Eur Arch Otorhinolaryngol
DOI 10.1007/s00405-015-3582-0
HEAD AND NECK
Peritonsillar abscess: remember to always think twice
Jochen P. Windfuhr • Alexandra Zurawski
Received: 12 January 2015 / Accepted: 24 February 2015
 Springer-Verlag Berlin Heidelberg 2015
Abstract Peritonsillar abscess (PTA) is the most common
complication of acute tonsillitis resulting in fever, unilateral
sore throat, odynophagia and trismus. This retrospective
study was undertaken to analyze the clinical courses of 775
patients with two different methods of the first-line treat-
ment. Abscess tonsillectomy (TAC) including contralateral
tonsillectomy was preferably performed between 2007 und
2010 (group A; n = 443). After that, incisional drainage
(ID) was chosen as first-line treatment between 2010 and
2013 (group B; n = 332). The data of the patients were
pooled from the individual charts to evaluate the prevalence
of smoking habits, the incidence of the recurrence/compli-
cation rates and the number/types of surgical procedures
associated with each therapy modality. Replacing TAC by
ID as first-line treatment of PTA resulted in a significant
decrease of days of inpatient treatment (4 vs. 7 days) and
hemorrhage rate (0.3 vs. 5.1 %). A second, third and fourth
surgical revision procedure was performed with comparable
rates in group A (21.6; 2.4; 0.5 %) and B (21; 4.9; 0.3 %).
Smoking habits were reported by almost every second pa-
tient. ID as first-line treatment of PTA is capable to reduce
the hemorrhage rate and length of inpatient observation
significantly. To suggest ID as first-line PTA treatment
mandates a close follow-up to indicate repeated drainage of
residual pus at an early stage. Further analysis is warranted
to verify whether a better surveillance in an academic
teaching hospital or surgical modification of the ID is fol-
lowed by a higher success rate. Smoking habits are over-
represented in PTA patients.
J. P. Windfuhr (&)
A. Zurawski
Department of Otorhinolaryngology, Plastic Head and Neck
Surgery, Kliniken Maria Hilf Mönchengladbach, Sandradstr. 43,
41061 Mönchengladbach, Germany
e-mail: jochen.windfuhr@mariahilf.de
Keywords Quinsy
Peritonsillar abscess
Incision
drainage
Immediate tonsillectomy
Complication

Hemorrhage
Introduction
Peritonsillar abscess (PTA) is a collection of pus between the
tonsil and the surrounding muscular layers. The entity is
clinically distinct from acute tonsillitis and occurs obviously
in people with a chronic underlying susceptibility [1]. Pa-
tients usually present with intense odynophagia, difficulties
in swallowing, fever, trismus and a typical voice (‘‘potato
speech’’). Clinical findings include a considerable asymme-
try of the oropharynx with protrusion of the soft palate and
contralateral displacement of the uvula. Successful man-
agement consists of abscess drainage and empiric antibiotic
treatment based on clinical response with antibiotics effec-
tive against aerobic and anaerobic bacteria [2]. Delayed or
inadequate therapy may lead to serious complications and
even death due to airway compromise from excessive
oropharyngeal swelling, epiglottal or laryngeal edema, deep
neck abscess of the para- or retropharyngeal spaces, or me-
diastinitis [3, 4]. Once a diagnosis of PTA is made, several
draining methods are accepted [5–9] but controversy exists
about the best drainage procedure, including needle aspira-
tion (NA), incision and drainage (ID), or abscess tonsillec-
tomy, i.e. tonsillectomy à chaud (TAC) [5, 9, 10].
First-line treatment of PTA consisted of TAC with si-
multaneous contralateral tonsillectomy (TE) until 2010 at
our institution and was then replaced by ID. Other mea-
sures of treatment were indicated only for selected cases
before and after 2010.
The aim of this study was to evaluate whether or not
changing the first-line treatment was associated with ben-
efits or drawbacks for PTA patients.
123
 Eur Arch Otorhinolaryngol

Materials and methods
Our department is part of a tertiary care hospital in a re-
mote area with a great likelihood that patients with a re-
current PTA or other postoperative complications will
return to our emergency department. At any time, PTA
patients were admitted for empiric intravenous antibiotic
treatment. The presence of PTA was determined by clinical
examination, an accepted gold standard [10]. Patients in
whom ID or TAC did not reveal any pus were defined as
peritonsillar cellulitis. As per protocol of the institute and
supported by the literature [11], pus was not regularly
collected for microbiological analysis. The length of hos-
pitalization was determined by the procedure with TAC
resulting in at least a 4-day inpatient observation, deter-
mined by the postoperative morbidity in terms of pain and
bleeding. Patients were dismissed after ID according to
resolution of pain and oral swelling. TAC with simulta-
neous contralateral tonsillectomy was performed in every
patient before April 1, 2010 with ID selected only for
special conditions such as refusal of the patient, reduced
general state of health, abnormal coagulation values or

Fig. 1 Causes for exclusion of

analysis Search term

„abscess tonsillectomy“ & „incision drainage“ & „peritonsillar abscess“

April 1, 2007 – March 31, 2013

775 paent charts

(462 male; 59.6%)

peritonsillar cellulis

67
infecous mononucleosis without PTA

11

concomitant extratonsillar abscess

(Epiglos, Parapharyngeal space)

10 inial non-surgical approach

unexpected histology

included

680 paent charts

(418 male; 61.5%)

