Ultrasound-guided drainage of peritonsillar abscess by the emergency physician

The diagnosis of peritonsillar abscess (PTA) poses a challenge to emergency physicians (EPs). The decision to perform an invasive procedure with potential complications is based on clinical judgment that is often inaccurate. Although there is some mention of intraoral ultrasound in otolaryngology practice, there is none in the emergency medicine (EM) literature. However, this bedside emergency application of ultrasonography has the potential to be of considerable use in EM practice, and could allow EPs who previously deferred blind needle aspiration of a potential abscess to perform the procedure themselves. We report the cases of 6 patients who presented with probable PTA and were evaluated with intraoral ultrasound at the bedside by an EP. All 6 patients then underwent needle aspiration. As diagnosed on ultrasound, 3 of the patients had negative aspirations and were diagnosed with peritonsillar cellulitis. Three others were found to have PTA, with 2 requiring real-time ultrasound needle guidance to accomplish abscess drainage after multiple failures with the blind approach.     

Prognostic factors and effects of early surgical drainage in patients with peritonsillar abscess

Peritonsillar abscess is a frequently encountered otorhinolaryngological emergency, but the characteristics of patients with this disease have not been described in detail. The objective of this study was to delineate prognostic factors associated with peritonsillar abscess and the effects of early surgical drainage for the treatment of peritonsillar abscess. We conducted a retrospective analysis of the medical records of 240 consecutive patients with PTA during the period from 2007 to 2013. Univariate analysis indicated that the period between symptom onset and relief was significantly longer in patients with high levels of C-reactive protein (CRP) (>8.53 mg/dL, p = 0.0073) and without early surgical drainage of pus (p < 0.0001). Multivariate analysis identified both of these values as independently associated with longer duration of symptoms (high CRP, P < 0.0001; no early drainage, P < 0.0001). Univariate analysis indicated that the duration between symptom onset and complete recovery from the disease was significantly longer with age ≥40 years (P = 0.0004), no history of recurrent tonsillitis (P = 0.022), high CRP level (P = 0.0017), and no early surgical drainage of the abscess (P = 0.0014). Multivariate analysis identified older age (P = 0.0004), high CRP level (P = 0.0001), and no early drainage (P < 0.0001) as independently associated with longer duration between symptom onset and complete recovery. Early surgical drainage of the abscess is important for the treatment of peritonsillar abscess. Patients ≥40 years old with peritonsillar abscess and high CRP levels should be recognized as a high-risk group.     

Abscess Management: An Evidence-Based Review for Emergency Medicine Clinicians

BackgroundAbscesses are commonly evaluated and managed in the emergency department. Recent research has evaluated the use of ultrasonography, packing, incision and drainage (I&D), and antibiotics. There are evidence-based nuances to the management of specific types of abscesses, such as Bartholin, breast, dental, hidradenitis suppurativa, peritonsillar, and pilonidal abscesses.ObjectiveThis review provides emergency medicine clinicians with a summary of the current literature regarding abscess management in the emergency department.DiscussionUltrasound is valuable in diagnosing abscesses that are not clinically evident and in guiding I&D procedures. Although I&D is traditionally followed by packing, this practice may be unnecessary for small abscesses. Antibiotics, needle aspiration, and loop drainage are suitable alternatives to I&D of abscesses with certain characteristics. Oral antibiotics can improve outcomes after I&D, although this improvement must be weighed against potential risks. Many strategies are useful in managing Bartholin abscesses, with the Word catheter proving consistently effective. Needle aspiration is the recommended first-line therapy for small breast abscesses. Dental abscesses are often diagnosed with clinical examination alone, but ultrasound may be a useful adjunct. Acute abscess formation caused by hidradenitis suppurativa should be managed surgically by excision when possible, because I&D has a high rate of abscess recurrence. Peritonsillar abscesses can be diagnosed with either intraoral or transcervical ultrasound if clinical examination is inconclusive. Needle aspiration and I&D are both suitable for the management of peritonsillar abscesses. Pilonidal abscesses have traditionally been managed with I&D, but needle aspiration with antibiotics may be a suitable alternative.ConclusionsThis review evaluates the recent literature surrounding abscess management for emergency medicine clinicians.     

Carotid hemorrhage: a complication of peritonsillar abscess

Carotid hemorrhage secondary to peritonsillar abscess occurs infrequently today because of the effectiveness of antibiotic therapy. When it does occur, however, emergency physicians unfamiliar with such a complication may have difficulty making its diagnosis and instituting appropriate therapy. Prevention is the easiest way to treat septic erosion. Abscesses are treated best with penicillin or, in the allergic patient, clindamycin followed by incision and drainage. Once the abscess has eroded into the carotid artery, it usually must be tied off to control the subsequent massive bleeding.     

