Transcervical ultrasonography in the diagnosis of pediatric peritonsillar abscess

The Role of Ultrasound in Pediatric Peritonsillar Infection: A Descriptive Analysis

In this study, we describe the role of ultrasound in diagnosing pediatric peritonsillar abscesses (PTAs). A retrospective chart review was conducted on 54 children aged 4 to 17 years who had an ultrasound performed for suspected PTA. Based on ultrasound imaging, the patients were classified into 2 groups: PTA-positive (8, 14.8%) and PTA-negative (46, 85.2 %). Trismus was significantly associated with PTA (50% vs. 13%, P = .03). PTA-positive patients were more likely to be given steroids, be admitted, and have extended hospital stays (P = .04, .004, and .002, respectively). The 2 groups had no significant difference in computed tomography (CT) acquisition, surgical intervention, and return visits (P = .92, .17, and .97, respectively). Larger abscesses trended toward surgical treatment (P = .087). Ultrasound is an efficient diagnostic modality for suspected peritonsillar infections in children, with similar clinical outcomes for PTA-positive and PTA-negative groups.

Predicting failure of detection of peritonsillar abscess with ultrasound in pediatric populations

PURPOSE

Some patients require additional imaging following ultrasound (US) to definitively diagnose a peritonsillar abscess (PTA), delaying intervention and disease resolution. We seek to evaluate patient characteristics which may predispose to a secondary imaging requirement to diagnose PTA, in order to better understand ultrasound limitations and predict who will require additional studies.

MATERIALS AND METHODS

Retrospective chart review of patients with an US for suspected PTA between July 2017 and July 2020. Patient age, weight, and clinical characteristics, such as pain, trismus, and reduced neck range of motion (ROM) were collected. The need for additional imaging, subsequent surgical intervention, and hospital length of stay (LOS) were also recorded.

RESULTS

Of 411 qualifying patients, 73 underwent additional imaging. Patients who required additional imaging were younger (9.8 vs 11.3 years, p = 0.026) and more likely to have decreased neck ROM (17.8 vs 5.3 %, p = 0.001). Surgical intervention was performed more commonly (27.4 vs 14.8 %, p = 0.015) and hospital LOS was longer (24.0 vs 5.0 h, p < 0.001) in those with secondary imaging.

CONCLUSIONS

Specific patient characteristics, such as younger age and decreased neck range of motion, are associated with a higher need for additional imaging. Additionally, the need for additional imaging is associated with a longer hospital LOS and increased likelihood of surgical intervention. Nearly 18 % of patients who underwent US evaluation of PTA required secondary imaging. Although transcervical US remains an excellent tool for diagnosing PTA, this data supports the utility of secondary imaging in certain instances.

Test characteristics of ultrasound for the diagnosis of peritonsillar abscess: A systematic review and meta-analysis

BACKGROUND

Distinguishing peritonsillar abscess (PTA) from peritonsillar cellulitis using clinical assessment is challenging as many features overlap for both conditions, and physical examination is only about 75% sensitive and 50% specific for diagnosing PTA. The primary objective of this systematic review was to determine the test characteristics of ultrasound for diagnosing PTA when compared to a reference standard of computed tomography or acquisition of pus via needle aspiration or incision and drainage.

METHODS

This systematic review was performed in accordance with the Preferred Reporting Items for a Systematic Review and Meta-analysis of Diagnostic Test Accuracy (PRISMA-DTA) guidelines. We searched seven databases from 1960 to November 2022. Two independent reviewers completed study selection, data extraction, and QUADAS-2 risk-of-bias assessment. We used a bivariate random-effects model to calculate pooled sensitivity, specificity, positive likelihood ratio (LR+), and negative likelihood ratio (LR-). We also conducted subgroup analyses on radiology ultrasound compared to point-of-care ultrasound (POCUS) and intraoral compared to transcervical scanning techniques.

RESULTS

From 339 citations, we identified 18 studies for inclusion. Because one study only reported positive cases of PTA (thereby preventing the calculation of specificity), it was excluded from the analysis, so the analysis included a total of 17 studies with 812 patients, of whom 541 had PTA. Pooled bivariate sensitivity was 86% (95% confidence interval [CI] 78%-91%), specificity 76% (95% CI 67%-82%), LR+ 3.51 (95% CI 2.59-4.89), and LR- 0.19 (95% CI 0.12-0.30). On subgroup analysis, radiology-performed ultrasound had a sensitivity and specificity of 89% and 71%, compared to POCUS, which had a sensitivity and specificity of 74% and 79%. Comparing the two different techniques, intraoral had a sensitivity and specificity of 91% and 75% while transcervical had a sensitivity and specificity of 80% and 81%.

CONCLUSIONS

Ultrasound demonstrates high sensitivity for ruling out PTA, but it only has moderate specificity for ruling in the diagnosis.

