Peritonsillar abscess in children: a 10-year review of diagnosis and management

A Systematic Review of Peritonsillar Abscess Simulators: Enhancing Training and Identifying the Need for Standardization

OBJECTIVES

To systematically review the literature regarding previously described peritonsillar abscess (PTA) drainage simulation.

DATA SOURCES

PubMed, Scopus, Web of Science, Ovid, and Cochrane.

REVIEW METHODS

A search of the abovementioned databases was performed in August 2022 using the terms "peritonsillar abscess/quinsy," "incision/drainage/aspiration," and "simulation." No time restrictions were applied. We included studies that clearly described how their PTA models were built and underwent validation from experts and/or evaluation from trainees. Articles describing a model only without any evaluation and reports in languages other than English were excluded.

RESULTS

Our search initially yielded 80 articles after duplicate removal, 10 of which met our criteria and were included. Two studies trained participants on both needle aspiration and incision and drainage (I&D), four studies on I&D only, and four on needle aspiration only. 87.5% to 100% of junior residents reported minimal exposure to PTA prior to simulation. Five studies provided some form of validation to their models. The value of the simulators to train participants on skills received better appreciation than their anatomical fidelity. The perceived confidence level of trainees in managing PTA, which was assessed in 7 studies, substantially improved after training.

CONCLUSION

PTA simulation improves the confidence of trainees to perform PTA drainage. There is, however, a lack of standardization and evidence regarding transfer validity among PTA simulators. The development of a standardized PTA simulator could allow for more widespread use and increase resident comfort with this procedure in a pre-clinical setting.

LEVEL OF EVIDENCE

NA Laryngoscope, 134:2495-2501, 2024.

Peritonsillar abscess on NSQIP: Safety of indicated quinsy tonsillectomy

OBJECTIVE

To compare surgical outcomes for children with peritonsillar abscess (PTA) who are taken to the operating room (OR) for incision and drainage (I&D) or quinsy tonsillectomy.

METHODS

This is a multicenter retrospective study of pediatric patients who underwent I&D of a PTA between 2012 and 2017 included in the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database. Patient demographics, comorbidities, and 30-day postoperative events (reoperation, readmission, and complications) were assessed.

RESULTS

777 patients were identified (mean age of 10.7 years, 54% female). 656 (84%) were admitted through the emergency department, and 395 (51%) met criteria for systemic inflammatory response syndrome or sepsis. Fifty-two (6.7%) had a quinsy tonsillectomy done at the time of incision and drainage. For quinsy tonsillectomy versus I&D alone, there was no statistically significant difference in length of stay (LOS) (1.9 v. 1.7 days, p = .523), readmission (17 v. 0, p = .265) or return to the OR (18 v. 1, p = .810). Patients younger than 5 years had a longer LOS (p < .001) while females (p = .003) and patients between 12 and 17 years of age (p = 0.021) were more likely to be readmitted. Of 725 patients treated with I&D alone, 10 (1.4%) patients required a repeat I&D and 6 (0.83%) went on to have an interval quinsy tonsillectomy.

CONCLUSIONS

Outcomes of I&D and quinsy tonsillectomy for pediatric PTA in the operating room are the same. If tonsillectomy is indicated in the case of recurrent tonsillitis or PTA, a quinsy tonsillectomy is a good option.

LEVEL OF EVIDENCE: 3

Immediate or interval abscess tonsillectomy? A systematic review and meta-analysis

OBJECTIVES

Peritonsillar abscess is a common complication of acute tonsillitis. However, no consensus has been reached yet on the optimal treatment of this condition. Therefore, this study aimed to compare clinical outcomes of immediate and interval abscess tonsillectomy.

METHODS

The databases of PubMed, Scopus, and Cochrane Central Register of Controlled Trials (CENTRAL) were searched for completed studies published until the 1st of November 2021. Comparative studies assessing intraoperative and postoperative outcomes of immediate and interval abscess tonsillectomy were considered, with the primary outcome being postoperative hemorrhage. Operative time, intraoperative blood loss, postoperative pain, and duration of hospital stay were classed as secondary outcomes. A random-effects pairwise meta-analysis of both randomized and non-randomized trials was conducted. Subgroup analysis linked to the randomization of trials was executed. Quality assessment was performed, utilizing the Cochrane risk of bias tool and ROBINS-I tool for randomized and non-randomized trials, respectively.

RESULTS

Data from 265 cases stemming from six trials were pooled together. For postoperative bleeding rates, no statistically significant difference between immediate and interval tonsillectomy was detected (OR = 1.26; 95% CI 0.27, 5.86; p = 0.77). By contrast, longer hospital stay was observed for patients subjected to interval tonsillectomy (SMD = - 0.78; CI - 1.39 to- 0.17; p = 0.01). For operative time and intraoperative blood loss, no statistically significant difference was noticed between immediate and interval tonsillectomy (SMD = 1.10; 95% CI - 0.13, 2.33; p = 0.08; and SMD = 0.04; 95% CI - 0.49, 0.57; p = 0.88; respectively).

CONCLUSIONS

This study shows that quinsy tonsillectomy appears to be a safe method, providing full abscess drainage and instant relief of the symptoms. Moreover, quinsy tonsillectomy was not associated with a statistically higher postoperative hemorrhage incidence rate than immediate tonsillectomy.

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.

Current trend of antibiotic prescription and management for peritonsillar abscess: A cross-sectional study

OBJECTIVE

There are no consensus guidelines for managing peritonsillar abscess (PTA) despite its prevalence. In order to devise best practice guidelines, current practice patterns must first be established.

METHODS

This was a cross-sectional study, surveying Otolaryngology-Head & Neck Surgery trainees (residents and fellows) and consultant (academic and community). The primary outcome was the type and duration of outpatient antibiotic prescription. Secondary outcomes included differences in workup, management, prescription, and follow-up.

RESULTS

There were 57 respondents to the survey; 24 (42%) trainees (residents/fellows) and 33 (58%) consultants. On average, each respondent managed an average of 15.2 (SD 11.2) PTAs within the last year. All respondents prescribed oral antibiotics, with amoxicillin-clavulanic acid being the most common (61%). Trainees prescribed amoxicillin-clavulanic acid more often than consultants (n = 21, 88% vs n = 14, 42%, P = .0084), respectively. Duration of antibiotic therapy ranged from 5 to 14 days. Most commonly, a 10-day course of antibiotics was prescribed (n = 31, 54%). Regarding the management of PTAs, a majority of respondents requested blood work (n = 39, 68%), performed needle aspiration (n = 42, 72%) and performed incision and drainage (n = 52, 91%). Culture and sensitivity of the aspirate/drainage fluid was frequently performed (n = 41, 72%). Patients were often provided non-opioid analgesics (n = 46, 81%), but more than half still received prescription opioids (n = 36, 63%). The majority of clinicians arranged for follow-up (n = 42, 74%), most often with Otolaryngology - Head & Neck Surgery (n = 27, 64%), with an average follow-up of 12.5 (SD 8.2) days.

