An outpatient medical treatment protocol for peritonsillar abscess.

Abstract

Several surgical methods are used to treat peritonsillar abscess, but no protocol for outpatient medical treatment has yet been published. Between February 2002 and February 2005, we treated 98 peritonsillar abscess patients with an outpatient medical regimen that involved hydration, antibiotics, steroids, and good pain control. All patients were Native Americans, who are known to have a particularly high incidence of peritonsillar abscess. The medical regimen was generally successful, as only 4 patients (4.1%) subsequently required post-treatment needle aspiration or incision and drainage. We conclude that the medical protocol described herein provides practitioners with a viable noninvasive alternative for treating peritonsillar abscess.

Introduction

Twenty years ago, the lead author (R.H.L.) first noticed a striking degree of synergy between antibiotics and steroids in the treatment of various head and neck infections. Ten years later, he began conducting clinical trials of various antibiotic and steroid combinations for the treatment of peritonsillar abscess. These regimens proved to be very effective, although treatment success required relatively high doses of steroids. Cephalosporins in particular seemed to provide adequate antibiotic coverage. Aspiration cultures were found to be of no value. At the same time, the lead author had also been successfully administering steroids via three routes following outpatient tonsillectomy to control pain and swelling.

More recently, we conducted a study to assess the effectiveness of an antibiotic-steroid protocol in Native Americans, who have a particularly high incidence of peritonsillar abscess. The Indian Health Service, a subsidiary of the United States Department of Health and Human Services, had been spending large sums of money to air-evacuate patients from rural field hospitals and clinics to our referral hospital in Phoenix for definitive otolaryngologic care because the outlying practitioners were not comfortable treating peritonsillar abscess.

Our outpatient medical treatment plan does not require immediate instrumentation, such as needle aspiration or incision and drainage, and it can be used with confidence by practitioners regardless of their level of training. To the best of our knowledge, no such medical protocol has been published previously. (1)

Patients and methods

Between February 2002 and February 2005, we treated 98 Native Americans in Arizona who had been diagnosed with peritonsillar abscess. Patients ranged in age from 9 to 48 years; most were aged 15 to 26 years. The diagnosis had been made solely on the basis of the clinical presentation; no immediate aspiration or incision and drainage had been performed for either diagnosis or treatment.

The treatment protocol is summarized in the table. Medication dosages were adjusted to the weight of each individual patient. Four patients with penicillin allergy were given clindamycin rather than a cephalosporin.

The medical regimen was considered successful if a patient was symptom-free 10 days following the completion of treatment. Patients who had not improved in 48 to 72 hours were asked to return to the emergency department. Because aspirations were not performed, no cultures were available; however, cultures are reportedly not helpful in the management of peritonsillar abscess. (2)

Results

Ninety-two of the 98 patients were treated strictly as outpatients; the other 6 were briefly admitted to the hospital for observation, intravenous fluids, and symptomatic care. Treatment was successful in 94 patients (95.9%); 2 patients required needle aspiration and 2 others underwent incision and drainage. No complications of medical treatment were observed. Seven patients requested an elective tonsillectomy at a later date because of recurrent tonsillar infections.

During the 12 months following the completion of this study, as this protocol continued to be used, no patient with peritonsillar abscess required air-evacuation from an outlying medical facility to our hospital in Phoenix.

Discussion

From a cost standpoint, this protocol has proved to be a very effective form of therapy. In our study, few patients required hospitalization and even fewer underwent a subsequent office procedure.

With experience, the practitioners in the field have been delighted with the results of treatment, and they have become more comfortable with the outpatient protocol. Initially, some of these practitioners were hesitant to use large doses of steroids in the presence of infection, but this reluctance was eventually overcome.

Patients, as well as practitioners, have been pleased that initial aspiration and incision and drainage are not necessary--particularly younger children and teenagers, who are especially fearful of needles around the facial area.

Cephalosporins were highly successful in this protocol and were preferred over clindamycin from a standpoint of medical risk. The administration of steroids via three routes might seem excessive, but the lead author deemed it necessary during the early clinical trials when the protocol was being developed. Dexamethasone has been reported to be of value in relieving pharyngeal pain in an emergency department setting. (3) Our study confirmed this finding, as most patients experienced immediate relief of some of their presenting symptoms after receiving a steroid in the emergency department.

While the combination of antibiotics (4) and steroids is the mainstay of this treatment plan, we must not discount the importance of hydration and pain control. During the development of this regimen, several patients were given ketorolac and an IV narcotic in the emergency department at the individual practitioner's discretion. The analgesia appeared to be quite beneficial, and both pain medications were eventually added to the protocol. Patients must be given adequate outpatient pain medication so they will be able to maintain a good level of oral hydration.

References

(1.) Johnson RF, Stewart MG, Wright CC. An evidence-based review of the treatment of peritonsillar abscess. Otolaryngol Head Neck Surg 2003;128:332-43.

(2.) Cherukuri S, Benninger MS. Use of bacteriologic studies in the outpatient management of peritonsillar abscess. Laryngoscope 2002; 112:18-20.

(3.) Wei JL, Kasperbauer JL, Weaver AL, Boggust AJ. Efficacy of single-dose dexamethasone as adjuvant therapy for acute pharyngitis. Laryngoscope 2002;112:87-93.

(4.) Sichel JY, Dano I, Hocwald E, et al. Nonsurgical management of parapharyngeal space infections: A prospective study. Laryngoscope 2002;112:906-10.

Roland H. Lamkin, MD, FACS; James Portt, PAC, MMS

From the Department of Otolaryngology (Dr. Lamkin) and the Emergency Department (Mr. Portt), Phoenix Indian Medical Center, Phoenix, Ariz.

Reprint requests: Dr. Roland H. Lamkin, Chief of Otolaryngology, 4212 N. 16th St., Phoenix, AZ 85016. Phone: [phone]; fax: [phone]; e-mail: [e-mail]

The opinions and assertions expressed in this article are those of the authors and do not necessarily reflect the views of the Indian Health Service.

Table. Outpatient medical treatment protocol for
peritonsillar abscess

No needle aspiration or incision and drainage is necessary.

Steroids (administer all three regimens):
   Dexamethasone 20 mg intravenously at presentation
   Methylprednisolone 80 to 120 mg intramuscularly
      (buttock) at presentation
   Prednisone 60 to 80 mg orally every morning for 10
      days at home

Hydration:
   5% dextrose in lactated Ringer's solution 1 to 2 L
      intravenously at presentation
   Force fluids 2 L/day orally at home

Antibiotics:
   Cefazolin 2 g intravenously at presentation
   Cephalexin 500 mg orally four times daily for 10 days
      at home

Analgesia:
   Ketorolac and a narcotic intravenously at presentation
   Narcotic pain medications orally at home

Other:
   Warm salt-water gargles hourly at home
   ENT follow-up in 48 to 72 hours if the patient does
      not improve
Admit if any airway distress is noted