The contemporary approach to diagnosis and management of peritonsillar abscess

Romaine F. Johnsona and Michael G. Stewartb

Purpose of review Peritonsillar abscess is a common problem, but some aspects of diagnosis and management remain controversial. We review the recent literature on peritonsillar abscess. Recent findings Intraoral ultrasound can be a helpful diagnostic tool for peritonsillar abscess. For management, needle aspiration, incision and drainage, and quinsy tonsillectomy all yield successful results. Recent reviews have still not established that one treatment is consistently preferred. A randomized, placebo-controlled trail found that the use of intravenous steroids seems to reduce many symptoms, when used along with abscess drainage. Summary The use of steroids may be beneficial in the treatment of peritonsillar abscess, and different techniques for abscess drainage are still used around the world, with consistently good results. Keywords incision and drainage, intraoral ultrasound, peritonsillar abscess
Curr Opin Otolaryngol Head Neck Surg 13:157160. 2005 Lippincott Williams & Wilkins.
a Department of Otolaryngology-Head and Neck Surgery, University of Cincinnati Medical Center, Cincinnati, Ohio, USA, and bThe Bobby R. Alford Department of Otorhinolaryngology and Communicative Sciences, Baylor College of Medicine, Houston, Texas, USA

Introduction
Peritonsillar abscess (PTA) remains a common clinical entity in otolaryngology. Although it is commonly seen, there is still debate regarding several aspects of its evaluation and treatment. In this review, we summarize the results from articles published in the last 2 years with a focus on studies since December 2003 that address some of these clinical issues. We also review some milestone articles on the topic. PTA occurs near the superior pole of the palatine tonsil, and arises from either suppuration in the soft tissue due to adjacent acute tonsillitis, or from obstruction of the Weber glands at the superior tonsil pole. The exact incidence of PTA is difficult to calculate, but it has been estimated at 30 cases per 100,000 people per year in the United States, and has also been estimated to result in at least $150 million a year in health care expenditures [1]. The major controversies surrounding PTA include the best tool for diagnosis, method of acute management, and indications for tonsillectomy, either urgent or elective. Management issues are more complicated in pediatric patients who are too young to tolerate drainage under local anesthesia. So, since the child will be taken to the operating room, what procedure should be performed?

Methods
We performed a literature search using MEDLINE with the search term, peritonsillar abscess, which is a medical subject heading term. Articles were limited to English language and review articles were excluded. Attention was paid to articles published in the last 2 years (20022004), and which addressed aspects of the diagnosis and management of peritonsillar abscess. Articles published before the review period were included if the authors deemed it of special interest.

Correspondence to Michael G. Stewart, MD, MPH, Bobby R. Alford Department of Otorhinolaryngology and Communicative Sciences, Baylor College of Medicine, One Baylor Plaza, NA-102 Houston, TX 77030, USA Tel: 713 798 7217; fax: 713 798-5078; e-mail: mgstew@bcm.tmc.edu Current Opinion in Otolaryngology & Head and Neck Surgery 2005, 13:157160 Abbreviation PTA peritonsillar abscess

Diagnosis of peritonsillar abscess

2005 Lippincott Williams & Wilkins. 1068-9508

The historical gold standard for diagnosis of PTA has been physical examination. However, as technology has advanced, other diagnostic techniques have become available. In the last two years, two articles were published on the use of ultrasound. In the first article Lyon et al. used intraoral ultrasound to diagnose and treat a patient with bilateral abscesses [2]. They performed intraoral ultrasound on a patient believed to have only a left-sided PTA, but ultrasound revealed the contralateral abscess as well. The patient was treated successfully with needle aspiration of both abscesses. In another study Blaivas et al. used
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intraoral ultrasound to help diagnose and guide abscess drainage by emergency room physicians [3]. They reported five cases of successful diagnosis and drainage, and one case where ultrasound did not show a PTA. That patient underwent attempted needle aspiration, which confirmed that there was no PTA. So in their small series they reported 100% accuracy using ultrasound. Prior studies of ultrasound have shown similar good results [4,5]. An important aspect of intraoral ultrasound is that it still requires a cooperative patient, and very young children are often unable to cooperate with the examination. Within the review period there were no articles published that examined the best methods for diagnosing PTA in young children. Historically, the CT scan is the best choice for diagnosing suspected PTA in young uncooperative patients [6].

