An evidence-based review of peritonsillar abscess

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

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

Effectiveness of antibiotic therapy for early recurrence of peritonsillar cellulitis and abscesses: A retrospective cohort study

OBJECTIVE

Short-term recurrence is common in patients with peritonsillar cellulitis and abscesses, leading to socioeconomic problems. Early switching from intravenous to oral antibiotics is feasible for treating certain diseases. However, reports on early switching and total antibiotic administration duration in peritonsillar cellulitis and abscesses are limited. This study aimed to determine the appropriate antibiotic therapy duration and examine the impact of early oral switch therapy on peritonsillar cellulitis and abscesses.

METHODS

We retrospectively identified 98,394 patients who received antibiotic therapy during hospitalization for peritonsillar cellulitis and abscesses between July 1, 2010, and December 31, 2019, using the Japanese Diagnosis Procedure Combination database.

RESULTS

Propensity score matching analysis revealed no significant between-group difference in the rehospitalization rate (early oral switch therapy and long intravenous therapy: 1.7 % [198 of 11,621] vs. 2.0 % [234 of 11,621], odds ratio [OR] 0.84, 95 % confidence interval [CI] 0.70-1.02). A long total duration of antibiotic therapy (reference: 1-9 days) was associated with a low risk of rehospitalization (10-14 days: OR 0.86, 95 % CI 0.78-0.95; 15+ days: OR 0.51, 95 % CI 0.38-0.66).

CONCLUSION

Early oral switch therapy may be a viable option for treating patients with peritonsillar cellulitis and abscesses in good condition who can tolerate oral intake. No less than 10 days of antibiotic therapy is desirable.

Recurrent Peritonsillar Abscess Caused by Vaginal Flora: A Common Problem From a Unique Source

Peritonsillar abscesses (PTAs) are typically caused by group A Streptococcus or mixed oral flora. Gardnerella vaginalis is a part of the normal vaginal microbiome, and overgrowth can cause bacterial vaginosis. We present a case of recurrent PTA with G. vaginalis superinfection, which occurred after the patient performed oral sex on a female after incision and drainage of her initial PTA. The patient continued to have recurrent PTAs until G. vaginalis was identified, and antibiotic coverage was broadened to cover both group A Streptococcus and G. vaginalis. This case highlights the importance of culturing PTA aspirate for directed antibiosis in persistent or recurrent infections. The rare superinfection also raises the question of advising abstinence from oral-genital contact after oral procedures to minimize risk of superinfection.

Anatomical Factor for Formation of Peritonsillar Abscess in a Tertiary Care Centre

Peritonsillar abscess is a polymicrobial infection with acute life threatening complications if not treated promptly. Primary objective is to find the anatomical factor for unilateral abscess formation and appropriate management protocols. Secondary objectives include the bacteriological study,antibiotic preference and comparison of crypt length of both tonsils post tonsillectomy to look for any significant association. A prospective study was carried out for one year in patients with peritonsillitis or peritonsillar abscess attending the Department of ENT in our hospital. Acute cases were treated by incision and drainage followed by IV antibiotics after taking pus or throat swab for culture and sensitivity. Patients further planned for interval tonsillectomy after 6 weeks followed by histopathological examination to compare the infected side and normal side. Crypt length measurements done to see any disparity which would have lead to the development of peritonsillar abscess unilaterally. In patients with peritonsillitis or peritonsillar abscess, histopathological examination of tonsils after interval tonsillectomy showed that risk of peritonsillitis or peritonsillar abscess were more on the tonsil with larger crypt length with more preponderance on left side and in males. This study concludes that deeper the crypt length,male sex, history of recurrent tonsillitis are main risk factors for development of peritonsillar abscess. Bacteriology showed Staphylococcus aureus against the most common Streptococcus Sp. Hence prompt use of antibiotics help in early recovery and reducing complications.

CT-guided transcutaneous drainage of peritonsillar abscess after failed ultrasound-guided drainage: A case report

Peritonsillar abscess (PTA) is the most common deep neck infection in the United States. Timely treatment of PTA with antibiotics and aspiration or drainage is paramount, as delay in management may lead to further complications. The oral approach is the preferred route of drainage however may not always be accessible, warranting consideration of other routes of drainage. To the best of our knowledge, CT guidance for aspiration or drainage of a PTA has not been previously described. We present a 50-year-old patient with a PTA who initially presented with throat pain and dysphagia, rapidly developed upper airway obstruction, and required intubation. After the failure of clinical improvement and unsuccessful PTA aspiration via the conventional oral route, successful CT-guided percutaneous needle aspiration was performed by neuroradiology. Shortly thereafter, the patient clinically improved and was discharged with an oral course of antibiotics and follow-up on an as-needed basis. Total hospital length of stay was seven days. The complex patient may not allow for simple incision and drainage or needle aspiration of a suspected PTA. Assistance with ultrasound guidance is often utilized, however, challenges may persist depending on the anatomical location of the PTA and patient comorbidities. In cases where external drainage is considered and conventional ultrasound imaging is particularly challenging, CT-guided percutaneous aspiration may provide a useful alternative. PTAs are common with the possibility of complication. Although the usual route of drainage is oral, there are instances in which this cannot be performed. This case exhibits an uncommon approach to PTA aspiration via an external CT-guided percutaneous approach with rapid subsequent clinical improvement, exhibiting the utility of CT guidance.

