Acta Oto-Laryngologica, 2012; 132: 1102–1107

ORIGINAL ARTICLE

Peritonsillar abscess: Treatment with immediate tonsillectomy –

10 years of experience

NICOLAS ALBERTZ1 & GONZALO NAZAR2

1
Public Health and 2Otolaryngology Department, Clinica Las Condes, University of Chile, Santiago, Chile

Abstract
Conclusion: Immediate tonsillectomy in patients with peritonsillar abscess is a safe and effective treatment that should be
considered as an alternative to conventional incision and drainage. Objective: To assess the efficacy, safety, and microbiology of
immediate tonsillectomy over 10 years, in patients with peritonsillar abscess. Methods: This was a retrospective study. We
reviewed the clinical charts of patients diagnosed with peritonsillar abscess in Clínica Las Condes from September 2000 to
August 2010, who were treated with immediate unilateral or bilateral tonsillectomy. The patients’ epidemiological informa-
tion, antibiotic therapy, laterality of the surgery, results of microbiological cultures, complications, and recurrences were
recorded. Results: A total of 112 patients were studied, with a mean age of 24 years. There were no events of sepsis, and there
were only four cases (3.6%) of postoperative bleeding, two of which resolved spontaneously. Only 29% of the patients required
morphine pump-based analgesia in the postoperative period. The mean length of hospital stay was 3.4 days. Among the
28 unilateral tonsillectomies, 4 (14.2%) developed streptococcal tonsillitis and 2 (7.1%) were readmitted with a contralateral
peritonsillitis: one cellulitis and one abscess that required drainage and tonsillectomy. The most frequently isolated
microorganisms were gram-positive bacteria (Streptococcus pyogenes and other streptococci) and anaerobic bacteria (mainly
Bacteroides spp. and Fusobacterium nucleatum).

Keywords: Safety, efficacy, microbiology, deep neck infection, quinsy

Introduction From a pathophysiological standpoint, peritonsillar

Peritonsillar abscess is the most common deep neck
space infection [1]. In most cases it is a complication of
a streptococcal pharyngotonsillitis, in which the inflam-
matory process spreads to the peritonsillar space. The
incidence is 30 cases per 100 000 inhabitants annually
in the United States, with approximately 45 000 cases
per year [2]. Other studies have reported even higher
incidences, likely due to recurrent infections and
increasing antimicrobial resistance [3].
Unlike acute bacterial tonsillitis, peritonsillar
abscess occurs most often during the third and fourth
decades of life [3]. However, there are increasing
communications of peritonsillar infection in younger
groups [4]. On the other hand, cases have been
reported in patients over the age of 80 years [1].
abscess is the result of the progression of an acute
bacterial infection in the palatine tonsils into the
peritonsillar space, often in the setting of an inade-
quate or incomplete course of antibiotics. Peritonsil-
litis initially presents as a cellulitis, progressing into a
peritonsillar abscess as there is tissue necrosis and
formation of a pus collection. The most commonly
affected area is the superior pole of the palatine tonsil
and its neighboring muscles. However, there are
also abscesses with atypical locations in other areas
surrounding the tonsils, intratonsillar abscesses,
posterior abscesses, bilateral abscesses, and even
multiple abscesses in the same tonsil. Patients usually
present with severe throat pain, fever, drooling, foul
breath, trismus, neck swelling, and altered voice
resonance.

Correspondence: Nicolas Albertz, Las Verbenas 9000, Dept 1105, Las Condes, Santiago, Chile. Tel: +56 9 9822 5859. E-mail: nicolas.albertz@gmail.com

(Received 7 March 2012; accepted 8 April 2012)