other patients (34%) had needle aspiration; in 26 patients, purulence was identified and drained. However, in this series 16 of 26 (62%) patients treated with initial needle aspiration had persistent symptoms and subsequently required incision and drainage, which in each case was ultimately successful. That failure rate of 62% after needle aspiration is the highest reported in the literature. In their series, all patients were admitted at least overnight for intravenous antibiotics. The overall rate of recurrent PTA was 7.6%; they did not analyze their data for risk factors predicting recurrent PTA. In another article, a German group published their results for PTA treatment [10]. They performed quinsy tonsillectomy exclusively and looked both retrospectively and prospectively at their data, specifically at outcomes of treatment. Although there have been consistent reports in the past of the success of the quinsy tonsillectomy technique, the recent study did confirm some findings. For example, quinsy tonsillectomy was well tolerated, and the complication rate was very low in their series. In addition, they found that the prevalence of PTA after recurrent tonsillitis was low (11%). The use of steroids as adjunctive therapy for pharyngitis and tonsillitis has been reported as safe and effective, and has become more commonplace in recent years. Although there have been few studies that have addressed the use of steroids in PTA, it seems that the use of steroids in PTA has also been increasing. Recently, Ozbek et al. studied the use of steroids for PTA in a randomized trial [11]. Patients received either intramuscular steroids or placebo, along with abscess drainage by needle aspiration and intravenous antibiotics which were continued at least 2 days and until the patient improved. All patients were hospitalized, so the results of treatment could be easily documented; specific outcomes assessed included hours hospitalized, throat pain, time to oral intake, fever, and trismus. The authors found a statistically significant difference favoring the use of steroids for several outcomes. For example, at 12 h 70% of the steroid group were able to swallow water without pain, whereas only 18% of the placebo group could; similar large differences were noted in the presence of fever at 24 h (28% and 86%), and other outcomes. The steroid group also did not have any increased frequency of complications. Johnson et al. performed an evidence-based review of the literature on PTA, which reviewed many of these issues [7]. The review asked three specific clinical questions: Are steroids beneficial in the treatment of PTA?, What is the most effective method of acute management?, and Which patients would benefit from tonsillectomy to prevent recurrences of PTA? The review did not address the diagnosis of PTA. English language articles published from 1966 to 2001 were retrieved using a systematic

Management
Most of the debate surrounding PTA centers on its management [7]. The choices are needle aspiration, or incision and drainage under either local anesthesia or general anesthesia, or abscess drainage with simultaneous tonsillectomy (quinsy tonsillectomy). As with diagnosis, the decision making can be more complex in an uncooperative young child, because general anesthesia may be needed for any method of treatment. One group performed a survey on the management of PTA by otolaryngologists in the United Kingdom [8]. Sixty percent of respondents used needle aspiration as the primary means of treating PTA, and 25% used incision and drainage. If needle aspiration failed, then the majority (52%) would perform incision and drainage. Interestingly, 68% of respondents admitted every PTA patient to the hospital, and 26% admitted at least 60% of PTA patients; so a total of 94% of British respondents treated most or all of their patients as inpatients, which is likely a much higher rate than in the United States. Physicians in the U.K. also commonly used intravenous antibiotics initially, although the mean number of doses was not specified. The survey noted that management strategy differed depending on volume of cases. Physicians who saw the largest number of patients with PTA tended to use needle aspiration more frequently. Additionally, there were geographic differences: Physicians in England performed incision and drainage more frequently than those in Scotland. Finally, the authors did not attempt to compare treatment efficacy or outcome in their report, but only reported which treatments were used. A retrospective review from Singapore reported on 185 patients with peritonsillar infection; 151 had abscess and 34 cellulitis [9]. Most patients (66%) were treated with incision and drainage, which was successful. The

