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Otolaryngology--head and Neck Surgery :... Aug 2016To review the literature concerning the 2 primary hypotheses put forth to explain the pathogenesis of peritonsillar abscess: "the acute tonsillitis hypothesis"... (Review)
Review
OBJECTIVE
To review the literature concerning the 2 primary hypotheses put forth to explain the pathogenesis of peritonsillar abscess: "the acute tonsillitis hypothesis" (peritonsillar abscess is a complication of acute tonsillitis) and "the Weber gland hypothesis" (peritonsillar abscess is an infection of Weber's glands).
DATA SOURCES
PubMed, EMBASE.
REVIEW METHODS
Data supporting or negating one hypothesis or the other were elicited from the literature.
CONCLUSIONS
Several findings support the acute tonsillitis hypothesis. First, the 2 main pathogens in peritonsillar abscess have been recovered from pus aspirates and bilateral tonsillar tissues with high concordance rates, suggesting that both tonsils are infected in patients with peritonsillar abscess. Second, studies report signs of acute tonsillitis in the days prior to and at the time of peritonsillar abscess. Third, antibiotic treatment reduces the risk of abscess development in patients with acute tonsillitis. However, some findings suggest involvement of the Weber's glands in peritonsillar abscess pathogenesis. First, high amylase levels have been found in peritonsillar pus. Second, the majority of peritonsillar abscesses are located at the superior tonsillar pole in proximity of the Weber's glands. We propose a unified hypothesis whereby bacteria initially infect the tonsillar mucosa and spread via the salivary duct system to the peritonsillar space, where an abscess is formed.
IMPLICATIONS FOR PRACTICE
Our findings support the rationale for antibiotic treatment of patients with severe acute tonsillitis to reduce the risk of abscess development. Improved understanding of peritonsillar abscess pathogenesis is important for the development of efficient prevention strategies.
Topics: Acute Disease; Anti-Bacterial Agents; Humans; Peritonsillar Abscess; Salivary Gland Diseases; Salivary Glands, Minor; Tonsillitis
PubMed: 27026737
DOI: 10.1177/0194599816639551 -
Brazilian Journal of Otorhinolaryngology 2018Peritonsillar abscess is the most common deep neck infection. The infectious microorganism may be different according to clinical factors.
INTRODUCTION
Peritonsillar abscess is the most common deep neck infection. The infectious microorganism may be different according to clinical factors.
OBJECTIVE
To identify the major causative pathogen of peritonsillar abscess and investigate the relationship between the causative pathogen, host clinical factors, and hospitalization duration.
METHODS
This retrospective study included 415 hospitalized patients diagnosed with peritonsillar abscess who were admitted to a tertiary medical center from June 1990 to June 2013. We collected data by chart review and analyzed variables such as demographic characteristics, underlying systemic disease, smoking, alcoholism, betel nut chewing, bacteriology, and hospitalization duration.
RESULTS
A total of 168 patients had positive results for pathogen isolation. Streptococcus viridans (28.57%) and Klebsiella pneumoniae (23.21%) were the most common microorganisms identified through pus culturing. The isolation rate of anaerobes increased to 49.35% in the recent 6 years (p=0.048). Common anaerobes were Prevotella and Fusobacterium spp. The identification of K. pneumoniae increased among elderly patients (age>65 years) with an odds ratio (OR) of 2.76 (p=0.03), and decreased in the hot season (mean temperature>26°C) (OR=0.49, p=0.04). No specific microorganism was associated with prolonged hospital stay.
CONCLUSION
The most common pathogen identified through pus culturing was S. viridans, followed by K. pneumoniae. The identification of anaerobes was shown to increase in recent years. The antibiotics initially selected should be effective against both aerobes and anaerobes. Bacterial identification may be associated with host clinical factors and environmental factors.
Topics: Adolescent; Adult; Anti-Bacterial Agents; Fusobacterium Infections; Fusobacterium necrophorum; Gram-Positive Bacteria; Gram-Positive Bacterial Infections; Humans; Klebsiella Infections; Klebsiella pneumoniae; Middle Aged; Peritonsillar Abscess; Prevotella; Retrospective Studies; Risk Factors; Viridans Streptococci; Young Adult
PubMed: 28756939
DOI: 10.1016/j.bjorl.2017.06.007 -
Emergency Medicine Clinics of North... Aug 2021Point-of-care ultrasound can improve efficacy and safety of pediatric procedures performed in the emergency department. This article reviews ultrasound guidance for the... (Review)
Review
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.