ISSN 0001-6489 print/ISSN 1651-2251 online
2012 Informa Healthcare
DOI: 10.3109/00016489.2012.684399
 Immediate tonsillectomy as treatment for peritonsillar abscess
Microbiological findings for peritonsillar abscesses
include both aerobic and anaerobic components
[3,5–8]. The aerobic bacterium Streptococcus
pyogenes is isolated in nearly a third of cases [1].
Peptostreptococci are among the anaerobic pathogens
most commonly implicated. It has been reported that
two-thirds of deep neck space infections involve beta-
lactamase-producing bacteria, which encourages the
use of antibiotics that are resistant to this enzyme [9].
Peritonsillar abscess should be treated rapidly and
effectively, as it can result in life-threatening compli-
cations. The mass effect of a pharyngeal collection
may obstruct the upper airway, and a spontaneous
rupture of the abscess may lead to pus aspiration.
Lateral extension into other deep neck spaces may put
at risk vascular and neurological structures [10].
Mediastinitis and septicemia are rare but highly lethal
complications [11,12].
Traditional management of peritonsillar abscess has
been needle aspiration or incision and drainage, but
more radical therapy involving immediate tonsillectomy
has shown favorable results [1,13–16]. However, quinsy
tonsillectomy (i.e. tonsillectomy performed to treat
peritonsillar abscess) is still avoided by many otolaryn-
gologists, as removing acutely infected tonsils is
expected to have a higher rate of complications: spread
of the infection and post-tonsillectomy hemorrhage.
The objective of the present study was to review our
cumulative experience of 10 years using immediate
tonsillectomy to manage peritonsillar abscess, to
determine the efficacy and safety of this therapeutic
modality in our setting.
Material and methods
We carried out a retrospective study spanning a
10-year period. We reviewed the clinical charts of
patients diagnosed with peritonsillar abscess treated
with immediate tonsillectomy in Clínica Las Condes
from September 2000 to August 2010. Bilateral and
unilateral tonsillectomies were included. Patients
were excluded if their peritonsillar abscess was treated
otherwise (i.e. drained without tonsillectomy) or if the
tonsillectomy was performed after the acute infection
had resolved. We recorded the patients’ epidemio-
logical information, antibiotic therapy, laterality of the
surgery, results of microbiological cultures, complica-
tions, and recurrences.
Peritonsillar abscess was defined as a localized
infection between the fibrous capsule of the palatine
tonsil and the superior pharyngeal constrictor muscle,
excluding other deep neck space collections but
including intratonsillar abscesses.
A complication was defined as any unexpected
intraoperative or postoperative event that put the
1103
patient at risk of suffering mortality or morbidity
attributable to the procedure. The most common
intraoperative and postoperative complications
reported in the literature are either hemorrhagic or
septic, including local and systemic spread of the
infection.
A recurrence was defined as an infectious process
(either tonsillitis or peritonsillitis) taking place in the
remaining tonsil after a unilateral tonsillectomy.
Results
A summary of the results is presented in Table I.
A total of 112 patients met inclusion criteria, with
slightly more males than females in the analyzed
group (n = 58, 52%). There was a wide age range
(1–66 years), with an average of 24 years and most
cases being in the second and third decades of life
(Figure 1).
Although a preliminary diagnosis was established in
all patients based on clinical history and physical
examination, a computed tomography (CT) scan
was used in most cases (90.2%) to confirm the pres-
ence of a peritonsillar abscess before performing the
tonsillectomy. All patients received parenteral
hydration, analgesics, and intravenous antibiotics
during the immediate preoperative and postoperative
periods.
The majority of the patients (89.2%) were treated
with concurrent courses of two antibiotics, providing
a broad coverage against aerobic and anaerobic
agents. The most commonly used regimen (82%)
was a third-generation cephalosporin (ceftriaxone or
cefotaxime) together with clindamycin. The antibiotic
regimens used are shown in Table II.
The standard practice at our Otolaryngology
Department is to resect both tonsils whenever
removal of an acutely infected tonsil is indicated.
However, some patients with unilateral pathology
and no prior history of tonsillar/peritonsillar infection
were treated with a unilateral tonsillectomy. Reliable
information regarding the laterality of the tonsillec-
tomy was available for 108 of the 112 cases: 28 were
unilateral tonsillectomies (26%) and 80 were bilateral
(74%). All tonsillectomies were performed using a
classic dissection technique.
A sample of the purulent secretion obtained upon
draining the abscess was sent for aerobic and anaer-
obic culture in all cases. There were positive findings
in 61.6% of aerobic and 35.7% of anaerobic cultures.
About one-third (30.4%) of the positive aerobic
cultures were commensal flora, while Streptococcus
pyogenes was the most common (23.2%) aerobic
pathogen. Other streptococci, Neisseria spp., and
Corynebacterium spp., were also isolated. The
1104 N. Albertz & G. Nazar