Palatine Tonsil Measurements and Echogenicity during Tonsillitis Using Ultrasonography: A Case-Control Study

This case-control study aimed to assess the size and echogenicity of inflamed tonsils using ultrasonography. It was carried out at different hospitals, nurseries, and primary schools in Khartoum state. About 131 Sudanese volunteers between 1 and 24 years old were recruited. The sample included 79 volunteers with normal tonsils and 52 with tonsillitis according to hematological investigations. The sample was divided into groups according to age-1-5 years old, 6-10 years old, and more than ten years. Measurements in centimeters of height (AP) and width (transverse) of both tonsils (right and left) were taken. Echogenicity was assessed according to normal and abnormal appearances. A data collection sheet containing all the study variables was used. The independent samples test (t-test) showed an insignificant height difference between normal controls and cases with tonsillitis. The transverse diameter increased significantly with inflammation (p-value < 0.05) for both tonsils in all groups. Echogenicity can differentiate between normal and abnormal tonsils (p-value < 0.05 using the chi-square test) for samples from 1-5 years and 6-10 years. The study concluded that measurements and appearance are reliable indicators of tonsillitis, which can be confirmed with the use of ultrasonography, helping physicians to make the correct diagnosis and decisions.

Are Computed Tomography Scans Necessary for the Diagnosis of Peritonsillar Abscess?

Background Peritonsillar abscess is one of the most common deep-space infections of the head and neck, accounting for significant healthcare costs in the United States. Contributing to this expenditure is the trend of increased usage of computed tomography (CT), particularly in the emergency department. However, CT can be falsely positive for peritonsillar abscess, prompting unnecessary drainage attempts that yield no purulence. The false positive findings question the accuracy of CT in diagnosing peritonsillar abscess. Objectives The objective of the study was to compare the accuracy of CT with clinical exam to assess if CT is warranted in peritonsillar abscess diagnosis. Methods A retrospective study was performed of patients presenting to eight Orlando emergency departments with throat pain from January 1, 2013, to April 30, 2013. Patients with clinical diagnoses of peritonsillar abscesses were reviewed. A note was made whether CT was performed and if peritonsillar abscess was seen. The reads were compared to the results of procedural intervention for abscess drainage to assess the accuracy of CT in diagnosing peritonsillar abscess. Results There were 116 patients diagnosed with peritonsillar abscess, of which 99 underwent CT scans to aid in diagnosis. Among these 99 patients, 23 received procedural intervention, with 16 having a return of purulence (69.6%), and seven remaining without purulence (30.4%). Conclusion This study highlights the potential inaccuracies of CT scan in diagnosing peritonsillar abscess, as 30.4% of scans interpreted as abscess lacked purulence on intervention. Given these findings, clinicians could serve as better fiscal stewards by using history and exam to guide management in the majority cases with infectious processes of the oropharynx.

Impact of Bedside Ultrasound on Emergency Department Length of Stay and Admission in Patients With a Suspected Peritonsillar Abscess

Introduction Patients presenting to the Emergency Department (ED) with a suspected peritonsillar abscess (PTA) often pose a diagnostic dilemma, as clinical impression is often unreliable and traditional diagnostic methods have multiple downsides. Bedside ultrasonography has been cited as a modality to improve the diagnosis and management of PTA. We aimed to determine the impact bedside ultrasound (US) could have in suspected PTA on ED length of stay (LOS) and hospital admission rates. Methods We performed a retrospective chart review on patients who presented to the ED with suspected ''peritonsillar abscess''. Results From a sample of 58 charts, seven had documented bedside US performed. The average ED length of stay for these seven cases was 160 minutes (range: 52 to 270 minutes). The ED length of stay for all other cases utilizing other diagnostic methods during the same time period was 293 minutes (range: 34 to 780 minutes). None of the patients who were diagnosed with US were admitted to the hospital, whereas 36.4% of patients where US was not used were admitted. Conclusion The use of bedside US in seven cases of suspected PTA had reduced LOS in the ED and none required hospital admission.

