Peritonsillar abscess: remember to always think twice

Blood, Sweat, and Tonsils: Bleeding After Abscess Tonsillectomy for Quinsy-A Meta-Analysis

OBJECTIVE

Abscess tonsillectomy is performed during an active episode of quinsy. Apprehensions regarding an elevated bleeding risk have hindered its widespread acceptance. This study aims to assess the prevalence of post-tonsillectomy bleeding (PTB) associated with abscess tonsillectomy.

DATA SOURCES

A search was performed on August 27, 2023 in Medline, Embase, PubMed, Cochrane CENTRAL, and Web of Science databases.

REVIEW METHODS

The systematic review was conducted in adherence to the PRISMA guidelines. Pooled PTB rate was determined using a meta-analysis of proportions. The JBI tool was used to assess the quality of the included studies.

RESULTS

Of the 525 search records, 18 studies met the eligibility criteria for final analysis. These comprised of retrospective single-center analyses. The pooled prevalence of PTB was 6.65% (95% C.I. 4.01-9.81), and the return-to-theatre rate was 2.35% (95% C.I. 1.48-3.37). There was no difference in PTB rate between unilateral and bilateral tonsillectomy. However, the bipolar technique was associated with a higher PTB rate compared to cold steel dissection. The overall quality of the body of evidence was moderate.

CONCLUSION

Our study highlights the complications associated with abscess tonsillectomy. These findings contribute valuable insights into this potential treatment option for quinsy.

LEVEL OF EVIDENCE

N/A Laryngoscope, 2024.

[Disproving the myth of "abscess weather" predisposing to peritonsillitis and peritonsillar abscess]

BACKGROUND

Peritonsillar abscess (PTA) is often seen as a complication of acute tonsillitis and is defined as pus retention between the tonsillar capsule and the peritonsillar tissue. The etiology and pathogenesis have not yet been fully elucidated. A connection between certain weather conditions and temperature fluctuations and the occurrence of abscesses in the head and neck region has been discussed for years. The question here is whether higher temperature fluctuations are predisposing for the formation of abscesses.

MATERIALS AND METHODS

A retrospective evaluation of all patients hospitalized with peritonsillitis or PTA in the Department of Otorhinolaryngology of the Klinikum Rechts der Isar of the Technical University of Munich during a period of 10 years (2012-2021) was performed. Each patient was individually correlated with daily temperature data from the statistical meteorological office of the City of Munich.

RESULTS

A total of 1450 patients were included, 270 patients (18.62%) with peritonsillitis and 1180 patients (81.38%) with PTA. A correlation between the occurrence of peritonsillitis or PTA and major temperature fluctuations could be excluded in this large patient population. Moreover, a similar frequency of peritonsillitis and PTA was seen throughout the year.

CONCLUSION

The myth of a temperature dependence of the development of peritonsillitis or PTA and a so-called abscess weather could be negated in this study.

Postoperative hemorrhage following coblation tonsillectomy with and without suture: A randomized study in Chinese adults

PURPOSE

Coblation tonsillectomy (TE) increases gradually in China. Hemorrhage is the main complication after tonsillectomy. The conclusions of the studies about suture after tonsillectomy are conflicting. To compare the post-tonsillectomy hemorrhage (PTH) rates in patients who underwent coblation with vs. without suture.

MATERIALS AND METHODS

This was a randomized controlled study of adult patients who underwent coblation TE at our hospital between 01/2017 and 08/2019. The patients were randomized to TE with or without suture. The primary endpoint was the secondary PTH. The secondary endpoints included the primary PTH, grade of PTH, and incidence of PTH within 4 weeks post-TE.

RESULTS

There were no differences between the two groups regarding sex, age, disease course, and BMI (all P > 0.05). The occurrence of secondary PTH was lower in the suture group compared with the non-suture group (2.8% vs. 7.7%, P = 0.016). Compared with non-suture group, the incidence of PTH within 4 weeks (2.8% vs. 10.6%, P = 0.009) and the PTH degree (P = 0.02) were all significantly lower in the suture group.

