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Journal of Education & Teaching in... Apr 2022Our reusable low-cost peritonsillar abscess simulator (PTA) simulator is designed to train emergency medicine (EM) residents, fellows, and medical students. Trainees who...
AUDIENCE
Our reusable low-cost peritonsillar abscess simulator (PTA) simulator is designed to train emergency medicine (EM) residents, fellows, and medical students. Trainees who are interested in otolaryngology (OTL) or this specific disease may also benefit from this simulator.
INTRODUCTION
Peritonsillar abscess is one of the most common deep infections 1 of the head and neck, accounting for 7589 consultations and 11069 hospital bed days in the UK between 2009-2010.1,2 Emergency medicine physicians commonly treat this pathology with surgical and medical modalities. Not only is this a common diagnosis, but there is a significant cost associated with the evaluation and management of primary PTA. 3Demands for high-volume patient care and good patient outcomes are increasing in a medical climate of limited financial resources and resident work hours. Given these complexities, medical education is viewing simulation training, with proven success in various surgical specialties, as a valuable addition to resident education and patient safety. 3-5The PTA is the collection of pus in the space between the palatine tonsil and its capsule. Successfully locating the abscess is crucial because it prevents the unwanted damage of nearby vascular structures, patient discomfort, and failure to treat the infection. Management of peritonsillar abscess is primarily surgical and includes incision and drainage (I & D), needle aspiration, or Quinsy tonsillectomy.The simulator provides a realistic characteristic of typical PTA presentations, such as uvula deviation, swelling, trismus, and purulence during aspiration. While learning to drain a PTA, trainees must locate the infection with a needle without injury to the surrounding structures of the oral cavity and deep structures of the neck. The discomfort caused during this procedure can be unsettling for both physician and patient. Simulation use and testing enable the trainee to develop familiarity with handling instruments, increase comfort with the sequence of a procedure, and improve confidence in the ability to perform a procedure safely.6,7,8 Simulators provide improved patient outcomes and increased EM residents' comfort level.
EDUCATIONAL OBJECTIVES
By the end of this training session, learners will be able to: 1) locate the abscess, 2) perform needle aspiration, and 3) develop dexterity in maneuvering instruments in the small three-dimensional confines of the oral cavity without causing injury to local structures.
EDUCATIONAL METHODS
Our PTA simulator was fabricated with a low-cost, non-degradable material and is the first known PTA simulator that used a validated survey for fidelity assessment. The simulator was fabricated using a silicone mold to mimic the oral cavity and oropharynx. A simulated abscess pocket consisting of saline encased in balloon material was placed in the proper anatomic location, allowing for abscess simulation on either side of the oropharynx model. The time to fabricate the model averaged 20 hours. The simulator was manufactured with low-cost materials at an expense of 45 USD and could be easily reproduced by any EM residency program.
RESEARCH METHODS
Twenty-one participants were instructed to expose and drain the simulated abscess. The model was evaluated using The Michigan Standard Simulation Experience Scale (MiSSES).7 Participants scored the simulator in five categories: Self-efficacy, fidelity, educational value, teaching quality, and the overall rating on a 5-point Likert scale of simulator. Overall rating and global evaluation scores were compared by groups (Group 1, Group 2) between training level (residents and attendings), specialty (emergency and otolaryngology), and previous experience (<5 or ≥5 drainages).Convenience sampling was used to determinate the sample. Variables were summarized using the mean and standard deviation for continuous variables and percentages and frequencies for categorical variables. The MiSSES was scored as previously described in the literature.7 The Kolmogorov-Smirnov test was used to test for normal distribution of the variables. T-test for independent samples was performed to determinate if there exists a difference between groups in perception of a PTA simulator. The statistical analyses were performed using SPSS version 20.0 Armonk, NY: IBM.
