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Recent data is providing accumulating evidence that treatment failure in the management of peritonsillar abscesses (PTAs, aka ‘quinsies’) is similar when these are managed with medical treatment (MT) alone versus MT plus surgical drainage (M+ST). However, in the absence of an assessment of true abscess size, these reports may be unreliable. Urban and colleagues set out to find a definitive answer to this issue. In their retrospective cohort study, they examined 214 patients who had a CT-confirmed PTA with reported measurements thereof, during a 12-year period at three medical centres in the USA. Patients were excluded if the presentation was complicated (e.g. by neoplasia, bilateral PTAs, other neck space infection, thrombophlebitis, airway compromise, chemotherapy, immunosuppressive treatment, or uncontrolled diabetes). Treatment failure was the primary study outcome, defined as a return to the emergency department within 30 days with a recurrent PTA requiring M+ST. Of the study group, 87 patients received MT, and 127 M+ST. Statistically significantly, the M+ST group contained more paediatric patients, presented more with voice change and trismus, had bigger abscesses (16.9 vs 23.2mm), was more likely to receive greater than one dose of IV antibiotics and IV steroids, and to require overnight hospital admission. Interestingly, treatment failure in both groups was comparable: 8.0% and 7.9% for the MT and M+ST groups, respectively. When abscess size was taken into account, treatment failure was comparable for both groups for sub-2cm PTAs. For abscesses 2cm or larger, there was a greater likelihood of treatment failure in the MT group, though not statistically significant. So is it worth draining all quinsies? This study would suggest not, especially for uncomplicated ones that are smaller than 2cm. However, in the absence of accurate size measurements of PTAs, especially in places where imaging thereof is not performed routinely, cautious clinical judgement will continue to be paramount.

Peritonsillar Abscess Size as a Predictor of Medical Therapy Success.
Urban MJ, Masliah J, Heyd C, et al.
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Lucy Dalton

University Hospitals Birmingham, UK.

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