123
Eur Arch Otorhinolaryngol
aspirin intake. After April 1, 2010 first-line PTA treatment
consisted of ID under general or local anesthesia. Unilat-
eral TAC was only performed in those patients who re-
ported a history of PTA/repeated attempts of ID or
presented with apparent complications. A simultaneous
contralateral TE was only indicated in patients with an
otherwise indication for TE, i.e. C3 episodes of acute
tonsillitis treated with antibiotics within the last year.
Demographic data, presence of peritonsillar cellulitis/
abscess, concomitant infectious mononucleosis or extra-
tonsillar spread, surgical and medical management of the
infection, rates of TAC, ID, postoperative hemorrhage
were collected by comprehensive chart and electronic
record review. The documents of all patients treated
36 months before (group A; n = 443) and after April 1,
2010 (group B; n = 332) were reviewed using the search
terms ‘‘abscess tonsillectomy’’, ‘‘incision drainage’’ and
‘‘peritonsillar abscess’’. We determined the prevalence of
smoking habits as well as the incidence of PTA recur-
rence/complication rates and the number/types of surgical
procedures performed in groups A and B. The data were
excluded from further analysis in case of peritonsillar
cellulitis (67) or proven infectious mononucleosis without
PTA (11), simultaneous extratonsillar abscess requiring
additional measures of treatment (10), initial intravenous
antibiotic therapy (4) or an unexpected histological finding
(three patients: malignant lymphoma; tumor-like lesion;
pleomorphic adenoma), respectively. Almost two-thirds of
all patients were male (Fig. 1). Due to the retrospective
design of this study, conclusive data concerning microfloral
composition, periodontal disease, previous antibiotic ad-
ministration or previous treatment of PTA were not ob-
tainable from the charts. Since results from microbiological
examination typically become available when empiric an-
tibiotic treatment proves to be successful, swabs are usually
not taken in PTA patients at our department.
Statistical differences between groups A and B con-
cerning cumulated days and episodes of hospital treatment
were tested by Wilcoxon’s rank sum test, differences be-
tween hemorrhage rates of the same groups were tested by
Chi-square test. A p value \0.05 was considered in both
tests as significant.
The study was exempt from institutional review board
approval due to the retrospective study design.
Results
Epidemiological data of both groups revealed a significant
difference in hemorrhage rates and length of hospitaliza-
tion (p \ 0.05). Smoking habits were reported for every
second patient in groups A and B. A bilateral PTA was
identified in 5 patients of group A, and 2 patients of group
B. There were 15 (A) and 16 (B) PTA patients with a
history of tonsillectomy with tonsillar remnants only in 12
(A) and 8 (B) patients, respectively. For this subpopulation,
treatment modalities in group A included ID (4), TAC (11)
and ID followed by TE 3 days later due to oral intake of
aspirin. All patients of group B were successfully treated
by a single ID (Table 1).
Clinical courses (Figs. 2, 3)
Group A encompassed 375 patients of whom 296 (79 %)
were initially scheduled for TAC with 17 patients who
experienced 19 bleeding episodes after TAC. The bleeding
events occurred with a delay of 6 days on average
(Table 1). Two bleeding patients with an initial TAC re-
quired a second treatment under general anesthesia 1 day
after hemostasis had been achieved. Moreover, there was
one patient with a bilateral abscess who experienced a life-
threatening hemorrhage 6 days after initial TAC. He-
mostasis was achieved under general anesthesia with a
bipolar forceps and packing of the oropharynx. After re-
moval of the packing, copious bleeding re-occurred and
was treated with a ligature of the external carotid artery.
The following course was uneventful. In contrast, there was
only one patient of group B who experienced an episode of
bleeding 1 day after TAC. Due to an uneventful history,
the contralateral tonsil had not been removed. Repeated
episodes of bleeding did only occur patients of group A
(n = 2; 0.5 %). Successful treatment in those 79 group A
patients initially treated by ID (21 %) required 2–4 revision
procedures. There were 2/79 patients with a return-to-the-
ater to achieve hemostasis after 59 secondary TE (3.4 %;
Fig. 2).
Group B comprised 254 patients with an initial ID
(83 %) and 51 patients with an initial TAC (17 %) of
whom one single patient experienced a return-to-theater to
achieve hemostasis (1.9 %). Due to an uneventful history, a
contralateral TE was not performed in six of those 51 pa-
tients. None of these six patients returned with a PTA of
the remaining contralateral tonsil during the follow-up. As
in group A, there was no other indication for a surgical
revision after an initial TAC. In contrast, initial ID was
followed by 2–4 revision procedures to resolve the abscess.
The rates of a second, third and fourth surgical revision
procedure were comparable between groups A (21.6; 2.7;
0.5 %) and B (21; 4.9; 0.3 %). Initial ID required either a
secondary ID in groups A and B (6.3 vs. 16.1 %) or a
secondary TAC (74.7 vs. 7.9 %).
The monthly presentation of all PTA cases ranged from
50 patients in July to 84 in January (mean 57.2, median
52.5, STD 10.3 patients). Most patients presented in winter
(n = 179) and less frequently in fall (n = 165), summer
(n = 162) and spring (n = 155), respectively.
123
 Eur Arch Otorhinolaryngol

Table 1 Epidemiological data of groups A and B

Group A (n = 375) Group B (n = 305)

Age range (y) (mean; median; STD) 2–86 (32.8; 31.0; 16.51) 6–87 (36.38; 34.0; 17.06)
Male:female ratio 1.27 2.02
Side: right/left/bilateral (n) 173/197/5 146/157/2
a
Bilateral PTA ? infectious mononucleosis (n) 2 0
History of tonsillitis (%) 14.67 % 18.69 %
ns 67.47 % 19.67 %
Single-sided PTA ? infectious mononucleosis (n) 18 (4.8 %) 2 (0.7 %)
History of tonsillectomy (n) 15 (4 %) 16 (5.2 %)
Smoking habits 47.47 % 46.56 %
Leukocytosis (range n/ll) 2.740–32.080 5.070–41.680
Mean; median; STD (n/ll) 3.826; 13.320; 4779.77 14.511; 14.170; 4.583, 37
\10.000 21 % 14.8 %
[10.000 67 % 74.1 %
[20.000 11 % 9.2 %
ns 1% 2%
C-Reactive protein (range) 0.1–39.6 mg/dl 0.1–35.0 mg/dl
Mean; median; STD (mg/dl) 9.58; 6.4; 8.24 mg/dl 9.76; 8.0; 7.10 mg/dl
\1 2.67 % 2.62 %
[1 33.9 % 53.8 %
[10 18.4 % 37.4 %
ns 45.1 % 6.2 %
Aspirin intake 17.33 % 17.70 %
Hospitalization (d) (range; mean; median; STD) 2600 (1–25; 7.0; 6.0; 2.6) 1282 (1–13; 4.0;4.0; 2.0)
Inpatient episodes (range; mean; median; STD) 397 (1–5; 1.0; 1.0; 0.31) 344 (1–3; 1.0; 1.0; 0)
Postoperative hemorrhage: range (d) (mean; median; STD) 0–11 (6.0; 6.0; 3.64) 1 (1.0; 1.0; 0)
Postoperative hemorrhage (n) (ipsilateral; contralateral; bilateral) 19 episodes/17 patients (6; 8; 5) 1/one patient (1; 0; 0)
Time interval between interventions (d)
1. ? 2. 0–34 (4.37; 3.0; 4.59) 1–1484 (58.25; 1.0; 225.08)
2. ? 3. 0–1773 (201.89; 1.0; 589.25) 1–6 (1.8; 1.0; 1.37)
3. ? 4. 5–83 (44.0; 44.0; 55.15) 1
ns not stated, STD standard deviation, d day, y year, n number
a
these were 2 of 5 patients with a bilateral PTA

A secondary TE after initial ID was not performed in
group A but in 12 patients of group B. This procedure was
indicated 2–48 months after ID (mean 19.08, median 19.5,
STD 14.6 months) in most (n = 6) cases due to recurrent
episodes of tonsillitis or PTA (n = 3) and less frequently to
exclude a malignoma (n = 2) or delayed consent by the
patient (n = 1).
Discussion
PTA patients typically present at a median age between 15
and 39 years [4, 12–19, 20]. As in all other studies in-
cluding the latest nationwide data analysis [21], the mean
and median age of PTA patients proved to be less than 40
years in our patient population (Fig. 4). Moreover, a de-
tailed analysis of the age distribution reveals an abrupt
increase by the age of 15, which has been identically
identified and extensively discussed by Klug who was
unable to explain this phenomenon [12]. A percentage of
33.7 % of our PTA patients was older than 40 years, which
is in contrast with most studies reporting a rate of 20 to
25 %, rarely more (43.3 % [3]; 40 % [3]) or less (11 %
[14]). This age group has shown to be of interest due to
more subtle and longer lasting clinical signs and different
microbiological compositions [22–24].
Our study confirms an overall male predominance in
PTA patients which has been reported by most authors in

123
Eur Arch Otorhinolaryngol

Fig. 2 Clinical courses group A

1st intervenon
ID TAC
(first-line treatment: abscess

n=375
tonsillectomy). TE 79 (21.1%) 296* (78.9%)
tonsillectomy as second-line
therapy, asterisk including 12
patients with tonsillar remnants,
double asterisk including 1
patient after tonsillectomy,
triple asterisk including 1
patient after previous TAC and
ID with tonsillar remnants, hash
including 1 patient requiring

2nd intervenon
ligature of the external carotid ID TE hemostasis ITE

n=81 (21,6%)
artery on day 7, calculated
5 (6.3%) 59** 15 (5.1%) 2 (2.5%)
separately for 2 patients initially
treated with ID and 2 patients (74.7%)
initially treated with TAC; not
included: 2 patients initially
treated with antibiotics finally
undergoing TAC with
uneventful postoperative course.
A total of 467 procedures were
performed in 375 patients. In
group A, 80 of the 85 ID
procedures were done under
local anesthesia (94.1 %).
Those ID procedures under
general anesthesia were done
only at initial presentation (5/
3rd intervenon

