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

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

OBJECTIVE

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

DATA SOURCES

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

REVIEW METHODS

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

RESULTS

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

CONCLUSION

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

LEVEL OF EVIDENCE

N/A Laryngoscope, 2024.

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.

[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.

High rate of early recurrence of peritonsillar abscess among adolescents and young adults

BACKGROUND

Peritonsillar abscess (PTA) can be treated with aspiration or incision for drainage, but a subsequent PTA can occur if tonsillectomy is not performed. Better understanding is needed of when tonsillectomy should be performed to avoid PTA recurrence.

OBJECTIVE

This study investigated the recurrence rate of PTA following aspiration or incision for drainage and evaluated the risk factors for recurrence.

METHODS

The medical records of 292 patients treated for PTA were reviewed. Recurrence of PTA and elective or quinsy tonsillectomy were the primary endpoints. A Cox proportional hazards regression model for PTA recurrence was constructed with sex, age, and PTA history as predictors.

RESULTS

Young age was the only significant predictor of PTA recurrence. Patients aged 15 to 24 years had a 30-day recurrence rate of 15.5% and a total recurrence rate of 26.6%. The total recurrence rate among patients over 30 years of age was significantly less at 4.0% (Fisher's exact test, p < .05).

CONCLUSION AND SIGNIFICANCE

Based on our results, tonsillectomy should be considered for PTA patients between 15 and 25 years of age and, to effectively avoid future recurrence of PTA, should be performed urgently.

Adalimumab (Humira®) Induced Recurrent Peritonsillar Abscess in A Patient Received Three Different Anti-TNF Therapies: A Case Report

Anti-tumor necrosis factor agents are widely used in treating ankylosing spondylitis, but they increase the risk of infection by suppressing the immune response. Therefore, physicians should be careful about recurrent infections in patients under anti-tumor necrosis factor agents.

[Abscesstonsillectomy: Uni- or bilateral?]

OBJECTIVE

In addition to an empirical use of antibiotics for treatment of a peritonsillar abscess (PTA) there is a drainage of pus or the abscess tonsillectomy. Postoperative bleeding after abscesstonsillectomy (ABTE) is this surgery's most feared complication which can rarely lead to patients' deaths. The objective of this study was to compare bleeding complications of ABTE with and without contralateral tonsillectomy (TE) and to analyze the occurrence of a metachronous PTA at the contralateral side.

METHODS

Retrospective study of n= 655 patients undergoing ABTE with and without TE of the contralateral side from January 2004 to February 2019. Bleeding complications needing surgical hemostasis were analyzed regarding demographic and surgical parameters. In addition, occurrence of PTA and need for ABTE of the contralateral side after unilateral ABTE were evaluated.

RESULTS

Overall, 10/655 (1.5 %) patients presented with postoperative bleeding after ABTE. In 404/655 an ABTE with contralateral TE was performed. Here, 8/404 (1.98 %) patients showed contra- or bilateral bleeding. Only in 2/251 (0.7 %) patients occurred a bleeding complication after unilateral ABTE. Therefore, bleeding after unilateral ABTE was significantly lower than ABTE with contralateral TE (1.98 % vs. 0.7 %, p= 0.001). In 0.8 % of the patients a contralateral ABTE was necessary due to a metachronous PTA.

CONCLUSION

Overall, the rate of postoperative bleeding after ABTE (1.5 %) was low. Unilateral ABTE showed significantly lower postoperative bleeding rates compared to ABTE with contralateral TE. Consequently, the indication of a contralateral TE must be very strict.

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.

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

OBJECTIVE

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

DATA SOURCES

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

REVIEW METHODS

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

RESULTS

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

CONCLUSION

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

Management of pediatric peritonsillar and deep neck infections- cross- sectional retrospective analysis

Objective

Deep neck infections (DNI) are responsible for significant morbidity in children and healthcare expenditures. Few studies exist specifically addressing the clinical and epidemiologic characterization and management of DNI's in the pediatric population. Our goal was to analyse the demographic characteristics, clinical presentation, diagnostic and therapeutic approaches of peritonsillar and DNI in pediatric patients.

Methods

The medical records of patients, aged up to 18 years, admitted for peritonsillar and DNI at our department, from 2011 to 2016, were retrospectively reviewed and compared with the literature available. Ninety-eight patients were enrolled.

Results

The mean age was higher in patients with peritonsillar abscess and lower in patients with retropharyngeal and parapharyngeal infections. Admissions have significantly increased from 2011. There was a seasonal variation for DNI incidence, with a peak incidence in Summer and Spring. All patients included were treated as inpatient and received empirical intravenous antibiotic therapy and steroids regardless of drainage procedures. Incision and drainage was performed in 72 patients. The hospital length of stay was higher among patients with retropharyngeal abscess and in the group with complications. Only 2 patients developed complications during hospital stay. The most common microbiological pattern was monomicrobial and the most commonly isolated pathogens were Streptococcus Pyogenes, Streptococcus Mitis and anaerobic bacteria.

Conclusions

Surgical incision and drainage followed by intravenous antibiotic and steroids proved to be successfull with low morbidity related to surgical approach. However, in selected cases, medical therapy may be an alternative to surgical management in uncomplicated infections.

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

OBJECTIVES

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

DESIGN

Prospective comparative aetiological study.

SETTING

Tertiary referral centre.

PARTICIPANTS

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

MAIN OUTCOME MEASURES

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

RESULTS

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

CONCLUSIONS

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

Indications for tonsillectomy stratified by the level of evidence

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

Specified data for tonsil surgery in Germany

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

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

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

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

Cranial tonsillotomy for peritonsillar abscess: what a relief!

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

Metronidazole in conjunction with penicillin neither prevents recurrence nor enhances recovery from peritonsillar abscess when compared with penicillin alone: a prospective, double-blind, randomized, placebo-controlled trial

OBJECTIVES

The objectives of this study were to evaluate the efficacy of metronidazole in conjunction with penicillin in preventing the recurrence of peritonsillar abscess (PTA) and to learn whether metronidazole enhances the recovery from PTA when compared with penicillin alone.

METHODS

In this prospective, double-blind, randomized, placebo-controlled trial, 200 adult outpatients with PTA at our ear, nose and throat emergency department received either penicillin (1 000 000IU) × 3 and metronidazole (400 mg) × 3 for 10 and 7 days orally (combination group, N = 100) or penicillin and placebo (penicillin group, N = 100) after incision and drainage of the PTA. Afterwards they received a symptom questionnaire via e-mail daily for 2 weeks, then weekly for 6 weeks. The primary outcome was efficacy of metronidazole in conjunction with penicillin in preventing PTA recurrence in 56 days; the secondary outcome was ability of metronidazole plus penicillin to enhance recovery from PTA in 28 days. All healthcare contacts were registered during follow-up. Registered on www.clinicaltrials.gov with the identifier NCT01255670.

RESULTS

Of the 200 patients, 20 returned to hospital with recurrent symptoms, 10 in each group (P = 1.00). In the combination group, the mean (SD) duration of throat-related symptoms was 5.6 (5.0) days and in the penicillin group it was 5.3 (2.7) days, values for fever were 1.5 (0.9) and 1.6 (1.0) days, respectively, and those for poor overall physical condition were 4.0 (3.9) and 4.5 (4.9) days; there were no significant differences between groups. The adverse effects nausea and diarrhoea lasted longer in the combination group (P = 0.01).

CONCLUSIONS

For healthy adult PTA patients treated with incision and drainage, metronidazole neither prevents recurrence nor enhances recovery when combined with penicillin compared with penicillin alone, but instead leads to increased adverse effects.