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

[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.

Treatment of recurrent acute tonsillitis-a systematic review and clinical practice recommendations

Background

There is an ongoing debate on the indications for tonsil surgery in both children and adults with recurrent acute tonsillitis. The aim is to provide practical recommendations for diagnostics and treatment for recurrent acute tonsillitis including evidence-based decision making for tonsillectomy.

Methods

A systematic literature search in PubMed, Embase, Web of Science, and ScienceDirect from 2014 until April 2023 resulted in 68 articles. These were the basis for the review and a comprehensive series of consensus statements on the most important diagnostics and indications for both non-surgical and surgical therapy. A consensus paper was circulated among the authors and members of the International Head and Neck Scientific Group until a final agreement was reached for all recommendations.

Results

The differentiation between sore throat and tonsillitis patient episodes is mostly not feasible and hence is not relevant for diagnostic decision making. Diagnostics of a tonsillitis/sore throat episode should always include a classification with a scoring system (Centor, McIssac, FeverPAIN score) to estimate the probability of a bacterial tonsillitis, mainly due to group A streptococcus (GAS). In ambiguous cases, a point-of-care test GAS swab test is helpful. Consecutive counting of the tonsillitis/sore throat episodes is important. In addition, a specific quality of life score (Tonsillectomy Outcome Inventory 14 or Tonsil and Adenoid Health Status Instrument) should be used for each episode. Conservative treatment includes a combination of paracetamol and/or non-steroidal anti-inflammatory drugs. In case of high probability of bacterial tonsillitis, and only in such cases, especially in patients at risk, standard antibiotic treatment is initiated directly or by delayed prescription. Tonsillectomy is indicated and is highly effective if the patient has had ≥7 adequately treated episodes in the preceding year, ≥5 such episodes in each of the preceding 2 years, or ≥3 such episodes in each of the preceding 3 years. An essential part of surgery is standardized pain management because severe postoperative pain can be expected in most patients.

Conclusion

It is necessary to follow a stringent treatment algorithm for an optimal and evidence-based treatment for patients with recurrent acute tonsillitis. This will help decrease worldwide treatment variability, antibiotic overuse, and avoid ineffective tonsillectomy.

Recurrent Peritonsillar Abscess in Post-tonsillectomy Patient

Peritonsillar abscess (PTA) is a common deep tissue infection of the head and neck. In the literature, most cases demonstrate PTA following acute tonsillitis; however, less documented are cases arising in post-tonsillectomy patients. Here, we report a 45-year-old woman with a history of tonsillectomy 16 years prior, who presented to the emergency department with signs and symptoms consistent with PTA, including sore throat and the presence of a right-sided abscess in the posterolateral oropharynx with apparent pus. The patient reported three previous episodes of right-sided PTA, all of which were addressed via drainage and antibiotic treatment. This episode was treated similarly; cultures from the abscess revealed no growth of organisms. The patient was started on a short course of clindamycin and discharged to follow-up with her primary care physician. Several theories for the etiology of PTA development in post-tonsillectomy patients exist. One theory suggests that PTA may develop in this group of patients due to imperfect margins during the initial surgery, with residual tonsil tissue serving as a nidus for abscess development. Other theories suggest that a congenital fistula may exist in these patients, which, when occluded by scar tissue following a tonsillectomy, may lead to PTA development. Similarly, occlusion of minor salivary ducts has also been suggested to play a role in this unique pathophysiology. Overall, documenting rare cases of PTA development in post-tonsillectomy patients serves as a means of better understanding the complicated etiology behind PTA development and may be able to guide treatment in the future.

Minor salivary gland infection as origin of peritonsillitis - novel theory and preliminary results

BACKGROUND

Peritonsillitis (PT) is defined as cellulitis in peritonsillar tissue without pus. The pathogenesis of peritonsillar infections is controversial.

OBJECTIVE

To explore whether minor salivary glands are involved in the development of PT and to identify clinical findings that predict the evolution of PT to peritonsillar abscess (PTA).

MATERIAL AND METHODS

We included 146 adult patients treated for acute tonsillitis (AT; n = 54), PT (n = 34), or PTA (n = 58) at the Helsinki University Hospital. The treating physician recorded tonsillar, oropharyngeal, and dental findings. We analysed serum C-reactive protein (S-CRP) and amylase (S-Amyl). For PTA, pus samples were analysed; for AT and PT, throat cultures were collected. Patients with PT or PTA (PT/PTA; n = 92) were classified into groups with or without tonsillar exudate or hyperaemia (tonsillar findings).

RESULTS

The PT group without tonsillar findings had lower S-CRP than the PT group with tonsillar findings (p=.0275). The PT/PTA group without tonsillar findings had higher S-Amyl than the PT/PTA group with tonsillar findings (p=.0278). Three out of 34 (8.8%) patients with PT returned to the emergency department; 1 (2.9%) developed PTA.

CONCLUSIONS

Elevated S-Amyl in the PT/PTA group without tonsillar findings suggests that minor salivary glands are sometimes involved in the development of peritonsillar infections.

Ubi pus, ibi evacua: a review of 601 peritonsillar abscess adult cases

Background

Peritonsillar abscess (PTA) is the most common deep neck infection, occurring as a consequence of bacterial acute tonsillitis or as a result of infection of the Weber glands, with frequent and life-threatening complications.

Aim

To investigate several factors associated with complications and worse prognosis, such as defining the method of surgical drainage and treatment of a PTA which remains an area of controversy in the literature

Methods

The purpose of this retrospective study is to examine the epidemiological, clinical, and laboratory findings of 601 adult patients and to discuss them along with their treatment plan.

Results

Pharyngalgia was the most common reported symptom, followed by trismus, odynophagia, fever, hot potato voice, malaise, and cervical lymphadenopathy. Sixty-eight patients developed complications. Streptococcus species were the most common pathogens. A statistically significant difference was found in days of hospitalization, WBC and CRP levels, age, and the pre-existing systemic diseases between patients with and without complications. A comparison of patients treated with intravenous and oral antibiotics revealed no statistically significant difference.

Conclusion

Οver 10% of PTA cases may develop complications, the most common of which is extension into deep neck spaces. Comorbid conditions increase the risk of complications. Despite the wide range of treatment strategies, incision and drainage remain the cornerstone of surgical treatment. In patients with no comorbidities, intravenous antibiotics appear to have no advantage over oral antibiotics.

Effect of erythritol and xylitol on Streptococcus pyogenes causing peritonsillar abscesses

Polyols are effective against caries-causing streptococci but the effect on oropharynx-derived pyogenic streptococci is not well characterised. We aimed to study the effect of erythritol (ERY) and xylitol (XYL) against Streptococcus pyogenes isolated from peritonsillar abscesses (PTA). We used 31 clinical isolates and 5 throat culture collection strains. Inhibition of bacterial growth by polyols at 2.5%, 5% and 10% concentrations was studied and the results were scored. Amylase levels in PTA pus were compared to polyol effectivity scores (PES). Growth curves of four S. pyogenes isolates were analysed. Our study showed that XYL was more effective than ERY inhibiting 71–97% and 48–84% of isolates, respectively, depending of concentrations. 48% of clinical and all throat strains were inhibited by polyols in all concentrations (PES 3). PES was negative or zero in 26% of the isolates in the presence of ERY and in 19% of XYL. ERY enhanced the growth of S. pyogenes isolated from pus with high amylase levels. Polyols in all concentrations inhibited the growth in exponential phase. In conclusion, ERY and XYL are potent growth inhibitors of S. pyogenes isolated from PTA. Therefore, ERY and XYL may have potential in preventing PTA in the patients with frequent tonsillitis episodes.