Table I. Summary of main findings from experience with There were four cases (3.6%) of postoperative
immediate tonsillectomy as a treatment for peritonsillar abscess hemorrhagic complications in the study group. Two
from 2000 to 2010. patients (1.78%) were readmitted and were taken
Absolute Relative back to the operating room for bleeding control.
Variable frequency frequency The other two cases had a minor hemorrhage that
stopped spontaneously. There was only one case
No. of patients 112 100%
(0.9%) of severe intraoperative bleeding, in a patient
Male 58 52% with von Willebrand disease.
Female 54 48% Other postoperative complications were pulmonary
Age (years) edema ex vacuo (n = 1), panic attack (n = 1), self-
Average 24.25 (10.9 SD) limiting diarrhea (n = 4), cutaneous rash (n = 2), and
persistent odynophagia (n = 5).
Median 21
The mean postoperative hospital stay was 3.4 days
Range 1–66
(mode, 3 days), ranging from 1 to 10 days. Two
Length of stay (days) patients had a hospital stay of 10 days: these patients
Average 3.4 (1.5 SD) were admitted with a diagnosis of febrile illness with-
Mode 3 out an apparent focus of infection, and the periton-
Range 1–10 sillar abscess was confirmed with imaging studies.
However, these patients still had a postoperative
Laterality of surgery
stay similar to the other patients. Less than one-third
Bilateral 80 74%
(29.4%) of the patients required patient-controlled
Unilateral 28 26% analgesia (PCA) with a morphine pump in the post-
Febrile status operative period.
Preoperative fever 58 52% Twenty-eight patients were treated with immediate
Fever 24 h post surgery 4 3.5% unilateral tonsillectomy, six of whom developed a
recurrent infection of the contralateral tonsil during
Fever 48 h post surgery 0 0%
the follow-up period. Four (14.2%) patients pre-
Complications
sented with purulent tonsillitis and the other two
Infection 0 0% (7.1%) with peritonsillitis. One case was a contrala-
Hemorrhage 4 3.57% teral cellulitis diagnosed 7 months after the tonsillec-
Self-limiting 2 1.78% tomy, which was treated with oral antibiotics. The
Hemostasis management 2 1.78% other case was a contralateral peritonsillar abscess,
in operating room 1 month after the initial tonsillectomy, treated with
Other 13 11.60% contralateral tonsillectomy.
Persistent odynophagia 5 4.4%
Discussion
Self-limiting diarrhea 4 3.5%
Other 3 2.6% This study confirms the safety and efficacy of imme-
Recurrences diate tonsillectomy as a treatment for peritonsillar
Bilateral 0 0 abscess. There were no septic complications, and
Unilateral 6 21.4% postoperative bleeding was infrequent, with a similar
rate to elective tonsillectomy [13,17,18].
Tonsillitis 4 14.2%
The microbiological results are consistent with
Peritonsillitis 2 7.1%
previous reports, showing a mixed microbiological
flora with a preponderance of commensal bacteria
most frequent anaerobic bacteria found were and streptococci over anaerobic agents.
Bacteroides (37.5% of positive anaerobic cultures), Immediate surgical treatment of peritonsillar
followed by Peptostreptococcus and Fusobacterium. abscess is not new. There are reports of immediate
The detailed microbiological findings are shown tonsillectomy for the management of this pathology
in Table II. by Chaissiagnac as early as 1859. The first publica-
There were no septic complications in any of the tions regarding this technique date from the 1920s
patients treated with immediate tonsillectomy. Fifty- and 1930s. The procedure rapidly gained popularity
eight patients were admitted with fever, 93% of whom in Europe, while in the United States there was more
became afebrile in the first postoperative day. No skepticism towards the technique, with incision and
patient had fever by the second postoperative day. drainage remaining the most common approach.
 Immediate tonsillectomy as treatment for peritonsillar abscess 1105

45%

40%

35%

30%

25%

20%

15%

10%

5%

0%
0–10 years 11–20 years 21–30 years 31–40 years 41–50 years 51–60 years >60 years

Figure 1. Age distribution of the study group, which shows the preponderance of the second and third decade of life.

