Ann Otol Rhinol Laryngoll00:1991
ROLE OF QUINSY TONSILLECTOMY IN THE MANAGEMENT OF PERITONSILLAR ABSCESS .LCDR RICKY LOCKHART, MC,
USN
PORTSMOUTH, VIRGINIA
CDR GREGG
THOMAS A. T AMI, MD
S. PARKER, MC, USN
SAN FRANCISCO, CALIFORNIA
PORTSMOUTH, VIRGINIA
Peritonsillar abscess (PTA) is the most frequent complication of acute tonsillitis requiring surgical intervention. Debate continues concerning optimal therapy in terms of patient morbidity and cost-effectiveness. A retrospective study was performed on 45 tonsillectomies for PTA in military personnel from December 1986 through December 1988. Twenty-three quinsy (abscess) tonsillectomies and 22 interval tonsillectomies were identified. Parameters studied were age, sex, abscess location, interval prior to operation, blood loss, operative time, operative experience, and combined hospital and convalescent days for the two groups. Significant differences were noted between the quinsy and interval tonsillectomy groups concerning the average number of days hospitalized (3.0 versus 4.5) and their respective convalescent periods (10.3 versus 17.3). We conclude that quinsy tonsillectomy is the best management for PTA in a young work force when the optimal treatment choice is between interval or acute tonsillectomy. KEY WORDS - peritonsillar abscess, tonsillectomy, tonsillitis.
INTRODUCTION
cost-effectiveness of these two treatment modalities in an active duty population were evaluated.
Peritonsillar abscess (PTA) is the most frequent complication of acute tonsillitis requiring surgical intervention. It is the most common deep infection of the head and neck and occurs most commonly in older children and young adults;':" Inadequate treatment of PTA can result in complications varying from dehydration, jugular venous thrombosis, hemorrhage, and phlebitis to aspiration pneumonia, brain abscess, and airway obstruction. 5,6
METHODS
A retrospective review of all active duty patients undergoing tonsillectomy for PTA from December 1986 through December 1988 was performed. Although 56 patients were identified, 11 cases were not included owing to incomplete follow-up or missing chart data. Of the remaining 45, 23 had undergone quinsy tonsillectomy, while 22 had interval tonsillectomies.
The appropriate management of this problem with respect to morbidity as well as cost-effectiveness continues to be widely debated. Recent studies that recommend aspiration alone or in combination with incision and drainage as the best and most 2 1 10 cost-effective treatment • - report a PTA recurrenee rate of 0 % to 22 % • A long-term study of pa1 tients treated by incision and drainage with a 3 / 2 - to 8-year follow-up also quoted a recurrence rate for PTA of 22 0/0. However, 49 % had continued symptoms (22 % PTA, 20 % recurrent tonsillitis with fever, 7 % episodic pharyngitis). 11 Most of these symptomatic patients were less than 40 years old (mean age, 26 years), a population encompassing most of the present military force. With emphasis on productivity and readiness, our policy has been to offer acute tonsillectomy as an alternative therapy for active duty members presenting with PTA. Since prior studies have suggested the efficacy and low morbidity of this technique.v" we examined our experience treating active duty patients with PTA by either tonsillectomy or simple drainage. Factors potentially contributing to increased morbidity as well as the
Data obtained on each patient included age, sex, abscess location, interval prior to operation, blood loss, operative time, and surgeon's level of experience. As an indicator of lost productivity, the total hospital and convalescent days for each patient were calculated. Operative findings and postoperative complications were also noted. Our routine treatment protocol for patients with PTA consists of aspiration and/or incision and drainage followed by hospitalization. Intravenous fluids and antibiotics (usually penicillin G or clindamycin phosphate) are administered in addition to analgesic medications as needed. All patients in the quinsy tonsillectomy group underwent operation within 48 hours of admission (18 of 23 [78 %] within 24 hours), while the interval group returned for operation during a second admission. Of these, 15 of 22 (68 %) underwent operation within 2 months of their PTA and 20 of 22 (91 %) within 3 months. Only 2 patients (9 %) had their operations delayed for
From the Department of Otolaryngology-Head and Neck Surgery, Naval Hospital, Portsmouth, Virginia (Lockhart, Parker), and the Department of Otolaryngology-Head and Neck Surgery, University of California, San Francisco, California (Tami). Sponsored by the Chief, Bureau of Medicine and Surgery, Washington, DC, Clinical Investigation Program (89-08-1969-65). The opinions or assertions expressed herein are those of the authors and are not to be construed as official or as reflecting the views of the Department of the Navy or the Department of Defense. REPRINTS - CDR Gregg S. Parker, MC, USN, Dept of Otolaryngology-Head and Neck Surgery, Naval Hospital, Portsmouth, VA 23708.
