Treatment aims to resolve discomfort, maintain the airway, and prevent abscess rupture. A ruptured PTA may result in the aspiration of purulence and lead to bronchopneumonia.2 The sixth century Byzantine physician Aetius of Amida treated spontaneously draining abscesses with gargles of honey, milk, and herbs, or with rose extract.14 Today, oral antibiotics are recommended to begin with, such as penicillin, amoxicillin/clavulanic acid, cephalosporins, and clindamycin. Antibiotic selection should be culture directed when possible. Hospitalization may be necessary for rehydration, analgesia, intravenous antibiotics, and/or airway observation.
Intravenous corticosteroid therapy may be considered to reduce inflammation in children with airway compromise, administered at the dose of 0.5 mg/kg of dexamethasone intravenously up to a maximum single dose of 10 mg, every 8 hours, for up to three total doses.
Many PTAs require either needle aspiration or incision and drainage (I&D). Needle aspiration may be performed diagnostically to confirm abscess formation, to identify the best point at which to perform I&D, or as a therapeutic measure to relieve symptoms and provide material for microbial culture. Needle aspiration is a rapid means of relieving the painful bulging of the abscess and may speed the course of recovery. Bacterial culture results are not clinically useful in most cases, but the cultures are valuable when there is a concern over antibiotic resistance, such as for immunodeficient children or those who have been recently treated with broad-spectrum antibiotics.15 CT guidance of needle aspiration is indicated after an unsuccessful surgical attempt and for an abscess that is located in an atypical location or that may be difficult to reach with standard surgical approaches.
I&D permits a more complete evacuation than that allowed by needle aspiration. I&D is performed trans-orally and is indicated for the older, more cooperative patients who may more easily permit a longer procedure. I&D may be performed awake, with the aid of local and topical anesthetic, with conscious sedation protocols or under general anesthesia in the operating room, the latter usually caused by a child's inability to cooperate. Acute tonsillectomy (“quinsy” tonsillectomy) may be necessary for relief of obstructive symptoms, a history of recurrent streptococcal pharyngotonsillitis, or an exposure of the abscess. Quinsy tonsillectomy is necessary in approximately one out of three cases of PTA in children.2,16
For both PTA and RPA, a proactive and coordinated airway management plan is critical when considering sedation, imaging, and surgery. A plan should be communicated between all providers, including physicians, anesthesiologists, and nursing and support staff. Appropriate preparation should be made for a variety of intubating laryngoscopes as well as flexible fiberoptic bronchoscopes. A discussion should be considered with the family of potential airway risks as well as the option for tracheotomy in the most dire circumstances.
When treating PTA, attention should be paid to the tissue characteristics of tonsillar and peritonsillar tissues. Fleshy, granular, or pale tissue may indicate a neoplasm presenting as a PTA.17 In such cases, tissue should be sent for immunohistopathologic evaluation. Follow-up should confirm resolution of fullness in the peritonsillar region along with normalization of swallowing and airway status.
Management of small collections—whether abscess or phlegmon—may be initiated with oral or intravenous antibiotics. Usually, children who present with RPA are dehydrated and receive intravenous fluid. Initial inpatient antimicrobial therapy via the intravenous route is therefore easily achieved and is advised until clinical improvement is clearly demonstrated by at least 24 hours without fever and the child is able to swallow secretions, liquids, and medications. Inpatient stay allows for rehydration and antimicrobial care while permitting for airway observation with expedient airway intervention, imaging, or surgical drainage if necessary. Length of stay is generally less than 2 weeks and is often shorter than 5 days.9
RPA may often be treated by antibiotics alone, particularly when the abscess is small and there is no airway compromise. Antibiotic therapy may empirically begin with clindamycin with or without cefuroxime or ceftriaxone, or ampicillin/sulbactam.8,9 Duration of therapy should be for 10–21 days and, in some cases, may require placement of an indwelling intravenous catheter for outpatient administration of antibiotics. As with PTA, antibiotic choice should be guided by microbiologic cultures when possible. Intravenous corticosteroid therapy may be considered for children with airway compromise, with the dosing detailed above for children with PTA.
RPAs that are extensive or refractory to antibiotics require surgical drainage, by the trans-oral route for RPA medial to the great vessels and/or transcervically for collections lateral to the great vessels. Airway considerations during surgical drainage include difficult laryngoscopy during intubation caused by neck stiffness and a limited view as a result of forward bulging of retropharyngeal tissues. Spontaneous or iatrogenic abscess rupture may permit foul secretions to pour into the tracheobronchial tree and lead to aspiration pneumonia.