Emergency department visits, hospitalizations, and readmissions of patients with a peritonsillar abscess

Peritonsillar Abscess Outcomes with and Without Computed Tomography: A Retrospective Cohort Study

OBJECTIVES

Peritonsillar abscess (PTA) is a common deep space head and neck infection, which can be diagnosed with or without computed tomography (CT). CT poses a risk for false positives, leading to unnecessary abscess drainage attempts without benefit, whereas needle or open aspiration without imaging could potentially lead to missed abscess in need of treatment. This study considered the utility and impact of obtaining CT scans in patients with suspected PTA by comparing outcomes between CT and non-CT usage.

METHODS

Retrospective cohort analysis using TriNetX datasets compared the outcomes of two cohorts: PTA without CT and PTA with CT. Measured outcomes included incision and drainage; quinsy adenotonsillectomy; recurrent PTA; airway emergency/obstruction; repeat emergency department (ED) visits; and need for antibiotics, opiates, or steroids. Odds ratios (OR) were calculated using a cohort analysis.

RESULTS

The CT usage group had increased odds of receiving antibiotics (OR 3.043, [2.043-4.531]), opiates (OR 1.614, [1.138-1.289]), and steroids (OR 1.373, [1.108-1.702]), as well as a higher likelihood of returning to the ED (OR 5.900, [3.534-9.849]) and developing a recurrent PTA (OR 1.943, [1.410-2.677]). No significant differences were observed in the incidence of incision and drainage, quinsy adenotonsillectomy, or airway emergency/obstruction.

CONCLUSION

Our study indicated that CT scans for PTA diagnosis were associated with increased prescription of antibiotics, opioids, steroids, return ED visits, and recurrent PTA. Future prospective trials are needed to determine if the use of CT scans indicates higher patient acuity that explains the potential negative outcomes.

LEVEL OF EVIDENCE

Level II Laryngoscope, 2024.

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.

A Low-Cost Ultrasound Phantom for Peritonsillar Abscess Drainage Training

BACKGROUND

Peritonsillar abscesses (PTAs) are encountered routinely in clinical practice. Ultrasound-guided aspiration has been proven both safe and effective in treating this condition. However, to date, there are no easily produced, low-cost models that enable the practice of point-of-care ultrasound-guided PTA aspiration and PTA diagnosis.

OBJECTIVES

The objective was to create a low-cost, easy-to-produce, ultrasound phantom to train emergency physicians on ultrasound-guided PTA drainage.

METHODS

We improved on previous work with ultrasound phantoms by creating a refillable phantom that approximates the oral cavity. This enabled learners to gain the manual dexterity necessary to operate an intraoral ultrasound probe while also aspirating a PTA.

RESULTS

We have created a low-cost ultrasound phantom that is amenable to repeated ultrasound-guided aspirations for the purpose of training both resident- and attending-level physicians.

CONCLUSION

With minimal lead time and readily available equipment, we successfully created a low-cost ultrasound phantom for the purpose of PTA identification and drainage.

Management of Peritonsillar Abscess Within a Local Emergency Department: A Quality Analysis Study

Objective: Peritonsillar abscess (PTA) is the most common deep space infection of the head and neck, affecting thousands of people annually with high treatment costs. The purpose of this project was to determine how in-network emergency departments (EDs) adhere to generally accepted guidelines regarding diagnosis and management of potential PTAs.

Methods: The authors performed a retrospective chart review to identify patients with PTA in five EDs in one year. Information pertaining to diagnostic tests, treatment, and airway status was also collected. Descriptive analysis was used to assess if EDs were consistent with generally accepted guidelines.