79) ITE
ID TE hemostasis
n=9 (2,.%)

1 (1.3%) #
3*** 4 1
(3.8%) (2.5%; 0.7%) (1.3%)
4th intervenon

n=2 (0.5%)

TE peculiarity

1 (1.3%) 1 (1.3%)

the past [18], confirmed by a most recent nationwide study
[21] in some studies reaching a 3:1 ratio [4, 16]. However,
an equal ratio has also been described [4, 12–16, 19, 23,
25–30]. A more detailed analysis of Risberg revealed, that
affected females were younger than males under the age of
29 [13] with an earlier peak of incidence, which was also
reported by Love [4]. The tendency of an age-related in-
cidence with a female preponderance at an age between 11
and 15 years is fully confirmed by the results of our study
(data not shown). Comparable to our results, male patients
were significantly more often affected at the ages 20–29
and 40–49 in Klug’s study [12].
As reported by other authors [16, 23], an equal affection
of both sides was registered in our patient population
whereas other authors identified a preponderance of the left
side [14, 31]. A bilateral PTA was identified in 1.0 % of
our PTA patients which compares to rates of 1.8 % [31],
1.0 % [16] and 0.8 % [3, 23, 32] and contrasts sharply to
the average rate of 4.9 % as reported by other authors [33,
34]. To the best of our knowledge, this finding has never
been explained in the scientific papers.
Although many authors acknowledged PTA develop-
ment as a complication of recurrent episodes of tonsillitis,
this statement was strongly contradicted by Wolf [35]. His
statement is supported by numerous data in the literature,
indicating an incidence of a significant history of tonsillitis
prior to PTA between 7.9 % and 56 % [3–5, 8, 16, 20, 23,
27, 28, 31, 32, 35–48]. The rates determined in group A

123
 Eur Arch Otorhinolaryngol

Fig. 3 Clinical courses group B

1st intervenon
(first-line treatment: incision ID TAC

n=305
and drainage). TE tonsillectomy
as second-line treatment, 254 (83.3%) 51 (16.7%)
asterisk histologically, but not
clinically diagnosed as PTA
with a primary bleeding after
18 h; not included: (1) 2
patients initially treated with
antibiotics finally undergoing
TAC with uneventful
postoperative course. (2) One
patient with initial ID,
secondary TE with abscess 2nd intervenon
formation in the oropharynx
ID TE peculiaries hemostasis
[1 year later. A total of 385 n=64 (21%)
procedures were performed in 41 (16.1%) 20 (7.9%) 2 (0.8%) 1* (1.9%)
305 patients. In group B, 116 of
the total 308 ID procedures
(37.7 %) were done under local
anesthesia (in detail: 71/254 1st;
35/41 2nd; 9/12 3rd; 1/1 4th ID
i.e. 28; 85; 75; 100 %,
respectively), the remainder
were performed under general
anesthesia
3rd intervenon

n=15 (4.9%)

ID TE ITE

12 (4.7%) 2 (0.8%) 1 (0.4%)

intervenon

n=1 (0.3%)

ID

1 (0.4%)

(14.7 %) and B (18.7 %) of this study are well within this
broad range. Although complete information concerning
this issue was not obtainable in a considerable number of
patient charts in group A (67.5 %) and some charts of
group B patients (19.7 %) it can be concluded from our
study, that PTA development is not necessarily depending
on a history of tonsillitis. Authors from contemporary
studies determined, that approximately half of the PTA
patients present without a history of a previous antibiotic
therapy [2, 25].
The quality of our data was insufficient to clarify in all
of our patients whether or not a PTA had been treated in
the long term prior to first presentation at our department.
This has been outnumbered in the literature to range be-
tween 7.8 % and 16.5 % [14, 23, 24, 31, 48–50], which
may not only be associated with a history of recurrent
tonsillitis but also extraperitonsillar spread [49] or male
gender [23]. Shaul identified a young age, female gender,
repeated treatment and a history of tonsillitis as a risk
factor for developing a recurrent PTA. In patients with a

123
Eur Arch Otorhinolaryngol
90
80
70
60
50
[n]
40
30
20
10
0 population [76]. Smoking habits were over-represented in
0-10 11-15 16-20 21-30 31-40 41-50 51-60 61+
group A 15 20 74 78 76 60 24 28
group B 7 15 43 71 52 46 43 28
Fig. 4 Age distribution group A vs. group B. The precise number of
patients registered per age group is obtainable from the table below
the diagram. An abrupt increase after the age of 15 years was
registered in both groups
positive history of tonsillitis, he therefore advised early TE
which was done in group B patients of our study. The rate
of recurrent treatment during hospitalization was lower
compared to our study (11 % vs. [21 %) but 16.1 in the
long term [28]. The overall recurrence rates range from
5 % to 22 % with variability in age, gender, duration of
follow-up, and different treatment modalities [5, 8, 11, 16,
35–39, 41–43, 46, 50, 51–62]. Higher recurrence rates of
peritonsillar abscess were found in some [39, 41, 63] but
not all [35] reports of people with prior tonsillitis and in
patients \40 years of age [41, 62]. The latest cohort study
from Taiwan reveled a PTA recurrence rate of 5.15 %
during a 4.74-year follow-up in 28.837 patients studied,
and it was described as an age-related phenomenon (6.7 %
\30 years vs. 2.1 % [30 years), but independent from
gender. A history of prior episodes of tonsillitis was
identified as a significant risk factor. The mean time to
recurrence was 1.16 ± 1.28 years after initial PTA ther-
apy. It is noteworthy to emphasize that the authors distin-
guished between recurrence ([30 days) and residual
disease (\30 days). A residual disease, in fact, was regis-
tered in 20.5 % of all patients, comparable to our results
[21].
Herzon stated that tonsillectomy is not capable of pre-
venting PTA as given in the literature [47, 64, 65] and does
not necessarily depend on the presence of remnant tonsillar
tissue or a history of sore throat/PTA [66]. It has been
speculated that this may result from infection of a second
branchial cleft fistula, infection of Weber’s glands and
dental disease [66–70]. The widespread belief that PTA
formation is the complication of tonsillitis is fundamentally
challenged by these reports and it appears likely that—at
least in PTA patients without concurrent tonsillitis—the
development of a PTA is caused by one of these factors.
Interestingly, there were 31 PTA patients in our study with
a history of a prior tonsillectomy including 11 patients
without any tonsillar remnants, challenging the theory of
PTA either as a complication of recurrent tonsillitis or in-
fection of Weber’s glands.
Powell [18] quoted smoking [9, 20, 26, 29, 71–75] as a
risk factor for PTA development and several studies indi-
cate, that daily tobacco smoking increases the risk of PTA
development by approximately 150 % [75], and PTA pa-
tients are 70 % more likely to smoke than the general
our patient population as it was reported for almost every
second patient which has been determined with smaller
(15 % [25]; 22 % [31]; 33.7 % [23]; 36 % [75]) and
greater (61.3 % [3]; 69 % [26]) rates. However, in the
study of Mazur, only 22.0 % were smokers and smoking
was therefore not identified as a risk factor in this study
[31].
A total of 22 patients presented with a concomitant in-
fectious mononucleosis (5.8 %), proven by selected EBV
IgM antibody testing. Evidence is given from the literature,
that compromised immunity gives rise to a high incidence
of PTA in patients with infectious mononucleosis and
Kawasaki’s disease [29, 77–83]. Heterophile antibody
testing was routine in the study of Hanna and revealed that
Epstein–Barr virus infectious mononucleosis had a preva-
lence of 1.8 % in a group of 128 patients but the value of
this strategy is questionable and therefore not performed at
our institution. Several retrospective case series indicate a
prevalence of coexistent infective mononucleosis in pa-
tients diagnosed with peritonsillar abscess of 1.5–6 % [78,
84, 85].
A greater number of our patients presented in winter,
and a somewhat smaller number in fall, summer and
spring. While significant seasonal variations were denied
by Klug and Mazur [12, 31], other authors identified a
decrease during summer [16, 17, 23, 86] or an increase
during autumn and spring [32].
Unfortunately, CRP values were not determined in a
considerable number of group A patients but almost all
patients of group B. The median value was 6.4 and 8.0 mg/
dl, respectively. Normal values were registered in \3 % in
both groups. White blood cell count revealed pathologic
values in at least [79 % with median values in groups A
and B of 13.320 vs. 14.170/ll, respectively. In the study of
Mazur, the median values of C-reactive protein and
leukocytes were 7.73 mg/dl and 14.700/ll, respectively
[31]. Tachibana reported mean values of 8.53 mg/dl and
14.260/ll, respectively [3].
The first critical appraisal of different PTA management
strategies was published in 1995 by Herzon and included a
national survey of members of AAOHNS, revealing that ID
(54 %) was the procedure of choice followed by needle
aspiration (32 %) and TAC (14 %) [5]. Moreover, 73% of
the respondents surveyed considered PTA as relative
123

