Conscious Sedation for Pediatric Peritonsillar Abscess: Comparison of Anesthetic Approaches.

OBJECTIVE: To compare the efficacy, safety, and cost of incision and drainage (I&D) for pediatric patients with peritonsillar abscesses (PTAs) under conscious sedation (CS) versus unsedated (awake) and general anesthesia (GA). STUDY DESIGN: Case series with chart review. SETTING: Tertiary pediatric hospital. SUBJECTS AND METHODS: Records for all pediatric patients (<18 years) treated for PTAs in the emergency department from 2005 to 2015 were reviewed and stratified into awake, CS, and GA groups for comparison. The primary outcome measure was procedure tolerance, with secondary measures including return to the emergency department within 15 days, complications, and facility costs associated with treatment. RESULTS: A total of 188 patients were identified. The median age was 14 years (interquartile range, 9-16). Awake drainage with injected local anesthetic was used in 115 children; 62 underwent CS; and 11 underwent GA. Over 92% of the children tolerated I&D regardless of anesthesia, with no difference among groups ( P = .60). None of those who underwent I&D via CS returned to the emergency department within 15 days of the procedure, as compared with 5.2% for the awake group and 9.1% for the GA group ( P = .06). None in the GA or awake group had a complication associated with the procedure, as opposed to 9.6% in the CS group ( P = .02). Complications included apnea and dental trauma (2 children each) and transient hypotension and desaturation (1 each). Cost was highest in the GA group and lowest for the awake group ( P < .0001). CONCLUSION: CS for PTA I&D is a viable treatment option with tolerance and success similar to that of the awake and GA groups. Complications were observed for those who underwent CS, but they were manageable.

Pediatric peritonsillar abscess: Outcomes and cost savings from using transcervical ultrasound.

OBJECTIVES: 1) To analyze clinical outcomes of children stratified by ultrasound into three diagnoses: acute tonsillitis, peritonsillar phlegmon, and abscess; and 2) To compare clinical outcomes and financial impact between children who underwent ultrasound protocol to those who did not. STUDY DESIGN: Retrospective analysis between two cohorts: ultrasound protocol group and control group. METHODS: Children with peritonsillar abscess (PTA) diagnosed in the emergency department (ED) were enrolled during a 2-year period for transcervical ultrasound evaluation of bilateral tonsillar fossae. Data from a cohort of patients with PTA prior to ultrasound screening were also collected from retrospective chart review. Outcome variables were analyzed using multivariate logistic regression. RESULTS: Seventy-eight children (mean 12.3 years) were enrolled in the ultrasound protocol, compared to 101 children (mean 13.6 years) evaluated using traditional methods of examination and/or computed tomography (CT) imaging. Demographics between the two groups were not significantly different. Only one-third of patients presumed to have PTA by ED staff had ultrasound findings consistent with abscess. Overall treatment failure rate was 8%, requiring readmission or surgical intervention for abscess. Length of stay, surgical drainage, and radiation exposure from CT scans were reduced significantly in the ultrasound group (P < 0.006). Differences in readmission rates and mean charges between the two groups did not reach significance. CONCLUSION: Peritonsillar abscess is a common infection in the pediatric population, but diagnosis can be challenging. Transcervical ultrasound is a safe, cost-effective, and accurate modality to help stratify patients into medical and surgical treatment arms. LEVEL OF EVIDENCE: 3b. Laryngoscope, 127:1924-1929, 2017.

Tonsillectomy is not a procedure of limited value - the unseen costs of tonsillitis and quinsy on hospital bed consumption.

OBJECTIVES: To assess the impact of the introduction of the SIGN Clinical guidelines in 1999 and subsequent revision in 2005 on tonsillectomy, hospital admission with tonsillitis and peritonsillar abscess rates in four countries. METHODS: Retrospective analysis using English, Welsh, Australian and New Zealand National healthcare hospital admission databases between 2000 and 2013. Primary outcomes measures included tonsillectomy rates and hospital admission rates for tonsillitis and peritonsillar abscess. Secondary outcome measures included bed-day usage in England and Wales. Linear forecasting was used to identify the potential impact of any trends. RESULTS: Following guideline introduction for tonsillectomy, a significant decline in tonsillectomy rates in England (P < 0.01) and Wales (P < 0.05) was seen. Hospital admissions for acute tonsil infections increased in England (P < 0.01) and Wales (P < 0.01). In Australia and New Zealand, tonsillectomy and admission for tonsillitis rates both increased (P < 0.01). During this time, the increased rate of admission for tonsillitis in England and Wales was significantly greater than Australasia (P < 0.01). CONCLUSIONS: Following the introduction of these Clinical guidelines, there was a decrease in the rate of tonsillectomy in England and Wales and a presumed associated increase in admissions with tonsillitis. This did not occur in Australasia where tonsillectomy rates rose over time. If these trends continue, it is likely that they will have a significant deleterious impact on healthcare spending in the future.