[The normal sonographic picture of the paratonsillar region and the prerequisites for ultrasound diagnosis of purulent pathology of the pharynx]

Paratonsillar abscess (PTA) stands out among all otorhinolaryngological diseases, since it can cause life-threatening complications that develop in the shortest possible time due to the close connection of the cellular spaces of the head, neck and mediastinum. In addition to physical examination, computed tomography and magnetic resonance imaging are routinely used to diagnose PTA, sonography is less often used. With the help of the latter, it is possible to reliably distinguish PTA from both paratonsillitis and a number of other diseases, including an aneurysm of the internal carotid artery, using the Doppler mode. However, there are significant gaps in the ultrasound diagnosis of PTA and paratonsillitis: the use of a percutaneous convex sensor is not described, there is no description of clear anatomical landmarks for reliable and rapid recognition of PTA, and diagnostically complete algorithms for verification and visualization of paratonsillitis and PTA using sonographic examination have not been developed. Our work is aimed at filling these gaps.

[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.

Unveiling the etiology of peritonsillar abscess using next generation sequencing

BACKGROUND

Peritonsillar abscess (PTA) is a severe deep neck space infection with an insufficiently characterized bacterial etiology. We aimed to reveal the bacteria associated with PTA applying next generation sequencing (NGS). Tonsil biopsies and pus samples of 91 PTA patients were analysed applying NGS method.

RESULTS

Over 400 genera and 800 species belonging to 34 phyla were revealed. The most abundant species in both sample types were Streptococcus pyogenes, Fusobacterium necrophorum and Fusobacterium nucleatum. When present, S. pyogenes was normally a predominant species, although it was recovered as a minor population in some samples dominated by F. nucleatum and occasionally F. necrophorum. S. pyogenes and F. necrophorum were the predominant species (> 10% in a community) in 28 (31%) pus samples, while F. nucleatum in 21 (23%) and S. anginosus in 8 (9%) pus samples. We observed no substantial differences between the microbial findings in pus and tonsil biopsies.

CONCLUSIONS

The most probable causative agents of PTA according to our NGS-study include Streptococcus pyogenes, Fusobacterium necrophorum and Fusobacterium nucleatum. Some other streptococci (S. anginosus) and anaerobes (Prevotella, Porphyromonas) may contribute to the infection as well. Pus of the peritonsillar abscess is more representative specimen for microbiological examination than the tonsillar tissue. Our results are important in the context of optimizing the handling of the PTA patients.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Use of Needle Guide for Dynamic Real-Time Ultrasound-Directed Aspiration of Peritonsillar Abscess in the Emergency Department: A Case Series

BACKGROUND

Needle aspiration is a common treatment of peritonsillar abscess (PTA). Point-of-care ultrasound (POCUS) can be used to guide this procedure. We describe our experience using a commercially available needle guide attached to an endocavitary ultrasound probe for dynamic real-time POCUS-guided PTA needle aspiration.

DISCUSSION

A convenience sample of patients were treated using the needle guide. The primary author (Peter Kumasaka) performed or supervised emergency medicine residents and physician assistants (PAs) for each case in which the needle guide was used. The electronic medical records were abstracted for procedure success, various length of stay (LOS) data, and to determine use of computed tomography imaging and otorhinolaryngologist (ENT) consultation. Dynamic POCUS-guided needle aspiration using the needle guide (DNG) was performed on 8 patients. There were no unexpected return visits to the emergency department (ED) or to the ENT clinic for any of the patients. The median time to perform DNG was 9 min (range 8-17 min). Median LOS was 182 min (range 78-287 min). Median time from POCUS order to patient discharge was 82.5 min (range 66-237 min). Median time from starting procedure to discharge was 43 min (range 18-148 min).

CONCLUSIONS

The needle guide is a useful adjunct to assist in PTA drainage. It provided rapid, safe, and efficient care. Additional research is needed to see how this technique compares with more traditional methods of PTA drainage.

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

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

The Use of Flexible Rhinolaryngoscopy for Allergy-Immunology Practice

Flexible rhinolaryngoscopy is an underused procedure that can provide allergists-immunologists and other physicians with several benefits over existing imaging techniques. In this article, we highlight the many benefits of flexible rhinolaryngoscopy and expand on its safety, cost-effectiveness, and convenience. This article also covers current procedure techniques and assesses the most common indications and relevant clinical findings for which flexible rhinolaryngoscopy can be used to evaluate the nasopharyngeal tract. Videos for the clinician showing some of the most common findings are included.

Trends in Emergency Department Computed Tomography Usage for Diagnosis of Peritonsillar Abscess

OBJECTIVES

Peritonsillar abscess (PTA) is the most common deep neck space infection and a frequent cause for otolaryngology consultation. Patients often undergo computed tomography (CT) scan for confirmation in addition to physical examination. Our aims were to determine whether patients unnecessarily undergo CT scans in the emergency department (ED) when presenting with sore throat and identify physical examination characteristics that predict PTA.

METHODS

The electronic medical records of all patients (>18 years) presenting to an ED between June 2014 and June 2015 with a primary diagnosis of acute pharyngitis, acute tonsillitis, or PTA were reviewed for presenting symptoms and diagnostic imaging use.

RESULTS

Four hundred eight patients met inclusion criteria; 21 were diagnosed with PTA, including 13 based on history and physical alone. A total of 21 CT scans were ordered, 11 (52.3%) of which did not demonstrate abscess. Soft palatal fullness, uvular deviation, drooling, and muffled voice were all significantly associated with increased CT usage (all P values <.02). Rising subjective pain scores were associated with increased use of CT imaging (P = .029). Multivariable analyses revealed that soft palatal fullness, uvular deviation, and drooling were all significant predictors of PTA (all P values <.001).