CONCLUSION

We found heterogeneity in the management of PTAs, with variability in the outpatient antibiotic prescription. This study highlighted the wide range of management strategies employed along with differences in workup, investigation, post-discharge analgesic prescription, and follow-up arrangements.

LEVEL OF EVIDENCE

5.

Nontraumatic Head and Neck Emergencies

Head and neck imaging is an intimidating subject for many radiologists because of the complex anatomy and potentially serious consequences of delayed or improper diagnosis of the diverse abnormalities involving this region. The purpose of this article is to help radiologists to understand the intricate anatomy of the head and neck and to review the imaging appearances of a variety of nontraumatic head and neck conditions that bring patients to the emergency department, including acute infectious and inflammatory diseases and acute complications of head and neck neoplasms. These conditions are presented in five sections on the basis of their primary location of involvement: the oral cavity and pharynx, neck, sinonasal tract, orbits, and ears. Important anatomic landmarks are reviewed briefly in each related section.Online supplemental material is available for this article.^©RSNA, 2019.

Clinical Practice Guideline: Tonsillectomy in Children (Update)

OBJECTIVE

This update of a 2011 guideline developed by the American Academy of Otolaryngology-Head and Neck Surgery Foundation provides evidence-based recommendations on the pre-, intra-, and postoperative care and management of children 1 to 18 years of age under consideration for tonsillectomy. Tonsillectomy is defined as a surgical procedure performed with or without adenoidectomy that completely removes the tonsil, including its capsule, by dissecting the peritonsillar space between the tonsil capsule and the muscular wall. Tonsillectomy is one of the most common surgical procedures in the United States, with 289,000 ambulatory procedures performed annually in children <15 years of age based on the most recent published data. This guideline is intended for all clinicians in any setting who interact with children who may be candidates for tonsillectomy.

PURPOSE

The purpose of this multidisciplinary guideline is to identify quality improvement opportunities in managing children under consideration for tonsillectomy and to create explicit and actionable recommendations to implement these opportunities in clinical practice. Specifically, the goals are to educate clinicians, patients, and/or caregivers regarding the indications for tonsillectomy and the natural history of recurrent throat infections. Additional goals include the following: optimizing the perioperative management of children undergoing tonsillectomy, emphasizing the need for evaluation and intervention in special populations, improving the counseling and education of families who are considering tonsillectomy for their children, highlighting the management options for patients with modifying factors, and reducing inappropriate or unnecessary variations in care. Children aged 1 to 18 years under consideration for tonsillectomy are the target patient for the guideline. For this guideline update, the American Academy of Otolaryngology-Head and Neck Surgery Foundation selected a panel representing the fields of nursing, anesthesiology, consumers, family medicine, infectious disease, otolaryngology-head and neck surgery, pediatrics, and sleep medicine.

KEY ACTION STATEMENTS

The guideline update group made strong recommendations for the following key action statements (KASs): (1) Clinicians should recommend watchful waiting for recurrent throat infection if there have been <7 episodes in the past year, <5 episodes per year in the past 2 years, or <3 episodes per year in the past 3 years. (2) Clinicians should administer a single intraoperative dose of intravenous dexamethasone to children undergoing tonsillectomy. (3) Clinicians should recommend ibuprofen, acetaminophen, or both for pain control after tonsillectomy. The guideline update group made recommendations for the following KASs: (1) Clinicians should assess the child with recurrent throat infection who does not meet criteria in KAS 2 for modifying factors that may nonetheless favor tonsillectomy, which may include but are not limited to multiple antibiotic allergies/intolerance, PFAPA (periodic fever, aphthous stomatitis, pharyngitis, and adenitis), or history of >1 peritonsillar abscess. (2) Clinicians should ask caregivers of children with obstructive sleep-disordered breathing and tonsillar hypertrophy about comorbid conditions that may improve after tonsillectomy, including growth retardation, poor school performance, enuresis, asthma, and behavioral problems. (3) Before performing tonsillectomy, the clinician should refer children with obstructive sleep-disordered breathing for polysomnography if they are <2 years of age or if they exhibit any of the following: obesity, Down syndrome, craniofacial abnormalities, neuromuscular disorders, sickle cell disease, or mucopolysaccharidoses. (4) The clinician should advocate for polysomnography prior to tonsillectomy for obstructive sleep-disordered breathing in children without any of the comorbidities listed in KAS 5 for whom the need for tonsillectomy is uncertain or when there is discordance between the physical examination and the reported severity of oSDB. (5) Clinicians should recommend tonsillectomy for children with obstructive sleep apnea documented by overnight polysomnography. (6) Clinicians should counsel patients and caregivers and explain that obstructive sleep-disordered breathing may persist or recur after tonsillectomy and may require further management. (7) The clinician should counsel patients and caregivers regarding the importance of managing posttonsillectomy pain as part of the perioperative education process and should reinforce this counseling at the time of surgery with reminders about the need to anticipate, reassess, and adequately treat pain after surgery. (8) Clinicians should arrange for overnight, inpatient monitoring of children after tonsillectomy if they are <3 years old or have severe obstructive sleep apnea (apnea-hypopnea index ≥10 obstructive events/hour, oxygen saturation nadir <80%, or both). (9) Clinicians should follow up with patients and/or caregivers after tonsillectomy and document in the medical record the presence or absence of bleeding within 24 hours of surgery (primary bleeding) and bleeding occurring later than 24 hours after surgery (secondary bleeding). (10) Clinicians should determine their rate of primary and secondary posttonsillectomy bleeding at least annually. The guideline update group made a strong recommendation against 2 actions: (1) Clinicians should not administer or prescribe perioperative antibiotics to children undergoing tonsillectomy. (2) Clinicians must not administer or prescribe codeine, or any medication containing codeine, after tonsillectomy in children younger than 12 years. The policy level for the recommendation about documenting recurrent throat infection was an option: (1) Clinicians may recommend tonsillectomy for recurrent throat infection with a frequency of at least 7 episodes in the past year, at least 5 episodes per year for 2 years, or at least 3 episodes per year for 3 years with documentation in the medical record for each episode of sore throat and ≥1 of the following: temperature >38.3°C (101°F), cervical adenopathy, tonsillar exudate, or positive test for group A beta-hemolytic streptococcus.

