The Laryngoscope C 2014 The American Laryngological, V
Rhinological and Otological Society, Inc.
Do Corticosteroids Improve Outcomes in Peritonsillar Abscess? John C. Hardman, MBChB, MRCS, DOHNS, AFHEA; Neil A. McCulloch, MBChB, BDS, MRCS, MFDS; Paul Nankivell, MBChB, MRCS, PhD QUESTION Do Corticosteroids Improve Outcomes in Peritonsillar Abscess?
BACKGROUND Peritonsillar abscess (PTA), also known as quinsy, is the collection of pus in the peritonsillar space. It is one of the most common emergency presentations to otolaryngologists, with an incidence of around 30 cases per 100,000 population.1 The use of systemic corticosteroids in PTA can reduce pain and trismus, resulting in an earlier return to normal diet and activities. Their use is widespread but inconsistent, perhaps due to concerns about the immediate immunosuppressive effects and long-term side effects associated with these drugs.2 This article aims to review the current evidence for the use of corticosteroids in patients with PTA.
LITERATURE REVIEW A literature review was conducted using the MEDLINE database and the search terms “peritonsillar abscess” OR “quinsy” AND “corticosteroids” OR “steroids.” This identified two randomized controlled trials (RCTs) and a single retrospective cohort study relevant to this question (Table I). Ozbek et al. (2004) conducted a double-blind randomized placebo-controlled trial including 62 patients admitted to a single center in Turkey.3 Patients received either a single bolus of 2 to 3 mg/kg of intravenous (IV) methylprednisolone (up to 250 mg) or a placebo. Management was otherwise standardized with drainage by needle aspiration and subsequent inpatient admission for IV antibiotics. Outcome measures were interincisor distance, which measures trismus, resolution of fever, From the Department of Otolaryngology Head and Neck Surgery, Heartlands Hospital, Bordesley Green East, Birmingham, B9 5SS, United Kingdom. Editor’s Note: This Manuscript was accepted for publication August 18, 2014. The authors have no funding, financial relationships, or conflicts of interest to disclose. Send correspondence to Mr. John Hardman, Department of Otolaryngology Head and Neck Surgery, Heartlands Hospital, Bordesley Green East, Birmingham, B9 5SS, United Kingdom. E-mail: [email protected] DOI: 10.1002/lary.24936
Laryngoscope 00: Month 2014
time to swallowing water without pain, and length of stay. The group receiving steroid therapy experienced statistically significant improvements in all measured outcomes. Seventy percent of the steroid group was able to swallow water pain-free at 12 hours compared with 18% of the placebo group. In addition, 88% of the steroid group was discharged by 4 days compared to 22% of the placebo group. There were no adverse side effects from the steroid therapy recorded, and no patients from either group required repeated drainage. However, certain methodological weaknesses must be acknowledged. The method of randomization is not clear in the study. There is an inconsistency in reporting intervals for some of the outcomes, the reason for which is not detailed in the methodology. This may have led to a reporting bias. Furthermore, P values were used selectively, weakening the conclusions that can be drawn from the study. Chau et al. (2014)4 recently performed a doubleblind, randomized placebo-controlled trial of 41 patients presenting to two Canadian centers. Patients received either a single 10-mg dose of IV dexamethasone or a placebo. The primary outcome of patient-reported pain was recorded on a 10-point visual analogue scale. Secondary outcomes were interincisor distance (at presentation and 48 hours), body temperature (at presentation, 24 and 48 hours), and patient-reported time to painless oral intake (measured in hours). The principal finding was a statistically significant reduction in median pain scores in the steroid group at 24 hours (1.4 vs. 5.1; P 5 0.009). In addition, a greater proportion of patients in the steroid group returned to normal activity at 24 hours, although this failed to reach statistical significance. In both of these outcome measures, the reported benefits were short-lived, and differences between the two groups were transient and had resolved by 48 hours. Therefore, it is possible that the early reported improvement may be attributable to reversible mood and cognitive changes known to occur with systemic steroid administration. No adverse events were noted in either arm of the study during the short follow-up of 7 days, with data from two patients in the steroid arm missing at day 7. The authors conclude that a single-dose corticosteroid treatment following needle aspiration can confer a transient improvement in patient-reported symptoms at 24 hours. Rightfully, they also caveat that any improvement should be weighed against the potential for delayed Hardman et al.: Corticosteroids and Peritonsillar Abscess
1
TABLE I. Summary of Studies Identified in Literature Review with Interpretations of Main Findings and Limitations. Paper
Ozbek et al., 20043
Millar et al., 20072
Chau et al., 20144
Study Design
Treatment Group
Double-blind randomized placebo-controlled trial
62
Single dose of 2–3 mg/kg methylprednisolone (max 250 mg) IV
Retrospective cohort
229
Double-blind randomized placebo-controlled trial
41
Steroid (no further information)
Laryngoscope 00: Month 2014
Main Limitations
Short-term improvement in pain scores and interincisor distance.
