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The Journal of Laryngology and Otology Sep 2023Peritonsillar abscess is a localised infection in the peritonsillar space. Pus from the abscess can contain anaerobes. Many clinicians prescribe metronidazole in... (Review)
Review
BACKGROUND
Peritonsillar abscess is a localised infection in the peritonsillar space. Pus from the abscess can contain anaerobes. Many clinicians prescribe metronidazole in addition to penicillin, but evidence to support this is limited. This review assessed the evidence of benefit of metronidazole for the treatment of peritonsillar abscess.
METHODS
A systematic review was conducted of the literature and databases including Ovid Medline, Ovid Embase, PubMed and Cochrane library. Search terms included all variations of peritonsillar abscess, penicillin and metronidazole.
RESULTS
Three randomised, control trials were included. All studies assessed the clinical outcomes after treatment for peritonsillar abscess, including recurrence rate, length of hospital stay and symptom improvement. There was no evidence to suggest additional benefit with metronidazole, with studies suggesting increased side effects.
CONCLUSION
Evidence does not support the addition of metronidazole in first-line management of peritonsillar abscess. Further trials to establish optimum dose and duration schedules of oral phenoxymethylpenicillin would benefit clinical practice.
Topics: Humans; Peritonsillar Abscess; Metronidazole; Penicillins; Penicillin V; Drainage; Anti-Bacterial Agents
PubMed: 37194922
DOI: 10.1017/S0022215123000804 -
The Cochrane Database of Systematic... May 2020Sore throat is a common condition associated with a high rate of antibiotic prescriptions, despite limited evidence for the effectiveness of antibiotics. Corticosteroids... (Meta-Analysis)
Meta-Analysis
BACKGROUND
Sore throat is a common condition associated with a high rate of antibiotic prescriptions, despite limited evidence for the effectiveness of antibiotics. Corticosteroids may improve symptoms of sore throat by reducing inflammation of the upper respiratory tract. This review is an update to our review published in 2012.
OBJECTIVES
To assess the clinical benefit and safety of corticosteroids in reducing the symptoms of sore throat in adults and children.
SEARCH METHODS
We searched CENTRAL (Issue 4, 2019), MEDLINE (1966 to 14 May 2019), Embase (1974 to 14 May 2019), the Database of Abstracts of Reviews of Effects (DARE, 2002 to 2015), and the NHS Economic Evaluation Database (inception to 2015). We also searched the World Health Organization International Clinical Trials Registry Platform (WHO ICTRP) and ClinicalTrials.gov.
SELECTION CRITERIA
We included randomised controlled trials (RCTs) that compared steroids to either placebo or standard care in adults and children (aged over three years) with sore throat. We excluded studies of hospitalised participants, those with infectious mononucleosis (glandular fever), sore throat following tonsillectomy or intubation, or peritonsillar abscess.
DATA COLLECTION AND ANALYSIS
We used standard methodological procedures expected by Cochrane.
MAIN RESULTS
We included one new RCT in this update, for a total of nine trials involving 1319 participants (369 children and 950 adults). In eight trials, participants in both corticosteroid and placebo groups received antibiotics; one trial offered delayed prescription of antibiotics based on clinical assessment. Only two trials reported funding sources (government and a university foundation). In addition to any effect of antibiotics and analgesia, corticosteroids increased the likelihood of complete resolution of pain at 24 hours by 2.40 times (risk ratio (RR) 2.4, 95% confidence interval (CI) 1.29 to 4.47; P = 0.006; I² = 67%; high-certainty evidence) and at 48 hours by 1.5 times (RR 1.50, 95% CI 1.27 to 1.76; P < 0.001; I² = 0%; high-certainty evidence). Five people need to be treated to prevent one person continuing to experience pain at 24 hours. Corticosteroids also reduced the mean time to onset of pain relief and the mean time to complete resolution of pain by 6 and 11.6 hours, respectively, although significant heterogeneity was present (moderate-certainty evidence). At 24 hours, pain (assessed by visual analogue scales) was reduced by an additional 10.6% by corticosteroids (moderate-certainty evidence). No differences were reported in recurrence/relapse rates, days missed from work or school, or adverse events for participants taking corticosteroids compared to placebo. However, the reporting of adverse events was poor, and only two trials included children or reported days missed from work or school. The included studies were assessed as moderate quality evidence, but the small number of included studies has the potential to increase the uncertainty, particularly in terms of applying these results to children.
AUTHORS' CONCLUSIONS
Oral or intramuscular corticosteroids, in addition to antibiotics, moderately increased the likelihood of both resolution and improvement of pain in participants with sore throat. Given the limited benefit, further research into the harms and benefits of short courses of steroids is needed to permit informed decision-making.