DIFFERENCES FROM PRIOR GUIDELINE

(1) Incorporating new evidence profiles to include the role of patient preferences, confidence in the evidence, differences of opinion, quality improvement opportunities, and any exclusion to which the action statement does not apply. (2) There were 1 new clinical practice guideline, 26 new systematic reviews, and 13 new randomized controlled trials included in the current guideline update. (3) Inclusion of 2 consumer advocates on the guideline update group. (4) Changes to 5 KASs from the original guideline: KAS 1 (Watchful waiting for recurrent throat infection), KAS 3 (Tonsillectomy for recurrent infection with modifying factors), KAS 4 (Tonsillectomy for obstructive sleep-disordered breathing), KAS 9 (Perioperative pain counseling), and KAS 10 (Perioperative antibiotics). (5) Seven new KASs: KAS 5 (Indications for polysomnography), KAS 6 (Additional recommendations for polysomnography), KAS 7 (Tonsillectomy for obstructive sleep apnea), KAS 12 (Inpatient monitoring for children after tonsillectomy), KAS 13 (Postoperative ibuprofen and acetaminophen), KAS 14 (Postoperative codeine), and KAS 15a (Outcome assessment for bleeding). (6) Addition of an algorithm outlining KASs. (7) Enhanced emphasis on patient and/or caregiver education and shared decision making.

Influenza A-Associated Epiglottitis and Compensatory Pursed Lip Breathing in an Infant

The last 3 decades have seen a shift in the epidemiology of epiglottitis. Epiglottitis was once most commonly associated with Haemophilus influenzae type B. However, with the implementation of the H. influenzae type B vaccine in 1985, the incidence has drastically declined. There are now new emerging pathogens-bacteria, viruses, and fungi-causing epiglottitis. Here, we report the first case of epiglottitis secondary to influenza A in a former full-term, vaccinated infant who presented with cough, fever, stridor, pursed lip breathing, and progressive respiratory distress and eventual respiratory failure. This case highlights the presentation and clinical course of epiglottitis and describes a rare clinical feature, pursed lip breathing, in an infant.

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.

Peritonsillar abscess in an infant with congenital bone marrow failure

Peritonsillar abscess is extremely rare in infants and is potentially life-threatening. We report the case of a 3 month old infant with a background of congenital bone marrow failure who presented with sepsis and desaturation requiring intubation and PICU care. Ultrasound and CT scan revealed an inflammatory mass. Examination in theatre revealed a self-draining quinsy. Following formal drainage in theatre, the child improved and was extubated uneventfully 1 day later. Prompt surgical and medical management as well as the presence of a well-coordinated multidisciplinary team are crucial in ensuring the adequate management of complex paediatric patients.

Intratonsillar abscess: A not-so-rare clinical entity

OBJECTIVE

To report the prevalence of intratonsillar abscess in the pediatric population at our institution and demonstrate that intratonsillar abscess is a more commonly encountered diagnosis than previously reported.

METHODS

A retrospective chart review was performed that included patients presenting to our pediatric tertiary referral academic emergency department from January 1, 2014 to December 31, 2014 diagnosed with intratonsillar abscess on computed tomography.

RESULTS

In the year 2014, 22 children were diagnosed with intratonsillar abscess by radiological criteria. The majority of patients (82%) required no surgical intervention and were successfully treated with antibiotics and supportive measures. All patients recovered from the infection uneventfully, and there were no treatment complications recorded.

CONCLUSION

Even in recent literature, intratonsillar abscess is described as a rare entity, with few cases reported. In our experience, CT imaging demonstrating the presence of intratonsillar abscess is more common than previously described. Regardless of treatment method, in our experience children with intratonsillar abscess do well clinically.

Conscious Sedation for Pediatric Peritonsillar Abscess: Comparison of Anesthetic Approaches

Objective

To compare the efficacy, safety, and cost of incision and drainage (I&D) for pediatric patients with peritonsillar abscesses (PTAs) under conscious sedation (CS) versus unsedated (awake) and general anesthesia (GA).

Study Design

Case series with chart review.

Setting

Tertiary pediatric hospital.

Subjects and Methods

Records for all pediatric patients (<18 years) treated for PTAs in the emergency department from 2005 to 2015 were reviewed and stratified into awake, CS, and GA groups for comparison. The primary outcome measure was procedure tolerance, with secondary measures including return to the emergency department within 15 days, complications, and facility costs associated with treatment.

Results

A total of 188 patients were identified. The median age was 14 years (interquartile range, 9-16). Awake drainage with injected local anesthetic was used in 115 children; 62 underwent CS; and 11 underwent GA. Over 92% of the children tolerated I&D regardless of anesthesia, with no difference among groups ( P = .60). None of those who underwent I&D via CS returned to the emergency department within 15 days of the procedure, as compared with 5.2% for the awake group and 9.1% for the GA group ( P = .06). None in the GA or awake group had a complication associated with the procedure, as opposed to 9.6% in the CS group ( P = .02). Complications included apnea and dental trauma (2 children each) and transient hypotension and desaturation (1 each). Cost was highest in the GA group and lowest for the awake group ( P < .0001).

Conclusion

CS for PTA I&D is a viable treatment option with tolerance and success similar to that of the awake and GA groups. Complications were observed for those who underwent CS, but they were manageable.

Acute Infections That Produce Upper Airway Obstruction

This chapter discusses the common and potentially serious infective causes of acute upper airway obstruction in children. The laryngeal anatomy of young children makes them particularly susceptible to upper airway obstruction, and during acute infections this is exacerbated by inflammation and edema of the airway mucosa. The most common cause of infective upper airway obstruction in children is viral laryngotracheobronchitis, or croup, which is usually a mild and self-limiting illness, but management with corticosteroids may still be necessary. Bacterial causes of upper airway obstruction have fortunately become rare since the introduction of the Haemophilus influenzae B (HiB) immunization, but a few cases of epiglottitis do still occur due to nonimmunization, vaccine failure, and infection with non-HiB organisms. These cases constitute a medical emergency due to the risk of rapid progression to complete airway obstruction. Other rare conditions are discussed including bacterial tracheitis, diphtheria, retropharyngeal, and peritonsillar abscesses. Key learning points in this chapter include the main discriminating factors of the various causes of infective upper airway obstruction, the importance of a calm and minimally distressing approach to the child presenting with stridor, and the need for early anesthetic team involvement in cases with a suspected bacterial etiology or signs of impending airway obstruction.