CONCLUSIONS

Patients with severe symptoms of PTA, including uvular deviation, drooling, and soft palatal fullness, were most likely to undergo CT imaging. Given the high likelihood of PTA, patients presenting with these symptoms could forego CT imaging, reducing exposure to ionizing radiation.

[The role of tonsillectomy in the treatment of chronic tonsillitis]

The problem of chronic tonsillitis remains one of the urgent problems of modern otorhinolaryngology. The article discusses the statistics and complications of chronic tonsillitis, provides indications for tonsillectomy and its main complications.

OBJECTIVE

Generalization and systematization of data on the impact of surgical treatment on the quality of life of patients with chronic tonsillitis.

MATERIAL AND METHODS

Search for literary sources, carried out using the search engines of the RSCI, PubMed, Web of Science, and eLibrary.

RESULTS

A review of literature sources demonstrates a significant improvement in the quality of life of patients after tonsillectomy; however, data from some studies show a trend towards a decrease in the number of planned tonsillectomies and an associated increase in the detection of local purulent-septic complications.

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

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

Parapharyngeal and floor‐of‐mouth abscess secondary to tonsillar phlegmon: A rare and unusual cause of Ludwig's angina

We present an unusual case of Ludwig's angina secondary to a left tonsillar phlegmon in a previously fit and well 50‐year‐old woman. This tonsillar phlegmon spread along the peritonsillar/parapharyngeal plane to cause a diffuse cellulitis and collection in the submental, sublingual, and submandibular spaces despite empirical intravenous antibiotic therapy.

Peritonsillar abscess caused by Prevotella bivia during home quarantine for coronavirus disease 2019: Case report

RATIONALE

Since late 2019, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) had rapidly spread worldwide, resulting in a pandemic. Patients with coronavirus disease 2019 (COVID-19) have difficulty in visiting clinics in person during pandemic because they might be encouraged to quarantine at home with supportive care. Peritonsillar abscess rarely coexists with COVID-19; however, patients with SARS-CoV-2 infection could get co-infections or become superinfected with other microorganisms which could cause peritonsillar abscess. We herein describe a case of peritonsillar abscess caused by Prevotella bivia that occurred as a co-infection with COVID-19 during home quarantine.

PATIENT CONCERNS

A 32-year-old Asian woman who was diagnosed with COVID-19 was instructed to stay home for quarantine. Her pharyngeal discomfort worsened, and she experienced trismus and dysphagia. An emergent visiting doctor referred her to our hospital. Contrast-enhanced computed tomography showed peritonsillar abscess findings, following which we referred her to an ear, nose, throat specialist. Prevotella bivia was identified on needle aspiration pus culture; however, two sets of blood and throat cultures were negative.

DIAGNOSIS

A definitive diagnosis of acute COVID-19 and peritonsillar abscess due to Prevotella bivia was made.

INTERVENTIONS

An antibiotic drug, antiviral drug, and adjunctive steroid were administered intravenously.

OUTCOMES

Her symptoms improved without the need for incision and drainage, and she was discharged on day 7.

CONCLUSION

Patients with suspected peritonsillar abscess should be triaged and referred to ear, nose, throat specialists appropriately. Scoring systems, such as modified Liverpool peritonsillar abscess score or the guidelines criteria might be useful tools to triage patients. During the early phase of SARS-CoV-2 infection, administration of corticosteroids is not recommended. When adjunctive steroids are considered for peritonsillar abscess, prior to or simultaneous use of the antiviral agent remdesivir for COVID-19 might be recommended.

Peritonsillar Abscess Simulator: A Low-Cost, High-Fidelity Trainer

Audience

Our reusable low-cost peritonsillar abscess simulator (PTA) simulator is designed to train emergency medicine (EM) residents, fellows, and medical students. Trainees who are interested in otolaryngology (OTL) or this specific disease may also benefit from this simulator.

Introduction

Peritonsillar abscess is one of the most common deep infections 1 of the head and neck, accounting for 7589 consultations and 11069 hospital bed days in the UK between 2009-2010.1,2 Emergency medicine physicians commonly treat this pathology with surgical and medical modalities. Not only is this a common diagnosis, but there is a significant cost associated with the evaluation and management of primary PTA. 3Demands for high-volume patient care and good patient outcomes are increasing in a medical climate of limited financial resources and resident work hours. Given these complexities, medical education is viewing simulation training, with proven success in various surgical specialties, as a valuable addition to resident education and patient safety. 3-5The PTA is the collection of pus in the space between the palatine tonsil and its capsule. Successfully locating the abscess is crucial because it prevents the unwanted damage of nearby vascular structures, patient discomfort, and failure to treat the infection. Management of peritonsillar abscess is primarily surgical and includes incision and drainage (I & D), needle aspiration, or Quinsy tonsillectomy.The simulator provides a realistic characteristic of typical PTA presentations, such as uvula deviation, swelling, trismus, and purulence during aspiration. While learning to drain a PTA, trainees must locate the infection with a needle without injury to the surrounding structures of the oral cavity and deep structures of the neck. The discomfort caused during this procedure can be unsettling for both physician and patient. Simulation use and testing enable the trainee to develop familiarity with handling instruments, increase comfort with the sequence of a procedure, and improve confidence in the ability to perform a procedure safely.6,7,8 Simulators provide improved patient outcomes and increased EM residents' comfort level.

Educational Objectives

By the end of this training session, learners will be able to: 1) locate the abscess, 2) perform needle aspiration, and 3) develop dexterity in maneuvering instruments in the small three-dimensional confines of the oral cavity without causing injury to local structures.