569
Downloaded from aor.sagepub.com at The University of Iowa Libraries on July 18, 2015
570
Lockhart et al, Peritonsillar Abscess TABLE 1. AGE, SEX, AND SIDE OF PERITONSILLAR ABSCESS
Age Mean Range Sex (M/F) Location (R/L)
TABLE 3. SURGICAL EXPERIENCE OF OPERATORS
Quinsy (n = 23)
Interval (n = 22)
24.3 18-39 21/2 12/11
23.5 19·34 20/2 7115
more than 3 months. All quinsy tonsillectomies and 16 of 22 interval tonsillectomies were performed under general anesthesia, while the remaining 6 interval tonsillectomies were performed under local anesthesia. All operations were performed by resident staff or rotating surgical interns under the guidance of attending otolaryngologists. Statistical analysis of the data was performed by means of Student's pooled t test. Significance was defined as p< .05. RESULTS
The age, sex, and sidedness of the PTA for the patients in this study are shown in Table 1. No statistical difference was noted between the two groups for any of these characteristics. Eighteen patients in the quinsy group underwent operation within 24 hours of admission, and the remainder by 48 hours. Fifteen of 22 in the interval group underwent tonsillectomy within 8 weeks of their abscess. An additional 5 patients were operated on between 2 and 3 months after abscess drainage, and the remainder completed treatment by 8 months. Intraoperative estimated blood loss and operative time for these two groups are illustrated in Table 2. No significant difference for either of these variables was noted. A significantly longer operative time was noted for the interval tonsillectomies done under general anesthesia compared to those done under local anesthesia. The surgical experience of the operators is displayed in Table 3. While most of the tonsillectomies were done by residents at the postgraduate years 2 and 3 level, no significant difference in distribution was noted between the two groups. The total hospitalization and convalescent time for these groups is shown in Table 4. The mean number of hospital days for the quinsy group was 3.0 with a convalescent period mean value of 10.3 days. The values for the interval group were 4.5 TABLE 2. INTRAOPERATIVE BLOOD LOSS AND OPERATIVE TIME (MEAN±SD)
Blood loss (mL) Operative time (min) .p< .005.
