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Academic Emergency Medicine : Official... Aug 2023Distinguishing peritonsillar abscess (PTA) from peritonsillar cellulitis using clinical assessment is challenging as many features overlap for both conditions, and... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Distinguishing peritonsillar abscess (PTA) from peritonsillar cellulitis using clinical assessment is challenging as many features overlap for both conditions, and physical examination is only about 75% sensitive and 50% specific for diagnosing PTA. The primary objective of this systematic review was to determine the test characteristics of ultrasound for diagnosing PTA when compared to a reference standard of computed tomography or acquisition of pus via needle aspiration or incision and drainage.
METHODS
This systematic review was performed in accordance with the Preferred Reporting Items for a Systematic Review and Meta-analysis of Diagnostic Test Accuracy (PRISMA-DTA) guidelines. We searched seven databases from 1960 to November 2022. Two independent reviewers completed study selection, data extraction, and QUADAS-2 risk-of-bias assessment. We used a bivariate random-effects model to calculate pooled sensitivity, specificity, positive likelihood ratio (LR+), and negative likelihood ratio (LR-). We also conducted subgroup analyses on radiology ultrasound compared to point-of-care ultrasound (POCUS) and intraoral compared to transcervical scanning techniques.
RESULTS
From 339 citations, we identified 18 studies for inclusion. Because one study only reported positive cases of PTA (thereby preventing the calculation of specificity), it was excluded from the analysis, so the analysis included a total of 17 studies with 812 patients, of whom 541 had PTA. Pooled bivariate sensitivity was 86% (95% confidence interval [CI] 78%-91%), specificity 76% (95% CI 67%-82%), LR+ 3.51 (95% CI 2.59-4.89), and LR- 0.19 (95% CI 0.12-0.30). On subgroup analysis, radiology-performed ultrasound had a sensitivity and specificity of 89% and 71%, compared to POCUS, which had a sensitivity and specificity of 74% and 79%. Comparing the two different techniques, intraoral had a sensitivity and specificity of 91% and 75% while transcervical had a sensitivity and specificity of 80% and 81%.
CONCLUSIONS
Ultrasound demonstrates high sensitivity for ruling out PTA, but it only has moderate specificity for ruling in the diagnosis.
Topics: Humans; Peritonsillar Abscess; Ultrasonography; Tomography, X-Ray Computed; Sensitivity and Specificity; Physical Examination
PubMed: 36625850
DOI: 10.1111/acem.14660 -
Annals of Clinical Microbiology and... Nov 2023Peritonsillar abscess (PTA) is a severe deep neck space infection with an insufficiently characterized bacterial etiology. We aimed to reveal the bacteria associated...
BACKGROUND
Peritonsillar abscess (PTA) is a severe deep neck space infection with an insufficiently characterized bacterial etiology. We aimed to reveal the bacteria associated with PTA applying next generation sequencing (NGS). Tonsil biopsies and pus samples of 91 PTA patients were analysed applying NGS method.
RESULTS
Over 400 genera and 800 species belonging to 34 phyla were revealed. The most abundant species in both sample types were Streptococcus pyogenes, Fusobacterium necrophorum and Fusobacterium nucleatum. When present, S. pyogenes was normally a predominant species, although it was recovered as a minor population in some samples dominated by F. nucleatum and occasionally F. necrophorum. S. pyogenes and F. necrophorum were the predominant species (> 10% in a community) in 28 (31%) pus samples, while F. nucleatum in 21 (23%) and S. anginosus in 8 (9%) pus samples. We observed no substantial differences between the microbial findings in pus and tonsil biopsies.
CONCLUSIONS
The most probable causative agents of PTA according to our NGS-study include Streptococcus pyogenes, Fusobacterium necrophorum and Fusobacterium nucleatum. Some other streptococci (S. anginosus) and anaerobes (Prevotella, Porphyromonas) may contribute to the infection as well. Pus of the peritonsillar abscess is more representative specimen for microbiological examination than the tonsillar tissue. Our results are important in the context of optimizing the handling of the PTA patients.
Topics: Humans; Peritonsillar Abscess; High-Throughput Nucleotide Sequencing; Fusobacterium necrophorum; Streptococcus pyogenes
PubMed: 37940951
DOI: 10.1186/s12941-023-00649-0 -
Clinical Practice and Cases in... May 2024Peritonsillar abscesses form between the tonsillar capsule, the superior constrictor, and palatopharyngeus muscles. Physicians traditionally make this diagnosis...
