Catastrophic caudad spread of a peritonsillar abscess: a case report

Complications of peritonsillar abscess

Background

The vast majority of patients with peritonsillar abscess (PTA) recover uneventfully on abscess drainage and antibiotic therapy. However, occasionally patient´s condition deteriorates as the infection spread in the upper airway mucosa, through cervical tissues, or hematogenously. The bacterial etiology of PTA is unclarified and the preferred antimicrobial regimen remains controversial. The current narrative review was carried out with an aim to (1) describe the spectrum of complications previously recognized in patients with peritonsillar abscess (PTA), (2) describe the bacterial findings in PTA-associated complications, and (3) describe the time relation between PTA and complications.

Methods

Systematic searches in the Medline and EMBASE databases were conducted and data on cases with PTA and one or more complications were elicited.

Results

Seventeen different complications of PTA were reported. The most frequently described complications were descending mediastinitis (n = 113), para- and retropharyngeal abscess (n = 96), necrotizing fasciitis (n = 38), and Lemierre´s syndrome (n = 35). Males constituted 70% of cases and 49% of patients were > 40 years of age. The overall mortality rate was 10%. The most prevalent bacteria were viridans group streptococci (n = 41, 25%), beta-hemolytic streptococci (n = 32, 20%), F. necrophorum (n = 21, 13%), S. aureus (n = 18, 11%), Prevotella species (n = 17, 10%), and Bacteroides species (n = 14, 9%). Simultaneous diagnosis of PTA and complication was more common (59%) than development of complication after PTA treatment (36%) or recognition of complication prior to PTA (6%).

Conclusion

Clinicians involved in the management of PTA patients should be aware of the wide range of complications, which may arise in association with PTA development. Especially males and patients  > 40 years of age seem to be at an increased risk of complicated disease. In addition to Group A streptococci and F. necrophorum, the current findings suggest that viridans group streptococci, S. aureus, Prevotella, and Bacteroides may also play occasional roles in the development of PTA as well as spread of infection. Complications occasionally develop in PTA patients, who are treated with antibiotics and surgical drainage.

Indications for tonsillectomy stratified by the level of evidence

Background: 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. Material and methods: 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". Results: 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. Conclusions: 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.

Innovative airway management for peritonsillar abscess

PURPOSE

To describe innovative airway management in an adult with a peritonsillar abscess (quinsy) located atypically in the inferior pole of the palatine tonsil.

CLINICAL FEATURES

A 25-yr-old male was admitted for surgical drainage of a left-sided, inferior pole peritonsillar abscess. Previous attempts at intraoral needle and scalpel drainage with topical anesthesia in the emergency department had failed. He had an interdental distance of 1.5 cm and computed tomography imaging showed narrowing of the airway diameter to 8 mm and lateral displacement of the epiglottis. He gargled 10 mL 0.5% lidocaine in the sitting position. We advanced a 3.1-mm pediatric fibreoptic bronchoscope (FOB) through an orally inserted nasopharyngeal airway to identify the glottis and sprayed 0.5% lidocaine onto the airway mucosa. We replaced the airway with a reinforced 6.5-mm internal diameter tracheal tube (TT), advanced the FOB through it until its tip was just above the carina, and then advanced the TT into the trachea. After iv induction of general anesthesia, the surgeon performed a tonsillectomy and drained the neck abscess. Postoperative direct laryngoscopy revealed a markedly improved airway lumen and tracheal extubation over a Cook Airway Exchange Catheter was uneventful. The patient was stable in the recovery room, and was discharged on the third postoperative day.

CONCLUSION

We present an innovative technique of fibreoptic intubation in an awake patient with an inferior pole peritonsillar abscess.

Peritonsillarabszess

BACKGROUND

Peritonsillar abscess (PTA) is the most common deep neck space infection treated by otolaryngologists affecting predominantly young adults. Children present a challenge owing to the difficulty in obtaining an exact history and adequate physical examination. Particularly for the pediatric age group controversy surrounds the question of optimal treatment. This study was undertaken to evaluate bleeding complications following immediate tonsillectomy (TAC) in a pediatric population (<16 years) of age and to compare our management protocol with the current status in the literature.

MATERIAL AND METHODS

The data of 218 children who had undergone TAC between January 1988 and January 2003 in our clinic were enrolled in a retrospective study. The youngest patient was 18 months, the oldest 15.9 years of age (mean: 14.53; median: 14; STD: 12.11 years). 95 patients were male (43.6%), 123 female (56.4%). Various treatment protocols of the current literature are addressed.

RESULTS

Postoperative hemorrhage (all from the opposite side) requiring surgical treatment under general anesthesia occurred in 4 children (1.8%). Repeated hemorrhage did not occur, blood transfusions were not required, there was no case with lethal outcome. Several reports indicate that needle aspiration (NP) or incision and drainage (ID) may suffice for the majority of cases but do not distinguish between different treatments for children and adults. More recently, conscious sedation has become a great support for pediatric treatment protocols.

CONCLUSIONS

The initial success rates of NP or ID are both very high (>90%) and the overall recurrence rate is low, particularly in children. Only for selected subgroups, patients may profit from TAC, which was clearly not associated with an increased risk of bleeding in our pediatric population.

