matter 2011 Elsevier Espaa, S.L. All rights reserved.

Document downloaded from http://www.elsevier.es, day 27/07/2015. This copy is for personal use. Any transmission of this document by any media or format is strictly prohibited.

Peritonsillar Infections: Prospective Study of 100 Consecutive Cases

PALABRAS CLAVE
Infeccin
periamigdalina;
Absceso;
Flemn;
Amigdalitis

213

Infecciones periamigdalinas: estudio prospectivo de 100 casos consecutivos

Resumen
Introduccin: La infeccin periamigdalina supone la complicacin ms frecuente de una
amigdalitis. Se dene como una coleccin purulenta localizada entre la cpsula amigdalar y
el msculo constrictor superior de la faringe. Puede clasicarse en emn y absceso periamigdalino.
Material y mtodos: Presentamos un estudio prospectivo descriptivo de 100 infecciones periamigdalinas diagnosticadas entre los a
nos 2008 y 2010. Se analizaron diversas variables
clnico-epidemiolgicas y el manejo de estos pacientes. El diagnstico de emn o absceso
periamigdalino se bas fundamentalmente en la obtencin de pus mediante puncin-aspiracin.
Resultados: El 77% de los pacientes no tenan antecedentes de amigdalitis de repeticin y el
55% estaban recibiendo tratamiento antibitico. En el 62% de los casos se clasic como absceso
y en el 38% como emn periamigdalino. La presencia de trismus, desviacin contralateral de la
vula y el abombamiento del pilar anterior se relacion con la presencia de absceso (p < 0,001).
Todos los pacientes fueron ingresados y tratados con puncin-drenaje, antibioterapia intravenosa (amoxicilina/clavulnico en el 83% de los casos) y una dosis de corticoides. Al alta,
todos los pacientes recibieron antibioterapia oral. La estancia media fue de 3 das y la tasa de
recurrencias del 5%.
Conclusiones: Debido a la ausencia de guas de prctica clnica, existen diversos protocolos
teraputicos. De acuerdo a nuestra experiencia, la puncin-aspiracin y la administracin de
antibioterapia intravenosa, es una opcin segura y ecaz en el manejo de estos pacientes.
Para determinar la ecacia y seguridad del manejo ambulatorio o mediante ingreso de estos
pacientes, seran necesarios estudios controlados.
2011 Elsevier Espaa, S.L. Todos los derechos reservados.

Introduction
Peritonsillar infections are the most common infections of
deep tissues of the head and neck region both in adults
and children, with an incidence of approximately 30 cases
per 100 000 population per year.1 Furthermore, despite the
widespread use of antibiotics, they are the most common suppurative complication in tonsillar infections.2 The
natural history of infections in the peritonsillar region is
represented by 2 main entities: phlegmon and peritonsillar abscess. Each reects a separate stage in the evolution
of the inammatory process originating from an exudative tonsillar infection. Peritonsillar abscess is dened as
a purulent collection located between the tonsillar capsule, the superior constrictor muscle of the pharynx and the
palatopharyngeal muscle.3 In the pathophysiology of peritonsillar infections, phlegmon would represent a stage prior
to an abscess, in which the peritonsillar inammation process is not limited.
Although group A -haemolytic streptococcus (Streptococcus pyogenes) is usually the pathogen involved in the
aetiology of this entity,4 in most cases the infection corresponds to a mixed ora of aerobic and anaerobic agents.5
Since there are no clinical guidelines for the management
of this disease, treatment varies between countries and
even between hospitals within the same country, in aspects
such as treatment regime (outpatient or inpatient), method
of drainage and antibiotic therapy employed. If peritonsillar
infections are not treated properly there is a risk of developing serious complications such as thrombosis of the internal
jugular vein, mediastinitis, pericarditis, pneumonia, formation of pseudoaneurysms and even sepsis.6,7 The mortality

rate of patients who develop these complications can

reach 42% in cases of mediastinitis or serositis.8 Nevertheless, although occasionally the development of peritonsillar
infection is torpid, morbidity and mortality are low if it
is treated correctly, and hence the importance of knowing its anatomical characteristics, triggering factors, clinical
aspects and therapeutic alternatives.9,10
The aim of this study is to review the diagnostic and therapeutic management of 100 consecutive cases collected at
our service between the years 2008 and 2010.