经口腔超声在扁桃体周围脓肿的应用

目的：评价经口腔超声对扁桃体周围脓肿的诊断价值。方法：３３例疑诊为扁桃体周围脓肿（ＰＴＡ）患者进行经口腔超声（ＩＯＵ）检查。结果：ＩＯＵ诊断ＰＴＡ２７例,扁桃体周围炎（ＰＴＣ）６例。２８例穿刺或切排抽取脓液,５例穿刺阴性。ＩＯＵ诊断ＰＴＡ的敏感度为９６．４％（２７／２８）,特异度为１００％。阳性预测值为１００％,阴性预测值为８３．３％。结论：ＩＯＵ是一种诊断准确率高,图像直观,非侵入性的诊断技术,是临床诊断ＰＴＡ的有用工具。     

New trends in the management of peritonsillar abscess

Peritonsillar abscess is the most common complication of acute tonsillitis. Signs and symptoms include fever, unilateral sore throat, odynophagia and trismus. Optimal management consists of antibiotic therapy and drainage of the abscess. Controversy exists about the drainage procedure, which includes needle aspiration, incision and drainage, or acute tonsillectomy. Data indicate that outpatient needle aspiration, antibiotics and pain medication are effective treatment in 85 to 90 percent of patients with uncomplicated peritonsillar abscesses.     

Peritonsillar abscess: diagnosis and treatment.

Peritonsillar abscess, the most common deep infection of the head and neck that occurs in adults, is typically formed by a combination of aerobic and anaerobic bacteria. The presenting symptoms include fever, throat pain, and trismus. Ultrasonography and computed tomographic scanning are useful in confirming a diagnosis. Needle aspiration remains the gold standard for diagnosis and treatment of peritonsillar abscess. After performing aspiration, appropriate antibiotic therapy (including penicillin, clindamycin, cephalosporins, or metronidazole) must be initiated. In advanced cases, incision and drainage or immediate tonsillectomy may be required.     

Throat culture in impending peritonsillar abscess

Throat cultures done immediately before the development of a peritonsillar abscess were positive for beta-hemolytic streptococci in only one of 12 cases. To prevent suppurative complications such as peritonsillar abscess, treatment with antibiotics may be indicated in selected severe cases of tonsillar infections despite negative throat cultures.     

Novel Technique for Management of Bartholin Gland Cysts and Abscesses

Background: Definitive methods for treatment of a Bartholin cyst and abscess include placement of a Word catheter, marsupialization, application of silver nitrate, and surgical excision. Placement of a Word catheter is the most frequently employed technique for office and emergency department (ED) management. However, many institutions do not have the Word catheter available; in addition, the catheter has a tendency to dislodge before epithelialization, leading to recurrence of the cyst. Objective: We have developed a simple technique for management of Bartholin gland abscess or cyst using readily available materials. This technique involves using a small loop of plastic tubing, which is secured to prevent expulsion before epithelialization of a drainage tract. Case Report: A 25-year-old woman presented to the ED with a Bartholin gland abscess. After administration of local anesthetic, a loop of tubing was placed, allowing for drainage of the abscess. The patient was discharged home with a course of oral antibiotics. At 3-week follow-up, the Bartholin gland abscess was found to be healed; the device was removed without difficulty, leaving two drainage tracts. Conclusion: This technique may be used as an alternative to placement of a Word catheter for management of Bartholin gland abscess or cyst.     

Bilateral peritonsillar abscesses: not your usual sore throat

We describe a rare case of a previously healthy 30-year-old man who presented to the Emergency Department (ED) with bilateral peritonsillar abscesses. The clinical presentation of fever, trismus and odynophagia was consistent with pertonsillar abscess (PTA), but the presence of symmetric tonsillar swelling and midline uvula confounded the diagnosis. The true incidence of bilateral peritonsillar abscesses is unknown, but the incidence of unsuspected contralateral peritonsillar abscess identified at tonsillectomy has been reported to be between 1.9% and 24%. The diagnosis of bilateral peritonsillar abscesses should be considered when the clinical presentation suggests the diagnosis of PTA, but the physical examination reveals bilateral swollen tonsils with a midline uvula.     

Topical anesthetic cream is associated with spontaneous cutaneous abscess drainage in children

Objective

The objective of the study was to determine whether use of topical anesthetic cream increases spontaneous drainage of skin abscesses and reduces the need for procedural sedation.

Methods

A retrospective multicenter cohort study from 3 academic pediatric emergency departments was conducted for randomly selected children with a cutaneous abscess in 2007. Children up to 18 years of age were eligible if they had a skin abscess at presentation. Demographics, abscess characteristics, and use of a topical analgesic were obtained from medical records.

