Standard treatment of peritonsillar abscess (PTA) has typically involved both medical therapy and surgical drainage either in the form of needle aspiration, or incision and drainage. However, is medical without surgical treatment sufficient? The authors suggest that medical therapy without surgical treatment (MT) is sufficient through this case series comparing outcomes between 211 patients treated with MT and 96 patients treated with both medical and surgical treatment (ST), between the years 2008 and 2013. The 211 MT patients were randomly selected among patients treated with MT at 12 Southern California Permanente Medical Group (SCPMG) centres that routinely treat PTA with MT. These centres had adopted MT as standard treatment following an initial prospective study comparing MT and ST in 2008. MT involved IV fluids, ceftriaxone, clindamycin and dexamethasone, and then 10 days of oral clindamycin upon discharge. The 96 ST patients were selected among patients (from seven other SCPMG centres) that were treated with the same medical therapy but with additional surgical treatment. There was no significant difference in the number of ‘sore days’ or days ‘off work’, complication, or failure rates. Patients in the MT group had less volume of narcotic pain relief refilled and less total volume prescribed. To address the issue of selection bias according to severity, a subset of patients presenting with trismus was analysed. Results had a similar pattern in this subset. This suggests that surgical treatment of uncomplicated PTA may be unnecessary thus avoiding procedural risks, patient discomfort and added costs. Limitations include the possibility that the ST group may simply have had more severe PTA. The authors recommend further work in the form of a randomised control trial in which PTA is assessed with ultrasound or CT scanning, and abscess size and microbiology data are recorded, and a single surgical technique is used. 

Comparison of medical therapy alone to medical therapy with surgical treatment of peritonsillar abscess.
Battaglia A, Burchette R, Hussman J, et al.
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Richard (Wei Chern) Gan

Royal Brisbane and Women's Hospital, Australia.

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