Materials and Methods

We performed a descriptive, prospective study of the
management of patients who were diagnosed and
treated for peritonsillar infection between April 2008 and
October 2010.
The diagnosis of peritonsillar infection was mainly based
on anamnesis and physical examination. We collected the
following clinical variables: age, gender, history of recurrent
tonsillitis, previous episodes of phlegmon/abscess, evolution, previous antibiotic therapy and its duration (the
information was provided by patients or their relatives),
symptoms at onset, physical examination ndings and therapeutic procedure applied. We also recorded the length of
hospital stay, treatment prescribed at discharge, recurrence
of the process and performance of subsequent tonsillectomy.
Following the protocol used in our department for the
management of peritonsillar infections, all patients attending the Emergency Service with symptoms and exploration
consistent with the diagnosis of peritonsillar infection were

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214

M. Costales-Marcos et al.

admitted for intravenous antibiotic therapy, analgesia and

possible intravenous corticosteroids. According to Szuhay
and Tewk, a diagnosis of phlegmon or peritonsillar abscess
was based primarily on the obtention of pus with needle
aspiration performed on patients upon admission, in the
region of maximum peritonsillar bulging.11
The criteria for hospital discharge included clinical and
analytical improvement of the patient.We used the statistical software SPSS 19.0 for Windows to conduct the statistical
analysis.

Results
We analysed 100 consecutive patients diagnosed with peritonsillar infection at our hospital between April 2008 and
October 2010. Table 1 shows the main clinical and epidemiological characteristics of patients included in the study.
The ages of the patients included in the study ranged
from 4 to 81 years, with a mean value of 34 years. As for
gender, the ratio in adults was 1.1/1 in favour of males (53
males and 47 females).
In total, 77% of patients had no documented history of
repeated bacterial tonsillitis. In most patients (86%), the
episode of peritonsillar infection was the rst with these
characteristics. However, in 9% of cases, the episode was a
second occurrence and in 5% it was a third, fourth and even
in 1 case, the fth episode with the same characteristics.
The vast majority (97%) had no prior history of tonsillectomy; nevertheless, 2 patients had undergone tonsillectomy
in childhood.
The time elapsed between onset of symptoms and diagnosis of the episode was a minimum of 2 and a maximum
of 6 days, with a mean latency of 3 days. Less than half
of patients (45%) had not received any doses of antibiotic
Table 1

Main Clinical and Epidemiological Characteristics.

Characteristics
Gender
Male
Female

53 (53%)
47 (47%)

Mean age
Repeated tonsillitis
Previous peritonsillar infection

34 years (4---81 years)

23 (23%)
14 (14%)

Laterality
Left
Right

59 (59%)
41 (41%)

Mean latency until diagnosis

Prior antibiotic therapy

3 days (2---7 days)

55 (55%)

Diagnosis
Phlegmon
Abscess

62 (62%)
38 (38%)

Treatment
Intravenous
amoxicillin/clavulanate
Mean hospital stay
Recurrences
Subsequent tonsillectomy

83 (83%)
3 days (1---7 days)
5 (5%)
26 (26%)

Table 2 Presentation Symptoms in 100 Patients With Peritonsillar Infection.a

Symptom/sign

No. of patients, %

Odynodysphagia
Bulging of anterior pillar
Contralateral displacement of uvula
Cervical lymphadenopathies
Fever
Trismus
Ptyalism
Dysphonia
Uvula hydrops
Dyspnoea

100 (100)
98 (98)
95 (95)
80 (80)
70 (70)
77 (77)
68 (68)
40 (40)
28 (28)
13 (13)

Patients normally presented more than 1 symptom.