indication for tonsillectomy, 23 % as absolute and 4 %
denied the indication. TAC was acknowledged to require
only a single brief hospitalization for the treatment of PTA
[53, 87–89]. TAC—albeit the only way to drain the abscess
completely and to eliminate the risk of recurrence—was
recommended for patients with a prior history of tonsillitis,
PTA recurrence or an age under 40 years [5, 11, 90, 91].
TAC proved to be well tolerated with a low complication
rate [6, 53, 92]. ID was as successful as NA [7, 8, 10, 11,
90, 93, 94], even in children [32], but associated with a
greater morbidity and demanded skilled surgeons to per-
form it correctly. However, needle aspiration on an out-
patient basis was proven to be successful in 96 % of the
reported studies and outpatient management was suggested
by several authors [8, 38, 39, 95]. Proponents of outpatient
management indicate a low re-admission rate (2 %) and
absent complications as evidence [8, 96, 97]. NA clearly
prevailed as first-line treatment in West Ireland [2], UK
[10, 98], Canada [25] or Poland [31]. Within 2 postop-
erative months needle aspiration did not [5, 8, 37, 38, 94,
95, 99–101] or rarely [35, 39] result in a second PTA. The
plea in favor for NA is challenged by reports revealing, that
NA was associated with a higher recurrence rate compared
to treatment with ID [16, 35, 63] resulting in secondary ID
or TE [102].
In the light of the promising results with NA or ID, we
were somewhat disappointed when we first saw the results
of our new strategy. On one hand, our goal of a reduced
hospitalization time and hemorrhage rate was achieved, but
we expected a lower overall-rate of revision procedures.
We speculated that the surgical procedures were performed
too carefully by the surgeons in-training, but this argument
is challenged by the fact, that our PTA definition included
drainage of pus which should be as safe as NA. However, it
is noteworthy to emphasize, that revision procedures in
group B were performed within one single day with a third
approach after another day (median values).
ID under local anesthesia with NA only on request of the
patients was performed in the study of Tachibana [3]. A
large proportion (22.9 %) was initially treated conserva-
tively, apparently because the patients declined surgical
drainage. He was able to demonstrate, that an age of 40
years and above, no history of tonsillitis, CRP values
greater than 8.53 mg/dl and an initial conservative therapy
were significantly associated with a longer duration of
hospitalization [3]. Due to the different concept at our in-
stitution, this cannot be compared, but the admonition, that
patients older than 40 years may present a subgroup of
patients with an increased risk for a more serious clinical
course is worthwhile repeating.
Variations concerning PTA management were at least in
part extremely variable in northern countries where TAC
plays a minor role and is mainly indicated by an age
123
Eur Arch Otorhinolaryngol
\15 years, previous PTA treatment, or a history of tonsil-
litis. Interval TE prevails, if a TE is ever indicated. This is in
contrast to Denmark , where 92 % of all procedures are
performed as TAC. A daily re-opening of the abscess cavity
was performed by 80 % of the responding ENT hospitals
[103] which is apparently higher compared to our results.
In the study of Wiksten from Finland, 639 PTA patients
were with ID and antibiotics of whom 163 required a
secondary TE with age-related rates of 42.5 % (\17 years),
31.3 % (\30 years) and 13.2 % ([30 years), respectively.
The overall revision rate was 26.3 % within the follow-up
period of 5 years [50]. This finding contrasts with the rate
of 2.9 % of PTA patients in the UK, eventually undergoing
secondary TE within a 2-year follow-up [59] and 1.48 %
within 4.74 years in the large-scale study of Wang who
reported a TE rate of 3.84 % in 1.486 patients with PTA
recurrence. Wang identified a greater risk of NA failure in
pediatric patients (\18 years) with better results after ID.
In his study, every second of his 28.837 PTA patients had
been treated with NA, 40.8 % with antibiotics alone and
8.2 % with ID [21].
Love reported a rate of 21 % secondary TE, preferably
performed after an interval instead of a TAC. All episodes
of post-tonsillectomy hemorrhage occurred after interval
tonsillectomy. The selection criteria of Love were com-
parable to those of group B patients of our study. In con-
trast to our study, ID was performed under local anesthesia
with overnight observation in two thirds of them. The re-
admission rate was reported to be 5.8 % [4].
Kodiya reported that only 6.7 % of 60 surveyed mem-
bers of the local ENT society in Nigeria treat PTA by
means of ID, and 93.3 % treat by a combination of ID and
TE, preferably (96.7 %) in terms of interval tonsillectomy;
57 % would suggest TE after failure of previous NA or ID,
20 % if there is a history of tonsillitis, and 23 % as first-
line treatment. NA alone was not identified as first-line
treatment and hemorrhage rates were not reported [104].
This strategy applies to the approach of Raut and Yung
who treated all patients with at least ID at initial presen-
tation. The authors determined that 83 % of surgeons ad-
vised interval tonsillectomies in the UK. Unfortunately,
hemorrhage rates were not inquired into [105]. While TAC
has been proved to be beneficial for the patients [106] and
not associated with an increased risk of postoperative
hemorrhage [107], it has been stated that interval TE
should be indicated, when skilled staff and adequate fa-
cilities are not available [108, 109]. Since PTA rather ap-
pears to be a separate entity than a complication of
tonsillitis, we think it is wise not to indicate TE in patients