RESULTS
Twenty-one participants were enrolled in the study: residents (n=15) and attending (n=6) from OTL and EM departments. The simulator's plasticity allowed multiple attempts of needle aspiration and drainage without degradation and received high ratings on teaching quality, fidelity, and educational value. This PTA simulator achieved high fidelity ratings in the standard simulator's assessment survey for realism of environment, simulation of trismus, uvular deviation, and realism of the mucosal surfaces. On the MiSSES, the model received positive ratings (range 3.6 to 4.9). The highest rating was on teaching quality (4.9), fidelity (4.6), and educational value (4.5) (Table 1). We found that self-efficacy and teaching quality sections were rated higher for those who had less experience (≥5 PTA drainage), while fidelity was rated higher for OTL. The overall rating average was 4 and was higher of attendings, OTL, and those with less experience. All comparisons between groups were not statically significant (Table 2). About 76% of participants found that the simulator can be used in training with slight improvement or no improvement needed. (Table 3).
DISCUSSION
With favorable participant ratings and comments, we believe that this tool can offer high-fidelity simulation at a low cost. Widespread use may be possible, allowing training of EM residents in performing instrumentation of PTA in a controlled simulation environment. We have created a reusable low-cost PTA simulator that achieved a high score fidelity in a standard simulator's assessment survey.
TOPICS
Peritonsillar abscess, oropharynx, emergency medicine residency, otolaryngology residency training.
PubMed: 37465440
DOI: 10.21980/J85M0B -
SAGE Open Medical Case Reports 2022Pharyngeal abscesses require urgent management as they have the propensity to cause severe and life-threatening complications. The introduction of antibiotics has led to...
Pharyngeal abscesses require urgent management as they have the propensity to cause severe and life-threatening complications. The introduction of antibiotics has led to a dramatic decline in the incidence of these infections. Regardless, abscess formation continues to be observed in the peritonsillar, parapharyngeal, and retropharyngeal spaces. Oropharyngeal and hypopharyngeal abscesses that cause airway obstruction are scarcely reported and tend to be secondary to other processes. Herein, we describe the case of an 83-year-old man presenting with an idiopathic, obstructive, oropharyngeal wall abscess, extending from the infratonsillar region to the hypopharynx, which recurred after initial surgical management 12 years prior for the same process. He required reintervention during both episodes for rapid reaccumulation. A detailed electronic literature search of PubMed and MedLine was performed for studies reporting on recurrent pharyngeal abscesses and their management. Results were limited to articles published in English from inception to August 2021. The timely management of pharyngeal infections acutely obstructing the airway is crucial. Physicians should adopt close and frequent monitoring and have a low threshold for reimaging should symptoms worsen or fail to improve after the initial surgical intervention.
PubMed: 35401981
DOI: 10.1177/2050313X221089119 -
BMJ Case Reports Apr 2022We present three cases who presented to the emergency department with severe complications of dental infections: Ludwig's angina, necrotising fasciitis and peritonsillar...
We present three cases who presented to the emergency department with severe complications of dental infections: Ludwig's angina, necrotising fasciitis and peritonsillar abscess. All of our cases presented at the beginning of COVID-19 pandemic, with complications of dental infections. They delayed their dental treatment due to the pandemic. The airway management was difficult in our cases. Their mortality risk increased due to complications. We aimed to draw attention to complicated odontogenic infections which are rarely seen in emergency department in the past, however started to show up increasingly particularly at the beginning of the COVID-19 pandemic.
Topics: Airway Management; COVID-19; Delayed Diagnosis; Humans; Ludwig's Angina; Pandemics
PubMed: 35396235
DOI: 10.1136/bcr-2021-247553 -
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 -
Cureus Jan 2022Although peritonsillar abscesses (PTAs) are a common presentation in pediatric patients, there are very few reports on a pediatric patient with both a PTA and uvular...
Although peritonsillar abscesses (PTAs) are a common presentation in pediatric patients, there are very few reports on a pediatric patient with both a PTA and uvular hydrops. Our patient presented to the emergency room after being unsuccessfully treated for pharyngitis, with odynophagia, dyspnea, muffled voice, drooling, and trismus. On physical examination, we observed a PTA as well as an edematous and erythematous uvula. Following the standard of care, the patient underwent a needle aspiration in the emergency department and subsequently was admitted overnight for observation. The patient had great symptom relief after undergoing drainage of his PTA and was discharged the next morning with symptom resolution of his dyspnea and odynophagia. We recommend drainage and close monitoring for airway compromise as an appropriate treatment course for PTAs and concurrent uvular hydrops.