treatment before attending the Emergency Service. Within

the group of patients (55%) who were being treated with
antibiotics as prescribed by their primary care physician, the
most frequently used drug (49 patients) was a combination
of amoxicillin/clavulanate at a dose of 500 mg/125 mg in 42
patients and 875 mg/125 mg in 7 patients. Only 2 patients
were prescribed a macrolide (azithromycin 500 mg) and 4
patients had taken both drugs consecutively before attending the Emergency Service. The mean duration of treatment
prior to diagnosis was 2 days (range: 1---12 days).
Table 2 shows the clinical characteristics of patients. The
clinical symptoms characterised by odynodysphagia, fever,
trismus, bulging of the anterior pillar, deviation of the uvula
to the contralateral side and laterocervical lymphadenopathy were present in 77% of cases. In 30% of patients we did
not nd fever and trismus was absent in 23% of cases. The
absence of trismus did not rule out the presence of peritonsillar abscess. In the haemogram which patients underwent
upon admission, the mean value of leukocytes was 16,922/l
(7300---33 400).
As mentioned previously, upon admission all patients
underwent puncture-aspiration in the most convex part
of the anterior tonsillar pillar. No purulent material was
obtained in 62 cases (62%), leakage of pus was observed in
32 cases (32%), in 5 patients (5%) we noted a spontaneous
drainage of purulent material and in 1 case (1%) puncture
was not performed at the time of diagnosis due to trismus.
Based on this result we classied patients into those with a
diagnosis of phlegmon, when there was no discharge of pus
(62%), or abscess, when puncture led to the leakage of purulent material (38%). Clinical signs signicantly associated
with the presence of peritonsillar abscess were the presence
of trismus (P<.001), contralateral deviation of the uvula
(P<.001) and bulging of the anterior pillar of the affected
side (P<.001). We did not nd a signicant association with
the rest of the clinical data recorded.
All patients were hospitalised and treated with
intravenous antibiotics. The combination of amoxicillin/clavulanate 1000 mg/200 mg every 8 h was the most
widely used antibiotic treatment (83% of patients), followed
by the association between clindamycin 600 mg every 8 h
and gentamicin 240 mg every 24 h (14% of patients). Three
patients received amoxicillin/clavulanate according to the
previous dosage but, due to lack of favourable evolution

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Peritonsillar Infections: Prospective Study of 100 Consecutive Cases

after 5 days, were changed to a combination of clindamycin
and gentamicin as described above. In all cases, antibiotic
treatment was carried out empirically and duration of
intravenous therapy varied between 1 day (only 1 case was
treated for 24 h) and 7 days. Most patients (82%) received
intravenous antibiotic treatment for at least 3 days. All
patients were given a dose of intravenous corticosteroids
(methylprednisolone 1 mg/kg) upon admission, as well as
intravenous analgesia. All patients evolved satisfactorily
and we did not observe progress of the infection to more
serious complications.
All patients received oral antibiotic therapy at discharge
for 7 days. Treatment consisted in amoxicillin/clavulanate
1000 mg/62.5 mg, in 2 tablets every 12 h in 83% of cases and
clindamycin 300 mg every 6 h in 17% of cases.
These cases of peritonsillar infection were the rst collected during the time of study in 95% of patients, whilst
1% experienced a new episode and 4% presented 2 consecutive episodes. In 26 cases (26%) we suggested performing
tonsillectomy after the episode of peritonsillar infection.

Discussion
Most studies published in current literature are based on a
retrospective analysis of cases. Thus, their results reect
the management of this condition in 10---15 years evolution.
In order to reduce the heterogeneity inherent to most retrospective series, we have chosen to analyse prospectively
100 consecutive cases treated at our hospital according to
the same diagnostic and therapeutic protocol.
In our series, 55% of patients were receiving antibiotic therapy for the treatment of pharyngotonsillitis. This
nding is more consistent with the classical concept that
peritonsillar infection is due to a torpid evolution of bacterial tonsillitis. However, this percentage is higher than
that described in the literature, where prior pharyngotonsillar infection was only reported in between 11% and 45%
of cases.12,13 The absence of prior tonsillar infection would
support the theory that the origin of peritonsillar infection
is cellulitis of Webers salivary glands. These small mucous
glands are located in the superior pole of the tonsillar bed
and the soft palate. When cellulitis of these glands takes
place and inammation progresses, it leads to symptoms
which are clinically indistinguishable from those caused
when a tonsillar infection does not evolve favourably. This
observation would also justify the development of peritonsillar infections in patients who had undergone prior
tonsillectomy.14,15
The diagnosis of this entity is simple and is based on
clinical data and physical exploration.1 It is characterised
by the presence of unilateral inammatory signs and symptoms, even in the absence of febrile syndrome. The presence
of trismus, bulging of the anterior pillar and deviation of
the uvula to the contralateral side can help to distinguish
between a phlegmonous early stage and peritonsillar abscess
without requiring puncture. While this datum conrms the
reports published by Kilty et al.,16 it should be taken with
caution since, as seen in our study, up to 23% of cases do not
present signicant trismus. Some authors advocate the use
of ultrasound for diagnosis and to conduct guided punctures,