Retropharyngeal, Parapharyngeal and Peritonsillar Abscesses

Deep neck infections (DNIs) include all the infections sited in the potential spaces and fascial planes of the neck within the limits of the deep layer of the cervical fascia. Parapharyngeal and retropharyngeal infections leading to parapharyngeal abscess (PPA) and retropharyngeal abscess (RPA) are the most common. DNIs remain an important health problem, especially in children. The aim of this narrative review is to describe the management of peritonsillar, retropharyngeal and parapharyngeal abscesses in pediatric age. Despite relatively uncommon, pediatric DNIs deserve particular attention as they can have a very severe course and lead to hospitalization, admission to the intensive care unit and, although very rarely, death. They generally follow a mild upper respiratory infection and can initially present with signs and symptoms that could be underestimated. A definite diagnosis can be made using imaging techniques. Pus collection from the site of infection, when possible, is strongly recommended for definition of diseases etiology. Blood tests that measure the inflammatory response of the patient may contribute to monitor disease evolution. The therapeutic approach should be targeted toward the individual patient. Regardless of the surgical treatment, antibiotics are critical for pediatric DNI prognosis. The diagnostic-therapeutic procedure to be followed in the individual patient is not universally shared because it has not been established which is the most valid radiological approach and which are the criteria to be followed for the differentiation of cases to be treated only with antibiotics and those in which surgery is mandatory. Further studies are needed to ensure the best possible care for all children with DNIs, especially in this era of increased antimicrobial resistance.

[Sonographic diagnosis of tonsillar abscesses: Our experience and a systematic review]

BACKGROUND

Transcutaneous sonography has been an integral part of imaging diagnostics in the head and neck region for several decades. Especially in the imaging of abscesses of the tonsillar fossa, sonography is a fast, safe, and cost-effective diagnostic method. This paper aims to provide an overview of the currently published studies in terms of diagnostic value.

MATERIAL AND METHODS

systematic literature search in the following online databases: PubMed und MEDLINE according to the search terms: transcutaneous ultrasound, tonsillar abscess, peritonsillar abscess, intratonsillar abscess, peritonsillar cellulitis, parapharyngeal abscess. Evaluation of the scientific relevance of the papers according to established criteria.

RESULTS

The publications were analyzed in terms of clinical application, clinical diagnosis, and diagnostic accuracy. Sensitivity and specificity are reported between 67 % - 100 %, and 50 % - 93 %, respectively, depending on the study and patient cohort.

CONCLUSIONS

In the synopsis of the currently published results, transcutaneous sonography promises a high potential to improve the diagnosis of peritonsillar abscess and allows a reliable differentiation to peritonsillar cellulitis. This fact seems crucial for the clinical management of patients with suspected abscesses.

Variability in advanced imaging of pediatric neck infections in US emergency departments

OBJECTIVES

To describe the use of computed tomography (CT) and ultrasound (US) imaging for the evaluation of neck infections in pediatric patients in United States emergency departments (EDs).

METHODS

This is a cross-sectional analysis, using the National Emergency Department Sample database, of pediatric patients evaluated for common neck infections between 2012 and 2018. We used bivariable analysis to assess for differences in US and CT use by ED type. We performed multivariable logistic regression to adjust for potential confounding factors including patient characteristics (sex, age, insurance status, discharge diagnosis) and ED characteristics (metropolitan statistical area, pediatric center). Results are reported as odds ratios and adjusted odds ratios with 95% confidence intervals.

RESULTS

There were 19,363 ED visits for pediatric neck infections in the database over the study period, representing 84,439 national visits. Of those imaged, 80.8% were imaged with CT and 19.2% were imaged with US. Pediatric patients evaluated in general EDs as compared to pediatric EDs (aOR 5.32, 95% CI 3.06, 9.24) and patients with a diagnosis of peritonsillar abscess (aOR 2.11, 95% CI 1.34, 3.33) and retropharyngeal abscess (aOR 6.12, 95% CI 2.14, 17.53) were more likely to be imaged with CT scan.

CONCLUSIONS

Children with neck infections evaluated in general EDs are significantly more likely to undergo CT scans when compared to those evaluated in pediatric EDs. To reduce exposure to radiation in children, we propose the dissemination of US-first protocols in general EDs for the evaluation of pediatric neck infections.

Utility of CT in the workup of adults with sore throat in the emergency department

OBJECTIVE

The goal of this study was to determine if computed tomography (CT) added any clinical information that was incorporated into the decision regarding treatment for patients who presented to the Emergency Department (ED) with sore throat.

METHODS

A retrospective chart review of adult patients who presented to the ED with a chief complaint of sore throat who subsequently underwent CT during that ED visit between 1/1/18 and 12/31/18 at our tertiary academic health center was performed. The association between palatal bulge on Otolaryngology physical exam with successful drainage procedure was examined. The mean Hounsfield units (HU) and maximum dimension of measurable fluid collection on CT were compared between patients who underwent a successful drainage procedure and those who did not undergo a drainage procedure or attempted drainage was unsuccessful.

RESULTS

Ninety-four patients met inclusion criteria, with 53% (50/94) men. Of the 22 patients with a palatal bulge on physical examination by Otolaryngology, 86% (19/22) underwent a successful drainage procedure (p < 0.001) when compared to those not undergoing successful drainage. Notably, 56% (53/94) of CT scans were interpreted as normal or tonsillitis. The mean HU was 42.0 in those patients who underwent a successful drainage procedure and 74.1 in those who did not undergo a drainage procedure (p < 0.001). Overall, 21/35 fluid collections had a palatal bulge (p < 0.001).

