Abstract 26 - Medical Therapy Versus Medical And Surgical Therapy For PTAs

Comparison Of Medical Therapy Alone To Medical Therapy With Surgical Treatment Of Peritonsillar Abscess Battaglia, A., et al, Otolaryngol Head Neck Surg 58(2):280, February 2018

SUMMARY:

• Peritonsillar abscesses (PTAs) can be a headache for many ED providers as some ED docs just don’t drain them and may even transfer the patient to another hospital for another ED doc to drain.
• It’s been known for a while that needle aspiration is as effective as standard I+D therefore many of us do simple a 4 quadrant needle aspiration.
• A tip that has emerged from the literature is that even when you get a dry tap, the PTAs resolve. The idea is that by poking holes you give the pus a track to work through. An alternative though is that there was no abscess there to begin with and maybe it was just cellulitis or phlegmon that would have responded to antibiotics anyway.
• The newest school of thought is that you just don’t need to drain it – steroids, IVF and antibiotics are all that is needed the vast majority of the time.
• 12 Southern California Kaisers centers adopted a PTA algorithm in 2008 that gave patients IV antibiotics (ceftriaxone and clinda) + IVF + 10 decadron, then reassessed. If they were feeling better, they followed them up in ENT next day. If they didn’t get any better, they would get an I+D. 7 Kaiser Southern California centers declined to adopt the algorithm instead opting to use the traditional needle aspiration or typical I+D. This allowed for direct comparison of the 2 strategies.
• The authors looked at patients seen at the I+D sites who got the exact same medical regimen and an I+D and compared them to controls in the no I+D sites .
• Turns out at the sites that used a trial of antibiotics before I+D, only 8% of PTAs required drainage while at the sites going straight to I+D, 92% were drained
• Failure rates were 8% in the I+D group and 6% in the medical therapy group. Medical therapy groups required less opioids, had fewer ‘sore days’ (4.5 vs 5.5) and fewer days of missed work (3.5 vs. 5). Complications were mild and infrequent in both groups.

PMID: 29110574

EDITOR’S COMMENTARY: This practice changing paper shows that you can decide to treat a PTA steroids and antibiotics and expect similar results to an I+D procedure. The catch is that these patients must have improvement following initial therapy and scheduled follow up to assess the need for a delayed I+D. I would also be very careful if the patient had severe trismus, a “hot potato voice” or especially if there is the hint of stridor.

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