Inconsistent reporting intervals.
Reduction in time to resolution of pyrexia and length of stay.
Selective use of P values. Overall follow-up not reported. Pediatric population.
Mean length of stay reduced, although not significantly (2.52 vs. 2.95 days, P 5 0.29). More likely to receive steroids if > 13 yrs (no P value).
Single dose of 10 mg Dexamethasone IV
adverse events, including the recurrence of PTA and progression to deep-space neck infections that may have been missed by their limited follow-up. Millar et al. (2007) set out to review cases of suspected PTA in children presenting to the Calgary Health Region in Canada. 2 In the nine centers they investigated, steroid usage ranged from 17.2% to 67.8%, with an overall rate of 36.7% in the 229 children. They found that the mean length of stay among those with PTA admitted to hospital (45%) was not significantly reduced (2.52 vs. 2.95 days; P 5 0.29). Among the variables analyzed, the only factor significantly associated with corticosteroid usage was an age greater than 13 years (OR 1.96; 95% CI[1.07– 3.65]). However, Millar et al. only looked at a pediatric population; thus, their findings may not be generalizable to adult patients. Furthermore, with the majority of cases managed as outpatients in this emergency room-based study, no follow-up data was reported. The literature review identified only two studies randomizing 103 patients that have investigated corticosteroid usage in PTA management and a single cohort study of 229 patients. In both of the RCTs, patients were randomized to either a single dose of IV corticosteroid or to a placebo at the time of presentation and drainage. The common outcome measures recorded were the subjective pain scores, interincisor distance, and body temperature. Both studies demonstrated improved outcomes in those receiving steroids, albeit only a transient one. It is not uncommon for patients to be started on a more regular dose of steroid after presentation, but the effectiveness of this has not yet been adequately assessed. Millar et al. were unable to comment on the outcomes of management of PTA with steroids due to their lack of routine follow-up.2 This may be less relevant, however, because their usage has been proven both efficacious and safe in cases of acute pharyngitis.5
2
Main Findings in Treatment Group
N
Transient improvement in pain scores and proportion of participants returning to normal activity and normal diet.
Steroid use varied from 17% to 67% between centers. Low numbers, recruitment ended early. Maximum 7-day follow-up.
Overall, the literature supports the ability of corticosteroids to reduce the patients’ perception of pain, reduce the length of stay, and augment an earlier return to normal activity compared with placebo. In both the RCTs relevant here, none of the 55 patients who were randomized to the steroid arms were reported to have experienced an adverse event from the single IV-dose regime, although follow-up may have been too short to reliably detect this.
BEST PRACTICE A single dose of IV corticosteroid at presentation is associated with reduced pain in PTA and may expedite recovery in patients. However, larger randomized trials are needed to establish any long-term benefits or adverse effects associated with corticosteroids in these patients. To date, the potential advantage of a more sustained steroid course has not been adequately assessed; therefore, it also warrants further investigation.
LEVEL OF EVIDENCE This literature review included two RCTs equating to level 1(b) evidence and a single retrospective cohort study equating to level 2(b) evidence.
BIBLIOGRAPHY 1. Herzon FS. Harris P. Mosher Award thesis. Peritonsillar abscess: incidence, current management practices, and a proposal for treatment guidelines. Laryngoscope 1995;105(suppl 74):1–17. 2. Millar KR, Johnson DW, Drummond D, Kellner JD. Suspected peritonsillar abscess in children. Pediatr Emerg Care 2007;23:431–438. 3. Ozbek C, Aygenc E, Tuna EU, Selcuk A, Ozdem C. Use of steroids in the treatment of peritonsillar abscess. J Laryngol Otol 2004;118:439–442. 4. Chau JKM, Seikaly HR, Harris JR, Villa-Roel C, Brick C, Rowe BH. Corticosteroids in peritonsillar abscess treatment: a blinded placebo-controlled clinical trial. Laryngoscope 2014;124:97–103. doi: 10.1002/lary.24283. 5. Hayward G, Thompson MJ, Perera R, Glasziou PP, Del Mar CB, Heneghan CJ. Corticosteroids as standalone or add-on treatment for sore throat. Cochrane Database Syst Rev 2012;10:CD008268. doi: 10.1002/14651858.CD008268.pub2.
