How to drain a peritonsillar abscess

Siamak Moayedi, MD
19th Nov 2020

There are two ways to drain a peritonsillar abscess: needle aspiration, and the incision and drainage technique. Comparisons of the techniques show that the incision and drainage method adds pain, bleeding, and increased risk without added benefit. 

Image of peritonsillar abscess, and needle aspiration beside incision and drainage technique. Cartoon.

Figure 1. There are two ways to drain a peritonsillar abscess, the needle aspiration technique has less pain, bleeding, and risk compared to the incision and drainage technique. 

The rates of recurrent abscess formation are the same for both techniques at 10%. However, if a patient comes back with a recurrent peritonsillar abscess, it may be time to consider using a scalpel. 

 

Identifying the tools for peritonsillar abscess drainage

The first step for the needle aspiration technique is to collect the necessary medication and tools:

  • Topical anesthetic spray (cetacaine or lidocaine)  
  • 3 cc syringe and 25 gauge (G) needle 
  • 1% lidocaine with epinephrine 
  • Yankauer suction catheter
  • Laryngoscope  
  • 10 cc syringe and 18 gauge (G) needle

Tools for peritonsillar abscess drainage. Multicomponent image of cetacaine spray, syringes, needles, lidocaine bottle, Yankauer, and laryngoscope. Cartoon.

Figure 2. Medication and tools for peritonsillar abscess drainage include topical cetacaine, 3 cc syringe and 25 gauge (G) needle, 1% lidocaine with epinephrine, Yankauer suction catheter, laryngoscope, and 10 cc syringe and 18 G needle. 

To avoid accidentally poking too deep with your needle, cut the needle cap to the maximum depth you need. You can measure the maximum depth on the ultrasound or computed tomography (CT) scan. If you did not perform diagnostic imaging during the diagnosis, you usually don’t need any more than 1.5 cm to go from mucus membrane to the abscess cavity.

 

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How to drain a peritonsillar abscess

Now that you have all your tools, it’s time to do the deed. Position your patient so that they can’t move their head backwards. Have the Yankauer suction ready to remove fluid. Throughout the procedure, the laryngoscope can be used as a light source and to position the tongue.

  1. Spray the abscess with cetacaine spray to numb the soft palate and reduces gag reflex. 
  2. Anesthetize the most compressible, or fluctuant area of the abscess using the 25 G needle and your 1% lidocaine with epinephrine. This will cause blanching, reduce bleeding, and anesthetize the mucosa. 
  3. After a few minutes, insert the 18 G needle and aspirate. As soon as you start to get pus into the syringe, stop advancing it and extract as much pus as possible. 

How to drain a peritonsillar abscess: Multi-component image of cetacaine topical anesthetic, needle with anesthetic, and needle aspirating pus. Cartoon.

Figure 3. Procedure for draining a peritonsillar abscess. 1) Spray the abscess with cetacaine to numb and reduce gag reflex. 2) Anesthetize the puffiest area of the abscess with lidocaine. 3) Insert the needle and advance until you get pus in the syringe. Extract as much pus as possible. 

 

 

Post-procedure care for a peritonsillar abscess

After you’ve finished aspirating the pus, if the patient is not toxic and can swallow, they can be discharged with antibiotics (usually amoxicillin / clavulanic acid dosed twice daily for the next 7 days). As well, 10 mg of intramuscular dexamethasone has been shown to decrease swelling and pain for the patient. 

Multi-component image of antibiotics, calendar, and dexamethasone bottle. Cartoon.

Figure 4. If the patient is not toxic and can swallow, post-procedure care for a peritonsillar abscess includes discharging the patient with antibiotics (amoxicillin / clavulanic acid) and 10 mg of intramuscular dexamethasone. 

After draining a peritonsillar abscess, if your patient is toxic or is still not able to swallow, they should be admitted to hospital for further treatment.

Arrange for a follow up in one or two days. Have your patient come back sooner if they experience increasing pain, fever, or difficulty swallowing. 

 

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Recommended reading

  • Ozbek, C, Aygenc, E, Tuna, EU, et al. 2004. Use of steroids in the treatment of peritonsillar abscess. J Laryngol Otol118: 439–442. PMID: 152285862
  • Powell, J and Wilson, JA.  2012. An evidence-based review of peritonsillar abscess. Clin Otolaryngol. 37: 136–145. PMID: 22321140