Emergency Imaging of the Nontraumatic Pediatric Head and Neck

Pediatric patients present emergently with a wide variety of infectious, inflammatory, congenital, traumatic, and neoplastic conditions. Imaging plays a crucial role in distinguishing among the potential diagnoses, as often, history and physical exam is limited in these young sick patients. Understanding the imaging appearance of the range of conditions which are commonly encountered and their potential complications, facilitates appropriate and expedient management. The radiologist must recognize the benefits of the various imaging modalities available and help the clinician choose among the possibilities depending on the clinical status of the patient.

Establishing the Need for an Evidence-Based Treatment Algorithm for Peritonsillar Abscess in Children

In this retrospective case series, we report clinical factors associated with pediatric peritonsillar abscess (PTA), with hopes of contributing to the design of an evidenced-based, economic treatment approach. Charts were examined for presenting symptoms and signs. Each of these were analyzed for association with the presence of PTA and for association with treatment. We found that, with the exception of leukocytosis, the signs/symptoms that prompted treatment correlate with those that indicate the presence of PTA. However, there are several signs/symptoms, namely, referred otalgia, cervical lymphadenopathy, and decreased oral intake, that were associated with PTA but unassociated with treatment. Treatment can be aided by establishing an algorithm that accounts for the symptoms/signs most correlated with true, drainable abscess.

Confluent Retropharyngeal, Lateral Pharyngeal, and Peritonsilar MRSA Abscess in an Infant

Neck abscesses such as retropharyngeal, peritonsilar, and lateral pharyngeal are well described, typically cause a characteristic illness, and have a known epidemiology. We present a rare occurrence of case of confluent, mixed retropharyngeal, lateral pharyngeal, and peritonsilar abscess in a 9-month-old female infant. The symptoms at presentation were very mild and not expected in association with this extensive an abscess. The causative organism was methicillin-resistant Staphylococcus aureus.

Unusual 'feathery' cause of a parapharyngeal abscess in an infant

A 7-month-old boy presented to the emergency department with reduced oral intake, neck swelling and fever. Clinical examination revealed a 3 cm left parotid and left level I neck swelling with left medialised tonsil but no trismus. Computed imaging confirmed the presence of an abscess in the peritonsillar area with extension into the parapharyngeal space and deep lobe of the parotid gland. The abscess was incised and drained transorally. Following drainage of the abscess, a small 3 mm suspicious foreign body was seen. After extraction, this was revealed to be a 60 mm feather. We would like to highlight this unusual case in an infant and to ensure that foreign body is considered as aetiology. There are only a handful of cases in the literature involving feathers causing neck abscesses and, to our knowledge, this is the first case where the patient presented with a pharyngeal abscess, which was drained transorally.

Bilateral Peritonsillar Abscess in an Infant: An Unusual Presentation of Sore Throat

Introduction

Peritonsillar abscess is considered a suppurative complication of acute tonsillitis. It is usually unilateral and clinically evident bilateral presentation is uncommon. The condition affects mainly children older than 10 years and young adults. Herein we present a rare case of bilateral peritonsillar abscess in an infant.

Presentation of Case

A 1-year-old boy presented with a two-day history of worsening sore throat, loss of appetite, vomiting, and fever. Examination of the oral cavity and oropharynx revealed enlarged and inflamed tonsils and a bilaterally congested and bulging soft palate. CT scan confirmed the hypothesis of bilateral peritonsillar abscess. Antibiotic therapy was instituted and after 5 days only slight regression of swelling of the soft palate was observed. He underwent a surgical procedure for draining the abscesses. After the procedure, he presented good clinical and laboratory evolution and was discharged home.

Discussion

Although peritonsillar abscesses are considered common complications of acute tonsillitis bilateral cases are extremely rare, especially in early childhood. The diagnosis is based on history and physical examination and the treatment remains controversial among otolaryngologists.

Conclusion

Bilateral peritonsillar abscess should be diagnosed and treated promptly and adequately to prevent respiratory obstruction and to avoid dissemination into the deep neck spaces.

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)

Antibiotics for preventing suppurative complications from undifferentiated acute respiratory infections in children under five years of age

BACKGROUND

Undifferentiated acute respiratory infections (ARIs) are a large and heterogeneous group of infections not clearly restricted to one specific part of the upper respiratory tract, which last for up to seven days. They are more common in pre-school children in low-income countries and are responsible for 75% of the total amount of prescribed antibiotics in high-income countries. One possible rationale for prescribing antibiotics is the wish to prevent bacterial complications.

OBJECTIVES

To assess the effectiveness and safety of antibiotics in preventing bacterial complications in children aged two months to 59 months with undifferentiated ARIs.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL 2015, Issue 7), which contains the Cochrane Acute Respiratory Infections Group's Specialised Register, MEDLINE (1950 to August week 1, 2015) and EMBASE (1974 to August 2015).

SELECTION CRITERIA

Randomised controlled trials (RCTs) or quasi-RCTs comparing antibiotic prescriptions with placebo or no treatment in children aged two months to 59 months with an undifferentiated ARI for up to seven days.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trial quality and extracted and analysed data using the standard Cochrane methodological procedures.

MAIN RESULTS

We identified four trials involving 1314 children. Three trials investigated the use of amoxicillin/clavulanic acid to prevent otitis and one investigated ampicillin to prevent pneumonia.The use of amoxicillin/clavulanic acid compared to placebo to prevent otitis showed a risk ratio (RR) of 0.70 (95% confidence interval (CI) 0.45 to 1.11, three trials, 414 selected children, moderate-quality evidence). Methods of random sequence generation and allocation concealment were not clearly stated in two trials. Performance, detection and reporting bias could not be ruled out in three trials.Ampicillin compared to supportive care (continuation of breastfeeding, clearing of the nose and paracetamol for fever control) to prevent pneumonia showed a RR of 1.05 (95% CI 0.74 to 1.49, one trial, 889 selected children, moderate-quality evidence). The trial was non-blinded. Random sequence generation and allocation concealment methods were not clearly stated, so the possibility of reporting bias could not be ruled out.Harm outcomes could not be analysed as they were expressed only in percentages.We found no studies assessing mastoiditis, quinsy, abscess, meningitis, hospital admission or death.

