Type 2 Diabetes Mellitus Increases Peritonsillar Abscess Susceptibility: Real-World Evidence

ObjectivesType 2 diabetes mellitus (T2DM) is a risk factor for deep neck infection (DNI) and leads to complications and poor outcomes. Our study aimed to investigate the risk, prognosis, and complications of peritonsillar abscess (PTA) in patients with T2DM.MethodsWe extracted data of patients newly diagnosed as having T2DM between January 2000 and December 2011 from Taiwan’s National Health Insurance Research Database. These patients were matched with patients without T2DM, and PTA incidence was compared between both cohorts.ResultsIn total, 67,852 patients with and 135,704 patients without T2DM were enrolled. PTA incidence was significantly higher in patients with T2DM (incidence rate ratio, 1.91; P<0.001); moreover, PTA incidence was higher at 1 to 5 years after T2DM diagnosis than at <1 and >5 years after T2DM diagnosis. Cox regression analysis showed that patients with T2DM had an approximately 2-fold higher PTA risk (adjusted hazard ratio [aHR]: 1.89, P<0.001). Patients with a higher adapted Diabetes Complications Severity Index (aDCSI) had higher PTA risk than those with a lower aDCSI (aHRs: 2.17 for aDCSI ≥1, P=0.006 and 1.81 for aDCSI=0, P=0.002). T2DM patients with a high aDCSI (≥1) had a nonsignificantly longer hospitalization duration and a higher rate of DNI complications than did those with a low aDCSI (=0).ConclusionIn patients with T2DM, PTA incidence was relatively high, and it increased with T2DM severity. Moreover, T2DM patients should be particularly careful about PTA within 1 to 5 years after the diagnosis, and physicians should keep in mind that the prognosis of PTA was correlated with T2DM severity.     

Parapharyngeal abscess: diagnosis,complications and management in adults

Parapharyngeal abscess may cause life-threatening complications. Peritonsillar abscess and tonsillitis may result in parapharyngeal abscess. Since the introduction of antibiotics, the incidence of parapharyngeal abscess secondary to tonsillitis and peritonsillar abscess has decreased dramatically. We present five cases of parapharyngeal abscess resulting from tonsillitis and peritonsillar infection extending to the parapharyngeal space in adult patients. Two were complicated by mediastinitis despite early treatment by wide spectrum antibiotics. We believe that early diagnosis and aggressive antibiotic treatment with early surgical drainage in cases associated with pus collection are the key points in preventing serious and fatal complications. We emphasize the diagnostic role of computerized tomography (CT) scan and the importance of early and proper drainage of these abscesses.     

Spontaneous parapharyngeal haematoma caused by a leaking vertebral artery pseudoaneurysm

We describe an unusual case of spontaneous parapharyngeal haematoma, in a patient with haemophilia. The cause was a leaking extracranial vertebral artery pseudoaneurysm eroding through the atlas at the level of the skull base. The leaking pseudoaneurysm was successfully controlled with embolisation of the vertebral artery. The haematoma caused a cerebral infarct and vocal cord paralysis, requiring external drainage and tracheostomy. This is the first reported case of a parapharyngeal haematoma originating from a vertebral artery pseudoaneurysm where imaging demonstrated a causal link.     

Screening for glandular fever in patients with Quinsy: is it necessary?

Quinsy (peritonsillar abscess) is a common emergency seen in otolaryngology practice. These patients are often screened for glandular fever in addition to routine haematological tests. In our unit, we have screened 66 patients with quinsy for glandular fever over a period of 12 months. All these patients were screened for glandular fever by rapid immunoassay. Only one out of 66 patients was tested positive for glandular fever. Due to the extremely low incidence of glandular fever in quinsy patients, we do not see any relevance in screening for glandular fever in quinsy patients. Hence we recommend that routine screening for glandular fever in quinsy patients is an unnecessary invasive investigation for the patients and not cost effective for the hospital.     

