The Acute Management of Adult Peritonsillar Abscess Tian-Tee Ng* and Diamanti Diamantaras ENT Unit, Department of Surgery, Frankston Hospital, Victoria, Australia Introduction Peritonsillar abscess is a complication of tonsillitis due to the collection of pus between the tonsil and superior constrictor muscle. It is the most common deep space infection of the head and neck region (1,2,3,4). This disease often results in emergency admission because of dehydration and great pain. The acute management of peritonsillar abscess is drainage of the abscess and intravenous antibiotics (5,6,7). The method of peritonsillar abscess drainage remains controversial with different institutions advocating their own method of choice. 3. Reciprocating procedure device (RPD) This is a modified version of needle aspiration. The RPD is formed around the core of a conventional syringe barrel and plunger, but with an additional plunger and barrel. The two plungers are linked by a pulley system in an opposing fashion, resulting in a set of reciprocating plungers (4). Usually, the technique for aspiration of a peritonsillar abscess requires using one hand to apply a tongue depressor while the other hand uses a syringe to simultaneously aspirate. However, one-handed aspiration with a syringe is a difficult and dangerous manoeuvre (4). Even experienced surgeons may lose control of the needle tip, resulting in unintentional forward penetration, which can result in puncture of the main blood vessels and the previously mentioned complications of needle aspiration. The Reciprocating procedure device (RPD) is a surgical syringe with inbuilt safety technology. The thumb is used to depress either plunger – one causes injection, the other aspiration. There are frequent clinical occasions where a definite diagnosis of either peritonsillar cellulitis or abscess cannot be made. Clinical diagnosis is often supplemented by diagnostic drainage in an effort to distinguish abscess from cellulitis (9). Hence all patients with peritonsillar infection have diagnostic needle aspiration. We advocate using the 14 gauge cannula needle attached to 20ml plastic syringe for our patients with peritonsillar infection. Aspiration of pus will confirm that the patient has a peritonsillar abscess and it helps in localising the pus collection for further I&D. Negative aspirate would thus tell us that patient is either having peritonsillar cellulitis or the collection of pus is further inferior or posterior to the tonsil. The process of doing an I&D, post needle aspiration for all our peritonsillar abscess patient is to make sure that any remaining locules of pus that have been missed by needle aspiration, are totally evacuated to minimise the incidence of recurrence. According to a recent review, the recurrence rate of peritonsillar abscess varies from 9 to 22 % (12). We did a retrospective review of admitted cases of peritonsillar infection in Frankston Hospital from February 2012 till August 2015. We found 133 cases of confirmed peritonsillar abscess that had undergone needle aspiration followed by I&D. Out of these cases, we had 6 recurrences which required further drainage. This brings our recurrence rate of peritonsillar abscess after post needle aspiration and I&D to 4.5%, substantially lower than the published rate. Moreover, more than 90% of our patients admitted with peritonsillar abscess were only admitted for an overnight stay (24 hours) compared to 3 days for other hospitals mean length of hospital stay(13). Plus, the majority of our patients were almost pain free the following day and were discharged home with oral antibiotics. A combination of needle aspiration followed by incision and drainage has a high cure rate, short hospital stay and a low recurrence rate. Objective To describe the various method of draining peritonsillar abscesses, in particular the method of choice for the ENT unit of Frankston Hospital. Method The few known methods of peritonsillar abscess drainage are:- 1. Incision and drainage (I&D) After infiltration of local anaesthetic agent, a cut using a size 11 or 15 blade of about 1.0cm is made on the peritonsillar bulge or the area of maximum fluctuation (Figure 1). Using an artery forceps, the soft tissue plane is then opened and any remaining locules evacuated (Figure 2). Figure 5. While the index and middle fingers support the position of the RPD and do not change position, either aspiration or injection occurs Figure 1. Peritonsillar infection (Dotted area is the site for needle drainage and I&D) Figure 2. Size 11 blade with a curved artery forceps Figure 4. Unlike a syringe, the reciprocating procedure device (RPD) does not lengthen during aspiration or injection, and provides markedly improved safety and needle control. by depressing the thumb on either the accessory or main plunger respectively(4). The RPD aspirates pus when the thumb is placed on the smaller aspiration plunger. During either manoeuver, the index and middle fingers do not change position (Figures 4 and 5) ensuring the unchanging position of the needle. These characteristics of stable finger positioning create a powerful and finely controlled one-handed procedure syringe that precisely controls the needle tip position, strength of vacuum, and depth of penetration (4). Conclusion We advocate needle aspiration, by using a 14 gauge cannula needle attached to 20ml plastic syringe; followed by incision and drainage, by using a sized 11 blade and a blunt artery forceps, for all adult patients with peritonsillar abscess. 