Acta Oto-Laryngologica. 2014; 134: 813–817
ORIGINAL ARTICLE
Variations in treatment of peritonsillar abscess in four Nordic countries JOHANNA WIKSTÉN1, KARIN BLOMGREN1, THOMAS ERIKSSON2, LIVIU GULDFRED3, METTE BRATT4 & ANNE PITKÄRANTA1 Department of Otorhinolaryngology – Head and Neck Surgery, Helsinki University Central Hospital, Helsinki University, Faculty of Medicine, Helsinki, Finland, 2Department of Otorhinolaryngology – Head and Neck Surgery, Sundsvall Hospital, Sundsvall, Sweden, 3Department of Otorhinolaryngology – Head and Neck Surgery, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark and 4Department of Otorhinolaryngology – Head and Neck Surgery, St Olav’s University Hospital, Trondheim, Norway
1
Abstract Conclusion: In four Nordic countries, peritonsillar abscess (PTA) patients are treated rather differently. Objectives: To study how such patients are treated in those countries. Methods: The 81 chief physicians of otorhinolaryngology departments of all central hospitals in Denmark (n = 15), Norway (n = 19), Sweden (n = 27), and Finland (n = 20) received a multiple-choice questionnaire. Results: A total of 73 physicians (90%) replied. The largest differences arose in treating patients with intravenous versus per oral antibiotics, and treating as inpatients versus outpatients. In Finland, 50% of PTA patients aged >16 years were treated as inpatients and 50% as outpatients, whereas the respective quotas in Sweden were 9 and 91%, Norway 19 and 81%, and Denmark 33 and 67%. Of Finnish physicians, 30% treated their patients primarily with oral antibiotics, 70% with intravenous antibiotics; in Sweden 91 vs 9%, Norway 53 vs 47%, and Denmark 18 vs 82%. In Denmark, almost all patients were operated on immediately, whereas in the other three countries, especially Sweden, operations more often were performed after a recovery period. Combining metronidazole with penicillin or cephalosporins was most common in Denmark: 58% reported usage, compared with 30% in Finland, 16% in Norway, and 4% in Sweden.
Keywords: Questionnaire, quinsy, practice guideline
Introduction Peritonsillar abscess (PTA), the most common complication of acute tonsillitis, is the most frequent otorhinolaryngological (ORL) infection requiring hospitalization [1]. One well-performed study shows an incidence of 37 per 100 000 [2]. No common clinical practice guidelines are available for the treatment of PTA. Various options for invasive management include incision and drainage, aspiration with a needle, and tonsillectomy (TE) au chaud. In the UK, most patients are inpatients, but in the USA, most physicians treat them as outpatients [3,4]. Antibiotic administration can be oral, intramuscular, or intravenous. In most cases, the antibiotic of choice is
oral procaine penicillin potentially combined with metronidazole or oral amoxicillin with clavulanic acid; inpatients usually receive intravenous benzylpenicillin, cefuroxime, or metronidazole [2,5,6]. Finland, Sweden, Norway, and Denmark are Nordic countries that closely resemble each other and are thus logical choices for comparison. Their similarities in health care, population, and relatively high levels of education, in addition to their similarly high standards of medicine make comparison both reasonable and interesting. Nevertheless, treatment for PTA differs even within these countries, as does the organization of public vs private health care between countries [7]. In the present study, we focused on PTA patients treated in public special health care
Correspondence: Johanna Wikstén MD, Department of Otorhinolaryngology – Head and Neck Surgery, Helsinki University Central Hospital, PO Box 220, FI-00290, Helsinki, Finland. Tel: +358 50 595 7227. Fax: +358 9 471 75010. E-mail: johanna.wiksten@hus.fi
(Received 31 October 2013; accepted 6 March 2014) ISSN 0001-6489 print/ISSN 1651-2251 online 2014 Informa Healthcare DOI: 10.3109/00016489.2014.905702