PubMed: 35237491
DOI: 10.7759/cureus.21701 -
European Archives of... Aug 2022To longitudinally evaluate the impact of the COVID-19-pandemic on the incidence of inpatient tonsil surgery and outpatient primary care of sore throat in Germany.
PURPOSE
To longitudinally evaluate the impact of the COVID-19-pandemic on the incidence of inpatient tonsil surgery and outpatient primary care of sore throat in Germany.
METHODS
A retrospective interrupted time-series analysis was conducted. The national database of the Hospital Remuneration System was used to retrieve the number of operations performed between January 2019 and September 2021 including elective and non-elective cases with the exception of malign diseases. Three episodes were compared on a weekly basis: before, during, and after the first national lockdown (March 16-May 3, 2020). We also analysed the number of outpatient doctor contacts of sore throat patients in 2019 and 2020.
RESULTS
Overall, 144,069 surgical cases were included in the analysis. The first lockdown resulted in an abrupt and significant decrease of all types of tonsil surgery (p < 0.01). The incidence of tonsillectomy decreased from 556 (before) to 111 (during) and 326 (after) cases per week (relative risk 0.24; 95% CI 0.19-0.30, and 0.82; 95% CI 0.73-0.92). After the lockdown, the incidence persisted on a lower level compared to 2019. The number of doctor contacts decreased from 2,967,322 in 2019 to 1,976,617 in 2020 (- 33.4%).
CONCLUSIONS
The first lockdown was associated with a significant decrease of all types of tonsil surgery. A return to pre-pandemic surgical activity was not identified. The findings were accompanied by a significant decrease of outpatient doctor contacts of sore throat patients in primary care, particularly in the subgroup of children and adolescents. The impact of the second lockdown, starting in December 2020, was by far not comparable.
Topics: Adolescent; COVID-19; Child; Communicable Disease Control; Humans; Incidence; Palatine Tonsil; Pandemics; Pharyngitis; Retrospective Studies; Tonsillectomy; Tonsillitis
PubMed: 35218385
DOI: 10.1007/s00405-022-07308-8 -
Cureus Jan 2022A 19-year-old male presented with a history of pulsatile tinnitus on the left side after he underwent drainage for a tonsillar swelling. He had noticed a painless neck...
A 19-year-old male presented with a history of pulsatile tinnitus on the left side after he underwent drainage for a tonsillar swelling. He had noticed a painless neck swelling one month ago that was associated with difficulty in swallowing. His physician had made a diagnosis of peritonsillar abscess, and drainage had been performed. After the procedure, the swelling had progressed further, leading to drooling of saliva and disabling tinnitus. When he presented to the emergency, local examination revealed a pulsatile neck swelling with peritonsillar mass. CT angiography/digital subtraction angiography (DSA) of the neck and brain revealed a large aneurysm of the distal cervical segment of the left internal carotid artery (ICA). The patient successfully underwent an urgent open repair. This case highlights the importance of a thorough history and examination in identifying a rare cause of pulsatile tinnitus. A stepwise approach to determine the reason behind tinnitus revealed an underlying ICA aneurysm of the extracranial segment.
PubMed: 35198266
DOI: 10.7759/cureus.21349 -
Pediatric Radiology May 2022Differences in the functioning of the immune system and the anatomical proportions of the neck between children and adults lead to different manifestations of deep neck...
BACKGROUND
Differences in the functioning of the immune system and the anatomical proportions of the neck between children and adults lead to different manifestations of deep neck infections. Magnetic resonance imaging (MRI) may serve as an alternative to computed tomography (CT) as the primary imaging modality.
OBJECTIVE
To study characteristic MRI findings and the diagnostic accuracy of MRI in pediatric deep neck infections.