INTRODUCTION
Peritonsillar abscesses form between the tonsillar capsule, the superior constrictor, and palatopharyngeus muscles. Physicians traditionally make this diagnosis clinically; however, ultrasound allows clinicians to further identify and differentiate between peritonsillitis, peritonsillar abscess, and phlegmon formation. By increasing both the sensitivity and specificity, ultrasound improves the diagnostic accuracy for patients with peritonsillar abscesses. This case demonstrates the utilization of ultrasound in peritonsillar abscesses and the application of point-of-care ultrasound (POCUS) in identifying complications of procedures used for treatment in the emergency department (ED).
CASE REPORT
A 19-year-old male presented to the ED with complaints of severe sore throat and fever for the prior five days. A POCUS using an endocavitary probe with sterile cover demonstrated hypoechoic debris with a "swirl sign." Ultrasound was used to successfully guide needle aspiration by using in-plane needle guidance. The patient had significant bleeding after needle aspiration, and repeat POCUS clearly identified a new pocket of blood that had formed and was contained in the soft tissue. We monitored the size of the hematoma in real time with ultrasound to ensure the hematoma had no rapid expansion and was stable.
CONCLUSION
Among the differential diagnoses for sore throat, the diagnosis of peritonsillar abscess is particularly concerning as it is both common and generally requires swift intervention. Presentations can range from a mild infection to a life-threatening emergency with potential airway compromise. The two primary avenues for treatment include either needle aspiration or incision and drainage. Ultrasound can successfully identify the abscess and other landmarks for safe and successful drainage, as well as early identification of complications.
PubMed: 38869335
DOI: 10.5811/cpcem.1645 -
The Laryngoscope Aug 2023This study aimed to investigate the risk factors associated with peritonsillar abscess (PTA) recurrence in adult patients.
OBJECTIVES
This study aimed to investigate the risk factors associated with peritonsillar abscess (PTA) recurrence in adult patients.
METHODS
This retrospective cohort study used a nationwide insurance claims database in Japan. Adult patients (aged ≥ 20 years) who received intravenous antibiotics or surgical therapy within 5 days of their first PTA diagnosis were included. Multivariable Cox proportional modeling was used to investigate the risk factors for PTA recurrence using the variables: age, sex, comorbidities, tobacco use, history of recurrent tonsillitis, duration of intravenous antibiotics, and surgical therapy for PTA.
RESULTS
This study included 12,012 patients (8784 men, 73.1%). Of them, 1358 (11.3%) experienced PTA recurrence. An age ≥40 years and treatment with intravenous antibiotics for 3 days or more were associated with a lower risk of PTA recurrence (aged ≥ 40 years: adjusted hazard ratio [HR]: 0.69; 95% confidence interval [CI]: 0.62-0.78, treated with intravenous antibiotics for 3 days or more: adjusted HR: 0.85; 95% CI: 0.76-0.96). Patients with a history of recurrent tonsillitis were associated with a higher risk of recurrence (adjusted HR: 1.79; 95% CI: 1.47-2.19).
CONCLUSION
A median age of 20-39 years, a history of recurrent tonsillitis, and less than 3 days of intravenous antibiotic therapy may be risk factors for PTA recurrence among adult patients. Further studies exploring more detailed clinical data are necessary to confirm the risk factors for PTA recurrence.
LEVEL OF EVIDENCE
3 Laryngoscope, 133:1846-1852, 2023.
Topics: Adult; Male; Humans; Young Adult; Peritonsillar Abscess; Retrospective Studies; Tonsillitis; Risk Factors; Anti-Bacterial Agents; Recurrence
PubMed: 36054512
DOI: 10.1002/lary.30367 -
International Journal of Pediatric... Aug 2023To compare surgical outcomes for children with peritonsillar abscess (PTA) who are taken to the operating room (OR) for incision and drainage (I&D) or quinsy...
OBJECTIVE
To compare surgical outcomes for children with peritonsillar abscess (PTA) who are taken to the operating room (OR) for incision and drainage (I&D) or quinsy tonsillectomy.