CONCLUSION

Palatal bulge is a reliable finding in identifying patients with a drainable peritonsillar abscess, and CT scans could largely be avoided in patients without physical exam findings suggestive of more extensive deep neck space abscesses. If a CT scan is obtained, HU should be measured and incorporated into the shared decision-making process with the patient.

A Novel Assessment Method With Ultrasound for Obstructive Tonsillar Hypertrophy in Children

OBJECTIVES

To develop a new method for the objective evaluation of airway obstruction due to tonsillar hypertrophy using ultrasound (US) in children.

METHODS

The oropharynx was examined in patients, and tonsil grades were evaluated according to the staging system of Brodsky et al (Int J Pediatr Otorhinolaryngol 1987; 13:149-156). The narrowest intertonsillar distance (ITD) and widest transverse length of the tongue base (TLTB) were then measured by US, and their ratio was calculated. The clinical value of US was investigated for the classification of tonsillar hypertrophies as nonobstructive or obstructive by matching the patients' clinical grades with the US data.

RESULTS

A total of 102 patients (age range, 2-12 years) were included in the study. According to the Brodsky staging system, 44.1% and 55.9% of the patients were in nonobstructive (stages I and II) and obstructive (stages III and IV) tonsillar hypertrophy groups, respectively. The area under the curve was 0.991 (95% confidence interval, 0.977-0.999) according to a receiver operating characteristic curve analysis between the Brodsky staging and the ITD/TLTB ratio. The optimal cutoff value for the ITD/TLTB ratio for the diagnosis of obstructive tonsillar hypertrophy was found to be 0.3 or less, which had 96.5% sensitivity and 95.6% specificity.

CONCLUSIONS

The degree of airway obstruction due to tonsillar hypertrophy can be objectively determined by US in children. An ITD/TLTB ratio of 0.3 or less was found to be compatible with obstructive tonsillar hypertrophy. This new and easily applicable evaluation method may provide considerable value and guidance for tonsillectomy decisions.

Feasibility of an inexperienced examiner using trans-cervical ultrasound in the diagnosis of peritonsillar abscesses

BACKGROUND

A peritonsillar abscess (PTA) is a common complication to acute tonsillitis. Needle aspiration (NA) is the gold standard for diagnosis of PTA. NA is usually painful and not risk-free. Ultrasound (US) is a noninvasive, portable radiological modality that could potentially be used in the diagnosis of PTA and selection of patients for NA. The reliability of US is dependent on the experience of the examiner which limits is usefulness.

AIM

To evaluate the reliability of US in the diagnosis of PTA by an inexperienced examiner.

METHODS

Thirty patients with suspected PTA were included. They were first examined with trans-cervical US by a medical student then clinically examined by a physician that performed a NA if clinically motivated. They were then followed for at least two days.

RESULTS

Three patients were excluded from analysis because no NA was performed. In these patients, US correctly classified them as negative for PTA. In the remaining 27 patients, the sensitivity and negative predictive value was 100%. The specificity was 64.3% and the positive-predictive value was 72.2%.

CONCLUSION

US can be very useful in the diagnosis of PTA and the selection for NA even with an inexperienced examiner.

SIGNIFICANCE

The results highlight the usefulness of ultrasound in otolaryngology.

The value of transcutaneous ultrasound in the diagnosis of tonsillar abscess: A retrospective analysis

OBJECTIVE

To identify the appropriate treatment in the tonsillar region's infections, a distinction between tonsillitis with or without abscess formation is essential. Ultrasound proved to be a valuable method in identifying abscess formation in the head and neck region. However, no report described the assessment of the tonsil region. This study aims to determine the feasibility of transcervical ultrasound for abscess visualization in the palatal tonsillar region.

METHODS

Retrospective analysis of 354 patients presenting with clinical suspicion of tonsillar abscess to a tertiary referral center and university hospital. All patients received a transcervical ultrasound to establish a primary diagnosis. The existence of an abscess was confirmed by puncture and incision, or final tonsillectomy. If no abscess could be delineated, non-abscessing tonsillitis was supposed, and conservative primary therapy and closed follow-up examinations were performed.

RESULTS

After the first diagnostic ultrasound examination, in 257 cases (72.59%), the diagnosis of an abscess could be established, but in 97 cases (27.40%), due to missing abscess formation criteria, non-abscessing tonsillitis was documented. Overall, ultrasonography demonstrated an overall accuracy of 78.8% in this selected cohort. The sensitivity, specificity, PPV, and NPV after the first ultrasound examination were calculated with 75.1%, 88.6%, 94.6%, and 57.3%, respectively.

