Short summary

Peritonsillar abscess (PTA) has a relatively high incidence of 41 per 100,000/year in Denmark. In spite of that, there is no regional or national consensus on treatment of PTA. Abscess drainage can be done by aspiration, incision or acute tonsillectomy. Several studies show that incision and aspiration are equally successful. The aim for this study is to compare aspiration to acute tonsillectomy (tonsillectomy a chaud) in a RCT study regarding sick-leave days, days of admission, pain, consumption of antibiotics, consumption of painkillers and patients´ self-assessed quality of life. 

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Rationale

Peritonsillar abscess (PTA) is a complication of acute tonsillitis. The condition occurs when the infection spreads from the tonsil to the peritonsillar tissue, resulting in accumulation of pus between the tonsil and the muscles of the throat.

PTA is a common condition with an incidence of 41 per 100.000/year in Denmark. Untreated, PTA may develop into a potentially fatal condition with respiratory problems due to para- or retrofaryngeal abscess or spread of infection to surrounding tissue with necrotizing fasciitis, sepsis and thrombophlebitis of the jugular vein (Lemierres syndrome).

In spite of the high incidence of PTA, there is no regional or national consensus on the treatment of the PTA. There are several methods used for the treating of PTA. Draining of the abscess can be done by puncture and aspiration, incision or immediate abscess tonsillectomy (tonsillectomy a chaud). Additional treatment may consist of antibiotics, analgesics and rehydration. Depending on the general condition patients are either hospitalized for treatment or receive outpatient treatment (aspiration or incision).

Acute surgical intervention (tonsillectomy a chaud) is relevant in children, adults who cannot cooperate to aspiration, if malignancy is suspected in the patient, patients who experience insufficient effect from treatment with aspiration and antibiotics, patients with recurrent PTA or history of recurrent tonsillitis. Based on these criteria, a previous published article reported a relative indication for immediate abscess tonsillectomy in approximately 30% of patients with PTA. The advantage of surgery is that the abscess cavity cannot reform and that, in many cases, antibiotic treatment may be discontinued after the operation. The risk of surgery is primarily post-operative hemorrhage. The hemorrhage rate after immediate abscess tonsillectomy is not significantly higher compared to elective tonsillectomy.

Alternative treatment options are puncture and aspiration of pus or incision and dilatation. Benefits of these treatments are that the patient usually can be treated in outpatient clinics, and avoid surgery in general anesthesia. Good patient compliance is required as well as concomitant antibiotic treatment. Incision treatment has not been found more successful compared to aspiration treatment (NNT=48)

Several studies have compared immediate abscess tonsillectomy to puncture and aspiration and reported high success rates (82-95%) for aspiration. However, the risk of aspiration or incision is that the PTA will reform, necessitating subsequent tonsillectomy. The PTA reformation risk is highest in patients with a history of recurrent tonsillitis.

The aim for this study is to compare aspiration to acute tonsillectomy (tonsillectomy a chaud) in a RCT study regarding sick-leave days, days of admission, pain, consumption of antibiotics and painkillers and patients' self-assessed quality of life.

The results of the study will improve information and advice given to patients with PTA as well as aid clinicians in choosing the best treatment.

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Description of the cohort

Inclusion criteria: Adult patients (age 18 years) with aspiration positive PTA in the region of Southern Denmark.

Exclusion criteria: No pus on aspiration, respiratory distress, suspected malignancy, previous PTA, history of recurrent tonsillitis (Paradise criteria 1984), patients who cannot participate for aspiration.

Patients will be enrolled from the four departments of ENT-HNS in Southern Denmark. The aim is at least 128 patients. 

Data and biological material

Patient information is obtained regarding history of tonsillitis, days with sore throat, antibiotics, throat swap for group A strep, smoking, alcohol, penicillin allergy, history of coagulation anomaly, VAS pain score, painkillers, trismus, amount of pus, complications of tonsillectomy (hemorrhage), recurrences, requirement for additional aspiration.

Patient information about quality of life is acquired by use of questionnaires QoL SF36.0 v2.0 score and ATOI-14, respectively.

Follow-up on patients are done after 1, 2 and 4 weeks and after 3 months. 

Collaborating researchers and departments

Department of Otolaryngology, Odense University Hospital and Hospital South West Jutland

• Daniel Skansing, MD 

Department of Otolaryngology, Odense University Hospital and Vejle Hospital

• Christian Heidemann, MD, PhD

Department of Otolaryngology, Odense University Hospital

• Professor Christian Godballe, MD, PhD

Department of Otolaryngology, Hospital South West Jutland

• Knud Larsen, MD
• Susanne Holm Nielsen, MD

Department of Otolaryngology, Vejle Hospital

• Peter Schousboe, MD