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PURPOSE: To assess the efficacy, safety, and tolerance of drainage under local anesthesia compared to immediate tonsillectomy to treat uncomplicated unilateral peritonsillar abscess (PTA) in adults. METHODS: A randomized clinical trial was conducted in a tertiary care university hospital. Adults with PTA radiologically confirmed as ≥1 cm and uncomplicated were randomly assigned to two groups using block randomization. They immediately underwent either tonsillectomy under general anesthesia or drainage under local anesthesia. The primary outcome was treatment success at 48 h, defined as a reduction in swelling and restoration of swallowing function, allowing hospital discharge. Secondary outcomes included pain and anxiety levels, along with postoperative bleeding. RESULTS: A total of 41 patients were included (66 % male; age range 18-77 years). Twenty-one patients underwent tonsillectomy, while 20 underwent drainage. The success rate was higher in the tonsillectomy group (100 %) than in the drainage group (75 %, p = 0.02). Pain and anxiety levels were significantly higher in the drainage group (p < 0.01). Postoperative bleeding occurred in 33 % of the tonsillectomy group, while no bleeding was reported in the drainage group (p < 0.01). CONCLUSION: Immediate tonsillectomy for treating PTA offers definitive management with high efficacy, albeit with an increased risk of postoperative bleeding. Drainage under local anesthesia is associated with a higher failure rate and increased patient discomfort but demonstrates a better safety profile. Treatment decisions should be tailored based on patient preferences, clinical presentation, and available resources. TRIAL REGISTRATION: ClinicalTrial.gov protocol record NCT04543708.