Impact of the COVID-19 era on clinical presentation, management and microbiology in paediatric peritonsillar abscess: A case-control study

OBJECTIVES

Peritonsillar abscess (PTA) is the most common soft-tissue infection of the head and neck. This potential complication of tonsillitis has demonstrated unique microbial trends during the COVID-19 pandemic. This era has resulted in a major shift in the hygiene and social habits of the general population, which has resulted in changes in the presentation, management and microbiology of several infectious diseases. To date, the impact of COVID 19 on PTA microbiology and clinical presentation in the paediatric population has yet to be investigated.

DESIGN

Retrospective chart review comparing all cases of paediatric (age 0-18) PTA in an academic tertiary centre during the COVID-19 pandemic (03/2020-02/2022) and compared them to two control groups: pre-COVID (03/2018-02/2020) and post-COVID (03/2022-03/2023). All patients were treated with either needle aspiration, incision and drainage or both means in addition to intravenous antibiotics.

SETTING

A large Ear Nose and Throat department in a tertiary referral center.

PARTICIPANTS

Consecutive children aged 18 years or under, admitted with a diagnosis of Peritonsillar abscess.

MAIN OUTCOME MEASURES

We analyzed the clinical and microbiologcal features of all cases of pediatric peritonsillar abscess during the COVID-19 era (03/2020-02/2022) and compared them to a pre and post control cases.

RESULTS

A total of 96 PTA cases were included (35 pre-COVID, 35 COVID and 26 post-COVID). The means of procedural treatment shifted in favour of incision and drainage versus needle aspiration during the COVID era. The length of hospitalisation increased during the COVID era (3.6 days vs. 2.1 and 3.1 pre and post-COVID respectively, p < .001). No other notable differences in the clinical and demographic features were found between the three eras. The COVID-19 era saw an increase in Fusobacterium (37.1% vs. 8.6% and 24% pre and post-COVID, respectively; p = .008) and Streptococcus Anginosus (31.4% vs. 5.7% and 7.7% pre and post-COVID, respectively; p = .007) species isolation.

CONCLUSIONS

The COVID-19 pandemic did not seem to impact the clinical presentation of paediatric PTA yet resulted in a change in microbiological pathogens. The choice of I&D as a means to shorten hospital stay during the pandemic may have led to an actual increase in hospital stay, suggesting that NA may be the preferred management approach.

The impact of social restrictions on the incidence and microbiology of peritonsillar abscess: a retrospective cohort study

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.

[Disproving the myth of "abscess weather" predisposing to peritonsillitis and peritonsillar abscess]

BACKGROUND

Peritonsillar abscess (PTA) is often seen as a complication of acute tonsillitis and is defined as pus retention between the tonsillar capsule and the peritonsillar tissue. The etiology and pathogenesis have not yet been fully elucidated. A connection between certain weather conditions and temperature fluctuations and the occurrence of abscesses in the head and neck region has been discussed for years. The question here is whether higher temperature fluctuations are predisposing for the formation of abscesses.

MATERIALS AND METHODS

A retrospective evaluation of all patients hospitalized with peritonsillitis or PTA in the Department of Otorhinolaryngology of the Klinikum Rechts der Isar of the Technical University of Munich during a period of 10 years (2012-2021) was performed. Each patient was individually correlated with daily temperature data from the statistical meteorological office of the City of Munich.

RESULTS

A total of 1450 patients were included, 270 patients (18.62%) with peritonsillitis and 1180 patients (81.38%) with PTA. A correlation between the occurrence of peritonsillitis or PTA and major temperature fluctuations could be excluded in this large patient population. Moreover, a similar frequency of peritonsillitis and PTA was seen throughout the year.

CONCLUSION

The myth of a temperature dependence of the development of peritonsillitis or PTA and a so-called abscess weather could be negated in this study.

High rate of early recurrence of peritonsillar abscess among adolescents and young adults

BACKGROUND

Peritonsillar abscess (PTA) can be treated with aspiration or incision for drainage, but a subsequent PTA can occur if tonsillectomy is not performed. Better understanding is needed of when tonsillectomy should be performed to avoid PTA recurrence.

OBJECTIVE

This study investigated the recurrence rate of PTA following aspiration or incision for drainage and evaluated the risk factors for recurrence.

METHODS

The medical records of 292 patients treated for PTA were reviewed. Recurrence of PTA and elective or quinsy tonsillectomy were the primary endpoints. A Cox proportional hazards regression model for PTA recurrence was constructed with sex, age, and PTA history as predictors.

RESULTS

Young age was the only significant predictor of PTA recurrence. Patients aged 15 to 24 years had a 30-day recurrence rate of 15.5% and a total recurrence rate of 26.6%. The total recurrence rate among patients over 30 years of age was significantly less at 4.0% (Fisher's exact test, p < .05).

CONCLUSION AND SIGNIFICANCE

Based on our results, tonsillectomy should be considered for PTA patients between 15 and 25 years of age and, to effectively avoid future recurrence of PTA, should be performed urgently.

Changes in Otorhinolaryngologic Disease Incidences before and during the COVID-19 Pandemic in Korea

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 p < 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 p < 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.

Impact of COVID-19 on nationwide pediatric otolaryngology practice: Adenotonsillectomies (TA) and tonsil-related diagnoses trends

Objectives/hypothesis

To determine the effects of the COVID-19 pandemic on Adenotonsillectomies (TA), Tonsil Related Cases (TC), and Peritonsillar Abscess (PTA) Trends.

Study design

Retrospective Cohort Study.

Methods

This is a retrospective cohort study using the Pediatric Health Information System® (PHIS) database, which consists of 51 children's hospitals. Regions were defined according to PHIS rules with at least five children's hospitals per region. We compared monthly total TA, TC, TC as a proportion of all hospital visits, and PTA from all encounters at each hospital from January 1, 2019, through December 31, 2021.

Results

Compared to 2019, April 2020 saw mean TC drop significantly from 371.62 to 68.37 (p < 0.001). Interestingly, June, September, and December 2020 had significantly higher mean TC compared to 2019. TC as a proportion of all hospital visits decreased significantly throughout the majority of 2021. Similarly, TA significantly decreased during 2020 and 2021 across all regions in the US, starting in March 2020 and this reduction in TA extended through the end of 2021 without any signs of recovery. PTA rates did not change significantly over the three years.

Conclusions

The pandemic-plagued 2020 saw a noticeable decrease in overall TC and TA but then rebounded quickly to even higher than pre-pandemic levels. However, this rebound halted for the majority of 2021 and subsequently decreased to lower than pre-pandemic levels, which differs from other communicable pathologies such as otitis media which decreased initially then recovered to pre-pandemic levels by Summer of 2021.

Patients with comorbid rheumatoid arthritis are predisposed to peritonsillar abscess: real-world evidence

PURPOSE

The peritonsillar abscess (PTA)-rheumatoid arthritis (RA) association remains unclear. Here, the effects of RA on PTA incidence and prognosis are elucidated.