without a significant history of tonsillitis. This is mainly
due to the risk of potentially life-threatening complications.
We also strongly disagree to indicate interval TE, since TE
was unable to prevent PTA development.
Eur Arch Otorhinolaryngol
Herzon concluded that an individual hospital stay should
not usually exceed 2 days [5] which is supported by the
findings of Mehanna [98]. Tachibana admitted all PTA
patients and reported a resolution of all symptoms within
3.2 days and a complete recovery within 5.5 days, re-
spectively [3]. This UK management is in stark contrast to
other countries, such as the United States where most
peritonsillar abscesses are managed as outpatients [5]. As
stated for 94 % surveyed ENT specialists in the UK [10] or
Singapore [16], hospitalization has been part of our man-
agement protocol, and ranged 1–13 days (median: 4 days)
in group B patients. Patients were also admitted in other
contemporary reports [3, 24] for 1–17 days (mean and
median: 5 days) [31], 1–10 days (mean: 3.4 days) [108] or
1.6 days on average with an overnight observation rate of
67 % [4]. Patients with a recurrent PTA, however, stayed
for 4.4 days on average which compares favorably with our
results [4]. Sowerby in Canada admitted only 7/46 patients
(15 %), for intravenous hydration, therapy and observation
and reported a duration of hospitalization of 2 days or less
for 5/7 [25]. A significant variation concerning inpatient
versus outpatient treatment of PTA in Denmark, Sweden,
Finland and Norway was revealed by the study of Wiksten
with inpatient rates of 9 % to 50 % [103]. Risberg deter-
mined an inpatient rate of only 13 % [13] and children in
Israel were admitted on average for 3 days [32] as in
Northern Ireland [14].
Albertz reported of two bleeding patients (1.78 %) re-
quiring surgical revision to achieve hemostasis under
general anesthesia and two with a spontaneous cessation of
the hemorrhage [108]. Comparison of the post-tonsillec-
tomy hemorrhage rates of quinsy versus elective tonsil-
lectomy in age- and gender-matched groups shows no
statistically significant difference (2.9 % vs. 2.8 %) [107].
However, the hemorrhage rate in our study was somewhat
higher but calculated from a smaller patient population.
A unilateral tonsillectomy was performed in 28 of 112
patients (26 %) without a prior history of recurrent ton-
sillitis/PTA in the study of Albertz. Six of the 28 developed
a recurrent infection of the contralateral tonsil resulting in a
TAC one month after the initial therapy [108]. This was not
registered in our patient population with a unilateral TAC
performed in 6 of 51 group B patients (11.8 %).
In a series of 275 PTA patients, Rokkjaer and Klug
identified a 40-year-old patient with an unexpected ma-
lignant tumor (acute myeloic leukemia) [110]. There were
three patients with clinical signs of a PTA in our study, in
whom the final histological result revealed a malignant
lymphoma, an unspecified tumor-like lesion and a pleo-
morphic adenoma. Only few authors reported comparable
findings in different case series without mentioning typical
findings to identify this rare entity [111–114]. Diagnosis is
therefore widely based on a high index of suspicion and a
close follow-up until healing has completed.
The limitations of our study are clearly related to its
retrospective character with commonly acknowledged
sources of bias. Unfortunately, it was impossible to eval-
uate whether or not the duration of sick leave was different
between both groups. Moreover, microbiological ex-
amination was not part of the routine management proto-
col, which would help to explain the different clinical
courses of our patients. The surgical procedure was per-
formed in an academic teaching hospital by multiple sur-
geons with different grades of surgical experience which
apparently is a source of bias. Although discharge from the
hospital was based on disappearance of symptoms and
normalization of pharyngeal findings, the length of inpa-
tient treatment does not necessarily mirror the particular
state of general health of PTA patients. Prospective studies
with a standardized management protocol including a
complete microbiological examination as well as devel-
opment of an improved ID-technique are warranted to
improve the clinical courses of PTA patients, at least at our
institution. Nonetheless, TAC will not return to be our first-
line treatment as it is associated with high costs, hospital-
ization, delay of drainage by many hours, greater morbidity
and requires a skilled team to perform the procedure. Most
importantly, the majority of patients do not have strong
indications for TE. The position that a tonsillectomy is
indicated acutely based on a single occurrence of PTA,
without any other history of prior tonsillar disease is not
supported by the fact that \85–90 % of patients do not
experience a recurrent PTA [5]. Quinsy tonsillectomy has a
clear role for those intolerant of an awake procedure (such
as children) and in patients with persistent peritonsillar
abscess who could benefit in overall reduced recovery time.
Conclusions
• Peritonsillar abscess is not necessarily a result of re-
current episodes of tonsillitis, since less than 20 % of
the entire patient population never experienced previ-
ous antibiotic treatment.
• Peritonsillar abscess is not solely resulting from an
infection of Weber’s glands, since almost 5 % of all
PTA patients previously had undergone tonsillectomy.
• Patients with smoking patients are overrepresented in
the entire patient population.
• Abscess tonsillectomy as first-line treatment is a safe
method to resolve a PTA by a single surgical step.
• Abscess tonsillectomy is associated with a significant
greater risk of postoperative hemorrhage compared
to ID.
123

