Reducing Unnecessary Instruments in Tonsil Hemorrhage Trays at a Canadian Tertiary Care Center: A Quality Improvement Project.

BACKGROUND: In the emergency department (ED), there are pre-assembled tonsillar hemorrhage trays for management of post-tonsillectomy hemorrhage and peritonsillar abscess. After use, the tray is sent to the medical device reprocessing (MDR) department for decontamination, sterilization, and re-organization, all at a significant cost to the hospital and environment. OBJECTIVE: The goal of this project was to reduce unnecessary instruments on the tonsil hemorrhage tray by 30% by 1 year and report on the associated cost and carbon dioxide (CO2) emissions savings. METHODS: This quality improvement project was framed according to the Institute for Healthcare Improvement's Model for Improvement. ED and Otolaryngology-Head & Neck Surgery staff and residents were surveyed to determine which instruments on the tonsil hemorrhage trays were used regularly. Based on results, a new tray was developed and compared to the old tray using MDR data and existing CO2 emissions calculations. RESULTS: Tray optimization resulted in a total cost reduction from $1092.63 to $330.21 per tray per year, decreased processing time from 12 to 6-8 minutes per tray, and decreased CO2 emissions from 6.11 to 2.85 kg per year for the old versus new tray, respectively. Overall, the new tray contains half the number of instruments, takes half the time to assemble, produces 50% less CO2 emissions, and will save the hospital approximately $100,000 over 10 years. CONCLUSION: Healthcare costs and environmental sustainability are collective responsibilities. Surgical and procedure tray optimization is a simple, effective, and scalable form of eco-action.

Conscious sedation for the management of peritonsillar abscess in pediatric patients: A prospective case series and literature review.

OBJECTIVE: Peritonsillar abscess (PTA) is a common pediatric infection requiring drainage. Conscious Sedation (CS) can facilitate drainage in uncooperative children. However, it carries risks, especially if the airway is compromised. Moreover, evidence on its safety and efficacy is limited. This study examined the safety, pain reduction, and anxiety management of hospitalized pediatric patients treated for PTA under CS. MATERIALS AND METHODS: We performed a prospective observational case series of 118 children aged 2-15 years with 155 PTA episodes, managed from 2016 to 2023. Conscious sedation was used in 42 episodes. Outcomes were compared among CS and non-CS (local anesthesia only). Complications assessed safety. Efficacy was evaluated by the amount of pus, hospitalization parameters, pain scores, and recurrence. RESULTS: No significant differences were found regarding the demographic and presentation parameters except for younger age among the CS group (9 vs 11 years p = 0.001). One minor oxygen desaturation (2 %) event occurred with CS. Abscess drainage amount was greater with CS than non-CS, 4.9±4 mL vs. 3.2±2 mL, respectively (p = 0.03). Hospitalization stays were similar among groups. Maximum pain scores were lower with CS than non-CS, 1.4 ± 2 vs 4.2 ± 3 (p < 0.001); similarly, IV pain medication was used less frequently, 0.9 ± 1 vs. 1.6 ± 3 (p = 0.045), and the need for re-aspiration was less common 14 % vs. 28 % (p = 0.04), with CS than non-CS, respectively. The three-month recurrence rate was numerically lower with CS (5 % vs. 14 % non-CS). CONCLUSIONS: Conscious sedation facilitates PTA drainage with excellent safety and improved efficacy compared to local anesthesia in children. Pain scores are reduced both during drainage and hospitalization. Our prospective data add to the limited evidence supporting CS as a viable option for abscess drainage in uncooperative pediatric patients. Further study is warranted to confirm potential long-term reductions in recurrence.

Cytobacteriological testing of drainage pus from peritonsillar abscess is not contributive in clinical practice: A STROBE analysis.