Results: Six hundred twenty-one patient records were identified and 140 were included in final analysis. Out of 140 patients, 71 were admitted for inpatient management and 23 were admitted for observation. Of the 46 patients diagnosed and discharged from the ED, 61% received a computerized tomography (CT) scan and only 39% had PTA drainage performed. Four (3%) patients received a point of care ultrasound and a CT scan and no patient received only an ultrasound. Out of all patients, 116/140 received a CT scan and 22 received drainage in the ED. The remainder of these patients either had drainage performed by an otolaryngologist or had no drainage performed. Of the 94 patients admitted for inpatient or observation, 84 received a CT scan and six received drainage by an ED physician. Only 62% of patients were given a penicillin derivative and 29% were given clindamycin, which has no Gram-negative coverage.

Conclusion: One-third of PTA patients were managed within the ED, far less than similar studies. Of these, over 50% received a CT scan and less than 50% had PTA drainage. PTA drainage can improve patients’ symptoms and antibiotic effectiveness. The majority of patients were prescribed a penicillin derivative with or without another antibiotic.

Empiric treatment for peritonsillar abscess: A single-center experience with medical therapy alone

PURPOSE

Compare the use of medical therapy alone (MTA) with surgical therapy (ST) for the empiric treatment of peritonsillar abscess (PTA).

MATERIALS AND METHODS

A consecutive cohort of patients treated for PTA at our institution from May 2013 to February 2019 was analyzed. Demographics, disease characteristics, management strategies, and treatment outcomes were compared between treatment groups. Primary outcomes included treatment failure, defined as the need for follow-up surgical intervention, and complications within 2-weeks of empiric treatment.

RESULTS

306 patients (72.7%) received MTA while 115 (27.3%) underwent ST. There was no significant difference in the rate of treatment failure between the MTA (7.2%) and ST (6.1%) groups (p = 0.879). Complications were rare in both groups (1.6% with MTA versus 0.9% with ST; p = 0.898). Dysphagia (p = 0.011), trismus (p = 0.045), larger abscesses (p < 0.001), and hospital admission (p < 0.001) were more common in the ST group. Corticosteroid prescriptions were a common component of MTA (53.3%) and less often used with ST (33.9%; p = 0.001). After adjusting for abscess size, there remained no significant difference in the rate of treatment failure between groups. Univariate analyses demonstrated no significant independent predictors of treatment failure including age, sex, race, tonsillitis history, smoking history, presenting signs and symptoms, abscess size, hospital admission, and corticosteroid prescriptions.

CONCLUSIONS

MTA may be a safe and effective alternative to surgical drainage for the empiric treatment of PTA, warranting larger-scale prospective analyses. Abscess size did not appear to influence treatment failure; however, careful patient selection is likely to optimize treatment outcomes.

Medical Intervention Alone vs Surgical Drainage for Treatment of Peritonsillar Abscess: A Systematic Review and Meta-analysis

OBJECTIVE

Peritonsillar abscesses (PTAs) are common emergency consultations for otolaryngologists. Medical management alone may offer satisfactory treatment without the risk associated with surgical drainage. Therefore, we performed a systematic review of medical treatment alone compared to surgical drainage for the treatment of PTA.

DATA SOURCES

MEDLINE, EMBASE, Cochrane CENTRAL, and ClinicalTrials.gov.

REVIEW METHODS

Studies comparing the outcomes of medically treated to surgically treated patients were included. Risk of bias was assessed using the Newcastle-Ottawa Scale. All screening and data extraction were completed by 2 independent reviewers. Meta-analysis was performed using a random-effects model. Subgroup and sensitivity analyses were performed.

RESULTS

Ten cohort studies and 2 randomized studies were included (n_total = 33,468). Study quality was low, with only 1 study providing multivariable analysis. The combined rate of treatment failure in patients initially treated with medical management alone was 5.7% compared to 5.5% in the surgical group. There was no statistically significant difference in the odds of treatment failure between interventions through random-effects meta-analysis (odds ratio [OR], 1.10; 95% CI, 0.53-2.26; I ² = 41%; P = .13). Subgroup analysis excluding pediatric-specific studies revealed similar odds of treatment failure when initially managed with medical intervention (OR, 0.92; 95% CI, 0.56-1.50; P = .39; I ² = 0%).