METHODS

We compared PTA incidence and prognosis of 30,706 RFCIP-registered patients with RA (RA cohort) with matched individuals without RA from another database of 1 million randomly selected people representing Taiwan's population (non-RA cohort).

RESULTS

The RA cohort had significantly higher PTA incidence [incidence rate ratio (IRR) (95% CI) 1.73 (1.10-2.71), P = 0.017) and cumulative incidence (P = 0.016, Kaplan-Meier curves). Cox regression analyses demonstrated RA cohort to have an estimated 1.72-fold increased PTA risk (95% CI 1.09-2.69, P = 0.019). PTA was more likely within the first 5 years of RA diagnosis (for < 1, 1-5, and ≥ 5 postdiagnosis years, IRRs: 2.67, 2.31, and 1.10, respectively, and P = 0.063, 0.021, and 0.794, respectively; average onset duration: 4.3 ± 3.3 years after RA diagnosis). PTA increased length of hospital stay significantly and risk of complication with deep neck infection nonsignificantly [6.5 ± 4.5 vs 4.6 ± 2.8 days (P = 0.045) and 18.52% vs 7.81% (P = 0.155), respectively]. Moreover, RA-cohort patients not receiving RA therapy exhibited 5.06-fold higher PTA risk than those receiving RA-related therapy (95% CI 1.75-14.62, P = 0.003).

CONCLUSIONS

In patients with RA, PTA incidence is the highest within 5 years of RA diagnosis, and RA therapy is essential for reducing PTA risk.

LEVEL OF EVIDENCE

4.

A 4-year retrospective study of tonsillectomy rate and admission rate of tonsillitis and complications in the East of England and nationally

OBJECTIVES

Guidance set out by Scottish Intercollegiate Guidelines Network (SIGN) sought to restrict the frequency of elective tonsillectomy in reaction to the recognised and substantial risks of the procedure, namely pain and bleeding. With stricter criteria in place before a patient can undergo tonsillectomy, patients must endure more episodes of tonsillitis than was previously the case. The cost of managing tonsillitis and its complications as an inpatient is substantial to the NHS and also to the economy as a whole in missed work days. The authors sought to establish if the reduced rate of tonsillectomy performed had any effect on the rate of acute hospital admission for tonsillitis or the associated abscesses-peritonsillar, parapharyngeal and retropharyngeal.

METHODS

A retrospective multi-centre study reviewed admission data across a 4-year period. The rate of tonsillectomies performed for recurrent tonsillitis across four trusts in Mid-Essex was compared with the number of admissions for tonsillitis, peritonsillar, parapharyngeal and retropharyngeal abscesses. National hospital episode statistics data over a 5-year period was also analysed.

RESULTS

For the regional data in 2015, 979 tonsillectomies were performed across the four centres, reducing to 875 in 2018. There was no trend in the rates of acute tonsillitis requiring admission but the rates of peritonsillar abscess increased from 156 to 192 cases per year in the same period. This correlation was found not to be statistically significant in the measured sample size. The National hospital episode statistics data showed a significant correlation between tonsillectomy rates and admissions from complications of tonsillitis as well as the associated abscesses.

CONCLUSION

This study shows that the reduced tonsillectomy rate was correlated with an increased number of admissions with peritonsillar abscess regionally. Nationally reduced tonsillectomy rate is significantly associated with increased admissions with tonsillitis and all its complications. A decreased rate of tonsillectomy may be increasing the rate of serious tonsillitis. This has an impact on patient morbidity, an increasing financial burden on the NHS and the UK economy.

Epidemiological and Microbiological Aspects of the Peritonsillar Abscess

Peritonsillar abscess (PTA) is the most common complication of tonsillitis. Cultivation usually reveals a wide spectrum of aerobic and anaerobic microbiota. This retrospective study compared PTA incidence and the spectrum of individual microbial findings in groups of patients divided by gender, age, and season. Of the 966 samples cultivated, a positive cultivation finding was detected in 606 patients (62.73%). Cultivation findings were negative in 360 (37.27%), meaning no pathogen was present or only common microbiota was cultivated. The highest incidence of PTA was found in group I patients (19–50 years) (p ≤ 0.0001) and the most frequently cultured pathogens was Streptococcus pyogenes (36.23%). Gender seemed to have an influence on the results, with higher incidence found in males (p ≤ 0.0001). The analysis of correlation between PTA incidence and season did not yield statistically significant results (p = 0.4396) and no statistically significant differences were observed in individual pathogen frequency. PTA had a higher incidence in adult males and a slightly higher incidence in girls in childhood. The following findings are clinically significant and have implications for antibiotic treatment strategy: (1) the most frequently cultivated pathogen was Streptococcus pyogenes; (2) an increased incidence of anaerobes was proven in the oldest group (>50 years).

Low rate of co-infection in complicated infectious mononucleosis

INTRODUCTION

It remains unclarified if bacterial co-infection is common in patients with infectious mononucleosis (IM) and acute tonsillitis and/or peritonsillar abscess (PTA). Recent studies suggest that Fusobacterium necrophorum is a prevalent pathogen in acute tonsillitis and PTA. We hypothesised that this anaerobe may play a significant role for the aggravated infection and the development of PTA among teenagers and young adults with IM.

METHODS

All patients with IM and clinical findings of acute tonsillitis or PTA admitted to our department in the 2001-2015 period were included in the study.

RESULTS

In total, 257 patients with IM and acute tonsillitis (n = 220) or PTA (n = 37) were included. Positive bacterial cultures were obtained in 28% of patients with AT and in 50% with PTA. The most prevalent bacterial findings were Group C/G streptococci (14%) among patients with acute tonsillitis and Staphylococcus aureus (22%) in patients with PTA. F. necrophorum was recovered in 9% and 2% of patients with acute tonsillitis and PTA, respectively.

CONCLUSIONS

We were unable to substantiate a prevalent role for F. necrophorum in patients with IM and acute tonsillitis/PTA. S. aureus may play a role in PTA development in patients IM. The majority of our findings did not support the use of antibiotics in patients with IM, even in this selected group of patients with severe symptoms and a high risk of PTA.

FUNDING

This work was funded by the Lundbeck Foundation (Grant number R185-2014-2482).

TRIAL REGISTRATION

The Danish Data protection Agency approved the project.