Quinsy (n =23)
Interval (n =22)
Interval (General) (n = 16)
143±87
112±73
123±78
41±14
37±12
51 ± 17·
Quinsy (n =23) No. %
Postgraduate Postgraduate Postgraduate Postgraduate Postgraduate
year year year year year
1 2 3 4 5
2 10
8 3
9 43 35 13
Interval (n =22) No. %
1 11 8 1 1
5
50 35 5 5
and 17.3 days, respectively. These differences were both significant (p < .005). The two separate hospital admissions in the interval group resulted in a much longer total hospital time and subsequent convalescent period. Intraoperative findings in the quinsy group included bilateral abscess in 2 cases (9%), residual abscess in 3 cases (13 %), and severe capsular fibrosis in 6 cases (26 %). In the interval group, capsular fibrosis and scar was noted on the abscess side in 4 of 22 cases (18 %). There were no immediate or delayed bleeding complications in the quinsy group. In the interval group, two episodes of delayed bleeding occurred on postoperative days 2 and 8. Both were treated with local measures without further incident. DISCUSSION
While optimal treatment of PTA remains controversial, consideration of total patient morbidity, lost productivity, and recurrence rates argues in favor of quinsy tonsillectomy as a reliable treatment. Studies in Europe by Moesgaard Nielsen and Greisen 12 and by Bonding' demonstrated a recurrence rate of 22 % for peritonsillar abscesses treated by incision and drainage over a 4-year follow-up period. In the United States, Litman et al'" also documented an average recurrence rate of 21 % to 22 % within 4 years of initial treatment. Bonding found that when followed up for up to 8 years, 20 % of patients under 40 years of age continued to have recurrent tonsillitis and 7 % had episodic pharyngitis. 3 In other words, 49 % or roughly half of this population might be expected to experience substantial morbidity if treated conservatively without tonsillectomy. Since our military patient population mirrors that in these and other studies examining PTA,4.14 these data provide strong support for seriously considering acute tonsillectomy as the initial management in these patients. Operative morbidity was not higher for the quinsy tonsillectomy group. Comparison of the blood loss and operative times demonstrates that quinsy tonTABLE 4. HOSPITALIZATION AND CONVALESCENT TIME (MEAN ± SD) Quinsy (n = 23)
Hospital days Convalescent days .p< .005.
Downloaded from aor.sagepub.com at The University of Iowa Libraries on July 18, 2015
3.0± .97 10.3±2.3
Interval (n
= 22)
4.5± 1.7'" 17.3:1:5.9'"
Lockhart et al, Peritonsillar Abscess
sillectomies have no significant increase in either of these variables. In fact, under general anesthesia, the interval group had considerably longer operative times. This finding probably reflects the presence of fibrosis of the tonsillar capsule, which has been well described in other studies following PTA5.15 and was documented in 18 % of our interval cases. The absence of complications in the quinsy group attests to the relative safety of this procedure. Two minor delayed hemorrhages occurred in the interval group and their significance, if any, would require a larger series of patients to eval uate. The occurrence of bilateral abscess and/or residual pus in up to 21 % of our quinsy patients also argues in favor of quinsy tonsillectomy, since some of these patients would not have been treated adequately with conservative therapy. This finding is well documented by other works in the literature.4.14.16 The most impressive difference between these two groups was in the total number of days of hospital and convalescent time required in their management. The total cost of operation and hospitalization for the quinsy group would be substantially less than that for the interval group, since only one hospitalization is required for these cases. Another,
571
even more meaningful comparison, however, can be made by examining lost man-hours for the two groups. Including both hospitalization and convalescent days lost to the work force, the range for the quinsy group was 106 to 133 hours, while that for the interval group was 174 to 218 hours, based on an 8- to 10-hour average work day. Consideration of the total cost including the dollar value for lost man-hours as well as hospitalization further amplifies the cost-effectiveness of quinsy tonsillectomy. Considering these various factors, what is the most efficacious, safest, and most cost-effective method of managing PT As? Quinsy tonsillectomy certainly appears to meet these criteria for an active duty patient population. Outpatient methods described by Herzon and Aldridge' and others that require aspiration and/or incision and drainage of PT As are often inappropriate for an active duty population. Furthermore, the natural history following an initial PTA treated conservatively will result in additional morbidity in up to 50 % of patients in our population. In light of these factors, as well as military readiness considerations in this population, we feel that quinsy tonsillectomy is the treatment of choice for the acute management of PTA in an active duty population.
REFERENCES 1. Gates GA. Deep neck infection. Am J OtolaryngoI1983;4: 420-1.