Educational Methods

Our PTA simulator was fabricated with a low-cost, non-degradable material and is the first known PTA simulator that used a validated survey for fidelity assessment. The simulator was fabricated using a silicone mold to mimic the oral cavity and oropharynx. A simulated abscess pocket consisting of saline encased in balloon material was placed in the proper anatomic location, allowing for abscess simulation on either side of the oropharynx model. The time to fabricate the model averaged 20 hours. The simulator was manufactured with low-cost materials at an expense of 45 USD and could be easily reproduced by any EM residency program.

Research Methods

Twenty-one participants were instructed to expose and drain the simulated abscess. The model was evaluated using The Michigan Standard Simulation Experience Scale (MiSSES).7 Participants scored the simulator in five categories: Self-efficacy, fidelity, educational value, teaching quality, and the overall rating on a 5-point Likert scale of simulator. Overall rating and global evaluation scores were compared by groups (Group 1, Group 2) between training level (residents and attendings), specialty (emergency and otolaryngology), and previous experience (<5 or ≥5 drainages).Convenience sampling was used to determinate the sample. Variables were summarized using the mean and standard deviation for continuous variables and percentages and frequencies for categorical variables. The MiSSES was scored as previously described in the literature.7 The Kolmogorov-Smirnov test was used to test for normal distribution of the variables. T-test for independent samples was performed to determinate if there exists a difference between groups in perception of a PTA simulator. The statistical analyses were performed using SPSS version 20.0 Armonk, NY: IBM.

Results

Twenty-one participants were enrolled in the study: residents (n=15) and attending (n=6) from OTL and EM departments. The simulator's plasticity allowed multiple attempts of needle aspiration and drainage without degradation and received high ratings on teaching quality, fidelity, and educational value. This PTA simulator achieved high fidelity ratings in the standard simulator's assessment survey for realism of environment, simulation of trismus, uvular deviation, and realism of the mucosal surfaces. On the MiSSES, the model received positive ratings (range 3.6 to 4.9). The highest rating was on teaching quality (4.9), fidelity (4.6), and educational value (4.5) (Table 1). We found that self-efficacy and teaching quality sections were rated higher for those who had less experience (≥5 PTA drainage), while fidelity was rated higher for OTL. The overall rating average was 4 and was higher of attendings, OTL, and those with less experience. All comparisons between groups were not statically significant (Table 2). About 76% of participants found that the simulator can be used in training with slight improvement or no improvement needed. (Table 3).

Discussion

With favorable participant ratings and comments, we believe that this tool can offer high-fidelity simulation at a low cost. Widespread use may be possible, allowing training of EM residents in performing instrumentation of PTA in a controlled simulation environment. We have created a reusable low-cost PTA simulator that achieved a high score fidelity in a standard simulator's assessment survey.

Topics

Peritonsillar abscess, oropharynx, emergency medicine residency, otolaryngology residency training.

[Modern approaches to the surgical treatment of chronic tonsillitis]

At the moment, all over the world there are a large number of various methods of surgical treatment of chronic tonsillitis. In particular: classical tonsillectomy, cryosurgical method for removing the palatine tonsils, shaver tonsillectomy, monopolar and bipolar tonsillectomy, tonsillectomy with an ultrasonic scalpel, bipolar dissection using cutting instruments, laser tonsillectomy, coldablation. This article analyzes the existing methods, describes the fundamental technique for their implementation, as well as their advantages and disadvantages. Given the abundance of various surgical approaches to the treatment of chronic tonsillitis, there is a need for studies aimed at comparative study of their clinical and microbiological efficacy, including the postoperative period.

Management of Peritonsillar Abscesses in Adults: Survey of Otolaryngologists in Canada and the United States

Objective

The management of peritonsillar abscess (PTA) has evolved over time. We sought to define contemporary practice patterns for the diagnosis and treatment of PTA.

Study Design

Cross-sectional survey.

Setting

The 15-question survey was distributed to members of the Canadian Society of Otolaryngology–Head and Neck Surgery (CSO) and the American Academy of Otolaryngology–Head and Neck Surgery (AAO-HNS).

Methods

An iterative, consensus-based process was used for survey development. Primary outcomes were to determine methods of diagnosis and first-line treatments for PTA. Exploratory, secondary outcomes were analyzed using multivariable logistic regression models.

Results

The survey response rate was 12.6% (n = 1176). Most participants were attending staff (86%) in a community hospital setting (60%) and had been in practice for more than 20 years (38%). Most respondents (78%) indicated that at least half of the time, cross-sectional imaging had already been performed before they were consulted. Half of respondents (49%) indicated that they perform incision and drainage of the abscess as first-line treatment, while few (16%) provide medical management alone. In exploratory analysis, participants from the AAO-HNS had higher odds of imaging already being performed before consultation (odds ratio [OR], 11.7; 95% CI, 4.6-29.4) and increased odds of using medical management alone as a first-line treatment (OR, 2.4; 95% CI, 1.3-4.2) compared to respondents from the CSO.

Conclusion

There is wide practice variation in the diagnosis and management of acute, uncomplicated PTA among otolaryngologists in Canada and the United States. The use of cross-sectional imaging and medical management alone may differ between countries of practice.