Serious tonsil infections versus tonsillectomy rates in Wales: A 15-year analysis

INTRODUCTION Sore throat and tonsillitis place a significant burden on the National Health Service. National guideline criteria for gauging the severity of sore throat and tonsillitis have reduced the number of tonsillectomies performed, which is thought to have increased the rate of tonsil-related infections. METHODS Data was extracted from the prospective Patient Episode Database of Wales and analysed to determine the annual number of tonsillectomies for recurrent tonsillitis, adjusted for population changes. Admissions to acute hospitals for tonsillitis, peritonsillar abscess and deep neck space abscesses were also examined. RESULTS Between 1999 and 2014, hospital admissions for tonsillitis rose three-fold (r=0.968), while admissions for peritonsillar abscess rose by 48% (r=0.857) and retro or parapharyngeal abscess admissions also increased (r=0.709). In contrast, the number of tonsillectomies per 100,000 population gradually decreased (r=-0.16). There was a positive correlation between the incidence of tonsillitis and admissions for peritonsillar abscess (adjusted r2 0.631; p=0.015) and retropharyngeal abscess (adjusted r2 0.442; p=0.00254). There was a statistically significant negative correlation between the incidence of tonsillitis and the number of tonsillectomies performed (adjusted r2=-0.07; p=0.0235). CONCLUSIONS The significant rise in tonsillitis in Wales raises the question as to whether we should revisit the criteria for tonsillectomy. The perceived cost saving from limiting certain procedures should not prevent healthcare policymakers from considering all other evidence. The rise in peritonsillar, retropharyngeal and parapharyngeal abscess is alarming, as they are associated with significant morbidity and mortality.

Predisposing factors and management of complications in acute tonsillitis

CONCLUSION

RPA and NF was diagnosed with a sensitivity/specificity of 100%/94% in patients with acute tonsillitis and without suspicion for disease complication after ENT examination, but an age >35 years and serum CRP >15.5mg/dl.

BACKGROUND

Acute tonsillitis represents a frequent disease in the otorhinolaryngology. Some patients exhibit disease aggravations resulting in (descending) peritonsillar abscess (PTA, dPTA), para-/retropharyngeal abscess (PPA, RPA), or necrotising fasciitis (NF). The study analyses the underlying predisposing factors.

METHODS

The retrospective cohort study includes a total of 1636 patients comprising 852 outpatients with acute bacterial tonsillitis, 279 in-patients with acute bacterial tonsillitis, 452 patients with PTA, 31 patients with dPTA/PPA, 12 patients with RPA, and 10 patients with NF. Patients were analysed for disease-related data.

RESULTS

While leucocytes do not distinguish the sub-groups, C-reactive protein demonstrated a significant increase resulting in the highest level for RPA and NF (p < 0.0001). PTA and RPA are usually caused by streptococcus, dPTA/PPA by anaerobic bacterias, and NF mixed infections (p < 0.0001). Patients with PTA were younger than dPTA/PPA (p = 0.002) or RPA/NF (p < 0.0001). Subsequently, the rate of internistic comorbidities was significantly increased in RPA/NF (p < 0.0001). ROC-analysis identified cut-offs for age <36 years and CRP <15.5mg/dl to distinguish acute bacterial tonsillitis from RPA.

Safety of reduced antibiotic prescribing for self limiting respiratory tract infections in primary care: cohort study using electronic health records

OBJECTIVE

 To determine whether the incidence of pneumonia, peritonsillar abscess, mastoiditis, empyema, meningitis, intracranial abscess, and Lemierre's syndrome is higher in general practices that prescribe fewer antibiotics for self limiting respiratory tract infections (RTIs).

DESIGN

 Cohort study.

SETTING

 610 UK general practices from the UK Clinical Practice Research Datalink.

PARTICIPANTS

 Registered patients with 45.5 million person years of follow-up from 2005 to 2014.

EXPOSURES

 Standardised proportion of RTI consultations with antibiotics prescribed for each general practice, and rate of antibiotic prescriptions for RTIs per 1000 registered patients.

MAIN OUTCOME MEASURES

 Incidence of pneumonia, peritonsillar abscess, mastoiditis, empyema, meningitis, intracranial abscess, and Lemierre's syndrome, adjusting for age group, sex, region, deprivation fifth, RTI consultation rate, and general practice.

RESULTS

 From 2005 to 2014 the proportion of RTI consultations with antibiotics prescribed decreased from 53.9% to 50.5% in men and from 54.5% to 51.5% in women. From 2005 to 2014, new episodes of meningitis, mastoiditis, and peritonsillar abscess decreased annually by 5.3%, 4.6%, and 1.0%, respectively, whereas new episodes of pneumonia increased by 0.4%. Age and sex standardised incidences for pneumonia and peritonsillar abscess were higher for practices in the lowest fourth of antibiotic prescribing compared with the highest fourth. The adjusted relative risk increases for a 10% reduction in antibiotic prescribing were 12.8% (95% confidence interval 7.8% to 17.5%, P<0.001) for pneumonia and 9.9% (5.6% to 14.0%, P<0.001) for peritonsillar abscess. If a general practice with an average list size of 7000 patients reduces the proportion of RTI consultations with antibiotics prescribed by 10%, then it might observe 1.1 (95% confidence interval 0.6 to 1.5) more cases of pneumonia each year and 0.9 (0.5 to 1.3) more cases of peritonsillar abscess each decade. Mastoiditis, empyema, meningitis, intracranial abscess, and Lemierre's syndrome were similar in frequency at low prescribing and high prescribing practices.

CONCLUSIONS

 General practices that adopt a policy to reduce antibiotic prescribing for RTIs might expect a slight increase in the incidence of treatable pneumonia and peritonsillar abscess. No increase is likely in mastoiditis, empyema, bacterial meningitis, intracranial abscess, or Lemierre's syndrome. Even a substantial reduction in antibiotic prescribing was predicted to be associated with only a small increase in numbers of cases observed overall, but caution might be required in subgroups at higher risk of pneumonia.

Increased incidence of head and neck abscesses in children

Objective

To describe increasing incidence and changing microbiology of head and neck abscesses in children admitted to the hospital during the first quarters of 2000 through 2003.

Study Design and Setting

Retrospective data warehouse review identified 89 children less than 19 years of age admitted to a tertiary care pediatric hospital during the first quarters of 2000 through 2003 for suspicion of head and neck abscess involving the neck, face, and peritonsillar, retropharyngeal, and parapharyngeal spaces; and for orbital and intracranial complications of acute sinusitis.

Outcome Measures

Outcome measures included the incidence of infection admissions and description of infection location and microbiology, calculated by χ2 technique.

Results

The incidence of infections increased in 2003. The greatest increase was in neck abscesses and complications of acute sinusitis.

Conclusions

The increase in group A strep infections may be related to its biologic properties.

Significance

Group A strep remains a significant cause of head and neck infections in children.

[Clinical Analyses of 115 Patients with Peritonsillar Abscess]

The clinical data of 115 patients with peritonsillar abscess (98 men and 17 women) treated between May 2011 and March 2014 were analyzed. We examined 9 items; the age, sex, affected side, duration of hospitalization, method of drainage, smoking history, history of diabetes, antibacterial drugs used, and the isolated bacteria. The disease predominantly affected males in their 30s (27.8% of all the patients). The median duration of hospitalization was 7 days. In regard to the affected side, the right side was affected in 52%, the left side in 44%, and both sides in 4%. The method of drainage used was incision in 63%, and puncture in 37%. In regard to the personal and past medical history, 51% of patients had a history of smoking and 3.5% had a history of diabetes. ABPC/SBT was used as the single-agent antibacterial drug in 75% of cases. The most commonly isolated aerobic bacteria were α-hemolytic streptococci, and the most commonly isolated anaerobic bacteria were Prevotella. The duration of hospitalization showed no significant correlation with the smoking history, drainage method or the antibiotic treatment used (ABPC/SBT single-agent or multiple drug use). On the other hand, the duration of hospitalization was significantly longer in the more than ≥65 years' age group than in the <65 years' age group. Therefore, especially careful interventions for prevention and treatment of peritonsillar abscess are required in the elderly. In relation to antibiotic selection, it may be reasonable to expect sufficient effect with the use of ABPC/SBT as a single agent, as this antibiotic has a broad antibacterial spectrum covering aerobic, anaerobic and drug-resistant bacteria.