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literature search. Articles were graded and assigned an evidence level according to the quality of the evidence, using the method of Sackett [12]. Summary evidence tables were created and an overall evidence grade of recommendation was assigned for each of the clinical questions. The review found no evidence on the use of steroids. Regarding the best method of management, the review found grade C evidence that either needle aspiration or incision and drainage are effective initial treatments. Compiling the data from multiple studies, incision and drainage had a slightly higher success rate than needle aspiration (94% vs. 92%), but incision and drainage are more painful. Furthermore, the number needed to treat was 48 patients. In other words, it would take 48 patients treated by incision and drainage to prevent one failure treated by needle aspiration. Based on those findings, the authors concluded that needle aspiration was probably the best initial treatment, with incision and drainage performed if needle aspiration fails. Other studies of interest included a study by Ono et al. on the airway management of patients with PTA [13]. The authors concluded that awake fiberoptic bronchoscopy was the method of choice for intubating PTA patients if there was significant pharyngeal edema, or if the patient was having airway distress. However, most patients in their series could be intubated orally using a standard technique. Another recent study suggested that infectious mononucleosis somehow plays a role in PTA [14]. In their study, they screened a large number of patients who presented with unilateral PTA and found a 6% incidence of infectious mononucleosis. Although we cannot make assumptions about cause and effect based on cross-sectional data, it is still an interesting finding. The authors recommended that routine screening of all patients with PTA might be beneficial, because the complications of infectious mononucleosis could perhaps be recognized and treated earlier.

PTA, in all patients, is usually around 10%. Based on these findings and the rest of the evidence, Johnson et al. recommended that routine elective tonsillectomy, or quinsy tonsillectomy, for patients who present with their first PTA was unnecessary. While not supported or contraindicated by the available evidence, if a patient was a candidate for elective tonsillectomy for other reasons, then it seems rational to perform a quinsy tonsillectomy for treatment, or to proceed with planned elective tonsillectomy after successful abscess drainage.

Pediatric patients
The management of patients that are too young to undergo drainage under local anesthesia is not well defined. The primary issue is to whether to perform quinsy tonsillectomy on all cases regardless of a prior history of tonsillitis or PTA. At first this may seem excessive, if considered from the perspective of prevention of recurrence. Needle aspiration or incision and drainage can be performed under general anesthesia, and the outcomes should be equivalent to those under local anesthesia, which is highly successful. However, the complication rate of quinsy tonsillectomy is low, the literature supports its use as definitive treatment, and one can make the argument that if a young child is being taken to the operating room, then the surgeon should perform the most definitive procedure, which is quinsy tonsillectomy. Therefore, quinsy tonsillectomy perhaps makes the most sense for children that require a general anesthetic. Indeed, based on that logic, quinsy tonsillectomy may be the treatment of choice for any patient undergoing general anesthesia for treatment.

Conclusion
Based on the available evidence, a reasonable approach for the diagnosis of PTA is to use physical examination as the primary diagnostic technique. If there is doubt on the physical examination, intraoral ultrasound is an option although it requires a cooperative patient, and CT scan is another diagnostic option. Attempted needle aspiration can be both diagnostic and therapeutic in skilled hands, so if alternative diagnostic methods such as ultrasound are not available, attempted needle aspiration can be used as a diagnostic tool as well. In the patient with PTA, if acute management outside of the OR is attempted, it appears as if needle aspiration may be slightly more advantageous due to its high efficacy, low cost, and patient tolerance. Incision and drainage is an effective and inexpensive option, although it is slightly more painful. If general anesthesia is required because of the patients age or lack of cooperation, then quinsy tonsillectomy should be considered, although aspiration or incision and drainage are also options.