CONCLUSION

The presented data confirm that an abscess formation due to tonsillitis can be detected by transcervical ultrasound, enabling prompt, adequate management. As transcervical ultrasound can be conducted fast and is not associated with radiation, it can be regarded as a first-line diagnostic tool in this condition.

[Small salivary glands in the paratonsillar space in children]

Was to study the changes in the small salivary glands in chronic tonsillitis and paratonsillar abscess in children. A histological examination of the palatine tonsils of 22 children aged 5 to 14 years old who had a paratonsillar abscess and 18 children suffering from chronic tonsillitis was carried out. Fragments of small salivary glands, located both superficially, in the mucous membrane between the stratified squamous non-keratinizing epithelium and the lymphoid tissue of the palatine tonsils, and between the muscles of the amygdala were found in 42 of the 80 (52.5%) tonsils studied. Along with the unchanged glandular structure, 26 (61.9%) samples revealed areas of destruction foci in small salivary glands with signs of inflammatory and compensatory regenerative activity. The presence of separate interlobular ducts of the salivary glands with pronounced periductal lymph - macrophage infiltration was noted. The subepithelial lymph-macrophage infiltrates found in the lamina propria are associated with the exit of the excretory ducts of the salivary glands to the surface of the mucous membrane. Many thin-walled veins are surrounded by perivascular lymphocellular infiltrates. The inflammatory and post-inflammatory changes in the small salivary glands revealed by us in children with chronic tonsillitis do not exclude their participation in the pathogenesis of paratonsillitis. At the same time, inflammation in the salivary gland can be both primary, as a result of its infection with live microorganisms from the tissues of the tonsil, and secondary, due to the compression of the excretory ducts by the edematous tissue of the tonsil in acute tonsillitis.

Advantages of otorhinolaryngologist performed transcervical ultrasonography in the management of peritonsillar abscess

OBJECTIVES

Peritonsillar abscess (PTA) is a very common infection, in particular in pediatric and adolescent population. A distinction between peritonsillar cellulitis and abscess should be made to determine the appropriate treatment. Nonetheless, the difference cannot always be made on physical examination alone and often requires imaging by computed tomography (CT). Radiation exposure as well as the cost and waiting time question the use of CT in this pathology. We present our experience in the use of Transcutaneous Cervical Ultrasonography for the diagnosis and management of peritonsillar abscess in the adult population.

STUDY DESIGN

Clinical-prospective.

METHODS

Adult patients were evaluated for suspicion of PTA. Clinical findings were documented and all patients underwent a Transcutaneous Cervical Ultrasonography performed by a second otorhinolaryngology specialist well versed in Ultrasonography without knowing the clinical history, details of the physical examination, or the suspected side. Ultrasonography findings were later compared with the clinical examination and outcome of the medical or surgical management.

RESULTS

Eight adult patients (range 18-53 year-old) were enrolled in the study. Six of them, had, ultrasonography findings compatible with a peritonsillar liquid collection underwent surgical drainage that confirmed and drained an abscess. On two patients, the ultrasonography images described an aspect of peritonsillar cellulitis that was managed conservatively and showed a favorable remission. No complications during stay or side effects or intolerance to the ultrasound were recorded.

CONCLUSION

Transcutaneous Cervical ultrasonography is a fast, useful tool, better tolerated than the intra-oral ultrasonography in diagnosing PTA. It avoids all irradiation exposure is much cheaper and the waiting time is shorter. Worth noting, is the richness of information pertaining the anatomy, vessels and abscess location and extension, for the surgeon performing the exam just prior to surgery. The efficiency and training of otorhinolaryngology specialists with this technique shows numerous promising benefits and deserves to be further developed.

Impact of Transcervical Ultrasound for the Diagnosis of Pediatric Peritonsillar Abscesses on Emergency Department Performance Measures

OBJECTIVES

To evaluate the impact of transcervical ultrasound (US) as the initial imaging study for suspected peritonsillar abscesses (PTAs) on pediatric emergency department (ED) throughput measures.

METHODS

A retrospective cohort study of patients evaluated for suspected PTAs between January 2009 and April 2017 was conducted. We compared the ED length of stay (LOS) before and after implementation of transcervical US to diagnose a PTA. The balancing measure was the rate of return visits within 2 weeks.

RESULTS

There were 387 eligible patients over the study period. A total of 101 patients were evaluated for PTAs with computed tomography and 286 with US. The mean LOS was significantly less for patients who had US (347 minutes; 95% confidence interval [CI], 330, 364 minutes) compared to computed tomography (426 minutes; 95% CI, 392, 459 minutes), with an absolute difference of 79 minutes (95% CI, 44, 113 minutes). Patients who were evaluated with US did not have an increased rate of return visits (5.9% versus 8.0%; P = .66).