Hardman et al.: Corticosteroids and Peritonsillar Abscess
Rhinological and Otological Society, Inc.
Do Corticosteroids Improve Outcomes in Peritonsillar Abscess? John C. Hardman, MBChB, MRCS, DOHNS, AFHEA; Neil A. McCulloch, MBChB, BDS, MRCS, MFDS; Paul Nankivell, MBChB, MRCS, PhD QUESTION Do Corticosteroids Improve Outcomes in Peritonsillar Abscess?
BACKGROUND Peritonsillar abscess (PTA), also known as quinsy, is the collection of pus in the peritonsillar space. It is one of the most common emergency presentations to otolaryngologists, with an incidence of around 30 cases per 100,000 population.1 The use of systemic corticosteroids in PTA can reduce pain and trismus, resulting in an earlier return to normal diet and activities. Their use is widespread but inconsistent, perhaps due to concerns about the immediate immunosuppressive effects and long-term side effects associated with these drugs.2 This article aims to review the current evidence for the use of corticosteroids in patients with PTA.
LITERATURE REVIEW A literature review was conducted using the MEDLINE database and the search terms “peritonsillar abscess” OR “quinsy” AND “corticosteroids” OR “steroids.” This identified two randomized controlled trials (RCTs) and a single retrospective cohort study relevant to this question (Table I). Ozbek et al. (2004) conducted a double-blind randomized placebo-controlled trial including 62 patients admitted to a single center in Turkey.3 Patients received either a single bolus of 2 to 3 mg/kg of intravenous (IV) methylprednisolone (up to 250 mg) or a placebo. Management was otherwise standardized with drainage by needle aspiration and subsequent inpatient admission for IV antibiotics. Outcome measures were interincisor distance, which measures trismus, resolution of fever, From the Department of Otolaryngology Head and Neck Surgery, Heartlands Hospital, Bordesley Green East, Birmingham, B9 5SS, United Kingdom. Editor’s Note: This Manuscript was accepted for publication August 18, 2014. The authors have no funding, financial relationships, or conflicts of interest to disclose. Send correspondence to Mr. John Hardman, Department of Otolaryngology Head and Neck Surgery, Heartlands Hospital, Bordesley Green East, Birmingham, B9 5SS, United Kingdom. E-mail: [email protected] DOI: 10.1002/lary.24936
Laryngoscope 00: Month 2014
time to swallowing water without pain, and length of stay. The group receiving steroid therapy experienced statistically significant improvements in all measured outcomes. Seventy percent of the steroid group was able to swallow water pain-free at 12 hours compared with 18% of the placebo group. In addition, 88% of the steroid group was discharged by 4 days compared to 22% of the placebo group. There were no adverse side effects from the steroid therapy recorded, and no patients from either group required repeated drainage. However, certain methodological weaknesses must be acknowledged. The method of randomization is not clear in the study. There is an inconsistency in reporting intervals for some of the outcomes, the reason for which is not detailed in the methodology. This may have led to a reporting bias. Furthermore, P values were used selectively, weakening the conclusions that can be drawn from the study. Chau et al. (2014)4 recently performed a doubleblind, randomized placebo-controlled trial of 41 patients presenting to two Canadian centers. Patients received either a single 10-mg dose of IV dexamethasone or a placebo. The primary outcome of patient-reported pain was recorded on a 10-point visual analogue scale. Secondary outcomes were interincisor distance (at presentation and 48 hours), body temperature (at presentation, 24 and 48 hours), and patient-reported time to painless oral intake (measured in hours). The principal finding was a statistically significant reduction in median pain scores in the steroid group at 24 hours (1.4 vs. 5.1; P 5 0.009). In addition, a greater proportion of patients in the steroid group returned to normal activity at 24 hours, although this failed to reach statistical significance. In both of these outcome measures, the reported benefits were short-lived, and differences between the two groups were transient and had resolved by 48 hours. Therefore, it is possible that the early reported improvement may be attributable to reversible mood and cognitive changes known to occur with systemic steroid administration. No adverse events were noted in either arm of the study during the short follow-up of 7 days, with data from two patients in the steroid arm missing at day 7. The authors conclude that a single-dose corticosteroid treatment following needle aspiration can confer a transient improvement in patient-reported symptoms at 24 hours. Rightfully, they also caveat that any improvement should be weighed against the potential for delayed Hardman et al.: Corticosteroids and Peritonsillar Abscess
1
TABLE I. Summary of Studies Identified in Literature Review with Interpretations of Main Findings and Limitations. Paper
Ozbek et al., 20043
Millar et al., 20072
Chau et al., 20144
Study Design
Treatment Group
Double-blind randomized placebo-controlled trial
62
Single dose of 2–3 mg/kg methylprednisolone (max 250 mg) IV
Retrospective cohort
229
Double-blind randomized placebo-controlled trial
41
Steroid (no further information)
Laryngoscope 00: Month 2014
Main Limitations
Short-term improvement in pain scores and interincisor distance.