Deep neck infections in children

BACKGROUND/PURPOSE

Deep neck infections (DNIs) often have a rapid onset and can progress to life-threatening complications. There are only a few reports on pediatric DNIs' clinical manifestations, diagnostic clues, and etiology in Taiwan.

METHODS

A retrospective chart review of patients (aged ≤ 18 years) diagnosed with DNI from January 2005 to December 2014 was performed. DNIs were classified into retropharyngeal, parapharyngeal, peritonsillar, submandibular, and multispace abscesses.

RESULTS

A total of 52 patients with DNI were identified. The most common site of DNI was the parapharyngeal space (n = 22, 42.3%). The most commonly associated antecedent illness was preceding upper respiratory tract infection (30.8%). The most common clinical presentation was neck mass or swelling (82.7%) and fever (75%). Pus drainage or needle aspiration was performed to obtain pus samples from the infection site for pus culture (n = 31). The most commonly isolated pathogen was Staphylococcus aureus (n = 7). Amoxicillin-clavulanic acid (56.6%) was the most commonly used antibiotics, followed by penicillin (15.1%). There was no long-term morbidity or mortality.

CONCLUSION

When a patient (regardless of age) presents with neck mass or swelling, the DNI should always be included in the differential diagnosis. The low culture rate in Taiwan and previous partial treatment of infections may have affected identification of pathogens in cultures. Performing Gram staining and acid-fast staining of pus, instead of culture alone, as early as possible before initiating the initial antimicrobial therapy are thus crucial. The recurrence of DNI should alert the physician to the possibility of an underlying bronchogenic cyst. Excision surgery is required to cure recurrent infections.

Variations in treatment of peritonsillar abscess in four Nordic countries

CONCLUSION

In four Nordic countries, peritonsillar abscess (PTA) patients are treated rather differently.

OBJECTIVES

To study how such patients are treated in those countries.

METHODS

The 81 chief physicians of otorhinolaryngology departments of all central hospitals in Denmark (n = 15), Norway (n = 19), Sweden (n = 27), and Finland (n = 20) received a multiple-choice questionnaire.

RESULTS

A total of 73 physicians (90%) replied. The largest differences arose in treating patients with intravenous versus per oral antibiotics, and treating as inpatients versus outpatients. In Finland, 50% of PTA patients aged >16 years were treated as inpatients and 50% as outpatients, whereas the respective quotas in Sweden were 9 and 91%, Norway 19 and 81%, and Denmark 33 and 67%. Of Finnish physicians, 30% treated their patients primarily with oral antibiotics, 70% with intravenous antibiotics; in Sweden 91 vs 9%, Norway 53 vs 47%, and Denmark 18 vs 82%. In Denmark, almost all patients were operated on immediately, whereas in the other three countries, especially Sweden, operations more often were performed after a recovery period. Combining metronidazole with penicillin or cephalosporins was most common in Denmark: 58% reported usage, compared with 30% in Finland, 16% in Norway, and 4% in Sweden.

The rising rate of admissions for tonsillitis and neck space abscesses in England, 1991-2011

INTRODUCTION

Sore throats and tonsillitis represent a considerable health burden as well as a significant source of expenditure for the National Health Service (NHS). As part of the recent NHS savings drive, the introduction of 'procedures of low clinical effectiveness' (PoLCE) lists has reinforced a large reduction in the number of tonsillectomies performed. We carried out a cross-sectional study of trends in emergency sore throat admissions in the context of the number of tonsillectomies performed.

METHODS

Hospital Episode Statistics (HES) data were extracted. Office for National Statistics data were also used.

RESULTS

Between 1991 and 2011, the overall tonsillectomy rate fell by 44%. In the same time, the admission rate for tonsillitis rose by 310% (Pearson's r=-0.67, p=0.01). The peritonsillar abscess admission rate rose by 31% (r=-0.79, p<0.01). Between 1996 and 2011, the overall tonsillectomy rate fell by 41% and the retro and parapharyngeal abscess admission rate rose by 39% (r=-0.55, p=0.026). There was a 14% overall increase in tonsillectomy and sore throat associated bed days. This was despite the large fall in tonsillectomy numbers and the reduction in length of hospital stay.

CONCLUSIONS

Efforts to reduce the tonsillectomy rate are correlated with a significant rise in emergency admissions. The rise in the retro and parapharyngeal abscess rate is perhaps most alarming given the very high mortality of these conditions. Bed day data suggest that no net saving has been made despite the new measures.

Epidemiological profile of non-traumatic emergencies of the neck in CT imaging: our experience

PURPOSE

This study was undertaken to collect information on the incidence and distribution of acute, non-traumatic conditions of the neck at our emergency radiology department and to review the literature about this topic.

MATERIALS AND METHODS

We retrospectively reviewed 143 consecutive patients who underwent neck computed tomography (CT) for non-traumatic emergencies between 1 December 2008 and 31 December 2012. For each of the conditions identified, we defined the overall incidence, the incidence based on the site, gender, average age and age range.

RESULTS

Computed tomography examination was positive in 125 out of 143 patients (87.4%), 74 men and 51 women, with an average age of 51.1 years, aged between 10 and 90 years. We found 79 inflammatory/infectious conditions (63.2% of positive cases, 55.2% of total cases), 46 men and 33 women, with an average age of 47 years. Computed tomography revealed 26 newly found tumours (20.8/18.2%), 19 men and 7 women, with an average age of 68.5 years, aged between 49 and 97 years. In 20 cases, 9 men and 11 women, with an average age of 57.3 years, aged between 21 and 90 years, we diagnosed other acute conditions: six cases of foreign body ingestion (4.8/4.2%), five benign swellings (4/3.5%), five cases of vascular disorders (4/3.5%), and four cases of oedema of the larynx (3.2/2.8 %).

CONCLUSIONS

Our study of emergency CT of non-traumatic conditions of the neck fundamentally revealed infectious/inflammatory diseases and newly found neoplasms.

[Oral, pharyngeal and neck infections in specialized care]

BACKGROUND, MATERIAL AND METHODS

All cases of acute dental, oral and pharyngeal infections that were referred to Mikkeli Central Hospital during a 25-month period were retrospectively analyzed.

RESULTS

Thirty-nine percent of the total of 394 cases needed intravenous antibiotics. Tonsillar infections were most prevalent (27%), followed by peritonsillar abscesses (25%) and dental infections (20%). Twenty patients (5%) had cervical or submandibular cellulitis or abscess requiring immediate surgery and an average 8.5 days of in-patient treatment. The most prevalent (45%) bacteriological result was miscellaneous "normal flora".