CONCLUSIONS

The introduction of transcervical US was associated with a decrease of greater than 1 hour in the ED LOS for patients with suspected PTAs. Given the better radiation profile of US and no increase in the rate of return visits after its implementation, we propose the adoption of a transcervical US-first approach for the diagnosis of PTAs in pediatrics.

Assessment of Tonsil Volume With Transcervical Ultrasonography in Both Children and Adults

OBJECTIVES

To investigate the success of ultrasonography (USG) in the objective measurement of palatin tonsil volume in both children and adults and to compare those results with clinical findings.

METHODS

Eighty-five patients, who were scheduled to undergo tonsillectomy with the indications of recurrent tonsillitis and obstructive sleep apnea syndrome, were included in the study. The tonsil grades of the patients were recorded according to the Friedman tonsil grading. The tonsil size and volume were measured with transcervical USG. After tonsillectomy, the volumes of the tonsils were calculated by the displacement method. The correlation between the obtained data was evaluated. In all analyses, P < .05 was accepted as a statistical level of significance.

RESULTS

Fifty children and 35 adults were included in the study. In children, the mean actual volume ± SD of 100 tonsils was measured as 3.5 ± 1.45 mL, and the USG volume was 3.67 ± 1.59 mL; a high correlation was found between both methods (r = 0.842; P < .05). In adults, the mean actual volume of 70 tonsils was measured as 5.15 ± 2.25 mL, and the USG volume was 5.71 ± 2.98 mL; a moderate correlation was found between the methods (r = 0.589; P < .05). In children, a moderate correlation was found between the Friedman grading and the USG (r = 0.532; P < .05), and actual (r = 0.549; P < .05) tonsil volumes. In adults, a low correlation was found between the Friedman grading and the USG (r = 0.363; P < .05) and actual (r = 0.384; P < .05) tonsil volumes.

CONCLUSIONS

Ultrasonography is a useful, accessible, and noninvasive imaging method for objective measurement of tonsil volume in adults and children.

Association of Computed Tomography With Treatment and Timing of Care in Adult Patients With Peritonsillar Abscess

Background: Peritonsillar abscess (PTA) is a common occurrence in adult patients, and an important question in such often-seen disease processes is whether we are treating these patients effectively, efficiently, and economically. We sought to determine if a diagnostic computed tomography (CT) scan was associated with a difference in clinical intervention in adult patients with PTA and if CT was associated with delaying this intervention.

Methods: We conducted a retrospective case-control study examining therapeutic interventions in adults with PTA. Patients were divided into a control group (those diagnosed without CT, n=159) and a case group (those diagnosed with CT, n=203). Patients were examined for 3 outcomes: admission, bedside procedure (needle aspiration, incision/drainage), and surgical procedure (incision/drainage, tonsillectomy). In addition, we calculated times to admission, otolaryngology consultation, bedside procedure, and surgical procedure.

Results: We found a significant association between CT and intervention, with the CT group more likely to be admitted (P< 0.001), the non-CT group more likely to undergo a bedside procedure (P<0.001), and the CT group more likely to undergo operative intervention (P=0.02). Mean times to otolaryngology consultation, admission, and bedside procedure were significantly longer in the CT group than in the non-CT group, determined by calculating the difference of the means with 95% confidence intervals for each comparison (P<0.001).

Conclusion: We found that CT scans appear to be useful in the workup and treatment of adult patients with PTA, evidenced by significant differences in interventions between groups with and without CT scans. We also found that CT scans have the potential to delay these interventions, as the time to each intervention examined was significantly longer in patients who had a CT scan. Given the need to reduce cost, enhance efficiency, and eliminate harmful side effects (in this case, radiation exposure and delays in care), we question whether CT is the gold standard imaging method for diagnostic work up of PTA.

Pilot study of the potential of 3D ultrasound to measure tonsillar volume and hypertrophy

OBJECTIVE

Obstructive sleep apnea (OSA), results in approximately 4-5 million outpatient visits per year in the United States. In pediatric patients, OSA is primarily caused by adenotonsillar hypertrophy, and therefore, adenotonsillectomy remains an effective surgical treatment. We investigate whether 3D ultrasound (3DUS) imaging can accurately and objectively assess tonsillar hypertrophy for the potential identification and stratification of candidates for adenotonsillectomy.

METHODS

A prospective study was performed evaluating pediatric patients (N = 17) between the ages of 4-14 years who were undergoing adenotonsillectomy for OSA symptoms. On the day of surgery, tonsillar ultrasound was performed by a single attending radiologist. Tonsillectomy was performed and each tonsils' principal axes and physical volume by water submergence were measured. The findings were compared using paired T-test, Pearson correlation coefficient and Bland-Altman analysis.