Topics: Abscess; Arthrocentesis; Catheterization, Central Venous; Catheterization, Peripheral; Child; Drainage; Foreign Bodies; Hip Joint; Humans; Intubation, Intratracheal; Nerve Block; Paracentesis; Pediatric Emergency Medicine; Peripheral Nerves; Peritonsillar Abscess; Point-of-Care Systems; Spinal Puncture; Ultrasonography, Interventional
PubMed: 34215401
DOI: 10.1016/j.emc.2021.04.006 -
The Cochrane Database of Systematic... Dec 2016Peritonsillar abscess is a common infection presenting as a collection of pus in the peritonsillar area. The condition is characterised by a severe sore throat,... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Peritonsillar abscess is a common infection presenting as a collection of pus in the peritonsillar area. The condition is characterised by a severe sore throat, difficulty in swallowing and pain on swallowing, fever and malaise, and trismus. Needle aspiration and incision and drainage are the two main treatment modalities currently used in the treatment of this condition. The effectiveness of one versus the other has not been clearly demonstrated and remains an area of debate.
OBJECTIVES
To assess the effectiveness and risks of needle aspiration versus incision and drainage for the treatment of peritonsillar abscess in older children (eight years of age or older), adolescents and adults.
SEARCH METHODS
The Cochrane ENT Information Specialist searched the ENT Trials Register; Central Register of Controlled Trials (CENTRAL 2016, Issue 7); Ovid MEDLINE; Ovid Embase; CINAHL; Web of Science; ClinicalTrials.gov; ICTRP and additional sources for published and unpublished trials. The date of the search was 25 August 2016.
SELECTION CRITERIA
Randomised controlled trials comparing needle aspiration with incision and drainage.
DATA COLLECTION AND ANALYSIS
We used the standard methodological procedures expected by Cochrane. Our primary outcomes were recurrence rate (proportion of patients needing repeat intervention) and adverse effects associated with the intervention. Secondary outcomes were time to resumption of normal diet, complications of the disease process and symptom scores. We used GRADE to assess the quality of evidence for each outcome; this is indicated in italics.
MAIN RESULTS
We included 11 studies (674 participants). The risk of bias was high or unclear in all of the included studies. All studies compared needle aspiration to incision and drainage.All but one of the 11 studies reported on the primary outcome of recurrence. When we pooled data from the 10 studies the recurrence rate was higher in the needle aspiration group compared with incision and drainage: risk ratio (RR) 3.74 (95% confidence interval (CI) 1.63 to 8.59; 612 participants). We detected moderate heterogeneity in this analysis (I = 48%). In interpreting the pooled result it is important to note that the evidence for this outcome was of very low quality.None of the other outcomes (adverse effects of the intervention, time to resumption of normal diet, complications of the disease process and symptom scores) were consistently measured across all studies.Only three studies reported on adverse effects/events associated with the intervention and only one such event in a single patient was reported (post-procedure bleeding following incision and drainage: 1/28, 3.6%) (very low-quality evidence). Time to resumption of normal diet was compared in two studies; neither found an obvious difference between needle aspiration and incision and drainage (very low-quality evidence).Only three studies stated that they would report complications of the disease process. In these three studies, the only complication reported was admission to hospital for dehydration in two patients who underwent incision and drainage (2/13, 6.7%). Symptom scores were measured in four studies; three evaluated pain using different scales and one other symptoms. The data could not be pooled in a meta-analysis. Two studies evaluating procedural pain reported this to be lower in the needle aspiration groups. One study found comparable rates of pain resolution at five days post-intervention between groups. The quality of the evidence for symptom scores was very low.
AUTHORS' CONCLUSIONS
Although a number of studies have sought to evaluate whether or not needle aspiration or incision and drainage is more effective in patients with peritonsillar abscess, there is no high-quality evidence to allow a firm conclusion to be drawn and the answer remains uncertain. Very low-quality evidence suggests that incision and drainage may be associated with a lower chance of recurrence than needle aspiration. There is some very low-quality evidence to suggest that needle aspiration is less painful.
Topics: Adolescent; Adult; Child; Drainage; Eating; Humans; Needles; Peritonsillar Abscess; Recurrence; Retreatment; Suction; Symptom Assessment; Time Factors
PubMed: 28009937
DOI: 10.1002/14651858.CD006287.pub4 -
The Journal of Laryngology and Otology Feb 2021Peritonsillar abscess, or quinsy, is one of the most common emergency presentations to ENT departments, and is the most common deep tissue infection of the head and...
BACKGROUND
Peritonsillar abscess, or quinsy, is one of the most common emergency presentations to ENT departments, and is the most common deep tissue infection of the head and neck. In the UK, junior members of the ENT team are regularly required to independently assess, diagnose and treat patients with peritonsillar aspiration or incision and drainage.