PURPOSE: Peritonsillar abscess (PTA) is a frequent pathology. Treatment consists in drainage of the collection, associated to probabilistic antibiotic therapy. The usefulness of cytobacteriological testing (CBT) of the drainage pus is controversial. MATERIAL AND METHODS: A retrospective study of patients managed for PTA between 2013 and 2020 in our university hospital was performed. The main objective was to assess the usefulness of CBT in the management of PTA. The secondary objectives were to determine the bacteriological profile involved in the onset of PTA and to assess the rate of bacterial resistance to antibiotics prescribed on a probabilistic basis. RESULTS: The study included 207 patients: 70 outpatients (33%) and 137 inpatients (67%). Probabilistic antibiotic therapy was implemented in 100% of patients. CBT was performed systematically and was negative in 106 patients, revealing oropharyngeal flora in 40% of cases, polymicrobial flora in 50% and sterile samples in 10%. In the 101 patients with positive CBT, the bacteria isolated were penicillin-sensitive in 99%. All patients were successfully treated. In the light of the bacteriological results, no changes were made to the probabilistic antibiotic therapy introduced on admission. CONCLUSION: CBT on drainage pus had no impact on the management of PTA. CBT is therefore unnecessary in patients with no comorbidities and no signs of severity at admission.

Impact of the COVID-19 era on clinical presentation, management and microbiology in paediatric peritonsillar abscess: A case-control study.

OBJECTIVES: Peritonsillar abscess (PTA) is the most common soft-tissue infection of the head and neck. This potential complication of tonsillitis has demonstrated unique microbial trends during the COVID-19 pandemic. This era has resulted in a major shift in the hygiene and social habits of the general population, which has resulted in changes in the presentation, management and microbiology of several infectious diseases. To date, the impact of COVID 19 on PTA microbiology and clinical presentation in the paediatric population has yet to be investigated. DESIGN: Retrospective chart review comparing all cases of paediatric (age 0-18) PTA in an academic tertiary centre during the COVID-19 pandemic (03/2020-02/2022) and compared them to two control groups: pre-COVID (03/2018-02/2020) and post-COVID (03/2022-03/2023). All patients were treated with either needle aspiration, incision and drainage or both means in addition to intravenous antibiotics. SETTING: A large Ear Nose and Throat department in a tertiary referral center. PARTICIPANTS: Consecutive children aged 18 years or under, admitted with a diagnosis of Peritonsillar abscess. MAIN OUTCOME MEASURES: We analyzed the clinical and microbiologcal features of all cases of pediatric peritonsillar abscess during the COVID-19 era (03/2020-02/2022) and compared them to a pre and post control cases. RESULTS: A total of 96 PTA cases were included (35 pre-COVID, 35 COVID and 26 post-COVID). The means of procedural treatment shifted in favour of incision and drainage versus needle aspiration during the COVID era. The length of hospitalisation increased during the COVID era (3.6 days vs. 2.1 and 3.1 pre and post-COVID respectively, p < .001). No other notable differences in the clinical and demographic features were found between the three eras. The COVID-19 era saw an increase in Fusobacterium (37.1% vs. 8.6% and 24% pre and post-COVID, respectively; p = .008) and Streptococcus Anginosus (31.4% vs. 5.7% and 7.7% pre and post-COVID, respectively; p = .007) species isolation. CONCLUSIONS: The COVID-19 pandemic did not seem to impact the clinical presentation of paediatric PTA yet resulted in a change in microbiological pathogens. The choice of I&D as a means to shorten hospital stay during the pandemic may have led to an actual increase in hospital stay, suggesting that NA may be the preferred management approach.

Predictive factors for abscessing tonsillitis: a retrospective analysis.

OBJECTIVE: In clinical practice, identifying abscesses in tonsillar infections is crucial for early therapeutic management. Diagnosis of a peritonsillar abscess is usually based on clinical symptoms. Complementary examination procedures, such as laboratory parameters and imaging, are available for confirmation. PATIENTS AND METHODS: A retrospective analysis was carried out of data for 752 patients who presented with acute tonsillar infection and were hospitalized between January 2012 and February 2021. The data analyses involved evaluating the patient's clinical symptoms, inflammatory parameters, and previous medical history in relation to the predictive power of these factors for the presence of an abscess. RESULTS: Predictor analysis for the presence of an abscess showed significant values for trismus (OR 2.392; 95% CI, 1.305 to 4.383; p=0.005) and palatal arch protrusion (OR 29.679; 95% CI, 17.460 to 50.447; p=0.000). The inflammatory parameter C-reactive protein and the leukocyte count were not statistically significant as predictors. CONCLUSIONS: The presence of a tonsillar abscess can be diagnosed from the clinical presentation alone if the findings are clear. Further diagnostic procedures are indicated in case of inconclusive findings, and ultrasound should be the primary noninvasive method. Computed tomography is only required in selected cases. Inflammatory parameters can be assessed in order to monitor therapy, but do not predict the presence of an abscess. However, if defined action sequences are being considered, tonsillar abscesses can be differentiated at an early point.