CONCLUSION

Meta-analysis of available studies demonstrated no difference in odds of treatment failure for patients with PTA managed through medical intervention alone compared to surgical intervention. These findings should be interpreted with caution due to high probability of bias and overall low quality of studies.

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.

Trends in the management of peritonsillar abscess in children: A nationwide population-based study in Taiwan

OBJECTIVE

Population-based studies analyzing peritonsillar abscess in children are lacking. In this study, a population-based survey of the epidemiology of pediatric peritonsillar abscess in Taiwan was conducted.

METHODS

This cross-sectional study was conducted using the Taiwan National Health Insurance Research Database. All cases of inpatient pediatric peritonsillar abscess (age < 18 years) in Taiwan between 2000 and 2012 were identified using the International Classification of Diseases, Ninth Revision, Clinical Modification. Incidence rates of inpatient peritonsillar abscess in children were calculated. Characteristics such as age, gender, hospital level, treatment modalities, imaging studies, drug administration, and length of hospital stays during the study period were analyzed.

RESULTS

A total of 12,965 children with peritonsillar abscess were included (mean age, 6.6 years [standard deviation, 4.8 years]; 56.5% boys). The overall incidence was 18 per 100,000 children. Incidence rates decreased from 2000 to 2012 (19.1/100,000 to 8.3/100,000 children) (p_trend < 0.001). During the study period, the proportion of peritonsillar abscess treatments at medical centers increased from 4.6% to 15.0%. The proportion of treatments involving incision and drainage or needle aspiration increased significantly (1.3%-4.1% and 49.4%-65.6%, respectively), whereas treatments with antibiotics only decreased significantly (48.9%-29.0%). The use of computed tomography (CT) increased (1.4%-12%, p_trend < 0.001). The use of nonsteroidal anti-inflammatory drugs, steroids, and penicillin increased during the study period. The mean length of hospital stays increased from 3.78 to 4.67 days.

CONCLUSIONS

The incidence of peritonsillar abscess in children decreased between 2000 and 2012 in Taiwan. Moreover, increasing trends were observed in the use of CT, the rates of incision and drainage and needle aspiration procedures, and the length of hospital stay in this study cohort.

Validating peritonsillar abscess drainage rates using the Pediatric hospital information system data

OBJECTIVES

To evaluate the accuracy of the Children's Hospital Association's Pediatric Health Information System (PHIS) registry data in determining surgical drainage rates as compared to a chart review on the same cohort of children with diagnosis of peritonsillar abscess.

STUDY DESIGN

Retrospective analysis.

METHODS

Our analysis included 200 children, ages 2 to 17 years, treated for a peritonsillar abscess from 2011 to 2016. The primary outcome was to determine the sensitivity, specificity, predictive values, receiver operating characteristics (ROC), and likelihood ratios of surgical drainage rates comparing the PHIS database to manual chart review of the same patients.

RESULTS

One hundred and fifteen (58%) children underwent drainage by chart review, whereas 87 (44%) had a drainage procedure by PHIS data. Age was a significant predictor of abscess drainage by chart review (age coefficient = 0.10; standard error = 0.04; 2 = 5.8; P = 0.02; odds ratio = 1.1; 95% confidence interval [CI] = 1.01-1.19). When using the chart review as the reference value for surgical drainage, the PHIS data had a sensitivity of 76% and 100% specificity. The positive and negative predictive values were 100% and 75%, respectively. The ROC area was 0.88 (95% CI, 84 to 92). Cases that lacked a clear procedure note composed the false negative cases in the PHIS.

CONCLUSION

At our institution, the PHIS Administrative data was adequate at predicting surgical drainage of the peritonsillar abscess when compared to chart review.

LEVEL OF EVIDENCE

4 Laryngoscope, 130:238-241, 2020.