CONCLUSIONS

Imminent oropharyngeal infection may require immediate surgery and intravenous antibiotics.

Peritonsillar infection in Christchurch 2006-2008: epidemiology and microbiology

AIM

Peritonsillar infection is a complication of acute tonsillitis. It is common and complications can be life-threatening. This study audits all cases of peritonsillar infection presenting to our unit between 2006 and 2008 in order to determine if the epidemiology, bacteriology and antibiotic sensitivity has changed since previous audits in our unit in 1981-1984 and 1990-1992.

METHODS

Retrospective chart review.

RESULTS

213 patients were admitted acutely with peritonsillar infection between January 2006 and December 2008. The average age was 29 years with 30.5% patients in the modal age group of 15-19 years. Male to female ratio was 1.5:1. 54% presented with their first episode. 39% received antibiotics prior to presentation. In two-thirds of cases, the duration of admission was less than 24 hours. Culture results were obtained from 69% of specimens. Cultures mostly contained mixed anaerobic and aerobic bacteria. The most common aerobes were streptococcal species. Organisms were almost uniformly sensitive to penicillin. 21% of patients subsequently underwent tonsillectomy, usually as a delayed procedure.

CONCLUSION

Peritonsillar infection is a common complication of tonsillitis and can be life-threatening. The number of cases presenting at Christchurch Hospital has increased disproportionate to the population increase since the previous audits. Culture results demonstrate a preponderance of mixed organisms, which may be pathological. Organisms and their sensitivities have not changed since the previous audits. Infection usually responds favourably to drainage in combination with penicillin as the first-line antimicrobial agent.

Peritonsillar abscess: is there any evidence of lateralized distribution? An analysis of 294 patients

OBJECTIVE

Generally, peritonsillar abscess (PTA) occurs only on one side. Diseases of paired organs show a distinct asymmetry of occurrence: for instance gynaecomastia, varicocele, trigeminal neuralgia, carcinoma of the breast and carcinoma of the ethmoid sinus. Therefore, the goal of the present study was to investigate a possible dominance of one side in PTA.

MATERIAL AND METHOD

Lateralization of a PTA was studied in 294 patients treated at Radebeul Hospital between January 2004 and December 2009.

RESULT

We found only a slight predominance of the left side in male as well as female patients.

CONCLUSION

The cause of the slight asymmetry is unclear. It is also possible that the non significant dominance is coincidental.

Clinical predictors of peritonsillar abscess in adults

OBJECTIVE

The primary objective was to identify clinical predictors that differentiate a peritonsillar abscess from peritonsillar cellulitis in adults. The secondary objective was to identify the prevalence of tobacco smoking behaviour in this group of patients with peritonsillitis.

SETTING

The Ottawa Hospital, a tertiary care centre.

METHODS

Retrospective chart review of patients diagnosed with peritonsillar abscess or peritonsillar cellulitis in the adult emergency department of The Ottawa Hospital during the years 2002 to 2004.

RESULTS

The charts of 130 patients with peritonsillitis were reviewed. Patients' ages ranged from 16 to 91 years. Fifty patients were diagnosed with a peritonsillar abscess and 80 with peritonsillar cellulitis. Forty-four percent of the patients in this study admitted to active tobacco smoking behaviour. Clinical signs significantly associated with peritonsillar abscess included trismus (p < .001), uvular deviation (p < .001), and inferior displacement of the superior pole of the tonsil (p < .001) on the affected side. Pain duration was not a significant discriminative factor (p = .069).

CONCLUSIONS

The diagnosis of a peritonsillar abscess is based on clinical findings. In this study, the prevalence of tobacco smoking behaviour in patients with peritonsillar disease was high. Further study is recommended to investigate the potential causal effects of tobacco smoke on the development of peritonsillar disease.

Suspected peritonsillar abscess in children

OBJECTIVES

(1) To describe the demographic features and clinical course of children diagnosed with suspected peritonsillar abscess (PTA), (2) to determine the incidence of suspected and confirmed PTA in children younger than 18 years, and (3) to examine the factors associated with corticosteroid use and outpatient management of suspected PTA.

METHODS

We conducted a population-based, retrospective chart review. The study was conducted within the Calgary Health Region (CHR). Patients met inclusion criteria if they were younger than 18 years, resided in the CHR, and were diagnosed with PTA (International Classification of Diseases, Ninth Revision 475) in the CHR between March 1994 and December 2001.

RESULTS

We identified 229 children (cases) who presented with 249 unique episodes of suspected PTA. The incidence of suspected PTA among children in the CHR was 14 cases per 100,000 person-years at risk. The incidence was highest among adolescents (40 cases per 100,000 person-years). The incidence of confirmed PTA was 3 cases per 100,000 person-years at risk. Among those with suspected PTA, surgical intervention, intravenous antibiotics, and corticosteroids were provided to 34%, 87%, and 37%, respectively. One hundred fifty-seven patients (69%) were initially managed as outpatients. Of these, 12 (8%) had subsequent uncomplicated hospital admissions.

CONCLUSIONS

Peritonsillar abscess is primarily a problem of adolescence, but the disease does occur in young children. Corticosteroid use was common but without either clear benefit or adverse outcomes. Two thirds of patients were managed as outpatients without any apparent increase in adverse outcomes.

Screening for glandular fever in patients with Quinsy: is it necessary?

Quinsy (peritonsillar abscess) is a common emergency seen in otolaryngology practice. These patients are often screened for glandular fever in addition to routine haematological tests. In our unit, we have screened 66 patients with quinsy for glandular fever over a period of 12 months. All these patients were screened for glandular fever by rapid immunoassay. Only one out of 66 patients was tested positive for glandular fever. Due to the extremely low incidence of glandular fever in quinsy patients, we do not see any relevance in screening for glandular fever in quinsy patients. Hence we recommend that routine screening for glandular fever in quinsy patients is an unnecessary invasive investigation for the patients and not cost effective for the hospital.

Use of antibiotics for sore throat and incidence of quinsy

BACKGROUND

Quinsy is the most common major suppurative complication of sore throat. Evidence on the effectiveness of antibiotics in preventing quinsy is sparse.

AIM

To assess the incidence of quinsy and the pattern of presentation, and to identify variables that predict the development of quinsy.

DESIGN OF STUDY

Case-control study.

SETTING

UK-wide primary care.

METHOD

Retrospective analysis of data from the General Practice Research Database (GPRD) for the years 1995-1997.

RESULTS

There were 606 recorded cases of patients with quinsy, but only 192 (31%) of these patients presented following an initially uncomplicated sore throat. Patients with quinsy were more likely to be aged 21-40 years (odds ratio [OR] = 2.5, 95% confidence interval [CI] = 1.7 to 3.6, compared with other ages), smokers (OR = 2.5, 95% CI = 1.8 to 3.5), and male (OR = 1.6, 95% CI = 1.1 to 2.2). Quinsy developed very quickly for most patients (median of 2 days after tonsillitis and 3 days after a sore throat). For cases initially labelled as tonsillitis, there was a nonsignificant trend of antibiotics preventing quinsy (OR = 0.6, 95% CI = 0.3 to 1.3), but no evidence that antibiotics prevent quinsy for cases labelled as sore throat or pharyngitis (OR = 1.2, 95% CI = 0.7 to 2.2).