2. Schechter GL, Sly DE, Roper AL, Jackson RT. Changing face of treatment of peritonsillar abscess. Laryngoscope 1982;92: 657-9. 3. Bonding P. Routine abscess tonsillectomy: late results. Laryngoscope 1976;86:286-90. 4. Yung AK, Cantrell RW. Quinsy tonsillectomy. Laryngoscope 1976;86:1714-7. 5. McCurdy JA. Peritonsillar abscess: a comparison of immediate tonsillectomy and interval tonsillectomy. Arch Otolaryngol 1977;103:414-5. 6. Lee KJ, Traxler ]H, Smith HW, Kelly JH. Tonsillectomy: treatment of peritonsillar abscess. ORL 1973;77:417-21. 7. Herzon FS, Aldridge JH. Peritonsillar abscess: needle aspiration. Otolaryngol Head Neck Surg 1981;89:910-1. 8. Stinger SP, Schaefer SD, Close LG. A randomized trial for outpatient management of peritonsillar abscess. Arch Otolaryngol Head Neck Surg 1988;114:296-8. 9. Spires ]R, Owens JJ, Woodson GE, Miller RH. Treatment
of peritonsillar abscess: a prospective study of aspiration vs incision and drainage. Arch Otolaryngol Head Neck Surg 1987;113: 985-6. 10. Ophir D, Bawnik J, Poria Y, Porat M, Marshak G. ·Peritonsillar abscess. A prospective evaluation of outpatient management by needle aspiration. Arch Otolaryngol Head Neck Surg 1988;114:661-3. 11. Herbild 0, Bonding P. Peritonsillar abscess: recurrence rate and treatment. Arch Otolaryngol 1981;107:540-2. 12. Moesgaard Nielsen V, Greisen O. Peritonsillar abscess. J Laryngol Otol 1981;95:801-7. 13. Litman RS, Hausman SA, Sher WHo A retrospective study of peritonsillar abscess. Ear Nose Throat J 1987;66:53~5. 14. Harley EH. Quinsy tonsillectomy as the treatment of choice for peritonsillar abscess. Ear Nose Throat J 1988;67:84-7. 15. Richardson KA, Birck H. Peritonsillar abscess in the pediatric population. Otolaryngol Head Neck Surg 1981;89:907-9. 16. Maisel RH. Peritonsillar abscess: tonsil antibiotic levels in patients treated by acute abscess surgery. Laryngoscope 1982;92: 80-7.
Downloaded from aor.sagepub.com at The University of Iowa Libraries on July 18, 2015
ROLE OF QUINSY TONSILLECTOMY IN THE MANAGEMENT OF PERITONSILLAR ABSCESS .LCDR RICKY LOCKHART, MC,
USN
PORTSMOUTH, VIRGINIA
CDR GREGG
THOMAS A. T AMI, MD
S. PARKER, MC, USN
SAN FRANCISCO, CALIFORNIA
PORTSMOUTH, VIRGINIA
Peritonsillar abscess (PTA) is the most frequent complication of acute tonsillitis requiring surgical intervention. Debate continues concerning optimal therapy in terms of patient morbidity and cost-effectiveness. A retrospective study was performed on 45 tonsillectomies for PTA in military personnel from December 1986 through December 1988. Twenty-three quinsy (abscess) tonsillectomies and 22 interval tonsillectomies were identified. Parameters studied were age, sex, abscess location, interval prior to operation, blood loss, operative time, operative experience, and combined hospital and convalescent days for the two groups. Significant differences were noted between the quinsy and interval tonsillectomy groups concerning the average number of days hospitalized (3.0 versus 4.5) and their respective convalescent periods (10.3 versus 17.3). We conclude that quinsy tonsillectomy is the best management for PTA in a young work force when the optimal treatment choice is between interval or acute tonsillectomy. KEY WORDS - peritonsillar abscess, tonsillectomy, tonsillitis.
INTRODUCTION
cost-effectiveness of these two treatment modalities in an active duty population were evaluated.
Peritonsillar abscess (PTA) is the most frequent complication of acute tonsillitis requiring surgical intervention. It is the most common deep infection of the head and neck and occurs most commonly in older children and young adults;':" Inadequate treatment of PTA can result in complications varying from dehydration, jugular venous thrombosis, hemorrhage, and phlebitis to aspiration pneumonia, brain abscess, and airway obstruction. 5,6
METHODS
A retrospective review of all active duty patients undergoing tonsillectomy for PTA from December 1986 through December 1988 was performed. Although 56 patients were identified, 11 cases were not included owing to incomplete follow-up or missing chart data. Of the remaining 45, 23 had undergone quinsy tonsillectomy, while 22 had interval tonsillectomies.