Topics: Adolescent; Adrenal Cortex Hormones; Adult; Anti-Bacterial Agents; Child; Child, Preschool; Drug Therapy, Combination; Humans; Middle Aged; Pharyngitis; Randomized Controlled Trials as Topic; Time Factors; Tonsillitis; Treatment Outcome; Young Adult
PubMed: 32356360
DOI: 10.1002/14651858.CD008268.pub3 -
GMS Current Topics in... 2016One of the most significant clinical trials, demonstrating the efficacy of tonsillectomy (TE) for recurrent throat infection in severely affected children, was... (Review)
Review
One of the most significant clinical trials, demonstrating the efficacy of tonsillectomy (TE) for recurrent throat infection in severely affected children, was published in 1984. This systematic review was undertaken to compile various indications for TE as suggested in the literature after 1984 and to stratify the papers according to the current concept of evidence-based medicine. A systematic Medline research was performed using the key word of "tonsillectomy" in combination with different filters such as "systematic reviews", "meta-analysis", "English", "German", and "from 1984/01/01 to 2015/05/31". Further research was performed in the Cochrane Database of Systematic Reviews, National Guideline Clearinghouse, Guidelines International Network and BMJ Clinical Evidence using the same key word. Finally, data from the "Trip Database" were researched for "tonsillectomy" and "indication" and "from: 1984 to: 2015" in combination with either "systematic review" or "meta-analysis" or "metaanalysis". A total of 237 papers were retrieved but only 57 matched our inclusion criteria covering the following topics: peritonsillar abscess (3), guidelines (5), otitis media with effusion (5), psoriasis (3), PFAPA syndrome (6), evidence-based indications (5), renal diseases (7), sleep-related breathing disorders (11), and tonsillitis/pharyngitis (12), respectively. 1) The literature suggests, that TE is not indicated to treat otitis media with effusion. 2) It has been shown, that the PFAPA syndrome is self-limiting and responds well to steroid administration, at least in a considerable amount of children. The indication for TE therefore appears to be imbalanced but further research is required to clarify the value of surgery. 3) Abscesstonsillectomy as a routine is not justified and indicated only for cases not responding to other measures of treatment, evident complications, or with a significant history of tonsillitis. In particular, interval-tonsillectomy is not justified as a routine. 4) TE, with or without adenoidectomy, is efficacious to resolve sleep-related breathing disorders resulting from (adeno)tonsillar hypertrophy in children. However, the benefit is reduced by co-morbidities, such as obesity, and further research is required to identify prognostic factors for this subgroup of patients. Further research is indicated to clarify selection criteria not only for this subpopulation that may benefit from less invasive procedures such as tonsillotomy in the long-term. 5) Further trials are also indicated to evaluate the efficacy of TE on the clinical course in children with psoriasis guttata as well as on psoriasis vulgaris in adults, not responding to first-line therapy. 6) Conflicting results were reported concerning the role of TE in the concert to treat Ig-A nephropathy, mandating further clinical research. 7) Most importantly, randomized-controlled clinical trials with an adequate long-term follow-up are desirable to clarify the benefit of TE in patients with recurrent episodes of tonsillitis, with or without pharyngitis. Factors like age, spontaneous healing rate and postoperative quality of life have to be included when comparing TE with antibiotic therapy.
PubMed: 28025609
DOI: 10.3205/cto000136 -
Ear, Nose, & Throat Journal Apr 2023The purpose of this study was to evaluate the diagnosis circumstances, predisposing factors, investigations, and therapeutic management of retropharyngeal and...
OBJECTIVE
The purpose of this study was to evaluate the diagnosis circumstances, predisposing factors, investigations, and therapeutic management of retropharyngeal and parapharyngeal abscesses.
METHODS
A retrospective chart review of patients diagnosed with retropharyngeal or parapharyngeal abscess from 2001 to 2021 was performed. Epidemiological characteristics, clinical signs, investigations, medical treatment, and surgical interventions were analyzed for each patient.
RESULTS
A total of 30 patients with retropharyngeal or parapharyngeal abscess were identified. Computed tomography was performed in all cases, and magnetic resonance imaging was performed in three cases. Twelve patients had a "pure" retropharyngeal abscess, nine patients had a prestyloid abscess, one patient had a prestyloid abscess associated with a peritonsillar abscess, three patients had a retrostyloid abscess, and five patients had a prestyloid abscess associated with a retropharyngeal abscess or a retrostyloid abscess. The median long axis of the abscess was 42 cm. All patients received intravenous antibiotics for a median period of 8 days [4-30]. Seventeen patients required surgical trans-cervical drainage. Other patients underwent transoral or transnasal drainage. The pus culture revealed no growth in six cases, (four cases), methicillin-sensitive (two cases), (two cases), (one case), Fungi (two cases), and (a twelve-year-old boy). It was not documented in twelve cases. Histological examination revealed caseofollicular tuberculosis in a 53-year-old man. In 25 patients, no adverse events were observed during follow-up. Five patients had an unfavorable outcome.