215

as well as computed tomography (CT) in uncooperative paediatric patients.1

One of the hypotheses which we considered at the beginning of the study was that an inappropriate use of antibiotics
in the treatment of pharyngitis favoured the development
of complications, specically the use of macrolides, due to
the high rate of resistance among the Spanish population.
However, although most patients were taking antibiotics at
the time of diagnosis of peritonsillar infection, we found
that only 3% of patients who had taken antibiotics previously had taken a macrolide and most were being treated
adequately with amoxicillin/clavulanate. Nevertheless, we
believe that not taking the appropriate dosage or failure
to adequately comply with the correct antibiotic pattern
could be a favouring factor since most authors report a
higher rate of peritonsillar infections in patients treated
with macrolides.9 In our series we found no relationship
between a history of repeated pharyngotonsillitis and the
development of peritonsillar infection. This coincides with
the ndings in other series.2 However, we did observe a relationship between suffering repeated pharyngotonsillitis and
suffering more than one episode of phlegmon/abscess.
Management on an outpatient basis or hospitalisation of
these patients is a source of disagreement between various authors (Table 3). While in countries such as the United
Kingdom the vast majority of patients are admitted, in the
United States they are mostly managed as outpatients.24
In our series, following the protocol at our service, we
admitted these patients in order to administer intravenous
antibiotics and provide hydration and nutritional support.
Nevertheless, we believe that, following the therapeutic
regime of Al Yaghchi et al.,25 certain patients without risk
factors could benet from outpatient management.
Drainage of the purulent material is part of the treatment (Table 3). The most appropriate method for this task
remains controversial, although both puncture-aspiration
and incision-drainage seem to be equally effective.18,21 In
our action protocol, we use puncture-aspiration at the time
of diagnosis. According to the leakage or not of purulent
material, we classify the infection as phlegmon or abscess.
The management guide for peritonsillar abscesses proposed
by Herzon et al.12 suggests that puncture-aspiration can
be used as the only drainage procedure, as it obtains a
resolution rate of 96%, and leaves incision-drainage as an
alternative for cases of failure of the rst technique. These
authors emphasise the scarce discomfort, technical simplicity and low cost of the technique, as well as the fact that it
does not require specialised equipment. Some authors advocate performing tonsillectomy immediately after draining
the abscess (quinsy or hot tonsillectomy) due to the low
rate of complications and recurrences.26 In our study, most
patients evolved adequately without having to repeat the
puncture or perform an incision for drainage.
Antibiotic treatment was established empirically, with
the rst option being intravenous amoxicillin-clavulanate
at high doses. This treatment progressed adequately in
84% of cases, including those previously treated with this
same combination. From this we can conclude that most
resistances remain dose-dependent. We believe that a combination of clindamycin and gentamicin may be an adequate
alternative in cases of -lactam allergy or unfavourable evolution with the rst option. Other authors advocate the

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216
Table 3

M. Costales-Marcos et al.
Comparative studies of drainage method and treatment regime.

Authors

Treatment regime

Number
of patients

Method

Mehanna et al.17

101

Ong et al.13

94% hospital
6% outpatient
100% hospital

Stringer et al.18

100% outpatient

Herzon et al.12
Ophir et al.19

100% outpatient
92% outpatient
8% hospital
100% outpatient

48% punction
52% incision
66% incision
34% punction
Punction
Incision
100% punction
100% punction