AUTHORS' CONCLUSIONS

There is insufficient evidence for antibiotic use as a means of reducing the risk of otitis or pneumonia in children up to five years of age with undifferentiated ARIs. Further high-quality research is needed to provide more definitive evidence of the effectiveness of antibiotics in this population.

Pediatric Patient and Hospital Characteristics Associated With Treatment of Peritonsillar Abscess and Peritonsillar Cellulitis

OBJECTIVE

To identify patient and hospital characteristics associated with the choice of treatment for pediatric patients who present in the acute setting with peritonsillar abscess/cellulitis (PTA/PTC).

STUDY DESIGN

A retrospective cohort study was performed using Healthcare Cost and Utilization Project emergency department, ambulatory, and inpatient state databases for the years 2010 and 2011. Children aged 0 to 17 years were identified using International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) diagnosis code for PTA/PTC. The main outcome of interest was treatment received, which included medical therapy alone, incision and drainage (IND) or tonsillectomy. Multiple logistic regression analyses were conducted to model non-clinical factors associated with treatment received after adjusting for age, hospital state, race, primary expected payer, existing chronic condition(s), and type of hospital.

RESULTS

We identified 2994 patients who presented with PTA/PTC. The most common treatment choice was medical therapy alone (30.8%), followed by IND (30.5%) and tonsillectomy (9.4%). There were significant associations between treatment choice and race, primary payer status, and type of hospital (P < .05). We found that Hispanic patients, those with Medicaid as their primary expected payer, and those treated at a designated children's hospital were 3 nonclinical factors independently associated with an increase in likelihood of receiving tonsillectomy as treatment.

CONCLUSION

There are important nonclinical factors associated with treatment of children who present in the acute setting with PTA/PTC. Additional research is recommended to understand these observed differences in care and how they may affect health outcomes.

Upper Airway Obstruction in Children

Children with upper airway obstruction are both unique and variable in their presentation and management, often posing a challenge to the pediatrician. Several anatomical and physiologic peculiarities make a child vulnerable to develop an obstruction of upper airways. The characteristic finding in upper airway obstruction is stridor-inspiratory, biphasic or expiratory. The etiologies vary widely throughout the age groups and according to the mode of presentation. The approach starts with suspicion, mandates careful clinical evaluation of the degree of obstruction and many a times emergency measures precede any investigation or even precise diagnosis. Maintaining an open and stable airway is of the utmost importance, often requiring a team approach of emergency physician, pediatrician, otorhinolaryngologist and pediatric pulmonologist. The commonest condition presenting with upper airway obstruction in pediatric population is viral croup. Croup is a clinical diagnosis in a febrile child, with barking cough and stridor preceded by upper respiratory infection. It is treated with systemic or inhaled steroids and nebulized epinephrine. Epiglottitis and bacterial tracheitis are acute bacterial infections of upper airways, presenting as true airway emergencies. Though the mainstay of therapy is IV antibiotics, the prime concern is maintenance of airway, which frequently requires endotracheal intubation. Rigid bronchoscopy is the procedure of choice for airway foreign bodies, a common cause of upper airway obstruction in children below 3 y of age. Airway malacias are the commonest cause of chronic stridor and are mostly managed conservatively.

Trends in the management of pediatric peritonsillar abscess infections in the U.S., 2000-2009

OBJECTIVES

To analyze temporal trends in the incidence and surgical management of children with peritonsillar abscesses (PTAs), and to examine whether there has been concurrent changes in hospital charges or length of stay.

METHODS

The Kids' Inpatient Database (KID) from 2000 to 2009 was examined for children less than 18 years old with ICD-9-CM diagnostic codes for PTA (475). Survey weighted frequency and regression analyses were performed across the entire study period on variables of interest in order to determine estimates of national incidence, demographics and outcomes.

RESULTS

A total of 20,546 weighted cases of PTA were identified during the study period. There was no significant change in the incidence of pediatric PTA across the study period (p=0.63) or in the rate of nonsurgical management (p=0.85). There was a significant increase in the rates of I&D from 26.4% to 33.7% (p<0.001) and a significant decrease in the rate of tonsillectomy from 13.0% to 7.8% (p<0.001). Mean inflation-adjusted charges significantly increased from approximately $8400 in 2000 to $13,300 in 2009 (p<0.001), and average length of stay was 2.15 days with no significant change during the study period (p=0.164). Mean inflation-adjusted charges for patients undergoing tonsillectomy alone were approximately $1800 greater than mean charges for those undergoing I&D alone (p=0.003) and length of stay was also significantly longer for tonsillectomy patients versus I&D patients [I&D 1.99 days versus tonsillectomy 2.23 days (p<0.001)].

CONCLUSIONS

There was no change in the incidence of pediatric PTAs from 2000 to 2009 but there was a change in surgical management, with a significant decrease in the rate of tonsillectomy and significant increase in the rate of incision and drainage procedures. Hospital charges during this period increased nearly 60% despite no change in rates of CT imaging, surgical intervention or length of stay.

The impact of prior tonsillitis and treatment modality on the recurrence of peritonsillar abscess: a nationwide cohort study

Background

Studies suggest an increased risk of peritonsillar abscess (PTA) recurrence in patients with prior tonsillitis. However, this association is inconsistent and could be confounded by different treatment modalities. This study aimed to assess the risk of recurrence among PTA patients with different degrees of prior tonsillitis and treatment modalities, and the role of tonsillectomy in current practice.

Methods

All in-patients with peritonsillar abscess between January 2001 and December 2009 were identified in a nationwide, retrospective cohort study. Recurrence was defined as the first occurrence of PTA ≧30 days from the initial PTA. Factors independently associated with recurrence were analyzed using Cox proportional hazard model after adjusting for demographic and clinical data.

Results

There were 28,837 patients, with a 5.15% recurrence rate and 4.74 years of follow-up. The recurrence rates were significantly higher among subjects with more than five prior tonsillitis or 1–4 prior tonsillitis compared to those without prior tonsillitis (adjusted hazard ratio, 2.82 [95% confidence interval, 2.39–3.33] and 1.59 [95% CI: 1.38–1.82]). The adjusted HR in patients treated with needle aspiration was 1.08 compared to those treated with incision & drainage (95% CI: 0.85–1.38). After age stratification, the adjusted HRs of more than five prior tonsillitis increased to 2.92 and 3.50 in patients aged ≦18 and 19–29 years respectively. The adjusted HR ofneedle aspiration only increased in patients ≦18 years old (aHR: 1.98 [95% CI: 0.99–3.97]). The overall tonsillectomy rate was 1.48% during our study period.