The appropriate management of this problem with respect to morbidity as well as cost-effectiveness continues to be widely debated. Recent studies that recommend aspiration alone or in combination with incision and drainage as the best and most 2 1 10 cost-effective treatment • - report a PTA recurrenee rate of 0 % to 22 % • A long-term study of pa1 tients treated by incision and drainage with a 3 / 2 - to 8-year follow-up also quoted a recurrence rate for PTA of 22 0/0. However, 49 % had continued symptoms (22 % PTA, 20 % recurrent tonsillitis with fever, 7 % episodic pharyngitis). 11 Most of these symptomatic patients were less than 40 years old (mean age, 26 years), a population encompassing most of the present military force. With emphasis on productivity and readiness, our policy has been to offer acute tonsillectomy as an alternative therapy for active duty members presenting with PTA. Since prior studies have suggested the efficacy and low morbidity of this technique.v" we examined our experience treating active duty patients with PTA by either tonsillectomy or simple drainage. Factors potentially contributing to increased morbidity as well as the
Data obtained on each patient included age, sex, abscess location, interval prior to operation, blood loss, operative time, and surgeon's level of experience. As an indicator of lost productivity, the total hospital and convalescent days for each patient were calculated. Operative findings and postoperative complications were also noted. Our routine treatment protocol for patients with PTA consists of aspiration and/or incision and drainage followed by hospitalization. Intravenous fluids and antibiotics (usually penicillin G or clindamycin phosphate) are administered in addition to analgesic medications as needed. All patients in the quinsy tonsillectomy group underwent operation within 48 hours of admission (18 of 23 [78 %] within 24 hours), while the interval group returned for operation during a second admission. Of these, 15 of 22 (68 %) underwent operation within 2 months of their PTA and 20 of 22 (91 %) within 3 months. Only 2 patients (9 %) had their operations delayed for
From the Department of Otolaryngology-Head and Neck Surgery, Naval Hospital, Portsmouth, Virginia (Lockhart, Parker), and the Department of Otolaryngology-Head and Neck Surgery, University of California, San Francisco, California (Tami). Sponsored by the Chief, Bureau of Medicine and Surgery, Washington, DC, Clinical Investigation Program (89-08-1969-65). The opinions or assertions expressed herein are those of the authors and are not to be construed as official or as reflecting the views of the Department of the Navy or the Department of Defense. REPRINTS - CDR Gregg S. Parker, MC, USN, Dept of Otolaryngology-Head and Neck Surgery, Naval Hospital, Portsmouth, VA 23708.
569
Downloaded from aor.sagepub.com at The University of Iowa Libraries on July 18, 2015
570
Lockhart et al, Peritonsillar Abscess TABLE 1. AGE, SEX, AND SIDE OF PERITONSILLAR ABSCESS
Age Mean Range Sex (M/F) Location (R/L)
TABLE 3. SURGICAL EXPERIENCE OF OPERATORS
Quinsy (n = 23)
Interval (n = 22)
24.3 18-39 21/2 12/11
23.5 19·34 20/2 7115
more than 3 months. All quinsy tonsillectomies and 16 of 22 interval tonsillectomies were performed under general anesthesia, while the remaining 6 interval tonsillectomies were performed under local anesthesia. All operations were performed by resident staff or rotating surgical interns under the guidance of attending otolaryngologists. Statistical analysis of the data was performed by means of Student's pooled t test. Significance was defined as p< .05. RESULTS
The age, sex, and sidedness of the PTA for the patients in this study are shown in Table 1. No statistical difference was noted between the two groups for any of these characteristics. Eighteen patients in the quinsy group underwent operation within 24 hours of admission, and the remainder by 48 hours. Fifteen of 22 in the interval group underwent tonsillectomy within 8 weeks of their abscess. An additional 5 patients were operated on between 2 and 3 months after abscess drainage, and the remainder completed treatment by 8 months. Intraoperative estimated blood loss and operative time for these two groups are illustrated in Table 2. No significant difference for either of these variables was noted. A significantly longer operative time was noted for the interval tonsillectomies done under general anesthesia compared to those done under local anesthesia. The surgical experience of the operators is displayed in Table 3. While most of the tonsillectomies were done by residents at the postgraduate years 2 and 3 level, no significant difference in distribution was noted between the two groups. The total hospitalization and convalescent time for these groups is shown in Table 4. The mean number of hospital days for the quinsy group was 3.0 with a convalescent period mean value of 10.3 days. The values for the interval group were 4.5 TABLE 2. INTRAOPERATIVE BLOOD LOSS AND OPERATIVE TIME (MEAN±SD)
Blood loss (mL) Operative time (min) .p< .005.