CONCLUSION
We have found an increase in the incidence of these infections in recent years. Computed tomography is the best imaging examination for the diagnosis and follow-up of retropharyngeal and parapharyngeal abscess. Early drainage and antimicrobial therapy are essential for rapid recovery and prevention of complications of these abscesses.
PubMed: 37019663
DOI: 10.1177/01455613231169232 -
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 -
International Journal of Environmental... Feb 2021Tonsillectomy is a routine surgery in otorhinolaryngology and the occurrence of postoperative bleeding is not a rare complication. The aim of this retrospective,...
Tonsillectomy is a routine surgery in otorhinolaryngology and the occurrence of postoperative bleeding is not a rare complication. The aim of this retrospective, observational, analytic, cohort study is to compare the incidence of this complication for the most common indications. A group of patients indicated for tonsillectomies for peritonsillar abscess (group I) was compared to a group of patients indicated for chronic and recurrent tonsillitis (group II). There are a lot of pathophysiological differences in patients indicated for acute tonsillectomy for peritonsillar abscess and in patients indicated for elective tonsillectomy for chronic or recurrent tonsillitis. No technique to minimize the risk of bleeding after tonsillectomy has been found and a large part of postoperative bleeding occurs in postoperative home-care, which makes this issue topical. In total, 2842 unilateral tonsillectomies from the years 2014-2019 were included in the study. Bleeding occurred in 10.03% and, surprisingly, despite completely different conditions in the field of surgery (oedema, acute inflammation in peritonsillar abscess), there was no statistically significant difference between incidence of postoperative bleeding in the studied groups ( = 0.9920). The highest incidence of bleeding was found in the patients of group I on the eighth postoperative day, with those aged 20-24 years ( = 0.0235) being the most at risk, and in group II, on the sixth postoperative day, with those aged 25-29 years ( = 0.0128) and 45-49 years ( = 0.0249) being the most at risk.
Topics: Adult; Cohort Studies; Humans; Peritonsillar Abscess; Retrospective Studies; Tonsillectomy; Tonsillitis; Young Adult
PubMed: 33671349
DOI: 10.3390/ijerph18041946 -
Clinical Otolaryngology : Official... Dec 2014Patients admitted with acute tonsillitis generate a substantial workload for the National Health Service (NHS), placing huge financial pressures on an already... (Review)
Review
BACKGROUND
Patients admitted with acute tonsillitis generate a substantial workload for the National Health Service (NHS), placing huge financial pressures on an already overstretched budget.
OBJECTIVE OF REVIEW
Due to the difficulty of accurate diagnosis and varying practices across the UK, there exist a number of controversial areas and non-standardised practice. These will be highlighted and tackled within this article.
TYPE OF REVIEW AND SEARCH STRATEGY
A literature review, last performed in September 2013, searched PubMed citing variations on the areas of controversies with 'tonsillitis', 'pharyngitis' and 'pharyngotonsillitis' - from 1956 to present with language restrictions. Excluded articles included those regarding sore throat after tonsillectomy and peritonsillar abscess.
EVALUATION METHOD
Titles and abstracts were initially screened, and full text of potentially relevant articles obtained. The bibliographies of articles were searched for relevant references. The references were then compiled and reviewed independently by two authors (JB & TB), overseen by the senior author (EK).
RESULTS
(i) Diagnosis and investigation: Use of the Centor criteria is inadequate within the secondary care setting. Blood testing is unnecessary in the majority of cases where patients do not require admission, as they are unlikely to change management. (ii) Antibiotics: Antibiotics are likely to be indicated in all those presenting to secondary ENT care, with penicillin being the antibiotic of choice for first-line therapy. (iii) Corticosteroids: Moderate evidence supports the benefit of steroid administration in this patient cohort, advocating a single dose initially followed by reassessment. (iv) Analgesia: Paracetamol and NSAIDs have good evidence of action. Codeine should be used with caution in the paediatric population. (v) Reduced admission rates and early discharge: There is evidence suggesting that a trial of medical therapy prior to admission is beneficial in reducing rates of admission and length of stay.