METHODS
This is a multicenter retrospective study of pediatric patients who underwent I&D of a PTA between 2012 and 2017 included in the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database. Patient demographics, comorbidities, and 30-day postoperative events (reoperation, readmission, and complications) were assessed.
RESULTS
777 patients were identified (mean age of 10.7 years, 54% female). 656 (84%) were admitted through the emergency department, and 395 (51%) met criteria for systemic inflammatory response syndrome or sepsis. Fifty-two (6.7%) had a quinsy tonsillectomy done at the time of incision and drainage. For quinsy tonsillectomy versus I&D alone, there was no statistically significant difference in length of stay (LOS) (1.9 v. 1.7 days, p = .523), readmission (17 v. 0, p = .265) or return to the OR (18 v. 1, p = .810). Patients younger than 5 years had a longer LOS (p < .001) while females (p = .003) and patients between 12 and 17 years of age (p = 0.021) were more likely to be readmitted. Of 725 patients treated with I&D alone, 10 (1.4%) patients required a repeat I&D and 6 (0.83%) went on to have an interval quinsy tonsillectomy.
CONCLUSIONS
Outcomes of I&D and quinsy tonsillectomy for pediatric PTA in the operating room are the same. If tonsillectomy is indicated in the case of recurrent tonsillitis or PTA, a quinsy tonsillectomy is a good option.
Topics: Humans; Child; Female; Male; Peritonsillar Abscess; Tonsillectomy; Retrospective Studies; Quality Improvement; Postoperative Complications
PubMed: 37352593
DOI: 10.1016/j.ijporl.2023.111636 -
Clinical Microbiology and Infection :... Jan 2024We aimed to explore the impact of social distancing on the incidence and microbiology of peritonsillar abscess (PTA).
OBJECTIVES
We aimed to explore the impact of social distancing on the incidence and microbiology of peritonsillar abscess (PTA).
METHODS
We performed a cross-sectional analysis of all patients with PTA and their microbiological findings in the 2 years preceding versus the 2 years following the COVID-19 lockdown in Denmark (11 March 2020), who were admitted to the Ear-Nose-Throat Department, Aarhus University Hospital. Age-stratified population data for the catchment area were obtained from Statistics Denmark.
RESULTS
The annual incidence rate was significantly higher in the 2-year period before (21.8 cases/100 000 inhabitants) compared with after (14.9 cases/100 000) the lockdown (p < 0.001). The number of cases with growth of Streptococcus pyogenes was significantly higher in the period before (n = 67) compared with after (n = 28) the lockdown (p < 0.001), whereas the number of cases positive for Fusobacterium necrophorum (n = 60 vs. n = 64) and streptococcus anginosus group (SAG) (n = 37 vs. n = 43) were stabile (p 0.79 and p 0.58, respectively). The relative prevalence of S. pyogenes was significantly higher in the period before (67/246 cultures, 27%) compared with after (28/179, 16%) the lockdown (p 0.007). On the contrary, the relative prevalence of F. necrophorum and SAG is significantly lower before (60/246, 24% and 37/246, 15%) compared with after (64/179, 36% and 43/179, 24%) the lockdown (p 0.013 and p 0.023).
DISCUSSION
Social distancing had a significant impact on the incidence and microbiology of PTA. Our findings suggest that S. pyogenes-positive PTA is highly related to direct social interaction, and represents a contagious pathogen. By contrast, PTA development caused by F. necrophorum and SAG is unrelated to direct social interaction and may be derived from flora imbalance.
Topics: Humans; Peritonsillar Abscess; Incidence; Retrospective Studies; Cross-Sectional Studies; Fusobacterium Infections; Streptococcus pyogenes
PubMed: 37562694
DOI: 10.1016/j.cmi.2023.08.003 -
The Journal of Laryngology and Otology Oct 2023Partly as a result of coronavirus disease 2019, YouTube has become a more frequent educational source for otolaryngology trainees. This study sought to assess the...
BACKGROUND
Partly as a result of coronavirus disease 2019, YouTube has become a more frequent educational source for otolaryngology trainees. This study sought to assess the quality of flexible nasendoscopy and peritonsillar abscess drainage videos.
METHOD
YouTube was systematically searched using 13 terms related to flexible nasendoscopy and peritonsillar abscess drainage. Two independent reviewers assessed the quality of each video using the Laparoscopic Video Educational Guidelines.