A cost-effectiveness analysis of identifying Fusobacterium necrophorum in throat swabs followed by antibiotic treatment to reduce the incidence of Lemierre's syndrome and peritonsillar abscesses.

The main purpose of this paper was to estimate the cost per quality-adjusted life year (QALY) saved by identifying Fusobacterium necrophorum in throat swabs followed by proper antibiotic treatment, to reduce the incidence of Lemierre's syndrome and peritonsillar abscesses (PTA) originating from a pharyngitis. The second purpose was to estimate the population size required to indicate that antibiotic treatment has an effect. Data from publications and our laboratory were collected. Monte Carlo simulation and one-way sensitivity analysis were used to analyse cost-effectiveness. The cost-effectiveness analysis shows that examining throat swabs from 15- to 24-year-olds for F. necrophorum followed by antibiotic treatment will probably be less costly than most other life-saving medical interventions, with a median cost of US$8,795 per QALY saved. To indicate a reduced incidence of Lemierre's syndrome and PTA in Denmark, the intervention probably has to be followed for up to 5 years. Identifying F. necrophorum in throat swabs from 15- to 24-year-olds followed by proper antibiotic treatment only requires a reduction of 20-25 % in the incidence of Lemierre's syndrome and PTA to be cost-effective. This study warrants further examination of the effect of antibiotic treatment on the outcome of F. necrophorum acute and recurrent pharyngitis, as well as the effect on Lemierre's syndrome and PTA.

Role of socioeconomic factors in deep neck abscess: A prospective study of 120 patients.

OBJECTIVE: To assess the socioeconomic factors, presentation, aetiological factors, microbiology, and management of deep neck abscesses. DESIGN: Prospective study. SETTING: Tertiary health care centre. PATIENTS AND METHODS: We studied 120 patients with deep neck abscess who were managed in the department of otolaryngology between May 2004 and December 2005. RESULTS: There were 54 male patients (45%) and 66 female (55%) with ages ranging from 18 months to 60 years. Most of the patients were of low socioeconomic status and 84 (70%) were illiterate. None were aware of the predisposing factors and potential complications of deep neck abscess. Ninety-six (80%) had poor orodental hygiene with dental infections and extraction as the most common predisposing factor followed by recurrent oropharyngeal infections. The median duration of delay before the patient presented to us was 1 week, and only 6 (5%) were aware of the primary health services available in their locality. The most common site was the submandibular region. Pain, fever, and dysphagia were the most common presenting symptoms, and Staphylococcus aureus was the most common micro-organism. All patients were treated by incision and drainage, and 10 required emergency tracheostomy. All patients responded with no complications. CONCLUSION: Socioeconomic factors, particularly ignorance, illiteracy, and poverty, are important contributory factors towards the high incidence of deep neck abscess in developing countries.

Management of peritonsillar abscess: needle aspiration versus incision and drainage versus tonsillectomy.

Peritonsillar abscess is the most common deep infection of the head and neck. This article focuses on the different methods to manage this infection. Efficacy, cost-effectiveness, patient discomfort, recovery time, and possibility of recurrence are the issues considered to determine the best treatment option.

[Socioeconomic aspects in the therapy of peritonsillar absscess]. / Aspects socio-économiques dans la prise en charge de l'abcès péritonsillaire.