Results

Of 300 subjects, 58% were female and the median age was 7.8 years (interquartile range, 2-15 years). Mean abscess size was 3.5 ± 2.4 cm, most commonly located on the lower extremity (30%), buttocks (24%), and face (12%). A drainage procedure was required in 178 children, of whom 9 underwent drainage in the operating room. Of the remaining 169 children who underwent emergency department-based drainage, 110 (65%) had a topical anesthetic agent with an occlusive dressing placed on their abscess before drainage. Use of a topical anesthetic resulted in spontaneous abscess drainage in 26 patients, of whom 3 no longer required any further intervention. In the 166 patients who underwent additional manipulation, procedural sedation was required in 26 (24%) of those who had application of a topical anesthetic and in 24 (41%) of those who had no topical anesthetic (odds ratio, 0.45; 95% confidence interval, 0.23-0.89).

Conclusions

Topical anesthetic cream application before drainage procedures promotes spontaneous drainage and decreases the need for procedural sedation for pediatric cutaneous abscess patients.     

Clinical findings in needle aspiration of peritonsillar abscess.

A retrospective study was undertaken of all patients admitted through the casualty department of St Mary's Hospital, London W2, with the diagnosis of peritonsillar abscess over a period of 4 years. Patients were divided into those in whom pus was aspirated from the peritonsillar swelling, and those in whom no pus was aspirated from the peritonsillar swelling. These two groups may be described clinically as peritonsillar abscess, and peritonsillar cellulitis respectively (Shoemaker et al., 1986). Relevant details from the history, examination, and investigations were recorded. The results were compared in order to determine whether there was any difference in the details recorded between those patients with pus aspirated, and those with no pus found. Of the 70 patients admitted with this diagnosis over the last 4 years, full data was available in 55 cases. Pus was found on routine needle aspiration of the peritonsillar swelling in 35(63%) cases. There was no pus found in 20(37%). There was no significant information recorded that would have predicted the presence or absence of pus in the peritonsillar space.     

Neglected peritonsillar abscess resulting in necrotizing soft tissue infection of the neck and chest wall

Necrotizing soft tissue infection (NSTI) of the neck and chest wall resulting from neglected peritonsillar abscess is a relatively rare but highly lethal surgical condition which has received little attention in the literature. The case of a 54-year-old male patient affected by this unusual infection is reported. Our recent experience and literature data suggest that NSTI resulting from peritonsillar abscess is rapidly spreading and life threatening. High index of suspicion, early diagnosis, broad-spectrum antibiotics and aggressive surgical debridement are essential to its successful treatment.     

Aspiration and injection-based technique for incision and drainage of a sacrococcygeal pilonidal abscess

The incision and drainage of a sacrococcygeal abscess is a common procedure in the Emergency Department (ED) both to decrease a patient's pain and to improve the local wound conditions for subsequent definitive surgical therapy. However, the local infiltration of anesthetics is often problematic due to the unacceptable and unavoidable pain resulting from the injection itself, as well as the inability to achieve a complete anesthetic response. Therefore, standard textbooks generally recommend the concomitant use of local and systemic analgesics in the treatment of sacrococcygeal abscesses. We describe herein an alternative technique to administer local analgesia after the aspiration of an abscess for incision and drainage of a sacrococcygeal abscess that is safe and rapid. The patient is placed in the prone position and the buttocks are separated from the midline with adhesive tape. The technique involves needle aspiration of the abscess with consecutive slow injections of the same amount of local anesthetic into the abscess cavity via the same needle, followed by abscess drainage by incision and gentle curettage. This method therefore eliminates multiple infiltrations of the abscess and the surrounding area and obviates the associated pain due to the low volume of anesthetic required. The described technique is well tolerated by the patient and reduces the frequently encountered difficulty with incision and drainage of coccygeal abscesses in the ED.     

Retropharyngeal calcific tendinitis: report of five cases and review of the literature

Retropharyngeal calcific tendinitis is an inflammation of the longus colli muscle tendon, which is located on the anterior surface of the vertebral column extending from the atlas to the third thoracic vertebra. Five cases of acute retropharyngeal calcific tendinitis seen in the emergency department (ED) over a 15-month period are reported. In addition, a retrospective review of four cases diagnosed as retropharyngeal abscess and admitted to the hospital revealed that two of these cases actually represented retropharyngeal calcific tendinitis. A review of the literature and potential differential diagnoses are presented. For those primary care physicians who must evaluate patients with acute cervical pain, sore throat, or odynophagia, an x-ray study of the neck revealing retropharyngeal calcium deposition should raise the question of the diagnosis of acute retropharyngeal tendinitis. Clinical characteristics of this entity include a painful condition which is treatable and is often mistaken for retropharyngeal abscess, pharyngitis, or peritonsillar abscess. In our opinion, this condition may be more prevalent than the literature suggests.     