MATERIALS AND METHODS
We retrospectively studied a cohort of pediatric patients who underwent a neck 3-tesla MRI study over a five-year period. Inclusion criteria were: 1) emergency MRI findings indicating an infection, 2) infection as the final clinical diagnosis, 3) diagnostic image quality verified by the radiologist reading the study and 4) age under 18 years. Patient record data, including surgery reports, were compared with the MRI findings.
RESULTS
Data of 45 children were included and analysed. Compared to adults, children had a higher incidence of retropharyngeal infection and lymphadenitis, and a lower incidence of peritonsillar/parapharyngeal infection. MRI showed evidence of an abscess in 34 children. Of these 34 patients, 24 underwent surgery, which confirmed an abscess in 21 but no abscess in three patients. In addition, three patients underwent surgery without MRI evidence of abscess, and an abscess was found in one of these cases. The measures of diagnostic accuracy among the children were sensitivity 0.96, specificity 0.77, positive predictive value 0.89, negative predictive value 0.91 and accuracy 0.89. Compared with adults, children had lower C-reactive protein, but a similar proportion of them had an abscess, and abscess size and rate of surgery were similar.
CONCLUSION
Despite the differences in the infection foci, emergency MRI in children had equal diagnostic accuracy to that in adults.
Topics: Abscess; Adolescent; Adult; Chest Pain; Child; Humans; Magnetic Resonance Imaging; Neck; Retrospective Studies; Tomography, X-Ray Computed
PubMed: 35184213
DOI: 10.1007/s00247-021-05275-6 -
Ear, Nose, & Throat Journal Jan 2022Branchial cleft cyst (BCC) most frequently arises from the second branchial cleft and is located anterior to the sternocleidomastoid muscle at the mandibular angle....
Branchial cleft cyst (BCC) most frequently arises from the second branchial cleft and is located anterior to the sternocleidomastoid muscle at the mandibular angle. However, very rarely, this may occur in the parapharyngeal space. Interestingly, the parapharyngeal BCC is frequently misdiagnosed as a peritonsillar abscess. In this study, we reported 2 cases of parapharyngeal BCC misdiagnosed as peritonsillar abscess.
PubMed: 35088618
DOI: 10.1177/01455613211067846 -
International Journal of Pediatric... Feb 2022The COVID-19 pandemic has shifted medical practice globally. The objective of this study was to examine the changes to the practice of pediatric otolaryngology...
BACKGROUND
The COVID-19 pandemic has shifted medical practice globally. The objective of this study was to examine the changes to the practice of pediatric otolaryngology internationally due to the COVID-19 pandemic and examine potential contributors.
METHOD
An online survey was designed to assess practice demographics, patterns of COVID-19 related restrictions in communities, and changes to practice and referrals. This was disseminated via an international Covid-19 WhatsApp™ group of pediatric otolaryngologists.
RESULTS
There were 45 respondents of 177 group members (25.4%) from 15 countries. The mean estimated time spent under strictest lockdown measures was 16.2 (±10.7) weeks (range: 1-45 weeks). Operating room time was reduced for 82.9%, with an average reported reduction of 41.5%. Almost all (>75%) of respondents reported reduced referrals for five common conditions: otitis media with effusion (average reported decrease - 56.1%); acute otitis media (average decrease 62.8%); acute mastoiditis (average decrease 66.6%); recurrent pharyngotonsillitis (average decrease 51.0%); and peritonsillar abscess (average decrease 52.1%). COVID-19 cases per million population significantly influenced the acuity of referrals received (p < .05). No conditions were reported as increased in frequency and the acuity of most conditions was reported as unchanged by the majority of respondents.
CONCLUSION
The measures taken to reduce the spread of COVID-19 have resulted in many changes to pediatric otolaryngology practice and the referral patterns of common conditions. Some of these changes may have enduring sequelae.
Topics: COVID-19; Child; Communicable Disease Control; Humans; Otolaryngology; Pandemics; SARS-CoV-2
PubMed: 34990923
DOI: 10.1016/j.ijporl.2021.111021