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

PURPOSE

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSIONS

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

High Risk of Peritonsillar Abscess in End-Stage Renal Disease Patients: A Nationwide Real-World Cohort Study

Background: Peritonsillar abscess (PTA) is an infectious emergency in the head and neck, and patients with end-stage renal disease (ESRD) have an immunocompromised status. However, no relevant research has focused on the ESRD–PTA relationship. This study explored PTA in ESRD patients and their prognosis. Methods: We identified 157,026 patients diagnosed as having ESRD over January 1997 to December 2013 from Taiwan’s National Health Insurance Research Database (NHIRD). Each patient with ESRD (hereafter, patients) was matched with one control without chronic kidney disease (CKD; hereafter, controls) by sex, age, urbanization level, and income. Next, PTA incidence until death or the end of 2013 was compared between the two groups, and the relative risk of PTA was analyzed using a multiple logistic regression model. Results: The patients had a significantly higher PTA incidence than did the controls (incidence rate ratio: 2.02, 95% confidence interval [CI]: 1.40–2.91, p < 0.001). The Kaplan–Meier analysis revealed that the patients had a higher cumulative incidence of PTA than did the controls (p < 0.001). In Cox regression analysis, the patients had nearly twofold higher PTA risk (adjusted hazard ratio [HR]: 1.98, 95% CI: 1.37–2.86, p < 0.001). The between-group differences in the PTA-related hospital stay length (8.1 ± 10.3 days in patients and 5.7 ± 4.6 days in controls, p = 0.09), consequent deep-neck infection complication (4.2% in patients and 6.3% in controls, p = 0.682), and mortality (0.0% in both groups) were nonsignificant. Conclusions: Although ESRD does not predict a poor prognosis of PTA, it is an independent PTA risk factor.

Methanobrevibacter smithii tonsillar phlegmon: a case report

Untreated tonsillar phlegmon is a life-threatening condition commonly caused by Streptococcus pyogenes and Fusobacterium necrophorum, among other pathogens. Here, using specific laboratory tools, we detected Methanobrevibacter smithii in addition to S. pyogenes. This unprecedented observation questions the role of methanogens in phlegmon and the optimal treatment of this mixed infection.

The Surgical Treatment of Peritonsillar Abscess: A Retrospective Analysis in 584 Patients

OBJECTIVES

There are three surgical treatment options for patients with peritonsillar abscess (PTA): needle aspiration, incision and drainage (ID), and abscess tonsillectomy (ATE). The updated German national guideline (2015) included changes in the treatment of PTA. The indication for tonsillectomy (TE) in patients became more stringent and preference was given to ID in certain cases.

STUDY DESIGN

Retrospective analysis.

METHODS

We performed a retrospective systematic analysis of patient data using the in-house electronic patient records and considered a 4-year period from 2014 to 2017. About 584 patients were identified. Our aim was to analyze the influence of the updated guideline on clinical practice.

RESULTS

236 of 584 patients (40.4%) underwent ATE with contralateral TE. In 225 patients (38.5%), unilateral ATE was performed. Mean surgery time was significantly shortened when only unilateral ATE was performed. Concerning postoperative bleeding, we noted a tendency toward a lower incidence after ATE in comparison to ATE with contralateral TE. Less than 1% of patients who underwent ATE had to be revised surgically due to postoperative hemorrhage. After the revision of the guideline, unilateral ATE and ID were conducted more frequently.

CONCLUSION

These results support that ATE in an inpatient setting is a considerably safe and effective primary therapeutic option. ID represents a favorable treatment option for patients with PTA and comorbidities, nevertheless, patient compliance is required and insufficient drainage or recurrence of PTA may occur. The revision of the guideline had a significant impact on the choice of interventions (P < .001), which is reflected by the increased number of unilateral ATE.

LEVEL OF EVIDENCE

IV Laryngoscope, 2021.

[Sonography of the head and neck area - Part 1: Endosonography]

Sonography of the head and neck area plays a major role in both outpatient and inpatient ear, nose and throat medicine. Transcervical ultrasound is an important imaging method, especially in lymph node and tumor diagnostics. Its advantage is the ubiquitous availability and the excellent combinability with endoscopy and palpation. Despite decades of experience with sonography in the head and neck area, in contrast to the transcutaneous application, the transoral or endosonographic approach has so far not been widely used. Here it is often not due to the technical capabilities of the examiner, but rather to the unusual approach within the scope of the investigation. In this context, endosonography may be used primarily in tumor diagnostics in order to establish a complete sonographic examination from in- and outside.

Improving the management of suspected tonsillitis and peritonsillar abscess referred to ENT - a coronavirus disease 2019 service improvement

Background

The impact of coronavirus disease 2019 on healthcare has led to rapid changes in otolaryngology service provisions. As such, new standard operating procedures for the management of suspected tonsillitis or quinsy were implemented in our centre.

Methods

A retrospective audit was performed of acute referrals to ENT of patients with suspected tonsillitis, peritonsillar cellulitis or quinsy, during the 10 weeks before (group 1) and 10 weeks after (group 2) implementation of the new standard operating procedures.

Results

Group 2 received fewer referrals. Fewer nasendoscopies were performed and corticosteroid use was reduced. The frequency of quinsy drainage performed under local anaesthetic increased, although the difference was not statistically significant. Hospital admission rates decreased from 56.1 to 20.4 per cent, and mean length of stay increased from 1.13 to 1.5 days. Face-to-face follow up decreased from 15.0 to 8.2 per cent, whilst virtual follow up increased from 4.7 to 16.3 per cent. There were no significant differences in re-presentation or re-admission rates.

Conclusion

Management of suspected tonsillitis or quinsy using the new standard operating procedures appears to be safe and effective. This management should now be applied to an out-patient setting in otherwise systemically well patients.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Utility of Smartphone Telemedical Consultations for Peritonsillar Abscess Diagnosis and Triage

Importance

Telemedicine is rapidly gaining traction as a way to reduce costs and connect patients with medical experts outside their local communities. Peritonsillar abscess (PTA) is a logical pathologic condition to evaluate for effectiveness of remote diagnosis given its prevalence and the paucity of on-site otolaryngologists at many institutions.

