Suction. Check. Head lamp. Check. Cetacaine. Check. Gauze. Check. Vaginal ultrasound probe. Check. Needle and syringe. Check.
Does that sound familiar? This has always been one of the most awkward procedures in the ED: Invasive drainage of a quinsy requires a patient patient, a patient nurse, and, if all goes well, a functional Yankauer. What could go wrong? An overactive gag reflex, a primal scream, or an unexpected intersection with Big Red.
Does it have to be this way, or might there be an opportunity to relegate peritonsillar abscess incision and drainage to the annals of the anachronistic, like plain films for nasal fractures, rectal exams in blunt trauma, and bloodletting for evil humors?
Some limited retrospective literature on the topic suggests that nonoperative management of peritonsillar abscess may already be fairly common and cost-effective and have complications and bounceback rates similar to those of invasive ED management.
The Evidence
Battaglia, et al., studied 12 centers in Southern California over six years (2008-2013) that adopted medical therapy for peritonsillar abscess while seven continued with the surgical drainage and needle aspiration. (Otolaryngol Head Neck Surg 2018;158[2]:280.) Diagnosis was primarily based on clinical exam, with low rates of CT and ultrasound. Medical management consisted of D5NS 1 L bolus; ceftriaxone 1 g and clindamycin 600 mg, both IV; dexamethasone 10 mg IV; and ED observation for one to two hours with PO trial prior to discharge and transition to incision and drainage or needle aspiration if medical management failed. (http://bit.ly/2ItYTnl.) Home management consisted of clindamycin 300 mg QID x 10 days and next-day follow-up with ENT for repeat IV meds and invasive management if the patient had no improvement or worsened.
The authors retrospectively identified 1,787 patients with uncomplicated peritonsillar abscess, and randomly selected 307 (211 receiving medical treatment only) in which to compare outcomes, which included complications, return visit and failure rates, and quality of life outcomes such as volume of opioid prescriptions and number of days feeling sore and days off work. They also performed a sensitivity analysis among those patients reporting trismus to address the potential for selection bias.
The authors reported no difference in complication or failure rates nor any difference in the time until patients could tolerate liquids or solids across cohorts with similar baseline demographic and clinical characteristics. They found, however, that medical management was associated with an eight percent rate of PO challenge failure in the ED, lower volumes of liquid opioid prescribed in the entire study group and trismus-present subgroup, and a lower average of days feeling sore and days off work across all patients. Recognizing that such outcomes could certainly be the result of unaddressed confounding, particularly treatment selection bias, the authors nonetheless concluded that aggressive intervention is not necessary to achieve resolution of pain, resume oral intake, or return to work. We agree with the premise here of less aggressive ED treatment with similar or perhaps even superior results, so let's see how it works in practice.
The Trial
One of our medical centers recently implemented medical management based on this study. It was brought to us by our ENT colleagues. We queried this ED group on their experience to date, and were met with a mix of crickets and deafening silence. So we asked the ENT chief, Brian Delfanti, MD, and he was cautiously bullish on the performance of the program so far. “I think [peritonsillar abscess] I&D is an effective way to deal with the condition, but it is painful and traumatic to the patient,” he said. Medical management, on the other hand, seems to work, and “the patients seem at least as happy as when we were draining them.”
The Verdict
Cop-out alert here: This is a promising concept with promising study results, but it is not yet proven as a new standard of care. Battaglia, et al., did the best they could with key outcomes (e.g., days feeling sore) based on chart review. That said, if your ED can incorporate the safety mechanisms built into this algorithm—the two-hour PO trial and next-day ENT follow-up—it would certainly save some awkward clinical circumstances, not to mention patient discomfort.
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