CONCLUSION

Intraoperative suture reduces the secondary PTH in adult patients who underwent coblation tonsillectomy. The incidence of PTH within 4 weeks, PTH degree and pain might all improved for intraoperative suture.

Peritonsillar abscess may not always be a complication of acute tonsillitis: A prospective cohort study

The present study aimed to specify diagnostics for peritonsillar abscesses (PTAs) and to clarify the role of minor salivary glands. This prospective cohort study included 112 patients with acute tonsillitis (AT) and PTA recruited at a tertiary hospital emergency department between February and October 2017. All patients completed a questionnaire concerning their current disease. Serum amylase (S-Amyl) and C-reactive protein (S-CRP) levels, tonsillar findings, and pus aspirate samples and throat cultures were analyzed. Eight of 58 PTA patients (13.8%) had no signs of tonsillar infection. The absence of tonsillar erythema and exudate was associated with low S-CRP (p<0.001) and older age (p<0.001). We also observed an inverse correlation between S-Amyl and S-CRP levels (AT, r = -0.519; PTA, r = -0.353). Therefore, we observed a group of PTA patients without signs of tonsillar infection who had significantly lower S-CRP levels than other PTA patients. These findings support that PTA may be caused by an etiology other than AT. Variations in the S-Amyl levels and a negative correlation between S-Amyl and S-CRP levels may indicate that minor salivary glands are involved in PTA development.

Post-operative haemorrhage after acute bilateral tonsillectomy in patients with peritonsillar abscess: prevalence, treatment, risk factors, and side of bleeding

Background: Bilateral quinsy tonsillectomy (QT) in patients with peritonsillar abscess (PTA) is associated with the risk of post-tonsillectomy haemorrhage (PTH) and current literature finds a significantly higher risk of PTH contralaterally to the quinsy.Aims: To determine the prevalence of PTH in a large cohort of patients undergoing QT, explore risk factors for PTH, describe our methods of treatment, and evaluate if contralateral haemorrhage is more common than ipsilateral haemorrhage.Materials & methods: All patients undergoing QT at Aarhus University Hospital in the period 2001-2017 were included in the study.Results: One hundred sixteen of 1671 (6.9%) QT patients were admitted with PTH. PTH patients were significantly more frequently males (66%) and infected with Streptococcus group A (GAS) (31%) compared to QT patients without PTH (53% and 18%, respectively) (p = .005 and p = .002, respectively). Haemostasis was obtained in general anaesthesia (n = 61) or local anaesthesia (n = 28) and stopped spontaneously in 25 patients. The side of PTH was not associated with the side of PTA (ipsilateral (n = 41), contralateral (n = 43), and bilateral PTH (n = 23), p = .93).Conclusions and significance: Our findings question if unilateral QT is preferable to bilateral QT when the PTA does not respond to conservative treatment, especially in males with GAS-positive PTA.

Do changing trends in tonsil surgery affect hemorrhage rates? A longitudinal study covering 1,452,637 procedures

PURPOSE

To evaluate whether changing trends in tonsil surgery between 2005 and 2017 in Germany were associated with different age- and gender-specific hemorrhage rates.

METHODS

A longitudinal population-based inpatient cohort study was performed including all patients who had undergone tonsillectomy (with or without adenoidectomy), tonsillotomy, abscess-tonsillectomy, removal of tonsillar remnants and surgical treatment to achieve hemostasis following tonsil surgery. The population was stratified by age (groups of 5 years) and gender. Operation rates were calculated in relation to the end-year population number according to the German Federal Office of Statistics.