Inconsistent reporting intervals.
Reduction in time to resolution of pyrexia and length of stay.
Selective use of P values. Overall follow-up not reported. Pediatric population.
Mean length of stay reduced, although not significantly (2.52 vs. 2.95 days, P 5 0.29). More likely to receive steroids if > 13 yrs (no P value).
Single dose of 10 mg Dexamethasone IV
adverse events, including the recurrence of PTA and progression to deep-space neck infections that may have been missed by their limited follow-up. Millar et al. (2007) set out to review cases of suspected PTA in children presenting to the Calgary Health Region in Canada. 2 In the nine centers they investigated, steroid usage ranged from 17.2% to 67.8%, with an overall rate of 36.7% in the 229 children. They found that the mean length of stay among those with PTA admitted to hospital (45%) was not significantly reduced (2.52 vs. 2.95 days; P 5 0.29). Among the variables analyzed, the only factor significantly associated with corticosteroid usage was an age greater than 13 years (OR 1.96; 95% CI[1.07– 3.65]). However, Millar et al. only looked at a pediatric population; thus, their findings may not be generalizable to adult patients. Furthermore, with the majority of cases managed as outpatients in this emergency room-based study, no follow-up data was reported. The literature review identified only two studies randomizing 103 patients that have investigated corticosteroid usage in PTA management and a single cohort study of 229 patients. In both of the RCTs, patients were randomized to either a single dose of IV corticosteroid or to a placebo at the time of presentation and drainage. The common outcome measures recorded were the subjective pain scores, interincisor distance, and body temperature. Both studies demonstrated improved outcomes in those receiving steroids, albeit only a transient one. It is not uncommon for patients to be started on a more regular dose of steroid after presentation, but the effectiveness of this has not yet been adequately assessed. Millar et al. were unable to comment on the outcomes of management of PTA with steroids due to their lack of routine follow-up.2 This may be less relevant, however, because their usage has been proven both efficacious and safe in cases of acute pharyngitis.5
2
Main Findings in Treatment Group
N
Transient improvement in pain scores and proportion of participants returning to normal activity and normal diet.
Steroid use varied from 17% to 67% between centers. Low numbers, recruitment ended early. Maximum 7-day follow-up.
Overall, the literature supports the ability of corticosteroids to reduce the patients’ perception of pain, reduce the length of stay, and augment an earlier return to normal activity compared with placebo. In both the RCTs relevant here, none of the 55 patients who were randomized to the steroid arms were reported to have experienced an adverse event from the single IV-dose regime, although follow-up may have been too short to reliably detect this.
BEST PRACTICE A single dose of IV corticosteroid at presentation is associated with reduced pain in PTA and may expedite recovery in patients. However, larger randomized trials are needed to establish any long-term benefits or adverse effects associated with corticosteroids in these patients. To date, the potential advantage of a more sustained steroid course has not been adequately assessed; therefore, it also warrants further investigation.
LEVEL OF EVIDENCE This literature review included two RCTs equating to level 1(b) evidence and a single retrospective cohort study equating to level 2(b) evidence.
BIBLIOGRAPHY 1. Herzon FS. Harris P. Mosher Award thesis. Peritonsillar abscess: incidence, current management practices, and a proposal for treatment guidelines. Laryngoscope 1995;105(suppl 74):1–17. 2. Millar KR, Johnson DW, Drummond D, Kellner JD. Suspected peritonsillar abscess in children. Pediatr Emerg Care 2007;23:431–438. 3. Ozbek C, Aygenc E, Tuna EU, Selcuk A, Ozdem C. Use of steroids in the treatment of peritonsillar abscess. J Laryngol Otol 2004;118:439–442. 4. Chau JKM, Seikaly HR, Harris JR, Villa-Roel C, Brick C, Rowe BH. Corticosteroids in peritonsillar abscess treatment: a blinded placebo-controlled clinical trial. Laryngoscope 2014;124:97–103. doi: 10.1002/lary.24283. 5. Hayward G, Thompson MJ, Perera R, Glasziou PP, Del Mar CB, Heneghan CJ. Corticosteroids as standalone or add-on treatment for sore throat. Cochrane Database Syst Rev 2012;10:CD008268. doi: 10.1002/14651858.CD008268.pub2.
Hardman et al.: Corticosteroids and Peritonsillar Abscess