ISSUE
Inexperienced practitioners can stumble at several obstacles: poor access due to trismus; poor lighting; difficulty in learning the therapeutic procedure; and difficulty in accurately documenting findings and treatment.
SOLUTION
To counter these and other difficulties, the authors describe the routine use of video endoscopy as a training tool and therapeutic adjunct in the management of quinsy.
Topics: Drainage; Endoscopy; Humans; Laryngoscopes; Laryngoscopy; Oropharynx; Otorhinolaryngologic Surgical Procedures; Peritonsillar Abscess
PubMed: 33599574
DOI: 10.1017/S0022215121000050 -
Cureus Feb 2022Peritonsillar abscess (PTA) is a common deep tissue infection of the head and neck. In the literature, most cases demonstrate PTA following acute tonsillitis; however,...
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.
PubMed: 35350518
DOI: 10.7759/cureus.22271 -
The Journal of Laryngology and Otology Mar 2021The global pandemic of coronavirus disease 2019 has necessitated changes to 'usual' ways of practice in otolaryngology, with a view towards out-patient or ambulatory... (Review)
Review
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.
Topics: Ambulatory Care; COVID-19; Emergencies; Emergency Service, Hospital; Epistaxis; Humans; Otolaryngology; Peritonsillar Abscess; Referral and Consultation; Tonsillitis
PubMed: 33593465
DOI: 10.1017/S0022215121000554 -
Pediatric Radiology Jun 2016Peritonsillar infections are one of the most common deep neck space infections, particularly in adolescents. Inaccurate diagnosis can lead to delay in management and... (Review)
Review
Peritonsillar infections are one of the most common deep neck space infections, particularly in adolescents. Inaccurate diagnosis can lead to delay in management and potentially life-threatening complications. Contrast-enhanced computed tomography (CT) scan of the neck traditionally has been used to diagnose suspected peritonsillar abscess. With growing concern over radiation exposure, there has been increasing utilization of ultrasound (US) using intraoral and transcutaneous approaches. We chose the transcutaneous US technique due to its ease of performance in children. The purpose of this article is twofold: a) to describe our technique of performing transcutaneous US of the tonsil showing sonographic appearance of normal tonsil, highlighting pertinent anatomy and unique considerations for this modality in children, and b) to illustrate the sonographic findings in the spectrum of pediatric peritonsillar infections, which includes uncomplicated tonsillitis, peritonsillar cellulitis, small intratonsillar abscess and frank peritonsillar abscess. Parapharyngeal abscess can sometimes be detected.
Topics: Child; Contrast Media; Diagnosis, Differential; Humans; Peritonsillar Abscess; Ultrasonography
PubMed: 26637999
DOI: 10.1007/s00247-015-3505-7 -
The Laryngoscope Aug 20171) To analyze clinical outcomes of children stratified by ultrasound into three diagnoses: acute tonsillitis, peritonsillar phlegmon, and abscess; and 2) To compare...
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.
Topics: Adolescent; Child; Child, Preschool; Cost Savings; Female; Humans; Infant; Male; Peritonsillar Abscess; Retrospective Studies; Treatment Outcome; Ultrasonography; Young Adult
PubMed: 28092120
DOI: 10.1002/lary.26470 -
Anaerobe Dec 2016Fusobacterium necrophorum is a gram-negative anaerobic bacterium that is the causative agent of the invasive disease Lemierre's syndrome. In addition, it is also... (Review)
Review
Fusobacterium necrophorum is a gram-negative anaerobic bacterium that is the causative agent of the invasive disease Lemierre's syndrome. In addition, it is also associated with peritonsillar abscess formation and otitis media in small children. Recent research has shown that F. necrophorum may be involved in pharyngotonsillitis especially in adolescent and young adults and that it may be the second most common bacterial cause of pharyngotonsillitis after Streptococcus pyogenes (Group A streptococci). Peritonsillar abscesses and Lemierre's syndrome due to F. necrophorum are also found in this age group, suggesting that they may be complications of F. necrophorum pharyngotonsillitis. In this review we present the present knowledge about the role of F. necrophorum in pharyngotonsillitis with special emphasis on the age distribution. We argue that F. necrophorum is an important pathogen involved in pharyngotonsillitis in the age group of 13-40 years of age and we urge clinical microbiology labs to set up the appropriate techniques to be able to detect F. necrophorum from throat swabs.
Topics: Adolescent; Adult; Age Distribution; Age Factors; Anti-Bacterial Agents; Child; Female; Fusobacterium necrophorum; Humans; Lemierre Syndrome; Male; Oropharynx; Otitis Media; Peritonsillar Abscess; Pharyngitis; Sex Factors; Tonsillitis
PubMed: 27693542
DOI: 10.1016/j.anaerobe.2016.09.006