92
90
93
41
92
93
90
52

75.4% punction 23.8%

incision 0.8% quinsy
tonsillectomy

96

Segal et al.20

Spires et al.21

100% outpatient

Maharaj et al.4

100% outpatient

Savolainen et al.22
Wolf et al.23

100% hospital
100% hospital

185
24
28
41
75
126

41
21
30
30
98
86
74

use of cefotaxime or penicillin alone or combined with

metronidazole, with similar results.13,27 We believe that
administration of a single dose of corticosteroids can be
very useful, having observed, like other authors, a faster
improvement of symptoms such as dysphagia, pain and
trismus.28
In accordance with other authors,29 we believe that
microbiological identication studies are unnecessary, since
empirical therapy is generally effective before culture
results are obtained. In addition, many patients take antibiotics previously, so, very often, the results of the culture do
not identify the causative agent. Conducting cultures and
antibiograms would only be useful in cases of infections
with very unfavourable evolution and in immunocompromised patients.
According to Wikstn et al. the risk of recurrence is
10%---15% depending on the follow-up period. This rate
increases to 50% in patients younger than 40 years and in
those with a history of repeated infections.30 Our recurrence
rate was 5%, which would conrm the effectiveness of our
protocol.
Regarding the indication for tonsillectomy after an
episode of peritonsillar infection, as described in the
literature,9,31 we do not consider having suffered such an
episode as an absolute criterion for the intervention. However, in patients with repeated pharyngotonsillitis and in
those cases with more than one peritonsillar event, we support the indication of delayed tonsillectomy.
We have not collected any cases of serious complications
during this time period, since cases of mediastinitis, necrotising fasciitis or septic embolisms are more common in
severely immunocompromised patients or in those who have
suffered a major delay in diagnosis.32

Punction
Incision
Punction
Incision
100% punction
Punction
Incision

Success, %

98
100
98
100
87
90
91
28
90

Conclusions
Peritonsillar infection is the most common complication of
bacterial pharyngotonsillitis. Although this entity is likely
to cause high morbidity and mortality, it has an excellent
prognosis when properly treated.
Due to the absence of clinical practice guidelines for
the management of this disorder there are various treatment protocols. From our experience, we believe that
puncture-aspiration in the most convex peritonsillar region
and administration of intravenous antibiotics represents a
safe and effective protocol in the management of these
patients. Further, controlled studies would be required in
order to determine the efcacy and safety of management
on an outpatient basis compared to hospital admission.

Conict of Interests
The authors have no conicts of interest to declare.

References
1. Johnson RF, Stewart MG. The contemporary approach to diagnosis and management of peritonsillar abscess. Curr Opin
Otolaryngol Head Neck Surg. 2005;13:157---60.
2. Barroso Braojos G, Raboso Garca-Baquero E, Martnez Sanmilln J, Martnez Vidal A. Absceso periamigdalino con extensin
parotdea y perifarngea. A propsito de un caso. Acta Otorrinolaringol Esp. 2000;51:737---9.
3. Martn Campagne E, del Castillo Martn F, Martnez Lpez MM,
Borque de Andrs C, de Jos Gmez MI, Garca de Miguel MJ,
et al. Abscesos periamigdalino y retrofarngeo: estudio de 13
a
nos. An Pediatr (Barc). 2006;65:32---6.

Document downloaded from http://www.elsevier.es, day 27/07/2015. This copy is for personal use. Any transmission of this document by any media or format is strictly prohibited.

Peritonsillar Infections: Prospective Study of 100 Consecutive Cases

4. Maharaj D, Rajah V, Hemsley S. Management of peritonsillar
abscess. J Laryngol Otol. 1991;105:743---5.
5. Brook I. Microbiology and management of peritonsillar,
retropharyngeal, and parapharyngeal abscesses. J Oral Maxillofac Surg. 2004;62:1545---50.
6. Marioni G, Staferi A, Parisi S, Marchese-Ragona R, Zuccon A,
Staferi C, et al. Rational diagnostic and therapeutic management of deep neck infections: analysis of 233 consecutive cases.
Ann Otol Rhinol Laryngol. 2010;119:181---7.
7. Freling N, Roele E, Schaefer-Prokop C, Fokkens W. Prediction
of deep neck abscesses by contrast-enhanced computerized
tomography in 76 clinically suspect consecutive patients. Laryngoscope. 2009;119:1745---52.
8. Yang SVV, Lee MH, Lee YS, Huang SH, Chen TA, Fang TJ. Analysis of life-threatening complications of deep neck abscess and
the impact of empiric antibiotics. ORL J Otorhinolaryngol Relat
Spec. 2008;70:249---526.
nez Gmez F, Sala Franco J,
9. Garca Callejo FJ, N
Marco Algarra J. Tratamiento de la infeccin periamigdalina.
An Pediatr (Barc). 2006;65:37---43.
10. Friedman NR, Mitchell RB, Pereira KD, Younis RT, Lazar RH.
Peritonsillar abscess in early childhood. Presentation and
management. Arch Otolaryngol Head Neck Surg. 1997;123:
630---2.
11. Szuhay G, Tewk TL. Peritonsillar abscess or cellulitis? A clinical comparative paediatric study. J Otolaryngol. 1998;27:
206---12.
12. Herzon FS, Harris P. Mosher Award Thesis. Peritonsillar abscess:
Incidence, current management practices, and a proposal treatment guidelines. Laryngoscope. 1995;105:117.
13. Ong YK, Goh YH, Lee YL. Peritonsillar infections: local experience. Singapore Med J. 2004;45:106---9.
14. Farmer SE, Khatwa MA, Zeitoun HM. Peritonsillar abscess after
tonsillectomy: a review of the literature. Ann R Coll Surg Engl.
2011;93:353---5.
15. Kordeluk S, Novack L, Puterman M, Kraus M, Joshua BZ. Relation
between peritonsillar infection and acute tonsillitis: myth or
reality. Otolaryngol Head Neck Surg. 2011;145:940---5.
16. Kilty SJ, Gaboury I. Clinical predictors of peritonsillar abscess
in adults. J Otolaryngol Head Neck Surg. 2008;37:165---8.
17. Mehanna HM, Al-Bahnasawi L, White A. National audit of
the management of peritonsillar abscess. Postgrad Med J.
2002;78:545---8.
18. Stringer SP, Schaefer SD, Close LG. A randomized trial for outpatient management of peritonsillar abscess. Arch Otolaryngol
Head Neck Surg. 1988;114:296---8.