RESULTS

The average tonsillar physical measurements of length, width and height were 1.54 ± 0.28, 2.0 ± 0.31 cm and 2.72 ± 0.41 cm, and 1.73 ± 0.17, 1.61 ± 0.21 mm and 2.98 ± 0.28 mm from physical and 3DUS estimations, respectively (P < 0.001 for all measurements). The average tonsillar volume was 3.84 ± 1.23 ml and 4.30 ± 1.15 ml from physical and 3DUS measurements, respectively (p = 0.04). The Bland-Altman mean difference ± 95% limit of agreement between length, width, height, and volume results from the two measurements were -0.186 ± 2.01 cm, -0.393 ± 6.33 cm, 0.25 ± 7.71 cm, and 0.45 ± 2.32 ml, respectively.

CONCLUSION

While 3DUS is feasible, it may not be an accurate estimate of tonsillar volume for assessing hypertrophy. A larger study will be required to establish the accuracy of 3DUS measurements of tonsillar volume.

Machine Learning Diagnosis of Peritonsillar Abscess

Peritonsillar abscess (PTA) is a difficult diagnosis to make clinically, with clinical examination of even otolaryngologists showing poor sensitivity and specificity. Machine learning is a form of artificial intelligence that “learns” from data to make predictions. We developed a machine learning classifier to predict the diagnosis of PTA based on patient symptoms. We retrospectively collected clinical data and symptomatology from 916 patients who underwent attempted needle aspiration for PTA. Machine learning classifiers were trained on a subset of the data to predict the presence or absence of purulence on attempted aspiration. The performance of the model was evaluated on a holdout set. The accuracy of the top-performing algorithm, the artificial neural network, was 72.3%. Artificial neural networks can use patient symptoms to exceed human ability to predict PTA in patients with clinical suspicion for PTA. Similar models can assist medical decision making for clinicians who have suspicion of PTA.

High-Frequency Ultrasound: A Novel Diagnostic Tool to Measure Pediatric Tonsils in 3 Dimensions

Objective

A wide variety of pathologies can affect the palatine tonsils. Ultrasound is a commonly used modality for assessing head and neck masses in children; however, its use in tonsillar evaluation has not been widely explored. The objective of this study was to measure 3-dimensional tonsillar size with ultrasound, in centimeters, and correlate these measurements with actual ex vivo dimensions on pathology specimens.

Study Design

We performed a prospective cohort study.

Setting

The study was set in a tertiary care children’s hospital.

Subjects and Methods

Children undergoing tonsillectomy were included in the study. Transcervical high-frequency ultrasonography (HFU) was performed prior to surgery to obtain 3-dimensional measurements of the right and left palatine tonsils. Mean sizes were compared to ex vivo tonsil measurements and correlations were obtained.

Results

Seventy-five consecutive children underwent a transcervical HFU, with a total of 150 tonsils analyzed. The mean differences between HFU and pathology measurements were −0.08 cm and −0.24 cm for the right and left craniocaudal axes, −0.19 cm and −0.18 cm for the right and left mediolateral axes, and 0.05 cm and 0.03 cm for the right and left anteroposterior axes. Correlation coefficients between ultrasound and pathology measurements were all above 0.5.

Conclusion

HFU can accurately measure the size of pediatric tonsils in 3 dimensions.

In-Office Ultrasonographic Evaluation of Neck Masses/Thyroid Nodules

Office-based ultrasonography is increasingly becoming an integral part of an otolaryngology-head and neck surgery practice. A thorough knowledge of the ultrasonic appearance of normal and abnormal pathology are key for performing/interpreting office-based head and neck ultrasonography. A focused but systematic approach allows for efficient and effective office-based head and neck ultrasonography. Office-based ultrasonography also allows for imaging procedures expanding the otolaryngologist's armamentarium. Ultrasound-guided fine needle aspiration (USgFNA) is an integral part of clinician-performed ultrasonography because it allows cytologic diagnosis of suspicious lesions. Understanding the successful techniques and pitfalls in this procedure are critical for the otolaryngologist performing USgFNA.

A Novel Technique for Intraoral Ultrasound-Guided Aspiration of Peritonsillar Abscess

Peritonsillar abscess (PTA) is a common complication to acute tonsillitis. The treatment is drainage of the abscess, but many needle aspirations are unsuccessful due to a low diagnostic accuracy based on oral examination only. In this article, we describe how intraoral ultrasound can be added to improve the diagnostic work-up of PTA and present a novel technique for ultrasound-guided aspiration of PTA, using a small pencil-shaped transducer. We present our first clinical experiences with this technique and describe how it could be integrated in a clinical setting to guide safe and successful needle aspirations of PTA.