Quinsy (n =23)
Interval (n =22)
Interval (General) (n = 16)
143±87
112±73
123±78
41±14
37±12
51 ± 17·
Quinsy (n =23) No. %
Postgraduate Postgraduate Postgraduate Postgraduate Postgraduate
year year year year year
1 2 3 4 5
2 10
8 3
9 43 35 13
Interval (n =22) No. %
1 11 8 1 1
5
50 35 5 5
and 17.3 days, respectively. These differences were both significant (p < .005). The two separate hospital admissions in the interval group resulted in a much longer total hospital time and subsequent convalescent period. Intraoperative findings in the quinsy group included bilateral abscess in 2 cases (9%), residual abscess in 3 cases (13 %), and severe capsular fibrosis in 6 cases (26 %). In the interval group, capsular fibrosis and scar was noted on the abscess side in 4 of 22 cases (18 %). There were no immediate or delayed bleeding complications in the quinsy group. In the interval group, two episodes of delayed bleeding occurred on postoperative days 2 and 8. Both were treated with local measures without further incident. DISCUSSION
While optimal treatment of PTA remains controversial, consideration of total patient morbidity, lost productivity, and recurrence rates argues in favor of quinsy tonsillectomy as a reliable treatment. Studies in Europe by Moesgaard Nielsen and Greisen 12 and by Bonding' demonstrated a recurrence rate of 22 % for peritonsillar abscesses treated by incision and drainage over a 4-year follow-up period. In the United States, Litman et al'" also documented an average recurrence rate of 21 % to 22 % within 4 years of initial treatment. Bonding found that when followed up for up to 8 years, 20 % of patients under 40 years of age continued to have recurrent tonsillitis and 7 % had episodic pharyngitis. 3 In other words, 49 % or roughly half of this population might be expected to experience substantial morbidity if treated conservatively without tonsillectomy. Since our military patient population mirrors that in these and other studies examining PTA,4.14 these data provide strong support for seriously considering acute tonsillectomy as the initial management in these patients. Operative morbidity was not higher for the quinsy tonsillectomy group. Comparison of the blood loss and operative times demonstrates that quinsy tonTABLE 4. HOSPITALIZATION AND CONVALESCENT TIME (MEAN ± SD) Quinsy (n = 23)
Hospital days Convalescent days .p< .005.