A systematic review of the role of penicillin versus penicillin plus metronidazole in the management of peritonsillar abscess.

BACKGROUND: Peritonsillar abscess is a localised infection in the peritonsillar space. Pus from the abscess can contain anaerobes. Many clinicians prescribe metronidazole in addition to penicillin, but evidence to support this is limited. This review assessed the evidence of benefit of metronidazole for the treatment of peritonsillar abscess. METHODS: A systematic review was conducted of the literature and databases including Ovid Medline, Ovid Embase, PubMed and Cochrane library. Search terms included all variations of peritonsillar abscess, penicillin and metronidazole. RESULTS: Three randomised, control trials were included. All studies assessed the clinical outcomes after treatment for peritonsillar abscess, including recurrence rate, length of hospital stay and symptom improvement. There was no evidence to suggest additional benefit with metronidazole, with studies suggesting increased side effects. CONCLUSION: Evidence does not support the addition of metronidazole in first-line management of peritonsillar abscess. Further trials to establish optimum dose and duration schedules of oral phenoxymethylpenicillin would benefit clinical practice.

Recognizing a Peritonsillar Abscess in Pediatric Patients.

A peritonsillar abscess (PTA) is a localized collection of pus in the peritonsillar space, between the palatine tonsillar capsule and the superior pharyngeal constrictor muscle (G. Gupta & R. McDowell, 2022). It is the most commonly occurring abscess in the head and neck region. Patient presentation usually includes odynophagia, unilateral otalgia, trismus, and voice changes. Managing a pediatric patient may be challenging, as children may not be able to describe their history of illness and symptoms. The management of a PTA can also differ between pediatric and adult patients (S. Ahmed Ali et al., 2018). It is important for practitioners to consider all aspects when providing treatment. This article describes the encounter and individualized treatment plan of an 11-year-old nonverbal autistic child who presented with fever, decreased oral intake, and left neck swelling. It also provides a general overview of PTAs and procedural steps to perform drainage through needle aspiration and incision and drainage.

Complicaciones ORL severas por mononucleosis infecciosa en adolescentes sanos: 2 casos clínicos y revisión de la literatura / ENT severe complications of infectious mononucleosis in healthy adolescents: report of two cases and literature review

Resumen La mononucleosis infecciosa (MI) es un cuadro clínico generalmente benigno y autolimitado en la infancia y adolescencia debido a la primoinfección del virus de Epstein-Barr caracterizado por la triada de faringitis, fiebre y adenopatías. El riesgo de complicaciones aumenta con la edad y la inmunosupresión, siendo las complicaciones letales más frecuentes las asociadas a rotura esplénica, alteraciones neurológicas y obstrucción de la vía aérea por el aumento del tamaño amigdalar. Los abscesos cervicales asociados a MI son poco frecuentes, siendo mayoritariamente periamigdalinos e intraamigdalares. Presentamos dos casos quirúrgicos de abscesos cervicales profundos de gran tamaño con afectación retrofaríngea y parafaríngea en adolescentes sanos de corta edad (14 y 15 años), sin ningún tipo de inmunosupresión o factores de riesgo, uno de ellos asociado además, a una relevante hemorragia amigdalar espontanea, condición no descrita previamente en la literatura en relación a MI en un paciente tan joven.

Abstract Infectious mononucleosis (MI) is a generally benign and self-limited condition in childhood and adolescence due to the primary EBV infection characterized by the triad of pharyngitis, fever, and lymphadenopathies. The risk of complications increases with age and immunosuppression. The most frequent fatal complications are those associated with splenic rupture, neurological alterations, and airway obstruction due to increased tonsillar size. Cervical abscesses associated with MI are rare, being mostly peritonsillar and intra-tonsil. We present two surgical cases of big deep cervical abscesses with retropharyngeal and parapharyngeal involvement in healthy very young adolescents (14 and 15 years old), without any type of immunosuppression or risk factors, one of them associated with a clinically relevant spontaneous tonsillar bleeding, which had not been described in the literature associated with MI in such young patient.