Current trends in tonsillitis and tonsillectomy

IntroductionThe aim of this study was to assess tonsillitis and tonsillectomy trends, both from a local and national perspective.MethodsRetrospective analysis was carried out of tonsillitis admissions and tonsillectomy rates over a ten-year period in a university teaching hospital from 2003 to 2012.ResultsSince 2003 tonsillitis admissions have increased locally by 118% in adults and 179% in children despite negligible changes in tonsillectomy rates. Similar trends have been observed nationally.ConclusionsThe findings of this study may be considered to be the result of current National Health Service policy. A reconsideration of agreed indications for tonsillectomy could potentially reduce hospital admissions of patients with tonsillitis in the long term.     

Bilateral peritonsillar abscesses

In the discussion about the management of the peritonsillar abscess (PTA) in regard to the pros and cons of tonsillectomy à chaud versus à froid, the risk of obscure contralateral abscesses is often neglected. To the authors knowledge, there are only a few series of PTA being analyzed for the abscess rate of bilateral PTA. A group of 541 abscess tonsillectomies was retrospectively analyzed for the presence of a bilateral manifestation of peritonsillar abscess. Twenty-one patients (3.88%) had bilateral abscesses. None of these had been detected prior to the operation. Of the 541 patients, 2.22% had postoperative hemorrhages that had to be arrested under general anesthesia. Within the discussion about abscess tonsillectomy versus stab incision followed by interval tonsillectomy (à froid), the rate of almost 4% bilateral abscesses should be taken into consideration as dangerous complications such as mediastinitis could develop from the remaining abscess formation of the contralateral side.     

Peritonsillar abscess after tonsillectomy: a review of the literature

INTRODUCTION

Peritonsillar abscess (PTA) is a common condition with a complicated aetiology. PTA after tonsillectomy is rare. This literature review of PTA in the absence of tonsil tissue aims to collate experience of these cases and examine the wider implications for understanding the aetiology of PTA formation.

METHODS

A structured literature review was performed using Ovid MEDLINE®. Keywords ‘quinsy’ or ‘peritonsillar abscess’ were combined with ‘tonsillectomy’.

RESULTS

The search resulted in 212 citations and the identification of 11 cases of PTA formation in the absence of tonsil tissue. The most common indication for tonsillectomy was recurrent tonsillitis or PTA. Nine patients had no interval peritonsillar infection (ie a peritonsillar infection after a tonsillectomy) prior to presenting with the PTA. The mean interval between tonsillectomy and PTA was 16 years. All patients were managed either by incision and drainage or by needle aspiration with or without antibiotics.

CONCLUSIONS

PTA in the absence of tonsil tissue is rare. Potential sources of infection include congenital branchial fistulas, Weber''s glands and dental disease. These alternatives should also be considered in patients presenting with PTA formation in the absence of concurrent tonsillitis and may influence management decisions.     

Tonsillectomy <Emphasis Type="Italic">à chaud</Emphasis> for quinsy: revisited

In a prospective study involving 16 patients over a 12 month period, we determined whether tonsillectomy à chaud is an acceptable alternative to interval tonsillectomy for patients with quinsy. Guidelines for the acute surgical management of quinsy (or peritonsillar abscess) were established following a departmental audit. Sixteen patients were admitted with a quinsy plus an indication for tonsillectomy; 12 were evaluated prospectively. Each was treated either by incision and drainage or needle aspiration, rehydration, analgesia and intravenous antibiotic therapy, followed by a tonsillectomy à chaud (immediate tonsillectomy) within 30 h of the acute admission. Despite initial drainage, a high incidence of pus was detected intra-operatively. A much larger group of patients had peritonsillitis rather than peritonsillar abscess. Of the 16 patients admitted with a quinsy and indication for tonsillectomy over a 12 month period, 12 consented to tonsillectomy à chaud. Aspiration was used to confirm the presence of a quinsy in seven patients (58%), and incision and drainage in the remaining five. There were no complications, and further hospitalisations were avoided thus reducing patient morbidity and costs. We propose that tonsillectomy à chaud remains a justifiable alternative to interval tonsillectomy for such patients when personnel and theatre facilities permit.