Peritonsillar Abscess Size as a Predictor of Medical Therapy Success

Abstract

Objective: To evaluate the success of sole medical therapy (MT) versus surgical therapy (ST) in patients with both clinically and radiographically confirmed peritonsillar abscess (PTA). To also determine treatment safety based on abscess size, and identify predictors of treatment failure. Methods: This was a retrospective cohort of 3 hospitals in a single academic health system. A total of 214 immunocompetent patients diagnosed with uncomplicated PTA underwent a contrasted CT scan of the neck. About 87 patients were treated with sole MT (intravenous antibiotics and steroids), and 127 patients were treated with ST (MT plus drainage). Results: Treatment failure occurred in 8.0% of the MT group and 7.9% of the ST group ( P = 1.00). In PTAs <2 cm, treatment failure occurred in 5.3% of the MT group and 5.0% of the ST group ( P = 1.00). In PTAs ≥2 cm, treatment failure occurred in 13.3% of the MT group and 9.0% treated with ST ( P = .53). Size ≥2 cm (OR – 3.46, P = .08) and IV clindamycin as sole IV antibiotic (OR – 2.46, P = .15) trended toward predicting treatment failure. In addition to those considered failures, 7.0% of the ST group returned to the ED with pain versus 0% of the MT group ( P = .01). Conclusion: Frequency of treatment failure was not significantly different among patients receiving MT and ST. Abscesses ≥2 cm in size were more likely to fail in both groups and ST was not statistically superior. Sole MT for uncomplicated PTA may help reduce unnecessary procedures and healthcare costs.

Test characteristics of ultrasound for the diagnosis of peritonsillar abscess: A systematic review and meta‐analysis

“…We did not specifically assess the effect of ultrasound on the patient's clinical management or clinical course. However, some studies have demonstrated relatively high success with the conservative management of PTA using IV antibiotics and corticosteroids, comparable to surgical intervention 34,35 . Conservative management seems to be more successful in smaller PTAs 35 .…”

“…However, some studies have demonstrated relatively high success with the conservative management of PTA using IV antibiotics and corticosteroids, comparable to surgical intervention. 34,35 Conservative management seems to be more successful in smaller PTAs. 35 Given this, the diagnostic test characteristics of ultrasound for PTA may be sufficiently acceptable for diagnosing clinically important PTA requiring either aspiration or drainage.…”

“…34,35 Conservative management seems to be more successful in smaller PTAs. 35 Given this, the diagnostic test characteristics of ultrasound for PTA may be sufficiently acceptable for diagnosing clinically important PTA requiring either aspiration or drainage. Within the current limitations of evidence, the benefits of ultrasound, including lack of ionizing radiation and ability to perform at the bedside, must be weighed against the limitations, including inaccurate diagnosis and patient discomfort.…”

Management Protocol for Uncomplicated Peritonsillar Abscess: Standardizing Care and Improving Emergency Medicine Resident Confidence

“…The study by Urban et al [ 4 ] supports the treatment of abscess sizes <2 cm using medical management alone. Due to resident physician and training availability, our institution has historically attempted drainage of much smaller abscesses, and we anticipated a difficult transition to endorse solely medical management for all PTAs <2 cm.…”

“…Due to resident physician and training availability, our institution has historically attempted drainage of much smaller abscesses, and we anticipated a difficult transition to endorse solely medical management for all PTAs <2 cm. To aid in this transition in management, the size cut-off for this protocol was 1.7 cm, based on the aforementioned study by Urban et al [ 4 ], where 1.69 cm was the average size of an abscess treated successfully with medical management alone.…”