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.

A multicentre retrospective cohort study on COVID-19-related physical interventions and adult hospital admissions for ENT infections.

PURPOSE: To report changes in adult hospital admission rates for acute ENT infections following the introduction of COVID-19-related physical interventions such as hand washing, use of face masks and social distancing of 2-m in the United Kingdom. METHODS: Retrospective cohort study comparing adult admissions with acute tonsillitis, peritonsillar abscess, epiglottitis, glandular fever, peri-orbital cellulitis, acute otitis media, acute mastoiditis, retropharyngeal abscess and parapharyngeal abscess in the 1-year period after the introduction of COVID-related physical interventions (2020-2021) with a 1-year period before this (2019-2020) in three UK secondary care ENT departments. RESULTS: In total, there were significantly fewer admissions for ENT infections (n = 1073, 57.56%, p < 0.001; RR 2.36, 95% CI [2.17, 2.56]) in the 2020-2021 period than in the 2019-2020 period. There were significant reductions in admissions for tonsillitis (64.4%; p < 0.001), peritonsillar abscess (60.68%; p < 0.001), epiglottitis (66.67%; p < 0.001), glandular fever (38.79%; p = 0.001), acute otitis media (26.85%; p = 0.01) and retropharyngeal and/or parapharyngeal abscesses (45.45%; p = 0.04). CONCLUSION: Our study demonstrates a sizeable reduction in adult admissions for ENT infections since the introduction of COVID-19-related physical interventions. There is evidence to support the use of physical interventions in the prevention of viral transmission of respiratory disease. Preventing ENT infections requiring admission through simple physical interventions could be of great benefit to the quality of life of patients and economical benefit to healthcare systems.

[From tonsillitis to peritonsillar abscess]. / De l'angine simple à l'abcès périamygdalien.

Acute tonsillitis is a common disease. The tonsillar infection can be uni- or bilateral with a high rate of spontaneous recovery. In some cases, a peritonsillar cellulitis or abscess can occur, characterized by an inflammatory reaction of the peritonsillar space. The red flags consist of a gradually worsening odynodysphagia, an ipsilateral swelling of the soft palate, a trismus (infrequent in children) and in some cases a change of voice (« hot potato voice ¼). A needle puncture of the swollen soft palate is then required. If pus is found, a surgical drainage by either hot tonsillectomy or incision under local anesthesia with an appropriate antibiotic therapy must be carried out.

L'amygdalite aiguë représente un motif de consultation fréquent. Elle est caractérisée par une infection amygdalienne uni ou bilatérale de résolution spontanée dans la majorité des cas. Dans certaines situations, celle-ci se complique d'un phlegmon ou d'un abcès périamygdalien caractérisés par respectivement une réaction inflammatoire ou du pus dans l'espace périamygdalien. Les signes d'alerte sont une odynodysphagie sévère latéralisée, une tuméfaction ipsilatérale du voile du palais, un trismus (rare chez l'enfant) et une modification de la voix. L'examen complémentaire comprend une ponction de la tuméfaction du voile à la recherche de pus. En cas d'abcès avéré, un drainage chirurgical en urgence par amygdalectomie à chaud ou incision sous anesthésie locale est préconisé en plus d'une antibiothérapie adéquate.

Procedural Applications of Point-of-Care Ultrasound in Pediatric Emergency Medicine.

Point-of-care ultrasound can improve efficacy and safety of pediatric procedures performed in the emergency department. This article reviews ultrasound guidance for the following pediatric emergency medicine procedures: soft tissue (abscess incision and drainage, foreign body identification and removal, and peritonsillar abscess drainage), musculoskeletal and neurologic (hip arthrocentesis, peripheral nerve blocks, and lumbar puncture), vascular access (peripheral intravenous access and central line placement), and critical care (endotracheal tube placement, pericardiocentesis, thoracentesis, and paracentesis). By incorporating ultrasound, emergency physicians caring for pediatric patients have the potential to enhance their procedural scope, confidence, safety, and success.

