Prognostic factors and effects of early surgical drainage in patients with peritonsillar abscess

[Design of a predictive score table for peritonsillar infection based on signs and symptoms]

BACKGROUND

Peritonsillar infection (PTI) is a reason for urgent consultation due to intense throat discomfort. A delayed or inaccurate diagnosis can jeopardize the upper aerodigestive tract and be fatal in its evolution. Our objective was to develop a predictive model for the presence of IPA helping in its rapid detection.

PATIENTS AND METHODS

A 66-month retrospective observational study from 2017 was carried out in a county and tertiary referral hospitals, registering data from all patients diagnosed with PTI and a proportional volume of subjects with pharyngeal symptoms without PTI. Collection of clinical, exploratory and demographic data among participants. Their higher relative risk of PTI presence allowed them to be considered as variables to be tested. Development of a scoring scale for the probability of suffering from it and logistic regression analysis, obtaining the ROC curve with the best diagnostic correlation. Internal validation and estimation of the predictive values of the model.

RESULTS

On 348 cases of PTI, the assessment scale scored the presence of six variables: trismus (3), unilateral dysphagia-odynophagia (2), velar bulging (2), reflex otalgia (1), pharyngolalia (1) and age between 16 and 46 years (1). With a range of 0-10, a cut-off ≥6 offered a sensitivity of 96.1%, a specificity of 93.9%, and an efficiency of 94.9%. The area under the ROC curve was 0.979.

CONCLUSIONS

The internal validation of this model based on signs and symptoms makes it a very useful tool for early detection of PTI in otorhinolaryngology and primary care.

A prospective multicentre external validation study of the Liverpool Peritonsillar abscess Score (LPS) with a no-examination COVID-19 modification

Objectives

Our primary aim was to validate the Liverpool Peritonsillar abscess Score (LPS) externally in a new patient cohort. Our secondary aim was to modify the LPS in the light of the COVID‐19 pandemic to produce a no‐examination variant for use in this instance.

Design

Prospective multicentre external validation study.

Setting

Six different secondary care institutions across the United Kingdom.

Participants

Patients over 16 years old who were referred to ENT with any uncomplicated sore throat such a tonsillitis or peritonsillar abscess (PTA).

Main outcome measures

Sensitivity, specificity, positive predictive value and negative predictive value for both the original LPS model and the modified model for COVID‐19.

Results

The LPS model had sensitivity and specificity calculated at 98% and 79%, respectively. The LPS has a high negative predictive value (NPV) of 99%. The positive predictive value (PPV) was slightly lower at 63%. Receiver operating characteristic (ROC) curve, including the area under the curve (AUROC), was 0.888 which indicates very good accuracy.

Conclusions

External validation of the LPS against an independent geographically diverse population yields high NPV. This may support non‐specialist colleagues who may have concerns about mis‐diagnosing a PTA. The COVID‐19 modification of the LPS has a similar NPV, which may be of use where routine oral examination is to be avoided during the COVID‐19 pandemic.

Bilateral peritonsillar abscess: a case study and literature review

While peritonsillar abscesses are the most common deep neck infections, bilateral forms are rare. A peritonsillar abscess occurs when pus accumulates in the peritonsillar space, located between the tonsils and superior constrictor muscle, causing medial displacement of the uvula, trismus, odynophagia or even upper airway obstruction. High clinical suspicion is needed to diagnose bilateral peritonsillar abscess due to frequent history, computerized tomography scan of the neck with IV contrast facilitates accurate diagnose and a full assessment of the patient. Incision and drainage are needed to evacuate the pus along with systemic antibiotics to relieve patient symptoms followed by interval tonsillectomy, which usually done after 6 weeks.

Implication of Fusobacterium necrophorum in recurrence of peritonsillar abscess

OBJECTIVE

Peritonsillar abscess (PTA) is a common infectious complication of pharyngeal infection managed by otolaryngologists and emergency room physicians. Streptococcus and Fusobacterium (e.g., Fusobacterium necrophorum, FN) species are commonly isolated pathogens. The aim of this study was to determine the implication of culture results on abscess recurrence following drainage.

METHODS

Single-institution retrospective review of patients treated at the University of Michigan between 2000 and 2017. Demographic and clinical outcome data were analyzed, including treatment details, culture data, and recurrence.

RESULTS

One hundred fifty-six of the 990 patients in our study developed recurrence of their abscess (16%). The age ranges most susceptible to recurrence included adolescent (22.9%) and young adult groups (17.1%). Recurrent patients were more likely to have experienced acute progression of symptoms (79% vs. 71%, P = 0.03), trismus (67% vs. 55%, P = 0.006), voice changes (65% vs. 57%, P = 0.04), and dysphagia (72% vs. 61%, P = 0.01) compared to nonrecurrent patients. They were also more likely to have clinical lymphadenopathy noted on initial examination (67% vs. 56%, P = 0.009). Culture data was sent for 852 patients (86%). The presence of FN was significantly more prevalent in the recurrent group (P < 0.0001).

CONCLUSION

There is a high observed prevalence of FN species within PTA aspirates in the recurrent PTA population. PTA aspirate should be sent for anaerobic growth to screen for Fusobacterium species. In addition, follow-up and lower threshold for subsequent tonsillectomy should be considered in this at-risk group.

LEVEL OF EVIDENCE

3 Laryngoscope, 129:1567-1571, 2019.

Analysis of smoking behaviour in patients with peritonsillar abscess: a prospective, matched case-control study

OBJECTIVE

Smoking is purported to increase the risk of peritonsillar abscess formation, but prospective data are needed to confirm this hypothesis. This prospective study aimed to identify this correlation.