Conclusions

The risk of PTA recurrence increases with higher degrees of prior tonsillitis in all age groups and management by needle aspiration only in the pediatric population. Patients younger than 30 years old with PTA and more than five prior tonsillitis have the greatest risk of recurrence.

Variations in treatment of peritonsillar abscess in four Nordic countries

CONCLUSION

In four Nordic countries, peritonsillar abscess (PTA) patients are treated rather differently.

OBJECTIVES

To study how such patients are treated in those countries.

METHODS

The 81 chief physicians of otorhinolaryngology departments of all central hospitals in Denmark (n = 15), Norway (n = 19), Sweden (n = 27), and Finland (n = 20) received a multiple-choice questionnaire.

RESULTS

A total of 73 physicians (90%) replied. The largest differences arose in treating patients with intravenous versus per oral antibiotics, and treating as inpatients versus outpatients. In Finland, 50% of PTA patients aged >16 years were treated as inpatients and 50% as outpatients, whereas the respective quotas in Sweden were 9 and 91%, Norway 19 and 81%, and Denmark 33 and 67%. Of Finnish physicians, 30% treated their patients primarily with oral antibiotics, 70% with intravenous antibiotics; in Sweden 91 vs 9%, Norway 53 vs 47%, and Denmark 18 vs 82%. In Denmark, almost all patients were operated on immediately, whereas in the other three countries, especially Sweden, operations more often were performed after a recovery period. Combining metronidazole with penicillin or cephalosporins was most common in Denmark: 58% reported usage, compared with 30% in Finland, 16% in Norway, and 4% in Sweden.

Antibiotics for preventing suppurative complications from undifferentiated acute respiratory infections in children under five years of age

BACKGROUND

Undifferentiated acute respiratory infections (ARIs) are a large and heterogeneous group of infections not clearly restricted to one specific part of the upper respiratory tract, which last for up to seven days. They are more common in pre-school children in low-income countries and are responsible for 75% of the total amount of prescribed antibiotics in high-income countries. One possible rationale for prescribing antibiotics is the wish to prevent bacterial complications.

OBJECTIVES

To assess the effectiveness and safety of antibiotics in preventing complications in children aged two to 59 months with undifferentiated ARIs.

SEARCH METHODS

We searched CENTRAL 2013, Issue 4, MEDLINE (1950 to May week 2, 2013) and EMBASE (1974 to May 2013).

SELECTION CRITERIA

Randomised controlled trials (RCT) or quasi-RCTs comparing antibiotic prescriptions with placebo or non-treatment in children up to 59 months with an undifferentiated ARI for up to seven days.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trial quality and extracted and analysed data using the standard Cochrane methodological procedures.

MAIN RESULTS

We identified four trials involving 1314 children. Three trials investigated the use of amoxicillin/clavulanic acid to prevent otitis and one investigated ampicillin to prevent pneumonia.The use of amoxicillin/clavulanic acid compared to placebo to prevent otitis showed a risk ratio (RR) of 0.70 (95% confidence interval (CI) 0.45 to 1.11, three trials, 414 selected children, moderate-quality evidence). Methods of random sequence generation and allocation concealment were not clearly stated in two trials. Performance, detection and reporting bias could not be ruled out in three trials.Ampicillin compared to supportive care (continuation of breastfeeding, clearing of the nose and paracetamol for fever control) to prevent pneumonia showed a RR of 1.05 (95% CI 0.74 to 1.49, one trial, 889 selected children, moderate-quality evidence). The trial was non-blinded. Random sequence generation and allocation concealment methods were not clearly stated so the possibility of reporting bias could not be ruled out.Harm outcomes could not be analysed as they were expressed only in percentages.No studies were found assessing mastoiditis, quinsy, abscess, meningitis, hospital admission or death.

AUTHORS' CONCLUSIONS

The quality of evidence currently available does not provide strong support for antibiotic use as a means of reducing the risk of otitis or pneumonia in children up to five years of age with undifferentiated ARIs. Further high-quality research is needed to provide more definitive evidence of the effectiveness of antibiotics in this population.

Clinical features of peritonsillar abscess in children

BACKGROUND

Peritonsillar abscess is an acute infection located between the capsule of the palatine tonsil and the superior constrictor muscle of the pharynx. The reports regarding pediatric cases have been scanty.

METHODS

A retrospective study was conducted to investigate the patients less than 18 years of age hospitalized at a medical center with a final diagnosis of peritonsillar abscess from January 1999 through December 2009. Only those who were confirmed by the drainage of pus from the peritonsillar spaces or confirmed by a computed tomography (CT) scan were enrolled.

RESULTS

In total, 56 children, 31 male and 25 female, were included. The mean age was 12.9 ± 4.6 years, ranging from 9 months to 17.9 years. Nineteen (34%) were less than 12 years of age. All 37 children ≧12 years of age complained of sore throat, but only 68% of children less than 12 years of age complained of sore throat. Thirty-one patients (55%) with a characteristic presentation of fever and sore throat plus an asymmetric swollen/bulging tonsil with or without uvular deviation suggestive of the diagnosis received surgical drainage at emergency department immediately, and 87% of them were older than 12 years of age. Twenty-five (45%) children needed a CT scan to confirm the diagnosis. The most common empirical antibiotics were penicillin-containing regimens. The predominant organisms identified were Streptococcus species. Eight children were treated successfully with antibiotics alone. No case was fatal.

CONCLUSION

Two-thirds of the children with peritonsillar abscess were ≥12 years of age. Not every patient <12 years of age had a characteristic presentation, and a CT scan was usually needed to confirm the diagnosis.

An evidence-based review of peritonsillar abscess

OBJECTIVE OF REVIEW

We present the current literature surrounding peritonsillar abscess management highlighting areas of controversy. TYPE OF REVIEW AND SEARCH STRATEGY: Literature review using Medline and Embase databases (search terms 'peritonsillar abscess', 'peritonsillar infection' and 'quinsy') limited to articles published from 1991 to 2011 (English language).

