Download An outpatient medical treatment protocol for peritonsillar abscess

ORIGINAL
ARTICLE
LAMKIN,
PORTT
An outpatient medical treatment
protocol for peritonsillar abscess
Roland H. Lamkin, MD, FACS; James Portt, PAC, MMS
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
strikingdegreeofsynergybetweenantibioticsandsteroids
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,althoughtreatmentsuccessrequiredrelativelyhigh
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,
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: (602) 263-1514; fax: (602)
263-1635; e-mail: [email protected]
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.
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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
patientsrequiredneedleaspirationand2othersunderwent
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
ENT-Ear, Nose & Throat Journal  October 2006
LAMKIN, PORTT
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
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
wasbeingdeveloped.Dexamethasonehasbeenreportedto
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 antibiotics4 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
parapharyngealspaceinfections:Aprospectivestudy.Laryngoscope
2002;112:906-10.
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ENT-Ear, Nose & Throat Journal  October 2006