Normative Values for Tonsils in Pediatric Populations Based on Ultrasonography

OBJECTIVES

Pediatric tonsillar infections are common, particularly in adolescents. Ultrasonography (US) has high sensitivity and specificity for diagnosing peritonsillar abscesses and can diagnose tonsillitis by enlargement of the gland. In this study, we established normal tonsillar measurements and volumes according to age in pediatric populations.

METHODS

Transcervical US of the peritonsillar region to measure tonsillar size and volume was performed in patients who had undergone neck US without throat symptoms from October 2016 to May 2017. Transverse and anteroposterior diameters, length, and volume were measured.

RESULTS

In total, 161 patients (age range, 1 month-18 years) were enrolled in the study. The mean tonsillar volumes ± SD were 1.58 ± 1.26 (total), 0.30 ± 0.14 (<1 year), 1.27 ± 0.57 (1-<5 years), 2.06 ± 1.09 (5-<10 years), and 2.19 ± 1.48 (>10 years) cm³ . Mean measurements for the sums of both tonsils for the transverse diameter, anteroposterior diameter, and length were 1.98 ± 0.61, 2.17 ± 0.66, and 2.28 ± 0.69 cm, respectively. Tonsillar size and volume increased according to age. Simplified models for volume estimation showed that anteroposterior diameters had the highest coefficients of determination (R²  = 0.71 and 0.74). Regression models for the tonsillar volume of 6 measurements in the multiple linear regression models showed an R² of 0.89. Regression models for log(volume) showed an improved coefficient of determination (R²  = 0.96).

CONCLUSIONS

These normal tonsillar sizes on transcervical ultrasound in pediatric patients can be used to diagnose tonsillar lesions.

Increased Levels of S100A8/A9 in Patients with Peritonsillar Abscess: A New Promising Diagnostic Marker to Differentiate between Peritonsillar Abscess and Peritonsillitis

Peritonsillar abscess (PTA) is a very frequent reason for urgent outpatient consultation and otolaryngological hospital admission. Early, correct diagnosis and therapy of peritonsillar abscess are important to prevent possible life-threatening complications. Based on physical examinations, a reliable differentiation between peritonsillar cellulitis and peritonsillar abscess is restricted. A heterodimeric complex called calprotectin consists of the S100 proteins A8 and A9 (S100A8/A9) and is predominantly expressed not only in monocytes and neutrophils but also in epithelial cells. Due to its release by activated phagocytes at local sites of inflammation, we assumed S100A8/A9 to be a potential biomarker for peritonsillar abscess. We examined serum and saliva of patients with peritonsillitis, acute tonsillitis, peritonsillar abscess, and healthy controls and found significantly increased levels of S100A8/A9 in patients with PTA. Furthermore, we could identify halitosis, trismus, uvula edema, and unilateral swelling of the arched palate to be characteristic symptoms for PTA. Using a combination of these characteristic symptoms and S100A8/A9 levels, we developed a PTA score as an objective and appropriate tool to differentiate between peritonsillitis and peritonsillar abscess with a sensitivity of 92% and specificity of 93%.

Transcervical ultrasonographic examination of palatine tonsil size and its correlation with age, gender and body-mass index in healthy children

OBJECTIVE

Our aim was to assess the palatine tonsil size with transcervical ultrasonography in healthy children and to analyze whether the palatine tonsil size is correlated with age, gender and body-mass index (BMI).

METHODS

This series consisted of 680 healthy children (340 females, 340 males) who underwent transcervical ultrasonography for evaluation of palatine tonsil size. A total of seventeen age groups (range: 1-17 years) comprised of 40 children (20 females, 20 males) were constituted. Demographic data including gender, height, weight and BMI were noted. Correlation between baseline descriptive data and tonsil volume was investigated.

RESULTS

The average age was 102.51 ± 59.24 months (range: 12 to 204) and body-mass index was 17.50-5.16 kg/m2 (min: 12.4-max:25.8). The average tonsil volume was 1819.5-2023.5 mm³ (min:601, max: 4007). The tonsil volume did not differ significantly between females and males (p = 0.108). However, there was a significant difference between tonsil volumes of various age groups (p < 0.001). Tonsil size seemed to be greater in parallel with advancement of age (p < 0.001) and increased BMI (p < 0.001).

CONCLUSION

Transcervical ultrasonography can be an accurate, safe, cheap, non-invasive and accessible measure for evaluation of the size of tonsils objectively. There were strongly positive correlations between age, BMI and palatine tonsil size in healthy children and variability with respect to descriptive characteristics must be considered during diagnostic procedures and preoperative evaluation.

ADVANCES IN KNOWLEDGE

In our study, we suggest that transcervical ultrasonography can be an accurate, safe, cheap, non-invasive and accessible measure for evaluation of the size of tonsils. There were positive correlations between age, BMI and palatine tonsil size in healthy children.