CONCLUSIONS
Management of acute tonsillitis within a secondary care setting largely consists of anecdotal or relatively low-quality evidence. Thus, much evidence from management comes from expert opinion or practice within a primary care setting. Management across the UK can also vary greatly. An evidence-based review of best practice has been presented here, but further evidence will be required in the future examining the significance of corticosteroids and antibiotic administration in this patient cohort specifically, ensuring practice is evidence based and clinically relevant.
Topics: Acute Disease; Adrenal Cortex Hormones; Analgesia; Anti-Bacterial Agents; Evidence-Based Medicine; Humans; Patient Discharge; Tonsillitis; United Kingdom
PubMed: 25418818
DOI: 10.1111/coa.12299 -
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 -
Irish Journal of Medical Science Aug 2022Peritonsillar abscess (PTA) is the most common deep neck infection, occurring as a consequence of bacterial acute tonsillitis or as a result of infection of the Weber... (Review)
Review
BACKGROUND
Peritonsillar abscess (PTA) is the most common deep neck infection, occurring as a consequence of bacterial acute tonsillitis or as a result of infection of the Weber glands, with frequent and life-threatening complications.
AIM
To investigate several factors associated with complications and worse prognosis, such as defining the method of surgical drainage and treatment of a PTA which remains an area of controversy in the literature METHODS: The purpose of this retrospective study is to examine the epidemiological, clinical, and laboratory findings of 601 adult patients and to discuss them along with their treatment plan.
RESULTS
Pharyngalgia was the most common reported symptom, followed by trismus, odynophagia, fever, hot potato voice, malaise, and cervical lymphadenopathy. Sixty-eight patients developed complications. Streptococcus species were the most common pathogens. A statistically significant difference was found in days of hospitalization, WBC and CRP levels, age, and the pre-existing systemic diseases between patients with and without complications. A comparison of patients treated with intravenous and oral antibiotics revealed no statistically significant difference.
CONCLUSION
Οver 10% of PTA cases may develop complications, the most common of which is extension into deep neck spaces. Comorbid conditions increase the risk of complications. Despite the wide range of treatment strategies, incision and drainage remain the cornerstone of surgical treatment. In patients with no comorbidities, intravenous antibiotics appear to have no advantage over oral antibiotics.
Topics: Adult; Anti-Bacterial Agents; Drainage; Humans; Peritonsillar Abscess; Prognosis; Retrospective Studies
PubMed: 34617243
DOI: 10.1007/s11845-021-02796-9 -
Changes in Otorhinolaryngologic Disease Incidences before and during the COVID-19 Pandemic in Korea.International Journal of Environmental... Oct 2022This study aimed to investigate the change in the incidence and variance of otorhinolaryngologic diseases during the coronavirus disease 19 (COVID-19) pandemic. The...
This study aimed to investigate the change in the incidence and variance of otorhinolaryngologic diseases during the coronavirus disease 19 (COVID-19) pandemic. The entire Korean population (~50 million) was evaluated for the monthly incidence of 11 common otorhinolaryngologic diseases of upper respiratory infection (URI), influenza, acute tonsillitis, peritonsillar abscess, retropharyngeal and parapharyngeal abscess, acute laryngitis and bronchitis, stomatitis and related lesions, acute sinusitis, rhinitis, otitis media, and dizziness from January 2018 through March 2021 using the International Classification of Disease (ICD)-10 codes with the data of the Korea National Health Insurance Service. The differences in the mean incidence of 11 common otorhinolaryngologic diseases before and during COVID-19 were compared using the Mann-Whitney U test. The differences in the variance of incidence before and during COVID-19 were compared using Levene's test. The incidence of all 11 otorhinolaryngologic diseases was lower during COVID-19 than before COVID-19 (all < 0.05). The variations in disease incidence by season were lower during COVID-19 than before COVID-19 for infectious diseases, including URI, influenza, acute tonsillitis, peritonsillar abscess, retropharyngeal and parapharyngeal abscess, acute laryngitis and bronchitis, acute sinusitis, and otitis media (all < 0.05), while it was not in noninfectious diseases, including stomatitis, rhinitis, and dizziness. As expected, the incidences of all otorhinolalryngolgic diseases were decreased. Additionally, we found that seasonal variations in infectious diseases disappeared during the COVID-19 pandemic, while noninfectious diseases did not.
Topics: Humans; COVID-19; Incidence; Rhinitis; Retropharyngeal Abscess; Pandemics; Laryngitis; Influenza, Human; Noncommunicable Diseases; Dizziness; Peritonsillar Abscess; Sinusitis; Respiratory Tract Infections; Otitis Media; Bronchitis; Stomatitis
PubMed: 36293687
DOI: 10.3390/ijerph192013083