• Simultaneous contralateral TE in PTA patients under-
going TAC to resolve a unilateral PTA appears not to
be justified.
• Replacing TAC by ID does not result in a decrease of
revision procedures, but reduces the days of inpatient
treatment.
• Incisional drainage can be done under local anesthesia,
TAC warrants general anesthesia.
• Incisional drainage is an alternative to TAC but
successful PTA treatment is associated with a greater
number of surgical procedures.
• Peritonsillar abscess may mimic a neoplasia.
• A modification of the surgical ID technique is warrant-
ed to increase the success rate, at least at an academic
teaching hospital.
• Incisional drainage under general anesthesia is not
associated with a higher success rate compared to
several reports in the literature with less invasive NA.
• The evidence is lacking and more is needed on the topic
of surgical management, in particular patients’ views
on procedures and the effects on quality of life.
Acknowledgments The authors would like to thank Yue-Shih
Chen, M.D., Bad Honnef, Germany, for the statistical calculations.
Conflict of interest The authors declare that they have no conflict
of interest.
References
1. Powell EL, Powell J, Samuel JR, Wilson JA (2013) A review of
the pathogenesis of adult peritonsillar abscess: time for a re-
evaluation. J Antimicrob Chemother 68(9):1941–1950. doi:10.
1093/jac/dkt128
2. Ryan S, Papanikolaou V, Keogh I (2014) Appraisal of the peri-
hospital management and evolving microbiology of peritonsillar
abscess disease. B-ENT 10(1):15–20
3. Tachibana T, Orita Y, Abe-Fujisawa I, Ogawara Y, Matsuyama
Y, Shimizu A, Nakada M, Sato Y, Nishizaki K (2014) Prog-
nostic factors and effects of early surgical drainage in patients
with peritonsillar abscess. J Infect Chemother Off J Jpn Soc
Chemother 20(11):722–725. doi:10.1016/j.jiac.2014.07.018
4. Love RL, Allison R, Chambers ST (2011) Peritonsillar infection
in Christchurch 2006–2008: epidemiology and microbiology.
N Z Med J 124(1337):16–23
5. Herzon FS (1995) Harris P. Mosher Award thesis. Peritonsillar
abscess: incidence, current management practices, and a pro-
posal for treatment guidelines. Laryngoscope 105(8 Pt 3 Suppl
74):1–17
6. Virtanen S, Laukkanen-Ninios R, Ortiz Martinez P, Siitonen A,
Fredriksson-Ahomaa M, Korkeala H (2013) Multiple-locus
variable-number tandem-repeat analysis in genotyping Yersinia
enterocolitica strains from human and porcine origins. J Clin
Microbiol 51(7):2154–2159. doi:10.1128/JCM.00710-13
7. Spires JR, Owens JJ, Woodson GE, Miller RH (1987) Treatment
of peritonsillar abscess. A prospective study of aspiration vs
incision and drainage. Arch Otolaryngol Head Neck Surg
113(9):984–986
123
Eur Arch Otorhinolaryngol
8. Stringer SP, Schaefer SD, Close LG (1988) A randomized trial
for outpatient management of peritonsillar abscess. Arch Oto-
laryngol Head Neck Surg 114(3):296–298
9. Herzon FS, Martin AD (2006) Medical and surgical treatment of
peritonsillar, retropharyngeal, and parapharyngeal abscesses.
Curr Infect Dis Rep 8(3):196–202
10. Johnson RF, Stewart MG, Wright CC (2003) An evidence-based
review of the treatment of peritonsillar abscess. Otolaryngol
Head Neck Surg 128(3):332–343
11. Powell J, Wilson JA (2012) An evidence-based review of
peritonsillar abscess. Clin Otolaryngol Off J ENT-UK Off J
Neth Soc Oto-Rhino-Laryngol Cerv Facial Surg 37(2):136–145.
doi:10.1111/j.1749-4486.2012.02452.x
12. Klug TE (2014) Incidence and microbiology of peritonsillar
abscess: the influence of season, age, and gender. Eur J Clin
Microbiol Infect Dis Off Publ Eur Soc Clin Microbiol
33(7):1163–1167. doi:10.1007/s10096-014-2052-8
13. Risberg S, Engfeldt P, Hugosson S (2008) Incidence of peri-
tonsillar abscess and relationship to age and gender: retrospec-
tive study. Scand J Infect Dis 40(10):792–796. doi:10.1080/
00365540802195226
14. Hanna BC, McMullan R, Gallagher G, Hedderwick S (2006)
The epidemiology of peritonsillar abscess disease in Northern
Ireland. J Infect 52(4):247–253. doi:10.1016/j.jinf.2005.07.002
15. Matsuda A, Tanaka H, Kanaya T, Kamata K, Hasegawa M
(2002) Peritonsillar abscess: a study of 724 cases in Japan. Ear
Nose Throat J 81(6):384–389
16. Ong YK, Goh YH, Lee YL (2004) Peritonsillar infections: local
experience. Singapore Med J 45(3):105–109
17. Galioto NJ (2008) Peritonsillar abscess. Am Fam Physician
77(2):199–202
18. Powell E, Powell J, Samuel J, Wilson J (2013) A review of the
pathogenesis of adult peritonsillar abscess: time for a re-eval-
uation. J Antimicrob Chemother 68:1941–1950
19. Gavriel H, Lazarovitch T, Pomortsev A, Eviatar E (2009) Var-
iations in the microbiology of peritonsillar abscess. Eur J Clin
Microbiol Infect Dis Off Publ Eur Soc Clin Microbiol
28(1):27–31. doi:10.1007/s10096-008-0583-6
20. Dunn N, Lane D, Everitt H, Little P (2007) Use of antibiotics for
sore throat and incidence of quinsy. Br J Gen Pract J Royal
College Gen Pract 57(534):45–49
21. Wang YP, Wang MC, Lin HC, Chou P (2014) The impact of
prior tonsillitis and treatment modality on the recurrence of
peritonsillar abscess: a nationwide cohort study. PLoS One
9(10):e109887. doi:10.1371/journal.pone.0109887
22. Franzese CB, Isaacson JE (2003) Peritonsillar and parapharyn-
geal space abscess in the older adult. Am J Otolaryngol
24(3):169–173
23. Marom T, Cinamon U, Itskoviz D, Roth Y (2010) Changing
trends of peritonsillar abscess. Am J Otolaryngol 31(3):
162–167. doi:10.1016/j.amjoto.2008.12.003
24. Gavriel H, Golan Y, Lazarovitch T, Eviatar E (2014) Bacteri-
ology of peritonsillar abscess in patients over 40 years-a ne-
glected age group. Eur Arch Otorhinolaryngol. doi:10.1007/
s00405-014-3029-z
25. Sowerby LJ, Hussain Z, Husein M (2013) The epidemiology,
antibiotic resistance and post-discharge course of peritonsillar
abscesses in London, Ontario. J Otolaryngol Head Neck Surg
(Le Journal d’oto-rhino-laryngologie et de chirurgie cervico-
faciale) 42:5. doi:10.1186/1916-0216-42-5
26. Hidaka H, Kuriyama S, Yano H, Tsuji I, Kobayashi T (2011)
Precipitating factors in the pathogenesis of peritonsillar ab-
scess and bacteriological significance of the Streptococcus
milleri group. Eur J Clin Microbiol Infect Dis Off Publ Eur
Soc Clin Microbiol 30(4):527–532. doi:10.1007/s10096-010-
1114-9
Eur Arch Otorhinolaryngol
27. Sunnergren O, Swanberg J, Molstad S (2008) Incidence, mi-
crobiology and clinical history of peritonsillar abscesses. Scand
J Infect Dis 40(9):752–755. doi:10.1080/00365540802040562
28. Shaul C, Koslowsky B, Rodriguez M, Schwarz Y, Muahnna N,
Peleg U, Sichel JY (2014) Is Needle Aspiration for Peritonsillar
Abscess Still as Good as We Think? A Long-term Follow-up.