Objective

To explore the potential of otolaryngology telemedical consultation in triaging and diagnosing patients with suspected PTA.

Design, Setting, and Participants

A comparative effectiveness research study was conducted from January 1 to June 30, 2018, at 3 tertiary care hospitals among 31 consecutive patients aged 18 to 85 years for whom the otolaryngology department was consulted to assess for PTA. Statistical analysis was conducted from July 1 to September 30, 2018.

Interventions

Telemedical evaluation of suspected PTA by 5 attending otolaryngologists blinded to patients' history aside from the chief report of odynophagia. Otolaryngologists rated each patient video on whether they believed the patient had a PTA and whether the case warranted prompt evaluation by an otolaryngologist. Predictions were compared with the criterion standard of drainage or negative needle aspiration. Otolaryngologists additionally assessed video quality.

Main Outcomes and Measures

Rates of accurate diagnosis and triage of PTA based on otolaryngologists' review of oropharyngeal examinations recorded using standard smartphone cameras, as well as percentage of videos of oropharyngeal examinations using standard smartphone cameras deemed of sufficiently high quality for clinical decision-making.

Results

A total of 31 patients (16 women [51.6%]; mean age, 31.9 years [range, 18-62 years]) were recruited, and 16 patients (51.6%) had a PTA. Comparing otolaryngologists' predictions with PTA status by the criterion standard, the prediction was consistent with that of the criterion standard 81% of the time averaged across otolaryngologists (mean diagnostic accuracy, 0.81). Similarly, the mean diagnostic accuracy was 0.83 when comparing the otolaryngologist's suggestion for a prompt in-person evaluation with actual PTA status by the criterion standard. Comparing patients who were deemed to require prompt otolaryngology evaluation and those with PTA by the criterion standard, mean sensitivity was 90%. Videos were rated as of sufficiently high quality to make a diagnosis in 154 of 155 videos (99.4%).

Conclusions and Relevance

This study suggests that telemedical consultation is a viable, cost-conscious, efficient, and safe approach to PTA management. Despite having some difficulty diagnosing PTAs based on "history concerning for PTA" and oropharyngeal video alone, otolaryngologists are able to determine, with high sensitivity, which patients require prompt otolaryngology evaluation. The recording of consistently high-quality video using a standard smartphone camera is achievable without formal training.

Patients with comorbid rheumatoid arthritis are predisposed to peritonsillar abscess: real-world evidence

PURPOSE

The peritonsillar abscess (PTA)-rheumatoid arthritis (RA) association remains unclear. Here, the effects of RA on PTA incidence and prognosis are elucidated.

METHODS

We compared PTA incidence and prognosis of 30,706 RFCIP-registered patients with RA (RA cohort) with matched individuals without RA from another database of 1 million randomly selected people representing Taiwan's population (non-RA cohort).

RESULTS

The RA cohort had significantly higher PTA incidence [incidence rate ratio (IRR) (95% CI) 1.73 (1.10-2.71), P = 0.017) and cumulative incidence (P = 0.016, Kaplan-Meier curves). Cox regression analyses demonstrated RA cohort to have an estimated 1.72-fold increased PTA risk (95% CI 1.09-2.69, P = 0.019). PTA was more likely within the first 5 years of RA diagnosis (for < 1, 1-5, and ≥ 5 postdiagnosis years, IRRs: 2.67, 2.31, and 1.10, respectively, and P = 0.063, 0.021, and 0.794, respectively; average onset duration: 4.3 ± 3.3 years after RA diagnosis). PTA increased length of hospital stay significantly and risk of complication with deep neck infection nonsignificantly [6.5 ± 4.5 vs 4.6 ± 2.8 days (P = 0.045) and 18.52% vs 7.81% (P = 0.155), respectively]. Moreover, RA-cohort patients not receiving RA therapy exhibited 5.06-fold higher PTA risk than those receiving RA-related therapy (95% CI 1.75-14.62, P = 0.003).

CONCLUSIONS

In patients with RA, PTA incidence is the highest within 5 years of RA diagnosis, and RA therapy is essential for reducing PTA risk.

LEVEL OF EVIDENCE

4.

Antibiotics in treatment of peritonsillar infection: clindamycin versus penicillin

OBJECTIVE

This study aimed to compare antibiotic treatment with clindamycin versus penicillin V or G in terms of time to recovery and recurrence in patients with peritonsillar infection, including both peritonsillar cellulitis and peritonsillar abscess.

METHOD

This retrospective cohort study examined the records of 296 patients diagnosed with peritonsillar infection. Based on the ENT doctor's choice of antibiotics, patients were divided into clindamycin and penicillin groups.

RESULTS

Mean number of days in follow up was 3.5 days in the clindamycin group and 3.4 days in the penicillin group. The recurrence rate within 2 months was 7 per cent in the clindamycin group and 4 per cent in the penicillin group.

CONCLUSION

This study found no significant differences in either recovery or recurrence between the groups. This supports the use of penicillin as a first-line treatment, considering the greater frequency of adverse effects of clindamycin shown in previous studies, as well as its profound collateral damage on the intestinal microbiota, resulting in antibiotic resistance.

Type 2 Diabetes Mellitus Increases Peritonsillar Abscess Susceptibility: Real-World Evidence

Objectives

Type 2 diabetes mellitus (T2DM) is a risk factor for deep neck infection (DNI) and leads to complications and poor outcomes. Our study aimed to investigate the risk, prognosis, and complications of peritonsillar abscess (PTA) in patients with T2DM.