217

19. Ophir D, Bawnik J, Poria Y, Porat M, Marshak G. Peritonsillar

abscess. A prospective evaluation of outpatient management by needle aspiration. Arch Otolaryngol Head Neck Surg.
1988;114:661---3.
20. Segal N, El-Saied S, Puterman M. Peritonsillar abscess in children
in the southern district of Israel. Int J Pediatr Otorhinolaryngol.
2009;73:1148---50.
21. Spires JR, Owens JJ, Woodson GE, Miller RH. Treatment
of peritonsillar abscess. A prospective study of aspiration
vs incision and drainage. Arch Otolaryngol Head Neck Surg.
1987;113:984---6.
22. Savolainen S, Jousimies-Somer HR, Makitie AA, Ylikoski JS.
Peritonsillar abscess. Clinical and microbiologic aspects and
treatment regimens. Arch Otolaryngol Head Neck Surg.
1993;119:521---4.
23. Wolf M, Even-Chen I, Kronenberg J. Peritonsillar abscess:
repeated needle aspiration versus incision and drainage. Ann
Otol Rhinol Laryngol. 1994;103:554---7.
24. Garas G, Ifeacho S, Cetto R, Arora A, Tolley N. Prospective audit
on the outpatient management of patients with a peritonsillar abscess: closing the loop: how we do it. Clin Otolaryngol.
2011;36:174---9.
25. Al Yaghchi C, Cruise A, Kapoor K, Singh A, Harcourt J. Outpatient management of patients with a peritonsillar abscess.
Clin Otolaryngol. 2008;33:52---5.
26. Dunne AA, Granger O, Folz BJ, Sesterhenn A, Werner JA. Peritonsillar abscess-critical analysis of abscess tonsillectomy. Clin
Otolaryngol. 2003;28:420---4.
27. Prior A, Montgomery P, Mitchelmore I, Tabaqchali S. The microbiology and antibiotic treatment of peritonsillar abscess. Clin
Otolaryngol. 1995;20:219---23.
28. Ozbek C, Aygenc E, Tuna EU, Selcuk A, Ozdem C. Use of
steroids in the treatment of peritonsillar abscess. J Laryngol
Otol. 2004;118:439---42.
29. Nelson TG, Hayat T, Jones H, Weller MD. Use of bacteriologic
studies in the management of peritonsillar abscess. Clin Otolaryngol. 2009;34:88---9.
30. Wikstn J, Hytnen M, Pitkranta A, Blomgren K. Who ends
up having tonsillectomy after peritonsillar infection? Eur Arch
Otorhinolaryngol. 2011 [Epub ahead of print].
31. Fagan JJ, Wormald PJ. Quinsy tonsillectomy or interval
tonsillectomy-a prospective randomised trial. S Afr Med J.
1994;84:689---90.
32. Alaani A, Grifths H, Minhas SS, Olliff J, Lee AB. Parapharyngeal
abscess: diagnosis, complications and management in adults.
Eur Arch Otorhinolaryngol. 2005;262:345---50.