METHODS

Fifty-four patients with peritonsillar abscess were prospectively asked about their smoking behaviour using a questionnaire that was designed and approved by the Robert Koch Institute (Berlin, Germany) to analyse smoking behaviour in epidemiological studies. Afterwards, a consecutive control group (without peritonsillar abscess), matched in terms of age and gender, was surveyed using the same questionnaire. A classification of smoker, former smoker and non-smoker was made, and the numbers of pack-years were calculated and compared.

RESULTS

Statistical analysis of both groups revealed a significant correlation between peritonsillar abscess and smoking experience (p = 0.025). Moreover, there were significantly fewer non-smokers in the non-peritonsillar abscess group (p = 0.04). The number of pack-years was higher in the peritonsillar abscess group (p = 0.037).

CONCLUSION

There is a statistically significant association between peritonsillar abscess and smoking.

Renewal of peritonsillar abscess: Impact of the bacterial species of the infection and clinical features of the patient-A prospective comparative aetiological study

OBJECTIVES

To compare the bacterial species and patient clinical features in peritonsillar abscesses between patients who had renewal (renewal group) and those who did not (recovery group).

DESIGN

Prospective comparative aetiological study.

SETTING

Tertiary referral centre.

PARTICIPANTS

A total of 180 adult peritonsillar abscess patients were prospectively enrolled and treated as outpatients with incision and drainage and oral antibiotics. Bacteria from the pus were evaluated with a microarray assay. All contact with the healthcare system and renewal of the symptoms were recorded.

MAIN OUTCOME MEASURES

Different bacterial species and patient clinical features between the renewal and recovery groups.

RESULTS

Of the 180 enrolled patients, 18 experienced a renewal of symptoms. Bacteria from the Streptococcus anginosus group were detected in the patient samples of the renewal group more often than in those of the recovery group (P=.002). No isolated Streptococcus pyogenes samples were reported in the renewal group, while in the recovery group it was reported on 24% of the patients (P=.014). In the renewal group, patients over age 40 experienced symptom renewal faster than the younger patients (P=.013) and were more likely to be male (P=.036).

CONCLUSIONS

Bacteria in the Streptococcus anginosus group appear to predict renewal of PTA symptoms, while Streptococcus pyogenes was not found in our patients with symptom renewal. Certain subgroups of patients should be followed more closely.

Bilateral peritonsillar abscess: A case report and pertinent literature review

INTRODUCTION

The peritonsillar space is defined as the area between the palatine tonsillar capsule medially and the superior pharyngeal constrictor muscle laterally. Unilateral peritonsillar abscess (PTA) is more common than the bilateral condition. To the best of our knowledge, only 13 cases of bilateral PTA have been reported worldwide; this is the first case reported from Saudi Arabia.

PRESENTATION OF CASE

We present a case involving a 16-year-old boy who presented to the emergency department with a5-day history of sore throat, dysphagia, trismus, drooling, and a muffled "hot-potato" voice, but with no symptoms of airway compromise. After several examinations, we diagnosed bilateral PTA. We performed an incision and drained the pus from both sides, which was positive for Streptococcus pyogenes. Postoperatively, the patient improved dramatically, and tonsillectomy was scheduled for 6 weeks later.

DISCUSSION

The difficulty in diagnosing bilateral PTA stems from the fact that it does not present with the usual clinical characteristics as unilateral PTA. These symptoms include asymmetry of the tonsils and palate, deviation of the uvula, and unilateral otalgia. As these cases carry the risk of impending airway compromise, we recommend airway management as the first step in treating such cases.

CONCLUSION

Based on our case and literature review, we recommend airway management as the first step, followed by further examinations, especially contrast-enhanced computed tomography, in cases of bilateral PTA. This condition lacks the hallmark of unilateral disease and may mimic many conditions, which will have different management approaches.

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.

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.

The role of bacteriological studies in the management of peritonsillar abscess

OBJECTIVE

Since most patients with peritonsillar abscess (PTA) can be successfully treated with surgical drainage and empirical antibiotic therapy, routine bacteriologic studies for all patients with PTA may be unnecessary. This study tried to evaluate which patients with PTA should certainly undergo bacteriologic studies.

METHODS

Hundred consecutive patients with PTA were treated and underwent culture tests of purulent contents obtained by surgical drainage between April 2008 and December 2013.

RESULTS

In 62 of the 100 patients, 71 pathogenic bacteria were identified; 61 (86%) were Gram-positive cocci (GPC), 8 (11%) were Gram-negative rods (GNR), and 6 (8%) were anaerobes. Normal flora were isolated in 27 patients, and culture results were negative in 11 patients. Although not significant, primary (without prior antibiotic therapy) case (odds ratio (OR)=2.19; 95% CI, 0.95-5.05) and laryngeal edema (OR=2.04; 95% CI, 0.82-5.03) showed a tendency of associations with detection of pathogenic bacteria. After taking into account interactions between smoking habit and laryngeal edema, the covariate-adjusted OR for non-smokers with laryngeal edema was significant and showed a strong relationship (OR=7.43; 95% confidence interval, 1.05-52.73) compared to non-smokers without laryngeal edema.

CONCLUSION

Although empirical antibiotic therapy was effective for most of the PTA patients, bacteriologic studies might be indispensable for the patients with laryngeal edema considering the failure of the first treatments. Particularly, the culture tests may be useful for non-smokers with laryngeal edema.