Downloaded from aor.sagepub.com at The University of Iowa Libraries on July 18, 2015
3.0± .97 10.3±2.3
Interval (n
= 22)
4.5± 1.7'" 17.3:1:5.9'"
Lockhart et al, Peritonsillar Abscess
sillectomies have no significant increase in either of these variables. In fact, under general anesthesia, the interval group had considerably longer operative times. This finding probably reflects the presence of fibrosis of the tonsillar capsule, which has been well described in other studies following PTA5.15 and was documented in 18 % of our interval cases. The absence of complications in the quinsy group attests to the relative safety of this procedure. Two minor delayed hemorrhages occurred in the interval group and their significance, if any, would require a larger series of patients to eval uate. The occurrence of bilateral abscess and/or residual pus in up to 21 % of our quinsy patients also argues in favor of quinsy tonsillectomy, since some of these patients would not have been treated adequately with conservative therapy. This finding is well documented by other works in the literature.4.14.16 The most impressive difference between these two groups was in the total number of days of hospital and convalescent time required in their management. The total cost of operation and hospitalization for the quinsy group would be substantially less than that for the interval group, since only one hospitalization is required for these cases. Another,
571
even more meaningful comparison, however, can be made by examining lost man-hours for the two groups. Including both hospitalization and convalescent days lost to the work force, the range for the quinsy group was 106 to 133 hours, while that for the interval group was 174 to 218 hours, based on an 8- to 10-hour average work day. Consideration of the total cost including the dollar value for lost man-hours as well as hospitalization further amplifies the cost-effectiveness of quinsy tonsillectomy. Considering these various factors, what is the most efficacious, safest, and most cost-effective method of managing PT As? Quinsy tonsillectomy certainly appears to meet these criteria for an active duty patient population. Outpatient methods described by Herzon and Aldridge' and others that require aspiration and/or incision and drainage of PT As are often inappropriate for an active duty population. Furthermore, the natural history following an initial PTA treated conservatively will result in additional morbidity in up to 50 % of patients in our population. In light of these factors, as well as military readiness considerations in this population, we feel that quinsy tonsillectomy is the treatment of choice for the acute management of PTA in an active duty population.
REFERENCES 1. Gates GA. Deep neck infection. Am J OtolaryngoI1983;4: 420-1.
2. Schechter GL, Sly DE, Roper AL, Jackson RT. Changing face of treatment of peritonsillar abscess. Laryngoscope 1982;92: 657-9. 3. Bonding P. Routine abscess tonsillectomy: late results. Laryngoscope 1976;86:286-90. 4. Yung AK, Cantrell RW. Quinsy tonsillectomy. Laryngoscope 1976;86:1714-7. 5. McCurdy JA. Peritonsillar abscess: a comparison of immediate tonsillectomy and interval tonsillectomy. Arch Otolaryngol 1977;103:414-5. 6. Lee KJ, Traxler ]H, Smith HW, Kelly JH. Tonsillectomy: treatment of peritonsillar abscess. ORL 1973;77:417-21. 7. Herzon FS, Aldridge JH. Peritonsillar abscess: needle aspiration. Otolaryngol Head Neck Surg 1981;89:910-1. 8. Stinger SP, Schaefer SD, Close LG. A randomized trial for outpatient management of peritonsillar abscess. Arch Otolaryngol Head Neck Surg 1988;114:296-8. 9. Spires ]R, Owens JJ, Woodson GE, Miller RH. Treatment
of peritonsillar abscess: a prospective study of aspiration vs incision and drainage. Arch Otolaryngol Head Neck Surg 1987;113: 985-6. 10. Ophir D, Bawnik J, Poria Y, Porat M, Marshak G. ·Peritonsillar abscess. A prospective evaluation of outpatient management by needle aspiration. Arch Otolaryngol Head Neck Surg 1988;114:661-3. 11. Herbild 0, Bonding P. Peritonsillar abscess: recurrence rate and treatment. Arch Otolaryngol 1981;107:540-2. 12. Moesgaard Nielsen V, Greisen O. Peritonsillar abscess. J Laryngol Otol 1981;95:801-7. 13. Litman RS, Hausman SA, Sher WHo A retrospective study of peritonsillar abscess. Ear Nose Throat J 1987;66:53~5. 14. Harley EH. Quinsy tonsillectomy as the treatment of choice for peritonsillar abscess. Ear Nose Throat J 1988;67:84-7. 15. Richardson KA, Birck H. Peritonsillar abscess in the pediatric population. Otolaryngol Head Neck Surg 1981;89:907-9. 16. Maisel RH. Peritonsillar abscess: tonsil antibiotic levels in patients treated by acute abscess surgery. Laryngoscope 1982;92: 80-7.
Downloaded from aor.sagepub.com at The University of Iowa Libraries on July 18, 2015