RESULTS
Twenty-seven videos were deemed suitable. The mean total Laparoscopic Video Educational Guidelines scores for videos on flexible nasendoscopy (18 videos) and peritonsillar abscess drainage (9 videos) were 10.3 (standard deviation = 3.1) and 11.7 (standard deviation = 4.6), respectively. Most of the videos were deemed of medium quality. The Laparoscopic Video Educational Guidelines score correlated positively with flexible nasendoscopy video length and how recently a peritonsillar abscess drainage video had been uploaded.
CONCLUSION
The limited high-quality videos on YouTube are difficult to identify from the search metrics available. Trainees and ENT induction programmes would benefit greatly from an online platform that contains a catalogue of high-quality surgical videos.
Topics: Humans; COVID-19; Drainage; Information Dissemination; Peritonsillar Abscess; Reproducibility of Results; Social Media; Video Recording
PubMed: 36155641
DOI: 10.1017/S0022215122002110 -
Ultraschall in Der Medizin (Stuttgart,... Dec 2023Peritonsillar abscess can be diagnosed by B-mode ultrasound and cross-sectional imaging. The latter (with MRI being the modality of first choice in children) is...
PURPOSE
Peritonsillar abscess can be diagnosed by B-mode ultrasound and cross-sectional imaging. The latter (with MRI being the modality of first choice in children) is associated with higher effort and risk for pediatric patients due to the administration of X-rays and/or the need of sedation. The purpose of this study is to evaluate whether the introduction of CEUS into the diagnostic algorithm for suspected pediatric peritonsillar abscess is suitable and advantageous.
MATERIALS AND METHODS
Single-institution retrospective review of data of pediatric patients who were presented to the department of pediatric radiology for sonographic evaluation under the suspicion of peritonsillar abscess. Diagnostic performance of CEUS was evaluated by using surgical exploration or clinical follow-up as the reference standard.
RESULTS
284 children included in the study underwent B-mode ultrasound. Mean age of all patients was 6,23 years. Peritonsillar abscess was the diagnosis in 42 patients. Diagnosis of peritonsillar abscess was made by B-mode ultrasound alone in 13 of 42 patients (31 %). In 17 of 42 patients (40 %), diagnosis was made by a combination of B-mode ultrasound and CEUS. Sensitivity rose from 37 % to 86 % in cases where B-mode ultrasound remained unclear and CEUS was used.
CONCLUSION
Contrast-enhanced ultrasound (CEUS) is suitable and efficient for the diagnosis of peritonsillar abscess in pediatric patients. It increases the sensitivity for the diagnosis of peritonsillar abscess and thereby reduces the need of additional cross-sectional imaging for the pediatric patients.
Topics: Child; Humans; Peritonsillar Abscess; Ultrasonography; Retrospective Studies
PubMed: 36690031
DOI: 10.1055/a-2017-7172 -
Archivos Argentinos de Pediatria Feb 2024The bilateral presentation of peritonsillar abscess is uncommon. Its management is controversial and it has been argued whether a quinsy tonsillectomy or an interval...
The bilateral presentation of peritonsillar abscess is uncommon. Its management is controversial and it has been argued whether a quinsy tonsillectomy or an interval tonsillectomy should be performed. Here we describe the case of a 14-year-old boy with sore throat, trismus, and fever. He had bilateral tonsillar hypertrophy, convex arches, and soft palate edema. Computed tomography: bilateral tonsillar hypertrophy, with post-contrast enhancement, both with collection, edema with moderate pharyngeal stenosis. The patient was hospitalized for intravenous therapy and tonsillectomy with bilateral drainage resulting in a complete resolution of his condition and discharge at 48 hours. In the presence of a peritonsillar abscess, an unsuspected contralateral abscess should be considered. It should be diagnosed and managed adequately to prevent complications. Quinsy tonsillectomy could be safe and should be considered in patients who will undergo anesthesia for abscess drainage. The final decision should be made for each patient on an individual basis.
Topics: Male; Humans; Adolescent; Peritonsillar Abscess; Tonsillectomy; Pharyngitis; Hypertrophy; Edema
PubMed: 37382552
DOI: 10.5546/aap.2023-03034.eng