1. Peritonsillar Abscess: I&D vs Needle Aspiration Mandisa McIver, MD Cohen Children’s Medical Center of New York Pediatric Emergency Medicine

2. Outline  Definition of peritonsillar abscess (PTA)  ED management options  Literature Review  Summary/Recommendations

3. 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

4. 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.

5. The Debate Needle 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

6. 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

7. Adult Literature Review Success 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

8. Adult Literature Review Success 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

9. 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

10. 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

11. 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 2 nd needle aspiration)  No recurrent PTAs

12. 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

13. 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

14. 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.

15. 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