Recommendations for interval tonsillectomy

The recurrence rate of PTA and the indications for elective interval tonsillectomy to prevent future PTA recurrence have not been clearly defined by well-designed prospective studies. In the Johnson review [7], two level II (retrospective cohort) studies were identified that addressed the risk of recurrent PTA. Both studies were small, and they reported conflicting results: One showed an increased rate of recurrent PTA in patients who also had recurrent tonsillitis, and the other study showed no difference in recurrent PTA based on a prior history of tonsillitis. Calculation of a true recurrence rate can be difficult because of issues surrounding follow-up and data reporting, however the reported prevalence of recurrent

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When considering the role of elective tonsillectomy, there is no clear evidence that routine tonsillectomy is indicated to prevent future PTA. If a patient has had multiple recurrent episodes of PTA, or has other clear indications for tonsillectomy (such as sleep-disordered breathing) then elective tonsillectomy should be strongly considered. In addition, quinsy tonsillectomy might be the best initial treatment in such a patient. While there are many studies on PTA, most are uncontrolled, and/or they do not compare any treatment or diagnostic options, so choosing the optimal methods for diagnosis and treatment is controversial. However, it is also clear that several techniques are highly effective for the diagnosis and management of this common problem, so the clinician has several good options from which to choose.

2 3 4

Lyon M, Glisson P, Blaivas M. Bilateral peritonsillar abscess diagnosed on the basis of intraoral sonography. J Ultrasound Med 2003; 22:993996. Blaivas M, Theodoro D, Duggal S. Ultrasound-guided drainage of peritonsillar abscess by the emergency physician. Am J Emerg Med 2003; 21:155158. Scott PM, Loftus WK, Kew J, et al. Diagnosis of peritonsillar infections: a prospective study of ultrasound, computerized tomography and clinical diagnosis. J Laryngol Otol 1999; 113:229232. Haeggstrom A, Gustafsson O, Engquist S, et al. Intraoral ultrasonography in the diagnosis of peritonsillar abscess. Otolaryngol Head Neck Surg 1993; 108:243247. Friedman NR, Mitchell RB, Pereira KD, et al. Peritonsillar abscess in early childhood. Presentation and management. Arch Otolaryngol Head Neck Surg 1997; 123:630632. Johnson RF, Stewart MG, Wright CC. An evidence-based review of the treatment of peritonsillar abscess. Otolaryngol Head Neck Surg 2003; 128:332 343. Mehanna HM, Al-Bahnasawi L, White A. National audit of the management of peritonsillar abscess. Postgrad Med J 2002; 78:545548.

8 9

Ong YK, Goh YH, Lee YL. Peritonsillar infections: local experience. Singapore Med J 2004; 45:105109. This case series and review of the literature provides a balanced discussion concerning the different options for treatment.

10 Dunne AA, Granger O, Folz BJ, et al. Peritonsillar abscesscritical analysis of abscess tonsillectomy. Clin Otolaryngol 2003; 28:420424.

References and recommended reading

Papers of particular interest, published within the annual period of review, have been highlighted as: of special interest of outstanding interest 1 Herzon FS, Harris P. Mosher Award thesis. Peritonsillar abscess: incidence, current management practices, and a proposal for treatment guidelines. Laryngoscope 1995; 105:117.

11 Ozbek C, Aygenc E, Tuna EU, et al. Use of steroids in the treatment of peritonsillar abscess. J Laryngol Otol 2004; 118:439442. 12 Sackett DL SS, Richardson WS. Evidence-based medicine: how to practice and teach EBM, 2nd ed. Edinbourgh: Wolfe Publishing; 2000. 13 Ono K, Hirayama C, Ishii K, et al. Emergency airway management of patients with peritonsillar abscess. J Anesth 2004; 18:5558. 14 Ryan C, Dutta C, Simo R. Role of screening for infectious mononucleosis in patients admitted with isolated, unilateral peritonsillar abscess. J Laryngol Otol 2004; 118:362365.