OBJECTIVE: To determine which treatment for quinsy is the most cost-effective option. MATERIAL AND METHOD: 277 quinsies were diagnosed in 262 patients in our institution between 1.1.1991 and 31.12.1998. Median age was 29 years (1-89 years), and sex ratio was 3 males:2 females. 82 quinsy tonsillectomies (AC), 91 drainages with interval tonsillectomy (DAF) and 104 drainages of the abscess without tonsillectomy (D) were carried out. RESULTS: Median hospital stay was 3 (1-7) days for quinsy tonsillectomy, and 10 (4-18) days for drainages with interval tonsillectomy (hospital stay after drainage added to hospital stay after tonsillectomy). If interval tonsillectomy is performed as an outpatient procedure, median hospital stay decreases to 5 (2-8) days. For patients who refused tonsillectomy, median hospital stay was 3 (0-14) days. Median disability after treatment was 15 (7-30) days for quinsy tonsillectomy. For drainages with interval tonsillectomy (disability succeeding the drainage added to that following interval tonsillectomy), the median is 20 (15-52) days. For patients who refused tonsillectomy it is 6 (0-15) days. In the AC group we counted 9 late haemorrhages (11%). In the DAF group 14 patients (15%) presented a late haemorrhage; 6 patients (6%) presented a postoperative superinfection of the tonsillar fossae. DISCUSSION: On the basis of the tariffs of our institution (CHUV), and of statistical data obtained from the National Institute for Social Insurance (SUVA) with regard to the economic impact of each day of disability, the cost of the various treatment options is presented. CONCLUSION: It results from our study that in the absence of a significant difference in the rate of complications, and even considering the possibility of carrying out interval amygdalectomy on an outpatient basis, the most cost-effective treatment of peritonsillar abscess is quinsy tonsillectomy.

Harris P. Mosher Award thesis. Peritonsillar abscess: incidence, current management practices, and a proposal for treatment guidelines.

Currently there is no agreement on the treatment of patients who develop a peritonsillar abscess (PTA). This lack of consensus results in highly variable and possibly expensive therapeutic regimens that may not provide optimum quality patient care at reasonable cost. The present study evaluates surgical, medical, diagnostic, and cost factors that affect the management of PTA based on the following: 1. a cohort study of 123 patients with PTA treated using needle aspiration as the initial surgical drainage; 2. a national survey of the PTA management practices of otolaryngologists; and 3. meta-analyses of various components of the treatment regimen for PTA. In the cohort study, patients diagnosed with PTA were treated by both otolaryngologists and emergency medicine specialists with needle aspiration as the primary surgical modality resulting in a 96% acute resolution rate for PTA. In the national survey, questionnaires were sent to 2000 randomly selected members of the American Academy of Otolaryngology-Head and Neck Surgery regarding their management of PTA. The return rate was 73%. Ninety-six percent of the physicians who returned survey forms treated an average of seven PTAs per year using either needle aspiration, incision and drainage, or abscess tonsillectomy to drain the abscess initially. The incidence of PTA in the United States and Puerto Rico among patients 5 to 59 years of age treated by survey practitioners is 30.1 per 100,000 person years, accounting for approximately 45,000 cases per year. Four meta-analyses were completed to quantify the success rate of needle aspiration in the treatment of PTA (94%), the recurrence rate of PTA (10% to 15%), the rate at which penicillin-resistant microorganisms are found in patients with PTA (0% to 56%), and the rate of prior oropharyngeal infections associated with PTA (11% to 56%). The recurrence rate for PTA in the United States is 10%, which is significantly different from the recurrence rate of 15% reported from the rest of the world (P < .002). A clinical intervention for PTA is proposed based on the clinical series, the national survey data, and the meta-analyses. These clinical guidelines recommend that needle aspiration be used as the initial surgical drainage procedure for all patients with a PTA other than those who have indications for abscess tonsillectomy. Patients should be treated in an outpatient setting, should receive penicillin if they are not allergic to it, and should receive adequate pain medication. The evidence does not suggest that there is any benefit in examining the abscess contents for microorganisms. Approximately 30% of patients with PTA can be expected to exhibit relative indications for a tonsillectomy.(ABSTRACT TRUNCATED AT 400 WORDS)

Peritonsillar abscess. A prospective evaluation of outpatient management by needle aspiration.

Outpatient management of peritonsillar abscess by needle aspiration and oral antibiotic therapy was evaluated for its effectiveness in providing rapid symptom relief and cure and in preventing recurrence. Between 1984 and 1987, 124 patients with peritonsillar infection were treated in our department, and 115 were included in this prospective study. Needle aspiration was not carried out in 11 patients because of young age, noncooperation, or severe trismus. The other 104 patients underwent permucosal aspiration and were followed up for periods of four months to three years. Of these, findings of aspiration were positive in 75 (72%). Only nine (12%) of the 75 patients with positive aspirates had to be hospitalized. In 64 (85%) of the 75 patients, the abscess resolved without further therapy. Aspiration of pus, along with oral administration of antibiotics, thus appears to be a reasonable alternative to incision and drainage or "hot" tonsillectomy in patients with peritonsillar abscess. This conservative approach obviates the need for hospital admission in most patients, thus enabling a significant cost reduction.