RESULTS

(i)

INVESTIGATIONS

Intraoral ultrasound has a sensitivity and specificity of between 89-95% and 79-100%, respectively, for correctly diagnosing peritonsillar abscess and is underutilised currently. (ii) Medical management: Steroids can effectively aid recovery, reducing hospitalisation time and improving symptom relief; however, further study is needed, especially related to risk and cost benefit. Penicillin and metronidazole are an effective combination in 98-99% of cases of peritonsillar abscess. (iii) Surgical management: Overall, there is no convincing evidence in favour of either aspiration or incision & drainage. Quinsy tonsillectomy is subject to great geographical variation, however, is a safe procedure and reduces overall recovery time when compared with interval tonsillectomy. (iv) Admission: peritonsillar abscess can be effectively managed as an outpatient in many cases. (v) Further management: Overall, the recurrence rate of peritonsillar abscess is poorly defined but estimated as 9-22% based on current evidence. Interval tonsillectomy may be indicated in selected groups of patients at high risk of recurrence.

CONCLUSIONS

Peritonsillar abscess is a common condition with increasing incidence. We demonstrate the potential for evidence-based modifications in clinical management. However, lack of national consensus may mean that this evidence base is not being adequately exploited in current practice. A national audit of peritonsillar abscess management, in particular looking at recurrence rates and patient experience with different management strategies, appears indicated.

Clinical practice guideline: tonsillectomy in children

OBJECTIVE

Tonsillectomy is one of the most common surgical procedures in the United States, with more than 530,000 procedures performed annually in children younger than 15 years. Tonsillectomy is defined as a surgical procedure performed with or without adenoidectomy that completely removes the tonsil including its capsule by dissecting the peritonsillar space between the tonsil capsule and the muscular wall. Depending on the context in which it is used, it may indicate tonsillectomy with adenoidectomy, especially in relation to sleep-disordered breathing. This guideline provides evidence-based recommendations on the preoperative, intraoperative, and postoperative care and management of children 1 to 18 years old under consideration for tonsillectomy. In addition, this guideline is intended for all clinicians in any setting who interact with children 1 to 18 years of age who may be candidates for tonsillectomy.

PURPOSE

The primary purpose of this guideline is to provide clinicians with evidence-based guidance in identifying children who are the best candidates for tonsillectomy. Secondary objectives are to optimize the perioperative management of children undergoing tonsillectomy, emphasize the need for evaluation and intervention in special populations, improve counseling and education of families of children who are considering tonsillectomy for their child, highlight the management options for patients with modifying factors, and reduce inappropriate or unnecessary variations in care.

RESULTS

The panel made a strong recommendation that clinicians should administer a single, intraoperative dose of intravenous dexamethasone to children undergoing tonsillectomy. The panel made a strong recommendation against clinicians routinely administering or prescribing perioperative antibiotics to children undergoing tonsillectomy. The panel made recommendations for (1) watchful waiting for recurrent throat infection if there have been fewer than 7 episodes in the past year or fewer than 5 episodes per year in the past 2 years or fewer than 3 episodes per year in the past 3 years; (2) assessing the child with recurrent throat infection who does not meet criteria in statement 2 for modifying factors that may nonetheless favor tonsillectomy, which may include but are not limited to multiple antibiotic allergy/intolerance, periodic fever, aphthous stomatitis, pharyngitis and adenitis, or history of peritonsillar abscess; (3) asking caregivers of children with sleep-disordered breathing and tonsil hypertrophy about comorbid conditions that might improve after tonsillectomy, including growth retardation, poor school performance, enuresis, and behavioral problems; (4) counseling caregivers about tonsillectomy as a means to improve health in children with abnormal polysomnography who also have tonsil hypertrophy and sleep-disordered breathing; (5) counseling caregivers that sleep-disordered breathing may persist or recur after tonsillectomy and may require further management; (6) advocating for pain management after tonsillectomy and educating caregivers about the importance of managing and reassessing pain; and (7) clinicians who perform tonsillectomy should determine their rate of primary and secondary posttonsillectomy hemorrhage at least annually. The panel offered options to recommend tonsillectomy for recurrent throat infection with a frequency of at least 7 episodes in the past year or at least 5 episodes per year for 2 years or at least 3 episodes per year for 3 years with documentation in the medical record for each episode of sore throat and 1 or more of the following: temperature >38.3°C, cervical adenopathy, tonsillar exudate, or positive test for group A β-hemolytic streptococcus.

[Bilateral peritonsillar abscess with lymph node abscess in a infant. A rare case]

Peritonsillar abscess (PTA) comprises approximately 30% of soft tissue head and neck abscesses. Bilateral occurrence in infants is rare. The present case demonstrates a bilateral peritonsillar abscess with a lymph node abscess in a 10.5-month-old infant without the typical clinical findings of PTA. This report highlights the importance of including peritonsillar abscesses in the differential diagnosis of abscess-forming cases of lymphadenitis colli refractory to therapy, even if the classical symptoms are absent. In individual cases, the indication for image-guided procedures to establish the diagnosis of PTA should be made generously.

Changing trends of peritonsillar abscess

OBJECTIVE

This retrospective, cohort study aims to assess the changing characteristics of peritonsillar abscess (PTA).

METHOD

Data were obtained from PTA patient records admitted to a secondary hospital over a 10-year period.

RESULTS

A total of 427 patients, aged 31.6 +/- 15.2 years (range, 3-91), were treated for PTA, reflecting an incidence of 0.9/10 000/y. Forty-seven (11%) patients had more than one episode. There was no sex, seasonal, or side predominance. Thirteen (3%) patients developed complications. One hundred four (24.4%) patients were 40 years or older, had a longer hospital stay, and were prone to complications. One hundred two (23.8%) patients did not have an anteceding pharyngotonsillitis. Smoking was more common among patients with PTA as compared with the general population and was associated with more complications. A total of 283 (66.2%) patients developed PTA in spite of prior antibiotic therapy; 51.1% of smokers that received prior antibiotics had a higher incidence of Streptococcus viridans isolates.

CONCLUSION

Peritonsillar abscess may have changed its characteristics: affecting more older patients having a worse and longer course and PTA evolvement without anteceding tonsillitis or in spite of a prior adequate antibiotic therapy. Smoking may be a predisposing factor.

Intracellular persisting Staphylococcus aureus is the major pathogen in recurrent tonsillitis

Background

The two major indications for tonsillectomy are recurrent tonsillitis (RT) and peritonsillar abscess (PTA). Unlike PTAs, which are primarily treated surgically, RT is often cured by tonsillectomy only after a series of failed drug therapy attempts. Although the bacteriological background of RT has been studied, the reason for the lack of success of conservative therapeutic approaches is not well understood.