Ann Otol Rhinol Laryngol. doi:10.1177/0003489414556083
29. Rusan M, Klug TE, Henriksen JJ, Ellermann-Eriksen S,
Fuursted K, Ovesen T (2012) The role of viruses in the patho-
genesis of peritonsillar abscess. Eur J Clin Microbiol Infect Dis
Off Publ Eur Soc Clin Microbiol. doi:10.1007/s10096-012-
1573-2
30. Kordeluk S, Novack L, Puterman M, Kraus M, Joshua BZ
(2011) Relation between peritonsillar infection and acute ton-
sillitis: myth or reality? Otolaryngol Head Neck Surg
145(6):940–945. doi:10.1177/0194599811415802
31. Mazur E, Czerwinska E, Korona-Glowniak I, Grochowalska A,
Koziol-Montewka M (2014) Epidemiology, clinical history and
microbiology of peritonsillar abscess. Eur J Clin Microbiol In-
fect Dis Off Publ Eur Soc Clin Microbiol. doi:10.1007/s10096-
014-2260-2
32. Segal N, El-Saied S, Puterman M (2009) Peritonsillar abscess in
children in the southern district of Israel. Int J Pediatr Otorhi-
nolaryngol 73(8):1148–1150
33. Pham V, Gungor A (2012) Bilateral peritonsillar abscess: case
report and literature review. Am J Otolaryngol 33(1):163–167.
doi:10.1016/j.amjoto.2010.12.010
34. Papacharalampous GX, Vlastarakos PV, Kotsis G, Davilis D,
Manolopoulos L (2011) Bilateral Peritonsillar Abscesses: a Case
Presentation and Review of the Current Literature with regard to
the Controversies in Diagnosis and Treatment. Case Report Med
2011:981924. doi:10.1155/2011/981924
35. Wolf M, Even-Chen I, Kronenberg J (1994) Peritonsillar ab-
scess: repeated needle aspiration versus incision and drainage.
Ann Otol Rhinol Laryngol 103(7):554–557
36. Bonding P (1973) Tonsillectomy a chaud. J Laryngol Otol
87(12):1171–1182
37. Schechter GL, Sly DE, Roper AL, Jackson RT (1982) Changing
face of treatment of peritonsillar abscess. Laryngoscope 92(6 Pt
1):657–659
38. Ophir D, Bawnik J, Poria Y, Porat M, Marshak G (1988) Peri-
tonsillar abscess. A prospective evaluation of outpatient man-
agement by needle aspiration. Arch Otolaryngol Head Neck
Surg 114(6):661–663
39. Savolainen S, Jousimies-Somer HR, Makitie AA, Ylikoski JS
(1993) Peritonsillar abscess. Clinical and microbiologic aspects
and treatment regimens. Arch Otolaryngol Head Neck Surg
119(5):521–524
40. Weinberg E, Brodsky L, Stanievich J, Volk M (1993) Needle
aspiration of peritonsillar abscess in children. Arch Otolaryngol
Head Neck Surg 119(2):169–172
41. Kronenberg J, Wolf M, Leventon G (1987) Peritonsillar abscess:
recurrence rate and the indication for tonsillectomy. Am J
Otolaryngol 8(2):82–84
42. Holt GR, Tinsley PP Jr (1981) Peritonsillar abscesses in chil-
dren. Laryngoscope 91(8):1226–1230
43. Holt GR (1982) The management of peritonsillar abscesses in
military medicine. Mil Med 147(10):851–855
44. Fried MP, Forrest JL (1981) Peritonsillitis. Evaluation of current
therapy. Arch Otolaryngol 107(5):283–286
45. Wolf M, Kronenberg J, Kessler A, Modan M, Leventon G
(1988) Peritonsillar abscess in children and its indication for
tonsillectomy. Int J Pediatr Otorhinolaryngol 16(2):113–117
46. Nielsen VM, Greisen O (1981) Peritonsillar abscess. I. Cases
treated by incision and drainage: a follow-up investigation.
J Laryngol Otol 95(8):801–805
47. Steghuis HR, Schousboe M (1986) Peritonsillar infection in
Christchurch in 1981–1984. N Z Med J 99:536–538
48. Costales-Marcos M, Lopez-Alvarez F, Nunez-Batalla F, Mor-
eno-Galindo C, Alvarez Marcos C, Llorente-Pendas JL (2012)
Peritonsillar infections: prospective study of 100 consecutive
cases. Acta Otorrinolaringol Esp 63(3):212–217. doi:10.1016/j.
otorri.2012.01.001
49. Chung JH, Lee YC, Shin SY, Eun YG (2014) Risk factors for
recurrence of peritonsillar abscess. J Laryngol Otol. doi:10.
1017/S002221511400259X
50. Wiksten J, Hytonen M, Pitkaranta A, Blomgren K (2012) Who
ends up having tonsillectomy after peritonsillar infection? Eur
Arch Otorhinolaryngol 269(4):1281–1284. doi:10.1007/s00405-
011-1807-4
51. Templer JW, Holinger LD, Wood RP 2nd, Tra NT, DeBlanc GB
(1977) Immediate tonsillectomy for the treatment of peritonsil-
lar abscess. Am J Surg 134(5):596–598
52. Lee KJ, Traxler JH, Smith HW, Kelly JH (1973) Tonsillectomy:
treatment of peritonsillar abscess. Trans Am Acad Ophthalmol
Otolaryngol Am Acad Ophthalmol Otolaryngol 77(6):ORL417–
ORL423
53. McCurdy JA Jr (1977) Peritonsillar abscess. A comparison of
treatment by immediate tonsillectomy and interval tonsillecto-
my. Arch Otolaryngol 103(7):414–415
54. Beeden AG, Evans JN (1970) Quinsy tonsillectomy–a further
report. J Laryngol Otol 84(4):443–448
55. Brandow EC Jr (1973) Immediate tonsillectomy for peritonsillar
abscess. Trans Am Acad Ophthalmol Otolaryngol Am Acad
Ophthalmol Otolaryngol 77(6):ORL412–ORL416
56. Litman RS, Hausman SA, Sher WH (1987) A retrospective
study of peritonsillar abscess. Ear Nose Throat J 66(2):53–55
57. Harma RA, Juola E, Ruoppi P, Vartiainen E (1979) Abscess
tonsillectomy a tiede. Acta Otolaryngol Suppl 360:67–69
58. Herbild O, Bonding P (1981) Peritonsillar abscess. Arch Oto-
laryngol 107(9):540–542
59. Mak CC, Spielmann PM, Hussain SS (2012) Recurrence of
peritonsillar abscess: a 2-year follow-up. Clin Otolaryngol Off J
ENT-UK Off J Netherlands Soc Oto-Rhino-Laryngol Cerv Fa-
cial Surg 37(1):87–88. doi:10.1111/j.1749-4486.2011.02426.x
60. Raut V, Yung M (2000) Peritonsillar abscess: the rationale for
interval tonsillectomy. Ear Nose Throat J 79(3):206–209
61. Apostolopoulos NJ, Nikolopoulos TP, Bairamis TN (1995) Peri-
tonsillar abscess in children. Is incision and drainage an effective
management? Int J Pediatr Otorhinolaryngol 31(2–3):129–135
62. Harris WE (1991) Is a single quinsy an indication for tonsil-
lectomy? Clin Otolaryngol Allied Sci 16(3):271–273
63. Szuhay G, Tewfik TL (1998) Peritonsillar abscess or cellulitis?
A clinical comparative paediatric study. J Otolaryngol 27(4):
206–212
64. Roos K, Lind L (1990) Peritonsillar abscess in spite of
adequately performed tonsillectomy. Arch Otolaryngol Head
Neck Surg 116(2):205
65. Randall CJ, Jefferis AF (1984) Quinsy following tonsillectomy
(five case reports). J Laryngol Otol 98(4):367–369
66. Farmer SE, Khatwa MA, Zeitoun HM (2011) Peritonsillar ab-
scess after tonsillectomy: a review of the literature. Ann R Coll
Surg Engl 93(5):353–355. doi:10.1308/003588411X579793
67. Licameli GR, Grillone GA (1998) Inferior pole peritonsillar
abscess. Otolaryngol Head Neck Surg 118(1):95–99
68. Stankiewicz JA, Talland C (1988) Peritonsillar like lateral
oropharyngeal abscess after tonsillectomy. Arch Otolaryngol
Head Neck Surg 114(10):1181–1183
69. Al-Kindy S (2002) Post tonsillectomy quinsy. Saudi Med J
23(2):240–241
70. Passy V (1994) Pathogenesis of peritonsillar abscess. Laryngo-
scope 104(2):185–190
123