Methods

We extracted data of patients newly diagnosed as having T2DM between January 2000 and December 2011 from Taiwan’s National Health Insurance Research Database. These patients were matched with patients without T2DM, and PTA incidence was compared between both cohorts.

Results

In total, 67,852 patients with and 135,704 patients without T2DM were enrolled. PTA incidence was significantly higher in patients with T2DM (incidence rate ratio, 1.91; P<0.001); moreover, PTA incidence was higher at 1 to 5 years after T2DM diagnosis than at <1 and >5 years after T2DM diagnosis. Cox regression analysis showed that patients with T2DM had an approximately 2-fold higher PTA risk (adjusted hazard ratio [aHR]: 1.89, P<0.001). Patients with a higher adapted Diabetes Complications Severity Index (aDCSI) had higher PTA risk than those with a lower aDCSI (aHRs: 2.17 for aDCSI ≥1, P=0.006 and 1.81 for aDCSI=0, P=0.002). T2DM patients with a high aDCSI (≥1) had a nonsignificantly longer hospitalization duration and a higher rate of DNI complications than did those with a low aDCSI (=0).

Conclusion

In patients with T2DM, PTA incidence was relatively high, and it increased with T2DM severity. Moreover, T2DM patients should be particularly careful about PTA within 1 to 5 years after the diagnosis, and physicians should keep in mind that the prognosis of PTA was correlated with T2DM severity.

Abscess Management: An Evidence-Based Review for Emergency Medicine Clinicians

BACKGROUND

Abscesses are commonly evaluated and managed in the emergency department. Recent research has evaluated the use of ultrasonography, packing, incision and drainage (I&D), and antibiotics. There are evidence-based nuances to the management of specific types of abscesses, such as Bartholin, breast, dental, hidradenitis suppurativa, peritonsillar, and pilonidal abscesses.

OBJECTIVE

This review provides emergency medicine clinicians with a summary of the current literature regarding abscess management in the emergency department.

DISCUSSION

Ultrasound is valuable in diagnosing abscesses that are not clinically evident and in guiding I&D procedures. Although I&D is traditionally followed by packing, this practice may be unnecessary for small abscesses. Antibiotics, needle aspiration, and loop drainage are suitable alternatives to I&D of abscesses with certain characteristics. Oral antibiotics can improve outcomes after I&D, although this improvement must be weighed against potential risks. Many strategies are useful in managing Bartholin abscesses, with the Word catheter proving consistently effective. Needle aspiration is the recommended first-line therapy for small breast abscesses. Dental abscesses are often diagnosed with clinical examination alone, but ultrasound may be a useful adjunct. Acute abscess formation caused by hidradenitis suppurativa should be managed surgically by excision when possible, because I&D has a high rate of abscess recurrence. Peritonsillar abscesses can be diagnosed with either intraoral or transcervical ultrasound if clinical examination is inconclusive. Needle aspiration and I&D are both suitable for the management of peritonsillar abscesses. Pilonidal abscesses have traditionally been managed with I&D, but needle aspiration with antibiotics may be a suitable alternative.

CONCLUSIONS

This review evaluates the recent literature surrounding abscess management for emergency medicine clinicians.

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

OBJECTIVES

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

STUDY DESIGN

Clinical-prospective.

METHODS

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

RESULTS

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

CONCLUSION

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

Evidence-Based Medicine Improves the Emergent Management of Peritonsillar Abscesses Using Point-of-Care Ultrasound

BACKGROUND

Physical examination for peritonsillar abscess (PTA) has limited sensitivity. Traditional management involves blind needle aspiration, which has a false negative rate of 10-24%. A randomized controlled trial by Costantino et al. demonstrated that point-of-care ultrasound (POCUS) improves PTA management.

OBJECTIVES

Compare the use and impact of POCUS between patient cohorts prior to and after the trial by Costantino et al.

METHODS

Retrospective cohort study of adult patients diagnosed with PTA. Cohort 1 presented to the emergency department (ED) January 2007-December 2008. Cohort 2 presented between January 2013 and December 2014. Data were separated into those with POCUS vs. without ultrasound (NUS). Primary endpoint was POCUS utilization. Secondary endpoints were successful aspiration, otolaryngology (ear, nose, and throat [ENT]) consultation, computed tomography (CT) imaging, unscheduled return visits, and length of stay (LOS). The Fisher's exact and t-tests analyzed data.

RESULTS

Cohort 1 enrolled 48 patients, vs. 114 patients for cohort 2. Twelve patients in cohort 1 had a POCUS (25%) vs 89 in cohort 2 (78%) (p < 0.0001; odds ratio [OR] 0.09 (95% confidence interval [CI] 0.04-0.20). Emergency physician (EP) successful aspiration: 89.1% POCUS vs. 24.5% NUS (p < 0.0001; OR 25 [95% CI 10-59]). Combined EP/ENT successful aspiration: 99.0% POCUS vs. 80.3% NUS (p < 0.0001; OR 24 [95% CI 3-193]). ENT consultation:12.9% POCUS vs. 65.6% NUS (p < 0.0001; OR 0.07 [95% CI 0.03-0.17]). CT usage: 23.8% POCUS vs. 37.7% NUS (p = 0.07; OR 0.51 [95% CI 0.25-1.02]). Return visits: 3.96% POCUS vs. 18.0% NUS (p = 0.004; OR 0.18 [95% CI 0.05-0.61]).

CONCLUSION

POCUS use has increased for PTA treatment, improves aspiration, and decreases consultations, CTs, return visits, and LOS.