RESULTS

The surgical rates per 100,000 had significantly decreased from 170.39 to 90.95 (46.62%) in female patients and from 147.33 to 88.19 (40.14%) in male patients within the study period (p < 0.001). A total of 42.352 female patients had required surgical treatment to achieve hemostasis following 783,005 procedures (5.41%). In contrast, only 669,632 operations were performed in male patients but were complicated by hemorrhage in 51.185 cases (7.64%) which was significantly different (p < 0.001). The male-to-female ratio of the surgical rates had increased from 0.86:1 to 0.93:1. Hemorrhage rates differed significantly between age groups (p < 0.001). Male gender is a significant risk factor for bleeding at all ages < 85 years with greatest differences in 20- to 25-year-old patients (12.19% male vs. 6.26% female).

CONCLUSIONS

Changing trends in tonsil surgery are not associated with increased rates of bleeding complications. Hemorrhage following tonsil surgery is significantly related to age and gender and this should be noted when reported hemorrhage rates in the literature are appraised by the reader.

Hospital admissions for acute throat and deep neck infections versus tonsillectomy rates in Germany

PURPOSE

To evaluate trends in hospital admissions in Germany for acute infections of the upper airway and deep neck in the context of the number of tonsil-related surgical procedures between 2005 and 2017.

METHODS

A retrospective longitudinal population-based cohort study was performed including all unplanned admissions for acute pharyngitis/tonsillitis, abscess formation of the peritonsillar or retropharyngeal/parapharyngeal space. Elective procedures included tonsillectomy (with or without adenoidectomy), secondary tonsillectomy, and tonsillotomy. Emergency operations encompassed abscess-tonsillectomy and transoral drainage procedures of the peritonsillar/parapharyngeal/retropharyngeal space.

RESULTS

553.600 admissions were registered in total with a significant, stepwise increase between 2005 and 2017, including retropharyngeal/parapharyngeal abscess (47.0%), acute tonsillitis (30.8%), acute pharyngitis (26.5%) and peritonsillar abscess (7.9%). There were 1.323.984 elective operations with a significant decrease during the study period. A total of 188.316 emergency operations were done, a significant decrease in the number of abscess-tonsillectomies was compensated by the increased number of transoral peritonsillar abscess drainages. The number of transoral parapharyngeal and retropharygeal abscess drainage procedures did not change significantly (p = 0.846; p = 0.846). Negative correlation was significant between admissions for chronic tonsillitis and emergency admissions (Pearson correlation coefficient = - 0.879, p < 0.001) and also between elective and emergency operations (r = - 0.667; p = 0.013).

CONCLUSIONS

Concerning infections of the upper airway and deep neck spaces, German Hospitals have to prepare strategies for the increasing challenge by unplanned admissions and emergency operations. Further research is required to clarify whether this phenomenon is caused by the significant decrease in the number of elective operations.

Comparison of Medical Therapy Alone to Medical Therapy with Surgical Treatment of Peritonsillar Abscess

Objective This study was performed to determine whether the efficacy and safety of medical management of uncomplicated peritonsillar abscess (PTA) presenting in the emergency department is equivalent to medical plus surgical therapy. Study Design Case series with chart review. Setting Southern California Permanente Medical Group (SCPMG). Subjects and Methods Upon successful completion of a prospective study comparing medical treatment (MT) to surgical treatment (ST) of PTA in 2008, MT was adopted by 12 SCPMG centers while 7 centers continued standard surgical drainage. Clinical outcomes are now reviewed on a random sampling of 211 patients with PTA treated with MT and 96 patients treated with ST between 2008 and 2013 at the respective medical centers. Patients were treated with intravenous (IV) fluids, weight-appropriate IV ceftriaxone, clindamycin, and dexamethasone, and then discharged on clindamycin × 10 days (MT). Patients in the ST group received MT but also surgical drainage. Primary end points were complication rates and failure rates. Results MT and ST resulted in no significant difference in treatment success or complications. However, patients in the MT group obtained significantly less liquid opioid prescriptions (MT, 30.8 ± 5.65; ST, 77.75 ± 13.41; P < .0001), reported fewer sore days (MT, 4.48 ± 0.27; ST, 5.77 ± 0.49; P = .0004), and required less days off from work (MT, 3.4 ± 0.44; ST, 4.9 ± 0.82; P = .044). Conclusions Compared to ST, MT appears to be equally safe and efficacious, with less pain, opioid use, and days off work, especially if patients with PTA present without trismus. MT for PTAs reduces the possibility of surgical complications, as well as the cost and inconvenience associated with ST.