Peritonsillar abscess

Peritonsillar abscess remains the most common deep infection of the head and neck. The condition occurs primarily in young adults, most often during November to December and April to May, coinciding with the highest incidence of streptococcal pharyngitis and exudative tonsillitis. A peritonsillar abscess is a polymicrobial infection, but Group A streptococcus is the predominate organism. Symptoms generally include fever, malaise, sore throat, dysphagia, and otalgia. Physical findings may include trismus and a muffled voice (also called "hot potato voice"). Drainage of the abscess, antibiotics, and supportive therapy for maintaining hydration and pain control are the foundation of treatment. Antibiotics effective against Group A streptococcus and oral anaerobes should be first-line therapy. Steroids may be helpful in reducing symptoms and speeding recovery. To avoid potential serious complications, prompt recognition and initiation of therapy is important. Family physicians with appropriate training and experience can diagnose and treat most patients with peritonsillar abscess. (Am Fam Physician.     

Acute neck infections in children: who is likely to undergo surgical drainage?

Background

Superficial neck infections including lymphadenitis and abscesses are commonly encountered in pediatric emergency departments (PEDs). It is often unclear which patients are likely to develop an abscess that necessitates surgical drainage. In evaluating these patients, computed tomography (CT) and ultrasound are often used to identify/confirm abscess formation. The criteria for determining the need for imaging studies are not well defined.

Design/Methods

All visits to the study PED were examined in 2009 to 2010. Visits with the diagnosis of cervical lymphadenitis or abscess were identified. Records were retrospectively reviewed to determine the duration of symptoms, fever, previous antibiotic therapy, prior PED visit, size of neck swelling, fluctuance on physical examination, white blood cell count, and results of CT and/or ultrasound obtained in the PED. Data were analyzed to determine which of these characteristics were more likely to be associated with an abscess that was operatively drained.

Results

A total of 768 patients were evaluated for neck infections. One hundred twelve (14%) of these pediatric patients underwent abscess drainage in the operating room. Two hundred eighty-nine patients underwent a neck CT and/or ultrasound, of which 119 were positive for abscess. Factors associated with surgical drainage included fluctuance (odds ratio [OR], 18.92; 95% confidence interval [CI], 3.66-31.37), previous emergency department visit (OR, 2.79; 95% CI, 1.34-5.84), and age less than 4 years (OR, 3.01; 95% CI, 1.15-9.87). A recursive partitioning model stratified patients' risk for going to the operating room. Patients without fluctuance and with no prior emergency department visit, along with no prior antibiotic use, have less than 4% chance of having an abscess that necessitates surgical drainage.

Conclusions

Pediatric patients who are more likely to have a neck infection that necessitates surgical drainage can be stratified based on clinical characteristics. This knowledge may allow physicians to better predict the resource needs including hospital admission and emergent imaging for neck infection.     

Ultrasound-Guided Transgluteal Sciatic Nerve Block for Gluteal Procedural Analgesia

BackgroundAdequate analgesia is difficult to achieve in patients with an abscess requiring incision and drainage (I&D). There has been a recent increase in regional anesthesia use in the emergency department (ED) to aid in acute musculoskeletal pain relief. Specifically, transgluteal sciatic nerve (TGSN) block has been used as an adjunct treatment for certain chronic lumbar and lower extremity pain syndromes in the ED.Case ReportA 21-year-old woman presented to the ED with a painful gluteal abscess. The pain was so severe that the patient barely tolerated light palpation to the abscess area. Using dynamic ultrasound guidance, a TGSN block was performed with significant pain reduction. Ultrasonographic confirmation of abscess was obtained followed by definitive I&D. She was discharged from the ED and her incision site was healing well at the time of follow-up.Why Should an Emergency Physician Be Aware of This?Abscess I&D is a common procedure in the ED. Procedural analgesia for I&D can be difficult to obtain. We describe the TGSN block as an additional analgesic option to be used for procedural analgesia. The use of regional anesthesia has the potential to decrease unwanted and at times dangerous side effects of opiate use and resource utilization of procedural sedation while optimizing patient comfort.     

Clinical, bactericidal and pharmacological evaluation of the effects of netromycin

AIM: To analyze clinical, bactericidal effectiveness and pharmacokinetics of wide-spectrum antibiotic netromycin (NM). MATERIALS AND METHODS: The trial entered 29 patients: 21 with bronchopulmonary diseases (pneumonia and chronic bronchitis), 5 with exacerbation of chronic pyelonephritis, 2 with infectious endocarditis and 1 with peritonsillar abscess. RESULTS: Microbiologically, most of the agents (80.36%) showed sensitivity to NM. Pharmacologically, NM persisted long in blood serum and sputum irrespective of the administration mode. Positive clinical dynamics after NM treatment was achieved in all the patients but one who had a peritonsillar abscess. CONCLUSION: NM is highly active against both gram-positive and gram-negative flora. Side effects are minimal.