Risk of internal carotid injury due to peritonsillar abscess drainage

OBJECTIVE

Peritonsillar abscess (PTA) is one of the most commonly seen ear nose and throat (ENT) emergencies. The most catastrophic complication that may occur due to surgical treatment of PTA is injury of internal carotid artery. The aim of this study is to determine distance and angle between PTA with ICA; and to prevent possible complications.

METHODS

A total of 34 adult patients with PTA were enrolled in this study. Neck computed tomographies of the patients with PTA were evaluated by a radiologist. The distance between PTA and ICA (DIP), and contralateral tonsil side and ICA (DIT) were measured and compared with each other. Also angle between PTA and ICA (AIP) was examined.

RESULTS

This study contained 20 (58.8%) males and 14 (41.2%) females with a mean age of 32.20 ± 12.75 years (range 18-60 years). Mean DIP and DIT scores were 13.39 ± 3.7 mm (min: 5.32, max: 19.07) and 9.61 ± 3.17 mm (min: 4.95, max: 16.35) respectively, and the difference was statistically significant (p<0.05). Mean distance between anterior border of PTA and ICA was 36.18 ± 6.42 mm (min: 17.12 max: 47.43). The AIP was 33.40 ± 2.29° (min: 30.10° and max: 40.71°). According to risk classification system, the 28 (82.4%) patients constituted low risk, and 6 (%17.6) patients constituted moderate risk.

CONCLUSION

According to the distance between the PTA and ICA, the risk of ICA injury was found to be mild and moderate in PTA patients. It is crucial for the surgeon to pay attention to the depth and angle of the incision during drainage of the abscess.

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.

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.

Epidemiology and Clinical Features of Peritonsillar Abscess: Is It Related to Seasonal Variations?

Objective

Peritonsillar abscess (PTA) is defined as pus accumulation between the tonsillar capsule and constrictor pharyngeal muscle. It can be seen as a complication of acute tonsillitis, but other mechanisms have also been proposed. In this study we aimed to reveal the seasonal variations and epidemiologic features of PTA.

Methods

This is a retrospective, observational study. We reviewed 221 patients, and together with 24 recurrent cases, 245 admissions were reviewed in total. Age, gender, the duration of admission, seasonal and monthly distribution of cases, diabetes and smoking status, white blood cell count, and C-reactive protein (CRP) levels were recorded. Monthly and seasonal incidences of PTA were reviewed to see if there is any association of climate variations and PTA incidence rate. Features associated with the length of hospitalization and recurrence were also analyzed.

Results

A total of 245 PTA cases were admitted to our clinic between June 2014 and June 2017. The highest amount of cases was observed in spring and winter. The C-reactive protein and white blood cell count (WBC) levels were found to be positively correlated with the length of hospitalization. There was no statistically significant correlation with recurrence and smoking, the WBC levels, CRP levels, and length of prior hospitalization. Diabetes status was not found to be associated with length of hospitalization and CRP levels.

Conclusion

The present study reflects the epidemiologic and clinical features of PTA in İstanbul. Our findings showed that seasonal variation was not significant, consistent with previous studies. The highest incidence rate was observed in spring and winter. Length of hospitalization was found to be positively correlated with C-reactive protein and white blood cell count (WBC) levels. Recurrence was not statistically correlated with and smoking, the WBC levels, CRP levels, and length of hospitalization. More studies are recommended to reveal the different epidemiologic factors affecting the incidence of PTA.

The Liverpool Peritonsillar abscess Score: Development of a predictive score through a prospective multicentre observational study

OBJECTIVES

While uncommon in the population at large, peritonsillar abscess (PTA) is a common subject of ENT referrals. Missed or uncertain diagnosis is a source of concern for non-specialist referrers. In line with the NHS England Second Sepsis Action Plan, we aimed to develop a predictive score for the presence of PTA. This would help to improve non-specialist colleagues' diagnostic certainty as well as to support ENT surgeons' triage of these referrals.

DESIGN

Prospective, multicentre observational study.

SETTING

Primary and secondary care.

PARTICIPANTS

Patients >16 years with symptoms of sore throat.

DATA

We prospectively collected comprehensive data on patient demographics, symptoms and clinical status. We documented whether the patient had aspiration-proven PTA or not. We performed binary logistic regression analysis, iterative development of a predictive score which we validated internally.

RESULTS

100 patients were included (46 PTA and 54 tonsillitis). Five variables added significantly to the logistic regression model: unilateral sore throat; trismus; male gender; pharyngeal voice change; and uvular deviation. Using the odds ratio outputs, we developed the Liverpool Peritonsillar abscess Score (LPS) iteratively. We validated the latest (third) iteration of the LPS internally (ie, on the same sample), yielding sensitivity 96%; specificity 85%; positive predictive value 85%; and negative predictive value 96%. The area under the receiver operating characteristics (AUROC) curve was 0.970.

CONCLUSIONS

We have developed the first predictive score for PTA based on symptoms and signs that do not require the user to have specialist experience. Its high negative predictive value may be particularly helpful to non-specialist colleagues.

Infections of the Oropharynx

This article reviews the presentation, diagnosis, and management of common and "can't miss" infections of the oropharynx, including streptococcal pharyngitis, infectious mononucleosis, peritonsillar abscess, retropharyngeal abscess, and epiglottitis.

Infections of the Neck

Infection of the neck is a relatively common emergency department complaint. If not diagnosed and managed promptly, it may quickly progress to a life-threatening infection. These infections can result in true airway emergencies that may require fiberoptic or surgical airways. This article covers common, as well as rare but emergent, presentations and uses an evidence-based approach to discuss diagnostic and treatment modalities.

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

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