Indications for tonsillectomy stratified by the level of evidence

Background: One of the most significant clinical trials, demonstrating the efficacy of tonsillectomy (TE) for recurrent throat infection in severely affected children, was published in 1984. This systematic review was undertaken to compile various indications for TE as suggested in the literature after 1984 and to stratify the papers according to the current concept of evidence-based medicine. Material and methods: A systematic Medline research was performed using the key word of "tonsillectomy" in combination with different filters such as "systematic reviews", "meta-analysis", "English", "German", and "from 1984/01/01 to 2015/05/31". Further research was performed in the Cochrane Database of Systematic Reviews, National Guideline Clearinghouse, Guidelines International Network and BMJ Clinical Evidence using the same key word. Finally, data from the "Trip Database" were researched for "tonsillectomy" and "indication" and "from: 1984 to: 2015" in combination with either "systematic review" or "meta-analysis" or "metaanalysis". Results: A total of 237 papers were retrieved but only 57 matched our inclusion criteria covering the following topics: peritonsillar abscess (3), guidelines (5), otitis media with effusion (5), psoriasis (3), PFAPA syndrome (6), evidence-based indications (5), renal diseases (7), sleep-related breathing disorders (11), and tonsillitis/pharyngitis (12), respectively. Conclusions: 1) The literature suggests, that TE is not indicated to treat otitis media with effusion. 2) It has been shown, that the PFAPA syndrome is self-limiting and responds well to steroid administration, at least in a considerable amount of children. The indication for TE therefore appears to be imbalanced but further research is required to clarify the value of surgery. 3) Abscesstonsillectomy as a routine is not justified and indicated only for cases not responding to other measures of treatment, evident complications, or with a significant history of tonsillitis. In particular, interval-tonsillectomy is not justified as a routine. 4) TE, with or without adenoidectomy, is efficacious to resolve sleep-related breathing disorders resulting from (adeno)tonsillar hypertrophy in children. However, the benefit is reduced by co-morbidities, such as obesity, and further research is required to identify prognostic factors for this subgroup of patients. Further research is indicated to clarify selection criteria not only for this subpopulation that may benefit from less invasive procedures such as tonsillotomy in the long-term. 5) Further trials are also indicated to evaluate the efficacy of TE on the clinical course in children with psoriasis guttata as well as on psoriasis vulgaris in adults, not responding to first-line therapy. 6) Conflicting results were reported concerning the role of TE in the concert to treat Ig-A nephropathy, mandating further clinical research. 7) Most importantly, randomized-controlled clinical trials with an adequate long-term follow-up are desirable to clarify the benefit of TE in patients with recurrent episodes of tonsillitis, with or without pharyngitis. Factors like age, spontaneous healing rate and postoperative quality of life have to be included when comparing TE with antibiotic therapy.

Specified data for tonsil surgery in Germany

Background: Tonsillectomy rates vary considerably among different states, regions, and times. This study was conducted to identify the prevalence of “chronic” tonsillitis, peritonsillar abscess, hypertrophy of the tonsils with and without adenoids in absolute and relative numbers in an 80 million people nation. Moreover, the number and rates of different surgical procedures to resolve either “chronic” tonsillitis, peritonsillar abscess, or upper airway obstruction due to (adeno)tonsillar hypertrophy over several years was evaluated in this study (tonsillectomy, adenotonsillectomy, tonsillotomy, abscess tonsillectomy, transoral incision and drainage). Finally, the post-tonsillectomy hemorrhage rate was calculated and analyzed in relation to age and gender.

Material and methods: Calculations were based on data as published by the Federal Institute of Statistics or on request, if needed. The latest data were provided for 2013.