CONCLUSION

Most patients with quinsy develop the condition rapidly, and many do not present with a respiratory tract infection to their GP first. The current low doses of antibiotics used in modern community settings may be less likely to protect against quinsy than the trial evidence suggests.

[Management of peritonsillar infections]

OBJECTIVE

To evaluate the clinical and epidemiologic characteristics in children with peritonsillar infections.

PATIENTS AND METHODS

A longitudinal retrospective study was performed through a review of the clinical histories of patients attending the emergency unit in the previous 6 years. The variables gathered were age, sex, recurrent tonsillitis, previous upper airway infection, antibiotic administration, and therapeutic approach.

RESULTS

Twenty-nine children were admitted, with a mean age of 7.4 +/- 1.6 years (boys 1.6:1). Twenty-seven percent had recurrent tonsillitis. At the visit, 57.8 % had an upper respiratory infection and 65 % were taking antibiotic treatment, especially macrolides. The treatment selected at our center consisted of the association of penicillin or amoxicillin-clavulanate acid with clindamycin, including corticosteroids. Ten children underwent computed tomography and nine underwent fine-needle aspiration. Drainage was performed in 20.6 % of confirmed abscesses. The mean length of hospital stay was 5.6 +/- 1.6 days. Delayed tonsillectomy was performed in 31 %, except in one patient who developed a parapharyngeal abscess. Currently, 18.9 % of all peritonsillar infections occur in the pediatric population.

CONCLUSIONS

The increase in these infections is probably related to inappropriate use of antibiotics in respiratory diseases. Diagnosis is clinical, and infections are often resolved by intravenous administration of beta-lactams with clindamycin and an expectant attitude. When an abscess is suspected or there is no clinical improvement, fine-needle aspiration or computed tomography is warranted and drainage should be performed if an abscess is confirmed. Tonsillectomy, usually delayed, is only indicated in patients with recurrent tonsillitis.

Demographics of Pediatric Head and Neck Infections in a Tertiary Care Hospital

EDUCATIONAL OBJECTIVE

Discuss potential patterns in the epidemiology of infectious disease of the head and neck.

STUDY OBJECTIVES

To investigate patterns in the epidemiology of severe head and neck infections that may reflect the impact of host factors.

STUDY DESIGN

Population-based, historic cohort study.

METHODS

Information on 1,010, incident head and neck infections occurring over a 5-year period was reviewed for demographics, location, and time of year. A nonparametric Kruskal-Wallis test was used to identify significant differences in the age distributions among the diagnosis groups. A Bonferroni, pair-wise comparison procedure was used for comparison of the average age of first onset of severe head and neck infections. Chi-square test was used to identify any significant association between season of the year and disease.

RESULTS

Significant differences were identified in the age distributions among the diagnosis groups (P < .001). The average age of first onset of cellulitis of the neck and retropharyngeal abscess is earlier than peritonsillar abscess, at 2 to 3 years and 13 years, respectively. Parapharyngeal and periapical abscesses and cellulitis of the face occur at approximately age 6. The incidence of parapharyngeal abscess and diseases of the pharynx is decreased during Spring, whereas peritonsillar abscesses and acute periodontitis occurs more often in Spring and Summer. Age does not appear to be related to season of first occurrence.

CONCLUSIONS

Head and neck infections are not random occurrences based on exposure alone; host factors are clearly important. Given the lack of correlation with school age, the results cannot be explained on the basis of exposure alone. Developmental patterns of the host immune response may be related to the age differential identified in the current study and are cause for further investigation.

The epidemiology of peritonsillar abscess disease in Northern Ireland

OBJECTIVES

1. To describe the epidemiology of peritonsillar abscess disease in Northern Ireland. 2. To describe the impact of the nature of microbiological sampling on culture results.

METHOD

Retrospective review of cases of peritonsillar abscess identified by diagnostic coding in three centres in Northern Ireland between August 2001 and July 2002.

RESULTS

One hundred and twenty eight cases of confirmed peritonsillar abscess were treated as inpatients accounting for 1 in 10,000/year of the population in the hospitals' catchment area. The mean age was 26.4 (range 9-78) years. Sixty-nine patients were male; the mean length of hospital stay was 3 days. Culture yield was greatest from needle aspirates; throat swabs and blood cultures were typically unhelpful. Beta haemolytic streptococci were the most common isolates. Resistance among Group A haemolytic streptococci to macrolide antibiotics was present in 26% of isolates. Heterophile antibody testing was routine and revealed that Epstein-Barr virus infectious mononucleosis had a prevalence of 1.8% in this group of patients.

CONCLUSION

In this population, although there were many similarities with the clinical features reported by other investigators, there were also several differences. Notably, we found a comparatively low proportion of anaerobic infections. Although cultures results did not influence individual patient treatment, reviewing data derived from populations is valuable for guiding empirical antibiotic therapy.

SUMMARY

The epidemiology of peritonsillar abscess disease is not well described. Other investigators describing the bacteriology give differing results, presumably reflecting different countries and techniques. The need for routine microbiological testing has been questioned in several reports, but the benefit of routine culture and sensitivity data for planning empirical antibiotic treatment has not been explored. We present a retrospective review of 128 cases of confirmed peritonsillar abscess in Northern Ireland from August 2001 to July 2002. The annual population incidence in this region is 1 in 10,000/year. In this group concurrent Epstein-Barr virus infection was found to have a prevalence of 1.8%. The yield of positive cultures from routine microbiological sampling was low in comparison to that reported in detailed prospective studies, from various countries. Needle aspiration was the best technique for obtaining pus for culture; throat swabs and blood cultures were unhelpful. Culture results did not affect individual patient treatment, but may have a potentially useful role for selecting empirical therapy.

Spectrum and management of deep neck space infections: an 8-year experience of 234 cases

OBJECTIVE

To study the clinical course and outcome of deep neck infections (DNI), with special emphasis on microbiology and histopathology.

STUDY DESIGN

Two hundred thirty-four patients with DNIs were included in this study. Patients with peritonsillar or dental infections, infections arising from salivary glands, as well as subjects with abscesses caused by neck trauma were excluded.

METHODS

Clinical analysis of all patients with DNIs who were treated between January 1, 1997 and May 31, 2005 in a single center.

RESULTS

In 13 patients, the DNI was the first manifestation of a malignant tumor. In 17 cases, the DNI was associated with cat-scratch disease (CSD). Six patients suffered from tuberculosis, and in another 7, an infected lateral cleft cyst was found. In 176 patients, the origin of DNI remained unclear.

CONCLUSIONS

Our results demonstrate that CSD, tuberculosis, and malignant tumors must be considered as possible causes of DNIs. The current study represents one of the largest series of DNIs in the modern medical literature.