2. Needle aspiration This is the method of choice for most institutions (9). Needle aspiration can be both diagnostic and therapeutic in itself; in some studies, patients were effectively treated with needle aspiration and antibiotics alone. A plastic syringe, sized 5 or 10 ml connected to an 18 or 21 gauge needle, is used to obtain pus from the peritonsillar space, after application of topical or local anaesthetic agent (1, 2, 3). At Frankston Hospital, we advocate using a larger bore needle (#14 gauge cannula needle) attached to a 20ml plastic syringe (Figure 3). 4. Hot tonsillectomy Also known as quinsy or abscess tonsillectomy, it is the surgical procedure for removal of the inflamed tonsils in the operating theatre under general anaesthesia during the acute episode. The incidence of bleeding during and following hot tonsillectomy is higher compared to elective tonsillectomy, which has made this method unpopular. However, recent evidence indicates that hot tonsillectomy is as safe as elective tonsillectomy and will also cure the problem. Advocates of the procedure point out that at surgery, deep-seated abscesses can be drained and would have likely been missed with needle aspiration or incision and drainage (10). A recent study has showed that hot tonsillectomy reduces hospital stay by between 2.04 and 4.84 days compared to incision and drainage followed by elective tonsillectomy (11). This is a significant saving in time and resources (11). Hot tonsillectomy also reduces patients lost to follow-up, avoids the social inconvenience of a second admission, effectively relieves symptoms and treats a contralateral abscess (11). Scheduling patients, post needle drainage or I&D of peri-tonsillar abscess, for elective tonsillectomy would still require two recovery periods - one from the initial drainage and one from the elective tonsillectomy later, and it could be argued that hot tonsillectomy would require only a single recovery period (10). References Management of Peritonsillar Abscess. D Maharaj, V Rajah, S Hemsley. The Journal of Laryngology and Otology (1991) 105; 743-745. Microbiological Features and Pathogenesis of Peritonsillar Abscesses. IJ Mitchelmore, AJ Prior, PQ Montgomery, S Tabaqchali. Eur. J. Clin. Microbiol. Infect. Dis (1995) 14; 870-877. Peritonsillar Abscess: Diagnosis and Treatment. TE Steyer. American Family Physician (2002) 65; 93-96. Needle Aspiration of Peritonsillar Abscess with the New Safety Technology: The Reciprocating Procedure Device. RR Sibbitt, WL Sibbitt, DJ Palmer, AD Bankhurst. Otolaryngology–Head and Neck Surgery (2008) 139; 307-309. Incidence and Microbiology of Peritonsillar Abscess: The Influence of Season, Age, and Gender. TE Klug. Eur J Clin Microbiol Infect Dis (2014) 33;1163–1167. Use of Steroids in the Treatment of Peritonsillar Abscess. C Ozbek, E Aygenc, EU Tuna, A Selcuk, C Ozdem. The Journal of Laryngology & Otology (2004) 118; 439–442. Changing Trends in Bacteriology of Peritonsillar Abscess. SB Megalamani, G Suria, U Manickam, D Balasubramanian, S Jothimahalingam. The Journal of Laryngology & Otology (2008) 122; 928–930. Role of Microbiological Studies in Management of Peritonsillar Abscess. C Repanos, P Mukherjee, Y Alwahab. The Journal of Laryngology & Otology (2009) 123; 877–879. Diagnosis of Peritonsillar Infections: A Prospective Study of Ultrasound, Computerized Tomography and Clinical Diagnosis. PMJ Scott, WK Loftus, J Kew, A Ahuja, V Yue. The Journal of Laryngology and Otology (1999) 113; 229-232. An Evidence-based Review of the Treatment of Peritonsillar Abscess. RF Johnson, MG Stewart, CC Wright. Otolaryngology– Head and Neck Surgery (2003) 128 (3); 332-343. The Management of Quinsy—A Prospective Study. CR Chowdhury, MCM Bricknell. The Journal of Laryngology and Otology (1992) 106; 986-988. Risk Factors for Recurrence of Peritonsillar Abscess. JH Chung, YC Lee, SY Shin, YG Eun. The Journal of Laryngology & Otology (2014) 128; 1084–1088. The Epidemiology of Peritonsillar Abscess Disease in Northern Ireland. BC Hanna, RM Mullan, G Gallagher, S Hedderwick. Journal of Infection (2006) 53; 247-253. Figure 3. 14-gauge needle attached to 20ml syringe The larger gauge needle helps to evacuate the thick viscid collection of pus in the peritonsillar space while the additional needle length is helpful in patients with severe trismus making the mouth opening limited, and the larger volume syringe provides more suction power. Although generally a safe procedure, aspiration of a peritonsillar abscess can result in patient pain, puncture of the carotid artery, haemorrhage, hematoma formation, aneurysm or pseudoaneurysm formation and respiratory compromise (4). In addition, while pus usually collects at the upper pole, in up to 40 per cent of abscesses pus collects at the lower or mid-pole of the tonsil (9). This can result in difficulty locating the pus by needle. For these reasons needle aspiration of peritonsillar abscess has a false negative rate of 12 per cent (9). Nevertheless, a previous study has shown that the incision and drainage and needle aspiration methods had a 93.7% vs 91.6% success rate respectively (10). The authors found no statistically significant difference between the outcomes of either method, supporting both treatments (10). Discussion Peritonsillar infection begins as a superficial infection around the tonsil and progresses into peritonsillar cellulitis. Peritonsillar cellulitis may form pus leading to peritonsillar abscess. Antibiotics alone can halt the progression from cellulitis to abscess. Once pus forms however, the principles advocated by Guy de Chauliac in the 14th century apply and pus must be drained (9). Acknowledgements Dr V Tobin, Ms E Dejager, Frankston Hospital Library Corresponding author’s contact details Dr Tian-Tee Ng, ENT Unit, Department of Surgery, Frankston Hospital, Frankston, Victoria, Australia. Email : tntdynamites@yahoo.com Phone : 0426 266 890