Results: The total number of the aforementioned diseases (stratified by ICD-10) decreased from 142,574 (in 2000) to 87,624 in 2013 (38.5%). Tonsillectomy, with or without adenoidectomy, was performed in a total of 833,896 patients between 2006 and 2013 in Germany. The yearly number decreased continually from 120,993 in 2006 to 84,332 procedures in 2013 (30.3%). The most significant decrease was registered in patients younger than 20 years of age for this time period: 70.92 per 10,000 in 2010 to 58.68 per 10,000 in 2013. If all age groups were included, the rate decreased from 13.34 per 10,000 to 10.90 per 10,000. In contrast, an increasing number of tonsillotomies was observed between 2007 (4,659 procedures) and 2013 (11,493). The cumulated number of procedures was 59,049. A constant number of 15,000 cases with peritonsillar abscess were diagnosed per year in Germany (19 patients per 100,000). The prevalence increased significantly at an age of 15 years and there was a preponderance of female patients below that age. Compared to the transoral incision and drainage, a 2.8-fold greater number of abscess tonsillectomies were performed annually. Post-tonsillectomy hemorrhage was experienced in 5.98% of all patients after 245,721 procedures in 2010 and 2013 (all indications, except tonsillotomy). Bleeding complications had occurred less frequently in female patients (5.06% vs. 7.02%). Finally, a considerable increase of post-tonsillectomy hemorrhage in patients older than 10 years of age was registered in male patients only.

Conclusion: Chronic tonsillitis was less frequently diagnosed and surgically treated in terms of tonsillectomy (with or without adenoidectomy), particularly in female patients. In contrast, the number of tonsillotomies increased continually, particularly in male patients. Peritonsillar abscess was diagnosed and surgically treated in a constant number of patients in the yearly comparison. Most of these patients were scheduled for abscess tonsillectomy, and only a 2.8-fold smaller number for transoral incision and drainage. Independent from the indication for surgery, post-tonsillectomy hemorrhage was clearly associated with male gender and age (>10 years). The study reveals a dramatic change mandating further surveillance in insurance companies and authorities in the national health system of an 80 million people nation. (Tab. 1)

Cranial tonsillotomy for peritonsillar abscess: what a relief!

Peritonsillar abscess (PTA) is a common infection of the oropharynx resulting in painful swallowing, sometimes associated with fever, trismus and a typical voice alteration. Several draining methods have been suggested, including needle aspiration (NA), incision and drainage (ID), or abscesstonsillectomy. However, a gold standard of surgical therapy still does not exist. The aim of this study was to evaluate the outcome in patients who had undergone ID supplemented by cranial tonsillotomy (IDTT) as first-line treatment. A retrospective chart review of all patients who had undergone IDTT at our department in 2015 was performed. Demographic data, clinical findings, pain intensity on a 10-point visual analog scale, operation time and routine bloods before and after IDTT were collected. In addition, a 10-point visual analog scale (VAS) was utilized to measure personal satisfaction 2 weeks and 2 months after surgery. A total of 104 procedures were performed in 65 male and 38 female patients (median age 35 years), including one patient with a contralateral PTA 2 weeks after IDTT. Three patients had experienced abscess formation after admittance for antibiotic treatment of acute tonsillitis. 57.7 % of all patients denied intake of antibiotic therapy in their history at initial presentation. Patients were hospitalized for 3 days (median). The median pain intensity (VAS) within the first three postoperative days was 2, 1 and 1, respectively. Two weeks and 2 months after surgery patients were highly satisfied with the procedure (median value 10). Bleeding complications did not occur. IDTT is a novel surgical concept and associated with great patient comfort. It is safe, easy to learn and associated with an early return to normal diet and physical activity. These findings are supported by a rapid normalization of white blood cell count and C-reactive protein. IDTT eliminates the necessity of painful re-draining of the wound cavity and is free of bleeding complications. In contrast to ID and NA, histological examination of tonsillar tissue is feasible to disclose a previously undetected malign disease. Further analysis is warranted to verify the success rate in the long-term.