Clinical versus computed tomography evaluation in the diagnosis and management of deep neck infection

CONTEXT

Deep neck infections have high potential for severe complications and even death, if not properly managed. The difference between clinical and computed tomography findings may demonstrate that clinical evaluation alone underestimates disease extent, which may lead to conservative treatment with worse prognosis.

OBJECTIVE

To compare clinical and computed tomography findings from neck spaces affected by deep neck infections and to determine the main clinical and radiological features associated with these.

TYPE OF STUDY

Non-randomized retrospective study.

SETTING

Department of Otolaryngology and Head and Neck, Universidade Estadual de Campinas.

METHODS

Medical charts of 65 patients with deep neck infections were evaluated. Age, gender, clinical complaints, physical findings, computed tomography scan and x-ray imaging, microbiology, treatment and outcome were analyzed. All clinical signs and symptoms were evaluated and stratified in order of frequency. The frequency of neck space involvement in such infections was also assessed from the clinical and tomographic evaluation. All clinical and computed tomography findings were compared with surgical observation.

RESULTS

The most frequent clinical findings were neck swelling, local pain, erythema and locally increased temperature. Physical evaluation showed that the most affected site was the submandibular triangle (49.2% of cases). However, computed tomography showed this to be the lateropharyngeal space (65% of cases) and that more than one deep cervical space was compromised in 90% of cases, as demonstrated by the extent of swelling and increased contrast signs in soft tissue.

DISCUSSION

The most frequent clinical symptoms of deep cervical infections were cervical pain, increased cervical volume and fever. The important signs seen via computed tomography were increased contrast in soft neck tissues and swelling. Such examination is the most important method for correct evaluation of cervical spaces involved in infection, and thus for correct surgical drainage.

CONCLUSIONS

The most frequent clinical findings were cervical mass, neck pain, local erythema and locally increased temperature. Computed tomography demonstrated that the lateropharyngeal space was the most affected neck space. More than one deep neck space was compromised in 90% of cases. Clinical evaluation underestimated the extent of deep neck infection in 70% of patients.

Ultrasound-guided drainage of peritonsillar abscess by the emergency physician

The diagnosis of peritonsillar abscess (PTA) poses a challenge to emergency physicians (EPs). The decision to perform an invasive procedure with potential complications is based on clinical judgment that is often inaccurate. Although there is some mention of intraoral ultrasound in otolaryngology practice, there is none in the emergency medicine (EM) literature. However, this bedside emergency application of ultrasonography has the potential to be of considerable use in EM practice, and could allow EPs who previously deferred blind needle aspiration of a potential abscess to perform the procedure themselves. We report the cases of 6 patients who presented with probable PTA and were evaluated with intraoral ultrasound at the bedside by an EP. All 6 patients then underwent needle aspiration. As diagnosed on ultrasound, 3 of the patients had negative aspirations and were diagnosed with peritonsillar cellulitis. Three others were found to have PTA, with 2 requiring real-time ultrasound needle guidance to accomplish abscess drainage after multiple failures with the blind approach.

Immediate abscess tonsillectomy--a safe procedure?

OBJECTIVE

Peritonsillar abscess is the most common infection involving deep neck planes to be treated by otolaryngologists with varying management strategies. In some countries, like Japan, immediate tonsillectomy is considered only for selected cases due to the risk of post-operative complications. Post-tonsillectomy bleeding is considered as the major complication following surgery and serves as a landmark for the safety of the operation. The purpose of this study was to evaluate if there is an increased risk of post-tonsillectomy haemorrhage following immediate tonsillectomy in non-selected patients.

METHODS

A retrospective study was performed on 6329 patients who underwent tonsillectomy, with or without adenoidectomy, in St. Anna Hospital, Duisburg, between January 1988 and August 2000 to evaluate the complication rate following 1481 immediate tonsillectomies (group A) compared to 4848 patients who underwent elective tonsillectomy (group B). 56.9% (group A) were male, the youngest patient was 18 months, the oldest 87 years old. Patients of group B were younger in general (mean age: 18.7 vs. 32.9 years), 49.9% were male, between 5 months and 93 years of age. Patients of both groups underwent surgery under general anaesthesia and were observed for 6 days. The incidence of post-tonsillectomy haemorrhage in both groups was compared using chi(2)-test, the age distribution was compared by Mann-Whitney U-test.

RESULTS

Bleeding occurred in 43 patients of group A (2.9%) and 138 patients (2.8%) of group B. Excessive bleeding requiring ligature of the external carotid artery became necessary in one patient of group A (0.13%) and four patients of group B (0.08%). A 42-month-old patient (group B) died due massive haemorrhage at home 6 days after surgery. The latest bleeding occurred 12 (group B) and 13 days (group A) after surgery. Statistical evaluation (Pearson chi(2)-test P=0.908) shows no significant difference of post-operative bleeding between the compared groups. Post-tonsillectomy haemorrhage occurred with statistical significance (P<0.001) in elder patients after immediate tonsillectomy.

CONCLUSIONS

We conclude, that immediate tonsillectomy can be recommended as a safe surgical procedure in non-selected patients to evacuate quinsy without an additional risk of bleeding thus making a second hospital stay unnecessary.