EBM RATING

C.

[Epidemiologic aspects of pharyngitis, Bamako]

We are reporting here a 12 month-prospective study on epidemiologic aspects of sore throat in the ENT department of the national hospital Gabriel Touré. We recorded 260 cases of sore throat with 23 loco-regional complications representing 1.8% of all pathologies in our department; the sex ratio was 2.6 in favour of women, and the age group most affected was 20-24 years (18.07%). Sore throat was most frequently diagnosed at the beginning and at the end of the rainy season respectively May and October. In 63 of the cases, local and regional complications were seen, and represented by peri-tonsils phlegm (54%), chronic tonsillitis (41.3%), retropharyngeal abscess (3.2%), and cervical adeno-phlegm (1.6%). Therapy with antibiotics should be of rule, and well justified surgical decisions should be made after informed consent of the patient. Sore throat with its complications should really benefit of better attention and better management.

"Hot potato voice" in peritonsillitis: a misnomer

The "hot potato voice" is widely recognized as a symptom of peritonsillar cellulitis or abscess; yet there have been no studies assessing the resonance characteristics of the vocal tract in peritonsillitis. Analysis was undertaken of formant frequencies in the articulation of the vowels /i:/. /a:/ and /u:/ in six subjects with peritonsillitis and compared with articulation once the peritonsillitis had settled. Significant variation was found in F1 when articulating /i:/ and in F2 when articulating /a:/, which are explainable by dyskinesis of the peritonsillar musculature. These findings were compared with six subjects articulating the same vowels with and without a hot potato in their mouth. Variation was found in both F1 and F2 when articulating /i:/, which can be related to interference of the potato with movement of the anterior tongue. The changes in the vocal tract differ in these two cases and the title "hot potato voice" in peritonsillitis is a misnomer.

Rauchen prädisponiert zum Peritonsillarabszess

INTRODUCTION

Smoking has not properly been investigated as a predisposing factor for the development of a peritonsillar abscess.

METHODS

In a retrospective study a group of 541 abscess tonsillectomies--performed in the department of Otorhinolaryngology (University of Duisburg/Essen) between 1994-2003--was retrospectively analysed for smoking habits of the patients. Further on we investigated the influence of smoking on the risk for a postoperative haemorrhage.

RESULTS

Smoking habits of 519/541 were known, 296/519 (57%) were smokers, which is much more than expected with regard to the prevalence of smokers in the German population. Beneath the 2.2% of patients with a postoperative haemorrhage that had to be arrested under general anaesthesia no statistical relation between the occurrence of a postoperative haemorrhage and smoking was found.

CONCLUSION

Smoking could be an important predisposing factor for the development of peritonsillar abscess e. g. due to alteration of the mucosa and microbiological changes. We could not identify a statistical relation between smoking and the risk of a postoperative haemorrhage after tonsillectomy à chaud.

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.

[Peritonsillar abscess associated with infectious mononucleosis: retrospective study of three cases]

Three cases with infectious mononuculeosis associated with peritonsillar abscess were reviewed. The initial diagnoses in these three cases were tonsillitis or peritonsillitis. However, infectious mononucleosis was suspected because of an elevation in aminotransferases and was later confirmed by elevations in the titers of antibodies for Epstein-Barr virus. Peritonsillar abscesses developed and surgical drainage was performed in all three cases. The present study suggests a higher incidence of peritonsillar abscess in patients with infectious mononucleosis than previously expected.

Peritonsillar infections: local experience

INTRODUCTION

The disease pattern and management of peritonsillar infections in Singapore General Hospital are studied. Other objectives are to determine if a seasonal variation exists and to examine the role of routine bacterial cultures and interval tonsillectomy.

METHODS

This is a retrospective review of the management and outcome of patients with peritonsillar infections who were admitted acutely to Singapore General Hospital over a three-year period.

RESULTS

Of 185 patients studied, 151 (81.6 percent) had peritonsillar abscess or quinsy and 34 (18.4 percent) had peritonsillar cellulitis. There were 139 males and 46 females, with a racial predisposition among Malays (p value is less than 0.0005). There may be a seasonal variation with a bi-annual trend, though no correlation with upper respiration tract infections was noted. Treatment consisted mainly of incision and drainage (66 percent) or needle aspiration (34 percent). No significant difference in the length of stay was noted in patients receiving penicillin alone, penicillin with metronidazole, or broad-spectrum antibiotics (p value is equal to 0.062). Fourteen (7.6 percent) patients had recurrences, all of which occurred after the first month. Two patients (1 percent) had bilateral quinsy.

CONCLUSION

Peritonsillar infections remain a common admitting diagnosis to the Otolaryngology department. A single episode of infection should no longer be an indication for tonsillectomy as the incidence of recurrence is low.

Increased diagnosis of Lemierre syndrome and other Fusobacterium necrophorum infections at a Children's Hospital

OBJECTIVE

To assess the apparent increase in the diagnosis of Lemierre syndrome (LS) and other Fusobacterium necrophorum infections at a large children's hospital. Infections with F necrophorum ranged from peritonsillar abscess to potentially fatal LS. LS is an oropharyngeal infection characterized by septic thrombophlebitis of head and neck veins, complicated by dissemination of septic emboli to pulmonary and systemic sites.

METHODS

Review of the medical and laboratory records was conducted of all patients who were seen at or admitted to the Children's Hospital of Wisconsin with the diagnosis of LS and/or isolation of F necrophorum from a clinical specimen between January 1995 and January 2002.

RESULTS

During the 7-year period of the study, there was an increase in the isolation of F necrophorum from patients who were seen at Children's Hospital of Wisconsin, as well as the number of cases of LS. There was 1 isolation of F necrophorum from clinical specimens per year from 1996 to 1999, which increased to 10 isolates of the organism from January 2000 to January 2002. During the most recent period, January 2001-January 2002, 5 cases of LS were diagnosed, a distinctive entity not recognized previously at the institution.

CONCLUSIONS

The cause for the recent increase in the number of serious infections caused by F necrophorum infection diagnosed at our institution is unclear but does not seem to be related to changes in microbiologic techniques or patient demography. We speculate that it could be attributable, in part, to alterations in antibiotic usage patterns in our region. Clinicians need to be aware of the increasing clinical importance of F necrophorum infections and the life-threatening nature of LS.