Johnson et al. [2] reviewed 42 articles on surgical
management of peritonsillar abscess, including
different procedures: needle aspiration, incision and
drainage, and immediate tonsillectomy. They con-
cluded that immediate tonsillectomy had a similar
efficacy and length of hospital stay to the other tech-
niques evaluated [2].
Immediate tonsillectomy has a high effectiveness in
resolving this pathology, as it maximizes the possible
drainage. This is particularly relevant for bilateral
abscesses (1.5–8% of cases) and posterior collections
(15% of cases) [2]. Immediate tonsillectomy is also an
effective treatment for intratonsillar abscesses.
Immediate tonsillectomy permanently addresses
tonsil pathology, reducing overall costs and absence
from work as compared with deferred tonsillectomy
[2,19]. The recurrence rate of peritonsillar abscess
after incision and drainage or needle aspiration is
10–15%, increasing to 40% in patients with prior
history of recurrent tonsillitis. Clearly, this risk dis-
appears after immediate bilateral tonsillectomy [2].
The present study included 28 patients treated
with unilateral tonsillectomies, of whom 6 (21.4%)
developed infections in the remaining tonsil during
the follow-up period, including two cases of peritonsil-
litis: one was a 17-year-old man with a contralateral
peritonsillar cellulitis at 7 months after unilateral ton-
sillectomy, and the other was a 16-year-old girl with a
contralateral peritonsillar abscess 1 month after surgery,
treated with tonsillectomy. Sorensen et al. [20] studied

Table II. Microbiological findings in cultured secretions and antibiotic(s) administered.

Bacteria isolated n % Antibiotic administered n %

Aerobic cultures 69
Streptococcus pyogenes 16 23.2 Third-generation cephalosporin – clindamycin 92 82.14
Other streptococci 18 26.1 Clindamycin alone 9 8.03
Neisseria spp. 5 7.2 Penicillin G sodium – clindamycin 5 4.46
Corynebacterium spp. 4 5.7 Ceftriaxone – cloxacillin 3 2.68
Normal and commensal flora 21 30.4 Cefazolin 3 2.68
Other 5 7.2
Anaerobic cultures 40
Bacteroides 15 37.5
Fusobacterium 12 30
Peptostreptococcus 13 32.5
1106 N. Albertz & G. Nazar
the recurrence of infection in 536 patients who had
unilateral tonsillectomy. Only 6.1% of patients were
readmitted for contralateral tonsillectomy, of whom
97% were under the age of 30 years. Thus, bilateral
tonsillectomy should be recommended as the treatment
of choice in patients under the age of 30 years with a
peritonsillar abscess, if immediate tonsillectomy is con-
sidered. Unilateral tonsillectomy may be a reasonable
procedure in older patients, unless there is another
indication for bilateral tonsillectomy, such as recurrent
tonsillitis [20].
The microbiological findings were similar to those
from previous reports on peritonsillar abscess
[3,6,8,9]. The antibiotic regimen most commonly
prescribed (third-generation cephalosporin plus
clindamycin) was active against all cultured micro-
organisms. Although a few cases were treated with a
single antibiotic (clindamycin), this regimen does not
eradicate gram-negative bacteria such as Neisseria
spp., which was isolated in 7.2% of the cases
(Table II). Considering the microorganisms isolated
in this series, it should be noted that penicillin alone
or penicillin plus clindamycin, as was prescribed for
five patients, would also have been adequate.
Immediate tonsillectomy is not a technically com-
plex procedure, as dissection is facilitated by the
location of the abscess in the peritonsillar dissection
plane. There were no infectious complications
(septicemia, mediastinitis) in our series, and the
rate of postoperative bleeding was similar to that
for elective scheduled tonsillectomy in adults.
Templer et al. published a series of 119 immediate
tonsillectomies for peritonsillar abscess in 1977 and
reported no serious complications: there were only
2 cases of hemorrhage (1.7%), neither of which
required transfusion [16]. Other studies have also
demonstrated a low rate of post-surgical bleeding
following immediate tonsillectomy [13,17,18].
Length of stay and analgesic requirements in our
study group were equivalent to those reported in the
literature for scheduled tonsillectomy in adults [16].
The methodological characteristics of our study
(descriptive and retrospective) limit our ability to
draw conclusions: we are unable to establish imme-
diate tonsillectomy as the best treatment for periton-
sillar abscess. In order to compare different treatment
modalities, we should have included a control group
with the same characteristics as the study group, but
managed with an alternative procedure (e.g. incision
and drainage). In spite of the limitations of this study,
the findings support the efficacy and safety of
immediate tonsillectomy as a treatment alternative
for peritonsillar abscess. New studies are needed to
further define the optimal management of periton-
sillar abscess.
Conclusion
Immediate tonsillectomy is a safe and effective treat-
ment for peritonsillar infection, permanently eradi-
cating tonsillar disease. It has a complication rate
similar to scheduled tonsillectomy in adults. Immediate
tonsillectomy should be considered as an alternative
to incision and drainage as a first-line treatment for
peritonsillar abscess.
Declaration of interest: The authors report no
conflicts of interest. The authors alone are responsible
for the content and writing of the paper.
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