Ear, Nose, Throat: Beyond Pharyngitis: Retropharyngeal Abscess, Peritonsillar Abscess, Epiglottitis, Bacterial Tracheitis, and Postoperative Tonsillectomy.

Ear, nose, and throat (ENT) emergencies presenting with a chief complaint of pharyngitis can be due to infection, trauma, or postprocedure complications. The entities described in this article include retropharyngeal abscess, peritonsillar abscess, epiglottitis, bacterial tracheitis, and post-tonsillectomy bleeding. This article provides the emergency physician with the tools needed to decipher between the mundane and the critical, variations in presentation, and their emergent management. All of them require early recognition for any airway compromise or obstruction in order to avoid serious complications.

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.

ENT UK coronavirus disease 2019 adult tonsillitis and quinsy guidelines: translating guidance into practice.

OBJECTIVES: This study examined the uptake of ENT UK coronavirus disease 2019 adult tonsillitis and quinsy guidelines at our tertiary centre, and assessed perceived barriers to uptake. METHODS: A retrospective case series of tonsillitis and quinsy patients was analysed in two arms: before and after the introduction of new ENT UK management guidelines. A survey assessed perceptions and practice differences between ENT and emergency department doctors. RESULTS: Each study arm examined 82 patients. Following the introduction of new ENT UK guidelines, ENT clinicians demonstrated significant changes in practice, unlike their emergency department counterparts. Survey results from emergency department doctors highlighted a lack of appreciation of guideline change and identified barriers to guideline uptake. CONCLUSION: The introduction of new management guidelines for tonsillitis and quinsy patients during the pandemic resulted in disparate uptake within ENT and emergency department departments at the tertiary centre. Clearer dissemination to all affected clinicians is paramount for future rapidly introduced changes to practice, to ensure clinician safety.

Ambulatory management of common ENT emergencies - what's the evidence?

OBJECTIVES: The global pandemic of coronavirus disease 2019 has necessitated changes to 'usual' ways of practice in otolaryngology, with a view towards out-patient or ambulatory management of appropriate conditions. This paper reviews the available evidence for out-patient management of three of the most common causes for emergency referral to the otolaryngology team: tonsillitis, peri-tonsillar abscess and epistaxis. METHODS: A literature review was performed, searching all available online databases and resources. The Medical Subject Headings 'tonsillitis', 'pharyngotonsillitis', 'quinsy', 'peritonsillar abscess' and 'epistaxis' were used. Papers discussing out-patient management were reviewed by the authors. RESULTS: Out-patient and ambulatory pathways for tonsillitis and peritonsillar abscess are well described for patients meeting appropriate criteria. Safe discharge of select patients is safe and should be encouraged in the current clinical climate. Safe discharge of patients with epistaxis who have bleeding controlled is also well described. CONCLUSION: In select cases, tonsillitis, quinsy and epistaxis patients can be safely managed out of hospital, with low re-admission rates.

Management of ENT emergencies during the coronavirus disease 2019 pandemic.

BACKGROUND: Coronavirus disease 2019 imposed dramatic changes on ENT service delivery. Pre-pandemic, such changes would have been considered potentially unsafe. This study outlines the impact of lockdown on the incidence and management of ENT emergencies at a large UK centre. METHODS: After modification of pre-pandemic guidelines, ENT emergency referrals data during the UK lockdown were prospectively captured. A comparative analysis was performed with retrospective data from a corresponding period in 2019. RESULTS: An overall reduction (p < 0.001) in emergency referrals (n = 119) and admissions (n = 18) occurred during the lockdown period compared to the 2019 period (432 referrals and 290 admissions). Specifically, there were reduced admission rates for epistaxis (p < 0.0001) and tonsillar infection (p < 0.005) in the lockdown period. During lockdown, 90 per cent of patients requiring non-dissolvable nasal packing were managed as out-patients. CONCLUSIONS: Coronavirus disease 2019 compelled modifications to pre-pandemic ENT guidelines. The enforced changes to emergency care appear to be safe and successfully adopted. Arguably, the measures have both economic and patient-related implications post-coronavirus disease 2019 and during future similar pandemics and lockdowns.