Current status of bacterial resistance in the otolaryngology field: results from the Second Nationwide Survey in Japan

The study reported here was a nationwide assessment of otitis media (466 patients with acute suppurative otitis media and 476 with chronic suppurative otitis media), sinusitis (447 with acute sinusitis and 426 with chronic sinusitis), acute tonsillitis (724 patients), and peritonsillar abscess (141 patients) performed between November 1998 and March 1999. Eighty university hospitals, 79 affiliated hospitals, and 103 general practitioners participated. Methicillin-resistant Staphylococcus aureus(MRSA) comprised 15.6% of the 786 isolated strains of S. aureus. MRSA was frequently detected in patients with suppurative otitis media, but was uncommon in those with acute tonsillitis or peritonsillar abscess, and it was more common in those who had already been treated than in those who had not, with a significant difference between the groups. Vancomycin (VCM) showed the highest antimicrobial activity against MRSA and no VCM resistance was detected. Penicillin-sensitive Streptococcus pneumoniae(PSSP), penicillin-intermediate-resistant S. pneumoniae (PISP), and penicillin-resistant S. pneumoniae (PRSP) accounted for 49.6%, 28.5%, and 21.9% of the 228 isolated strains of S. pneumoniae, respectively. PISP and PRSP were frequently detected in children aged 5 years or younger. beta-Lactamase was produced by 96 of the 100 strains (96%) of Moraxella (Branhamella) catarrhalis. The 281 strains of Haemophilus influenzae isolated consisted of 199 beta-lactamase-negative, ampicillin-sensitive (BLNASe) strains (70.8%), 65 beta-lactamase-negative ampicillin-resistant (BLNAR) strains (23.1%), and 17 beta-lactamase-producing strains (6.0%). BLNAR strains were frequently detected in pretreated patients. Of these 281 strains of H. influenzae, 214 had nontypable capsules. In conclusion, the major bacterial species showed resistance to beta-lactams, indicating that care should be taken when selecting an appropriate antimicrobial agent.

The association between periodontal disease and peritonsillar infection: a prospective study

OBJECTIVE

To study the relationship between periodontal status and peritonsillar disease/recurrent tonsillitis.

STUDY DESIGN AND SETTING

A total of 158 patients presenting over a 3-year period with peritonsillar abscess (PTA) confirmed by needle aspiration and a control group of 112 patients booked for elective tonsillectomy for recurrent tonsillitis (RT) were examined in terms of their periodontal status using the WHO Community Periodontal Index of Treatment Needs (CPITN).

RESULTS

The mean CPITN index was 2.81 (Standard Deviation [SD], 1.10) in patients with PTA and 1.41 (SD, 0.92) in patients with RT. One hundred seven of 158 patients with PTA had significant periodontal pathology (CPITN, 3 or 4) compared with 12 of 112 patients with RT. These differences were statistically significant.

CONCLUSION

Patients with peritonsillar abscess had an increased prevalence of periodontal disease as compared with patients with recurrent tonsillitis.

SIGNIFICANCE

There is a need to further explore this correlation and determine its nature, although it could be the result of common pathogenic factors, a causal relation cannot be excluded.

Peritonsillar abscess in children: a 10-year review of diagnosis and management

OBJECTIVE

peritonsillar abscess is the most common deep neck infection in adults and children. However, pediatric patients with their smaller anatomy and often inability to cooperate with exam and treatment, provide a challenge. This study reviews the experience over the last 10 years at a children's hospital in the diagnosis and treatment of pediatric peritonsillar abscess.

METHODS

a retrospective chart review of 83 children diagnosed with a peritonsillar abscess by the Otolaryngology service over a 10-year period (March 1989-February 1999) were reviewed. Presenting signs and symptoms, physical findings, age, season of presentation, prior pharyngitis history, and prior treatment was collected from the charts. Additionally, diagnostic studies (if any), treatment performed, bacteriology, and outcome/complications were noted.

RESULTS

due to either an inability to cooperate fully for examination and treatment, or because of an earlier history of significant recurrent pharyngitis or obstructive tonsillar hypertrophy, half of the children required treatment in the operating room. Twenty-six out of 83 (31%) underwent a quinsy tonsillectomy. Length of stay was relatively short (0.9 days). There were no recurrent PTAs in our series, although four children initially treated with incision and drainage required tonsillectomy for persistent symptoms or residual abscess. Ten of those not treated with tonsillectomy (19%) required interval tonsillectomy for recurrent pharyngitis.

CONCLUSION

limited by the ability to cooperate with treatment, children often require different treatment plans. We offer a treatment algorithm for managing children with PTAs that takes into account their age, level of cooperativeness, co-morbidities and prior history of pharyngitis, PTA or obstructive sleep disorder.

Pathogenesis of peritonsillar abscess

The pathogenesis of peritonsillar abscess is described in textbooks as being a direct communication and progression of acute exudative tonsillitis. Little study has been done on the true etiology and pathogenesis of peritonsillar abscess. This paper focuses on the pathogenesis of peritonsillar abscess. A group of salivary glands (Weber's glands) proven to be located in the supratonsillar space have been shown to be implicated in the pathogenesis of peritonsillar abscess. A review of peritonsillar abscess has been undertaken, and evidence has been presented to support the premise that the true cause for peritonsillar abscess is not necessarily an extension of an acute exudative tonsillitis, but an abscess formation of Weber's salivary glands in the supratonsillar fossa.

Needle aspiration of peritonsillar abscess in children

Needle aspiration for the treatment of peritonsillar abscess was assessed in 43 consecutive children aged 7 to 18 years (mean age, 13.9 +/- 2.5 years) during the 3-year period from 1988 through 1991. A positive aspirate was obtained in 31 (76%) of the 41 patients who cooperated for needle aspiration; a mean of 2.9 +/- 1.9 mL of pus was withdrawn. Of the 31 children with a positive aspirate, in 27 (87%) the abscess resolved, two (6%) required a second aspiration for resolution, and two (6%) underwent immediate tonsillectomy for persistent abscess. Of the 10 children (24%) with negative aspirations, in six (60%) the abscess resolved with antibiotic treatment alone, three (30%) underwent immediate (quinsy) tonsillectomy, and in one (10%) the abscess spontaneously drained. No bleeding, airway obstruction, or anesthetic complications occurred. Needle aspiration of peritonsillar abscess in children, with tonsillectomy reserved for nonresponders, appears to be an efficacious and safe method of treatment.

[Peritonsillar abscess in the ultrasonic image]

A prospective study was carried out to evaluate the sensitivity of ultrasonography in diagnosis of peritonsillar abscess (Quinsy). In 1986 through 1989 all cases of doubtful peritonsillitis were subjected to B-mode ultrasonography of tonsils before tonsillectomy was carried out. 36 patients were included in this clinical study. In cases of clinically uncertain peritonsillar abscesses the sensitivity of the method was 82%. However, only four false positive cases ("abscess in the scan but no pus during surgery") occurred.

Peritonsillar infection in Christchurch 1981-1984

Retrospective review of the notes of 83 peritonsillar infection sufferers over three years at Christchurch Hospital reveals that the typical sufferer is a young adult male who is most likely to present in winter or summer. Only a quarter of the patients had a significant recent history of tonsillitis but four had had a previous quinsy and six had had a previous tonsillectomy in childhood. Length of symptoms does not appear helpful in differentiating an abscess from a cellulitis. Anaerobic organisms were found in 49% of aspirates and streptococci were the most important aerobic organism. Potential beta lactamase producing organisms, H influenzae, Staph aureus and Bacteroides sp were infrequent and penicillin remains the drug of choice. Appropriate antibiotics and drainage are the essentials of management and tonsillectomy may be indicated.