Methods

In a prospective study, tonsil specimens from 130 RT patients and 124 PTA patients were examined for the presence of extra- and intracellular bacteria using antibiotic protection assays. Staphylococcus aureus isolates from RT patients were characterized by pulsed-field gel electrophoresis (PFGE), spa-typing and MSCRAMM-gene-PCR. Their ability for biofilm formation was tested and their cell invasiveness was confirmed by a flow cytometric invasion assay (FACS), fluorescent in situ hybridization (FISH) and immunohistochemistry.

Findings

S. aureus was the predominant species (57.7%) in RT patients, whereas Streptococcus pyogenes was most prevalent (20.2%) in PTA patients. Three different assays (FACS, FISH, antibiotic protection assay) showed that nearly all RT-associated S. aureus strains were located inside tonsillar cells. Correspondingly, the results of the MSCRAMM-gene-PCRs confirmed that 87% of these S. aureus isolates were invasive strains and not mere colonizers. Based upon PFGE analyses of genomic DNA and on spa-gene typing the vast majority of the S. aureus isolates belonged to different clonal lineages.

Conclusions

Our results demonstrate that intracellular residing S. aureus is the most common cause of RT and indicate that S. aureus uses this location to survive the effects of antibiotics and the host immune response. A German translation of the Abstract is provided as supplementary material (Abstract S1).

Peritonsillar abscess in children in the southern district of Israel

OBJECTIVE

Peritonsillar abscess is the most common deep neck infection and still provides a challenge to care givers in terms of diagnosis and treatment in the pediatric population. This study reviews our experience over the years 2004-2007 at the Soroka University Medical Center in the southern district of Israel in treating children with peritonsillar abscess. We compared our results with data regarding peritonsillar abscess in adults.

METHODS

We performed a retrospective chart review of 126 children diagnosed and proved to have a peritonsillar abscess. Data regarding: age, sex, ethnicity, number of patients per year, seasonality, prior history of tonsillar infection, prior antibiotic treatment, length of hospitalization, surgical treatment, bacterial results and in hospital antibiotic treatment was collected from the medical charts of the patients.

RESULTS

The average age of children with peritonsillar abscess was 12.8 years. 92 patients (73%) were above 10 years of age. We did not find an increase in the number of children with peritonsillar abscess per year over the time period of the study. The number of patients with peritonsillar abscess was significantly higher in the autumn and spring, 79 (62.6%) patients did not have prior history of tonsillar infections and 64 (67.4%) children were treated with antibiotics prior to the diagnosis of an abscess. In 95 (75.4%) patients the drainage method was needle aspiration, in 30 (28.3%) patients incision and drainage was performed and only one patient underwent bilateral quinsy tonsillectomy (0.8%). The bacterial culture was negative in 37 (36.7%) patients. In 29 patients (45% of positive cultures) the causative organism was Streptococcus group A. Mixed culture was present in 10 (15.6%) patients, nine cultures (14%) were positive for anaerobes, alone or in combination with other pathogens. Eighty-one patients (64.2%) were treated with amoxicillin-clavulanate potassium, 24 (19%) received cefuroxime and 17 (13.5%) were treated with cefuroxime+ metronidazole. The average hospital stay was 3 days.

CONCLUSION

Peritonsillar abscess, a potentially life threatening infection, is similar in presentation and bacteriology in the pediatric and the adult population. Based on our review we conclude that peritonsillar abscess in children can be effectively treated by the same methods used in the adult population.

Tonsillectomy in children

INTRODUCTION

Tonsillectomy is one of the most frequently performed surgical interventions in children. In the following, indications, preoperative evaluation, surgical techniques and postoperative complications will be discussed.

METHODS

Literature search in PubMed (National Library of Medicine) focusing on publications in German or English up to June 2008.

RESULTS

Indications are selected infectious diseases, upper airway obstruction for example due to tonsillar hypertrophy, and a suspected malignancy. Viral infections of the tonsils without upper airway obstruction are not an indication for surgery; in the case of acute bacterial tonsillitis, tonsillectomy is no longer recommended. In recurrent tonsillitis, tonsillectomy is only effective in specific and narrow indications. The indication for tonsillectomy in sleep-disordered breathing due to adenotonsillar hypertrophy has to be based on clinical assessment, medical history, and a sleep history. The most relevant risk factors are obstructive sleep apnea and coagulation disorders. A standardized history regarding hemostasis and bleeding is mandatory, and is superior to routine coagulation tests. Postoperative bleeding is still the most relevant complication of tonsillectomy and is always an emergency situation.

CONCLUSION

Tonsillectomy is one of the most frequently performed interventions in children but should be considered with care, as life-threatening complications can occur.

[Management of peritonsillar infections]

OBJECTIVE

To evaluate the clinical and epidemiologic characteristics in children with peritonsillar infections.

PATIENTS AND METHODS

A longitudinal retrospective study was performed through a review of the clinical histories of patients attending the emergency unit in the previous 6 years. The variables gathered were age, sex, recurrent tonsillitis, previous upper airway infection, antibiotic administration, and therapeutic approach.

RESULTS

Twenty-nine children were admitted, with a mean age of 7.4 +/- 1.6 years (boys 1.6:1). Twenty-seven percent had recurrent tonsillitis. At the visit, 57.8 % had an upper respiratory infection and 65 % were taking antibiotic treatment, especially macrolides. The treatment selected at our center consisted of the association of penicillin or amoxicillin-clavulanate acid with clindamycin, including corticosteroids. Ten children underwent computed tomography and nine underwent fine-needle aspiration. Drainage was performed in 20.6 % of confirmed abscesses. The mean length of hospital stay was 5.6 +/- 1.6 days. Delayed tonsillectomy was performed in 31 %, except in one patient who developed a parapharyngeal abscess. Currently, 18.9 % of all peritonsillar infections occur in the pediatric population.

CONCLUSIONS

The increase in these infections is probably related to inappropriate use of antibiotics in respiratory diseases. Diagnosis is clinical, and infections are often resolved by intravenous administration of beta-lactams with clindamycin and an expectant attitude. When an abscess is suspected or there is no clinical improvement, fine-needle aspiration or computed tomography is warranted and drainage should be performed if an abscess is confirmed. Tonsillectomy, usually delayed, is only indicated in patients with recurrent tonsillitis.

Peritonsillar abscess in a 40-day-old infant

A peritonsillar abscess is one of the most commonly occurring deep space infections of the head and neck in adults and children. A peritonsillar abscess that appears in newborns, however, is extremely rare. The treatment of a peritonsillar abscess requires both the selection of appropriate antibiotics and the best procedure to remove the abscessed material. We report a case of a peritonsillar abscess in a 40-day-old infant who was treated with antibiotic therapy alone.