Management of peritonsillar abscesses – should we be offering a hot tonsillectomy?
Reviewed by Christopher Burgess

Peritonsillar abscesses (PTAs) are one of the most common reasons for patients being referred to ENT services on an emergent basis worldwide. The conventional treatment for adult patients with a PTA in the UK involves needle aspiration or incision and drainage under local anaesthetic, combined with intravenous antibiotic administration, fluid resuscitation and analgesia. Alternative approaches are described, however, including an immediate (‘hot’) tonsillectomy under general anaesthesia. In this study undertaken at a tertiary centre in Switzerland, adult patients presenting with a CT-proven PTA of greater than or equal to 1 cm were randomised to either local anaesthetic incision and drainage (LA I&D) or immediate tonsillectomy (IT). A total of 41 patients were included: 66% were male with an age range of 18–77 years. Of these patients, 21 underwent IT, whilst 20 underwent LA I&D. The success rate (defined as reduction in swelling and restoration of swallowing function, allowing hospital discharge at 48 hours) was 100% in the IT group versus 75% in the LA I&D group (p = 0.02). Treatment failure in the I&D group was mostly due to inability to find the abscess (4/5). Pain and anxiety levels were significantly higher in the LA I&D cohort (p <0.01). These findings favouring IT as the treatment for a PTA need to be weighed against the significant rate of postoperative bleeding encountered in the group treated with IT, a complication that is not unexpected and has historically been used as an argument against immediate surgical intervention. Seven out of 21 (33%) IT patients experienced bleeding, and five of these seven required operative reintervention. Moreover, in the LA I&D group, rinsing of the abscess cavity with saline and povidone-iodine solution was performed daily for 48 hours, which may have contributed to the high levels of pain and anxiety recorded in this cohort 48 hours after intervention. Overall, the high rate of postoperative bleeding associated with immediate surgery arguably outweighs any benefit in terms of higher chance of treatment ‘success’. It is possible that needle aspiration might have increased the chance of abscess localisation in the cohort not treated with immediate surgery, and would have resulted in less pain and anxiety. The results presented in this paper are therefore unlikely to change UK practice, but do help to quantify the risks associated with an immediate tonsillectomy for patients unwilling or unable to undergo PTA drainage under LA.

A randomized clinical trial of peritonsillar abscess treatment comparing drainage and tonsillectomy.
Voruz F, Revol R, Mermod M, et al.
AM J OTOLARYNGOL
2025;46(6):104745.