Peritonsillar Abscess:

I&D vs Needle Aspiration

Mandisa McIver, MDCohen Children’s Medical Center of New York

Pediatric Emergency Medicine

Outline

Definition of peritonsillar abscess (PTA)

ED management options

Literature Review

Summary/Recommendations

Definition

Peritonsillar abscess (PTA) Collection of pus within the space between the

tonsil and the superior constrictor muscle Most common deep infection of head and neck Adolescents, adults

ED Management Options

In many ED settings, the ED physician is treating pts with PTA

Important to know which method is the most successful with the least number of complications

Carotid artery may sit millimeters away from the posterior extent of the PTA.

The DebateNeedle Aspiration

? Easier to perform

? Minimal trauma

? Well tolerated by pts

Risk of puncture to Carotid A, Jugular V, Parotid Gland

I&D

? More definitive

? More painful

? Risk of pulmonary aspiration of pus

Adult Literature Review

Adult literature has multiple studies

I&D vs needle aspiration

Primary Outcome Acute resolution of illness

Secondary Outcomes Recurrence rate Pain Complications- bleeding, pulmonary aspiration

Adult Literature ReviewSuccess Rates

Spires et al, 1987, 62 pts I&D (100%), Needle Aspiration (95%)

Stringer et al, 1988, 52 pts I&D (93%), Needle Aspiration (92%)

Maharaj et al, 1991, 60 pts I&D (90%), Needle Aspiration (87%)

No significant statistical difference

Adult Literature ReviewSuccess Rates

Wolf, et al, 1994

74 pts had I&D

86 pts had needle aspiration

I&D group: no immediate recurrence 3/74 (4%) had late recurrent episode

Needle aspiration group: 24/86 had single needle aspiration 38/86 had a repeat needle aspiration 24/86 (23%) had 2 or more repeat needle

aspirations

Statistically significant difference in recurrence rate

Literature Review

Johnson, et al, 2003

Medline search, 42 articles

Overall PTA recurrence rate is 10-15%

Concluded that both needle aspiration and incision and drainage are effective for initial management

Management is the same for adults and cooperative children

Pediatric Literature Review

Weinberg E, et al 1993, Prospective study, 3 year period

43 children with PTA, ages 7-18 yr

All treated with needle aspiration

94% success rate

No bleeding/airway/anesthetic complications

Pediatric Literature Review

Schraff, et al, 2001, retrospective chart review, 10 year period

83 children with PTA, (10m-18y), seen by ENT

51% treated in ED

42 I&D, 12 needle aspiration (2 required 2nd needle aspiration)

No recurrent PTAs

Pediatric Literature Review

Recommendations:

Cooperative child: Consider conscious sedation

Uncooperative child: CT scan or US Conscious sedation or OR

Hx of previous PTA, recurrent tonsillitis, OSA OR for tonsillectomy

Summary/Recommendations

Both needle aspiration and I&D are effective management options for drainage of PTAs

Similar success rates

Appropriate f/u is necessary for possible repeat drainage

Children are more challenging and therefore may require sedation or OR management

References

Johnson, FR, et al. An evidence-based review of the treatment of peritonsillar abscess. Otolaryngol Head Neck Surg 2003;128:332-43

Maharaj D, et al. Management of peritonsillar abscess. J Laryngol Otol. 1991 Sep;105(9)743-5 

Stringer SP, et al. A randomized trial for outpatient management of peritonsillar abscess. Arch Otolaryngol Head Neck Surg. 1988 Mar;114(3):296-8

Spires JR, et al. Treatment of peritonsillar abscess. A prospective study of aspiration vs incision and drainage. Arch Otolaryngol Head Neck Surg. 1987 Sep;113(9):984-6.

Viljoen, M, Loock, JW. Quinsy treated by aspiration: the volume of pus at initial aspiration is an accurate predictor of the need for subsequent re-aspiration. Clin Otolaryngol. 2007, 32, 98-102.

Wolf M, et al. Peritonsillar abscess: repeated needle aspiration versus incision and drainage. Ann Otol Rhinol Laryngol. 1994 Jul:103(7):554-7

Weinberg E, et al. Needle aspiration of peritonsillar abscess in children. Arch Otolaryngol Head Neck Surg. 1993. Feb:119(2)169-72.

Schraff, S, et al. Peritonsillar abscess in children: a 10-year review of diagnosis and management. Int J Pediatric Otorhinolaryngol 57 (2001) 213-218.

References

Apostolopoulos NJ, et al. Peritonsillar abscess in children. Is incision and drainage an effective management? Int J Pediatr Otorhinolaryngol. 1995 Mar;31(2-3):129-35.

Herzon, FS. Harris P. Mosher Award thesis. Peritonsillar abscess: incidence, current management practices, and a proposal for treatment guidelines. Laryngoscope. 1995 Aug;105(8 Pt Suppl 74):1-17.

Ozbek C, et al. Use of steroids in the treatment of peritonsillar abscess. The Journal of Laryngology and Otology. June 2004, Vol 118, pp.439-442

Friedman NR, et al. Peritonsillar abscess in early childhood. Presentation and management. Arch Otolaryngol Head Neck Surg 1997; 123:630-632

Scott PM, et al. Diagnosis of peritonsillar infections: a prospective study of ultrasound, computerized tomography and clinical diagnosis. J Laryngol Otol 1999; 113:229-23

Ramirez-Schrempp, et al. Ultrasound Soft Tissue Applications in the Pediatric Emergency Department. To drain or not to drain? Pediatric Emergency Care. Vol 25, Number 1, Jan 2009.

Bauer, et al. The safety of conscious sedation in peritonsillar abscess drainage. Arch Otolaryngol Head Neck Surg. Vol 127. Dec 2001