71. Brook I (2004) Microbiology and management of peritonsillar,
retropharyngeal, and parapharyngeal abscesses. J Oral Max-
illofac Surg 62(12):1545–1550
72. Kilty SJ, Gaboury I (2008) Clinical predictors of peritonsillar
abscess in adults. J Otolaryngol Head Neck Surg (Le Journal
d’oto-rhino-laryngologie et de chirurgie cervico-faciale)
37(2):165–168
73. Lehnerdt G, Senska K, Fischer M, Jahnke K (2005) Rauchen
prädisponiert zum Peritonsillarabszess. Laryngorhinootologie
84(9):676–679
74. Torre V, Bucolo S, Giordano C, Cicciarello R, Cavallari V,
Garofalo L, Beatrice F (2005) Palatine tonsils in smoker and
non-smoker patients: a pilot clinicopathological and ultrastruc-
tural study. J Oral Pathol Med Off Publ Int Assoc Oral Pathol
Am Acad Oral Pathol 34(7):390–396. doi:10.1111/j.1600-0714.
2005.00319.x
75. Klug TE, Rusan M, Clemmensen KK, Fuursted K, Ovesen T
(2013) Smoking promotes peritonsillar abscess. Eur Arch
Otorhinolaryngol 270(12):3163–3167. doi:10.1007/s00405-013-
2474-4
76. Dilkes MG, Dilkes JE, Ghufoor K (1992) Smoking and quinsy.
Lancet 339(8808):1552
77. Choi SH, Kim HJ (2010) A case of Kawasaki disease with
coexistence of a parapharyngeal abscess requiring incision and
drainage. Korean J Pediatr 53(9):855–858. doi:10.3345/kjp.
2010.53.9.855
78. Arkkila E, Sipila J, Laurikainen E, Suonpaa J (1998) Periton-
sillar abscess associated with infectious mononucleosis. ORL J
Otorhinolaryngol Relat Spec 60(3):159–163
79. Burstin PP, Marshall CL (1998) Infectious mononucleosis and
bilateral peritonsillar abscesses resulting in airway obstruction.
J Laryngol Otol 112(12):1186–1188
80. Koch KU, Lindhardt C, Andersen OO, Kristensen S (2005)
Bilateral peritonsillar abscess in mononucleosis. Ugeskr Laeger
167(17):1862–1863
81. Monem SA, O’Connor PF, O’Leary TG (1999) Peritonsillar
abscess and infectious mononucleosis: an association or a dif-
ferent presentation of the same condition. Ir Med J 92(2):
278–280
82. Johnsen T (1981) Infectious mononucleosis and peritonsillar
abscess. J Laryngol Otol 95(8):873–876
83. Portman M, Ingall D, Westenfelder G, Yogev R (1984) Peri-
tonsillar abscess complicating infectious mononucleosis. J Pe-
diatr 104(5):742–744
84. Ryan C, Dutta C, Simo R (2004) Role of screening for infectious
mononucleosis in patients admitted with isolated, unilateral
peritonsillar abscess. J Laryngol Otol 118(5):362–365. doi:10.
1258/002221504323086552
85. Shareef MM, Balaji N, Adi-Romero P (2007) Screening for
glandular fever in patients with Quinsy: is it necessary? Eur
Arch Otorhinolaryngol 264(11):1329–1331. doi:10.1007/s00405-
007-0355-4
86. Segal N, El-Saied S, Puterman M (eds) (2009) Peritonsillar
abscess in children in the southern district of Israel. Int J Pediatr
Otorhinolaryngol Irel 73. doi:10.1016/j.ijporl.2009.04.021
87. Dodds B, Maniglia AJ (1988) Peritonsillar and neck abscesses in
the pediatric age group. Laryngoscope 98:956–959
88. Chowdhury C, Bricknell M (1992) The management of quin-
sy—a prospective study. J Laryngol Otol 106(11):986–988
89. Lockhart R, Parker G, Tami T (1991) Role of quinsy tonsil-
lectomy in the management of peritonsillar abscess. Ann Otol
Rhinol Laryngol 100(7):569–571
90. Johnson RF, Stewart MG (2005) The contemporary approach to
diagnosis and management of peritonsillar abscess. Curr Opin
Otolaryngol Head Neck Surg 13(3):157–160
123
Eur Arch Otorhinolaryngol
91. Baugh RF, Archer SM, Mitchell RB, Rosenfeld RM, Amin R,
Burns JJ, Darrow DH, Giordano T, Litman RS, Li KK,
Mannix ME, Schwartz RH, Setzen G, Wald ER, Wall E,
Sandberg G, Patel MM (2011) Clinical practice guideline:
tonsillectomy in children. Otolaryngol Head Neck Surg 144(1
Suppl):S1–S30
92. Dünne AA, Granger O, Folz BJ, Sesterhenn A, Werner JA
(2003) Peritonsillar abscess—critical analysis of abscess ton-
sillectomy. Clin Otolaryngol Allied Sci 28(5):420–424
93. Khayr W, Taepke J (2005) Management of peritonsillar abscess:
needle aspiration versus incision and drainage versus tonsillec-
tomy. Am J Ther 12(4):344–350
94. Maharaj D, Rajah V, Hemsley S (1991) Management of peri-
tonsillar abscess. J Laryngol Otol 105(9):743–745
95. Herzon FS (1984) Permucosal needle drainage of peritonsillar
abscesses—a five year experience. Arch Otolaryngol Head Neck
Surg 110:104–105
96. Nwe TT, Singh B (2000) Management of pain in peritonsillar
abscess. J Laryngol Otol 114(10):765–767
97. Lamkin RH, Portt J (2006) An outpatient medical treatment
protocol for peritonsillar abscess. Ear Nose Throat J 85(10):658,
660
98. Mehanna HM, Al-Bahnasawi L, White A (2002) National audit
of the management of peritonsillar abscess. Postgrad Med J
78(923):545–548
99. King JT (1961) Aspiration treatment of peritonsillar abscess.
J Med Assoc Ga 50:18–19
100. Strome M (1973) Peritonsillar abscess—a different approach.
J Med Assoc Ga 62(1):4–6
101. Herzon FS, Aldridge JH (1981) Peritonsillar abscess: needle
aspiration. Otolaryngol Head Neck Surg 89(6):910–911
102. Sibbitt RR, Sibbitt WL Jr, Palmer DJ, Bankhurst AD (2008)
Needle aspiration of peritonsillar abscess with the new safety
technology: the reciprocating procedure device. Otolaryngol
Head Neck Surg 139(2):307–309. doi:10.1016/j.otohns.2008.04.
003
103. Wiksten J, Blomgren K, Eriksson T, Guldfred L, Bratt M,
Pitkaranta A (2014) Variations in treatment of peritonsillar ab-
scess in four Nordic countries. Acta Otolaryngol 134(8):
813–817. doi:10.3109/00016489.2014.905702
104. Kodiya AM, Ngamdu YB, Sandabe BM, Isa A, Garandawa HI
(2014) Management strategies of peritonsillar abscess in the
tropics: a survey of surgeons’ preference. Indian J Otolaryngol
Head Neck Surg Off Publ Assoc Otolaryngol India 66(2):
127–130. doi:10.1007/s12070-012-0540-7
105. Raut VV, Yung MW (2000) Peritonsillar abscess: the ra-
tionale for interval tonsillectomy. Ear Nose Throat J
79(3):206-209
106. Page C, Chassery G, Boute P, Obongo R, Strunski V (eds)
Immediate tonsillectomy: indications for use as first-line surgi-
cal management of peritonsillar abscess (quinsy) and parapha-
ryngeal abscess. J Laryngol Otol Engl 124. doi:10.1017/
S0022215110000903
107. Windfuhr JP, Chen YS (2001) Immediate abscess tonsillecto-
my–a safe procedure? Auris Nasus Larynx 28(4):323–327
108. Albertz N, Nazar G (2012) Peritonsillar abscess: treatment with
immediate tonsillectomy—10 years of experience. Acta
Otolaryngol 132(10):1102–1107. doi:10.3109/00016489.2012.
684399
109. Berry S, Pascal I, Whittet HB (2008) Tonsillectomy a chaud for
quinsy: revisited. Eur Arch Otorhinolaryngol 265(1):31–33
110. Rokkjaer MS, Klug TE (2014) Tonsillar malignancy in adult
patients with peritonsillar abscess: retrospective study of 275
patients and review of the literature. Eur Arch Otorhinolaryngol.
doi:10.1007/s00405-014-3186-0
Eur Arch Otorhinolaryngol
111. Alvi A, Vartanian AJ (1998) Microscopic examination of rou-
tine tonsillectomy specimens: is it necessary? Otolaryngol Head
Neck Surg 119(4):361–363
112. Windfuhr J (2002) Malignant neoplasia at different ages pre-
senting as peritonsillar abscess. Otolaryngol Head Neck Surg
126(2):197–198
113. Kallel S, Hadj Taieb H, Makni S, Ghorbel A (2013) Lymphoma
presenting as a peritonsillar abscess. Eur Ann Otorhinolaryngol
Head Neck Dis. doi:10.1016/j.anorl.2012.09.012
114. Glazer DV, Romeling F (2014) [Pleomorphic adenoma causing
a peritonsillar abscess.]. Ugeskrift for laeger 176(52):2–3
123