814
J. Wikstén et al.
with the aim of learning how PTA is treated in these Nordic countries. The emergence of major differences would warrant further study to discover the optimal means to standardize predominant intervention practices and possibly to propose guidelines. Material and methods A questionnaire translated into the four Nordic languages was e-mailed to all ORL department chief physicians in all 20 central hospitals (including university hospitals) in Finland, 27 in Sweden, 19 in Norway, and 15 in Denmark. If the chief physician did not treat PTA patients, he or she was asked to forward the questionnaire to a colleague who did. The 23 multiple-choice questions enquired about TE treatment in each ORL clinic, such as how the abscess was opened, and if so, whether the management of distinct age groups differed, and whether the patient eventually underwent TE. Additionally, we explored inpatient or outpatient status, and the choice of antibiotic. Most questions were multiple-choice with from 2 to 12 answer alternatives. For some questions, more than one answer was possible. The questionnaire, created and distributed by web-based Webropol survey and analysis software, arrived by e-mail and took approximately 5 min to answer. The responses were automatically transferred to MS Excel and Webropol. No ethical approval was required. Statistical analysis We performed the statistical analysis with NCSS (Kaysville, UT, USA) 2009 statistical analysis 0%
Yes No
10 % 20%
software using Fisher’s exact test. p values < 0.05 were considered significant. Results Of the 81 physicians who received questionnaires, 73 replied, yielding a response rate of 90%. The eight nonrespondents included one Norwegian, four Swedes, and three Danes. Most (88%) respondents considered the treatment policy in their hospital uniform, and 68% felt that the treatment policy had not changed in the past 3 years. All agreed that PTA patients received treatment in referral clinics with oncall personnel rather than in primary health care; 15% had participated in PTA-related training in the previous 3 years. Of the 73 respondents, 4 (5%) always performed TE on PTA patients, and 27 (37%) did so in cases with bilateral PTA (Figure 1); 80% reopened the abscess cavity daily or every other day. Clearly, in most hospitals, children under 7 years underwent TE. Four respondents used aspiration or incision if the child’s co-operation permitted, and two chose inpatient treatment with intravenous antibiotics. As many as five respondents (7%) treated their pediatric patients with PTA under general anesthesia without removing the tonsils. The choice of treatment among 8–15-year-old patients seemed to depend on their degree of co-operation. The treatment of patients over age 16 with intravenous versus per oral antibiotics showed the most variation between countries (Figure 2). Clear differences also emerged in the treatment of patients as inpatients versus outpatients, with 50 vs 50% in 30%
40%
50%
60%
70%
80%
90% 100%
1. Always 2. Patient < 7 years 3. Patient 8–15 years 4. In cases with a second abscess 5. In cases with bilateral abscess 6. With history of tonsil infections 7. If healing has slowed down
8. If abscess cannot be opened at a polyclinic 9. Cases with simultaneous mononucleosis Figure 1. Question 7. ‘When do you perform a tonsillectomy on a patient with peritonsillar abscess?’
Treatment variations for peritonsillar abscess
815
100% 80% 60%
Peroral Intravenous
40% 20% 0% Finland
Sweden
Norway
Denmark
Figure 2. Question 14. ‘Do you treat a patient with peritonsillar abscess primarily with oral or intravenous antibiotics?’
Finland, 9 vs 91% in Sweden, 19 vs 81% in Norway, and 33 vs 67% in Denmark, and in the administration of one versus multiple antibiotics, with 70 vs 30% in Finland, 96 vs 4% in Sweden, 82 vs 18% in Norway, and 42 vs 58% in Denmark. Penicillin, whether oral or intravenous, was the first choice for most (65%) respondents. Only one respondent identified an intramuscular dose as the first choice (Figure 3). Combining metronidazole with penicillin or cephalosporins was most common in Denmark, where 58% reported doing so, compared with 30% in Finland, 16% in Norway, and 4% in Sweden. In Denmark, nearly all (92%) TEs in this age group were performed immediately. In the three other countries, especially in Sweden, such operations were performed more often after a 1–6-month recovery period (Figure 4). Comparison of treatment protocols between large (over 10 ENT specialists, n = 22) and small (10 or fewer ENT specialists, n = 49) clinics showed no
3% 8%
significant differences. In both large and small clinics, 82% of the respondents reopened the abscess cavity. Patients were treated primarily as inpatients in 31% of the small clinics, but in only 18% (p = 0.386) of the large clinics. Immediate TE, carried out mostly in Denmark, was performed in 55% of the cases in large clinics, but in only 38% (p = 0.282) of cases in small clinics. Discussion Even in closely related Nordic countries, adult patients with PTA received markedly different treatment. Although some common trends in management emerged, treatment protocols varied widely even within countries, but especially between them. Respondent physicians followed guidelines when treating PTA in children, and the literature indeed describes such treatment well, taking into account
p.o. penicillin 40% 1% p.o. clindamycin 7%
1%
p.o. penicillin+metronidazole 13%
1%
40% i.v. penicillin 25% i.v. cephalosporins 1%
25%
i.v. clindamycin 1% i.v. penicillin+metronidazole 8% i.v. cephalosporins+metronidazole 3% 13%
7% i.m. penicillin 1% Figure 3. Question 16. ‘First-choice antibiotic (choose one).’
816
J. Wikstén et al. 100 %
80 % Depends on patient Within 6 months Within 3 months Within 1 month Within one to three days Within 24 h
60 % 40 %
20 %
0% Sweden
Finland
Norway
Denmark
Figure 4. Question 10. ‘If you decide on a tonsillectomy, how soon after diagnosing the peritonsillar abscess do you attempt to perform a tonsillectomy on a patient over 16?’
that the preferred protocol usually depends on patient co-operation [4,8,9]. The opposite was true among adult patients; outpatient vs inpatient differences were especially large. Long distances sometimes make it more convenient to follow up on a patient overnight in a ward instead of scheduling a separate follow-up visit. Most physicians (80%) reopened the abscess cavity within the next 1–2 days, although almost all patients (94%) actually heal well with a single opening [4]. The literature has thoroughly described the pathogens of PTA with only slight variations between studies; anaerobes and polymicrobial growth show a rising trend [10]. In the present study, penicillin was the antibiotic of choice (65%), which is in line with published treatment suggestions [4,5]. A recent Danish study reported that Fusobacterium necrophorum was the main pathogen [11]; it was thus surprising that Denmark had the highest percentage of metronidazole use, as well as a combination of antibiotics. Physicians in Denmark also perform immediate surgery more often and show a higher incidence of intravenous antibiotic use, which may indicate that less severe cases of PTA are treated by private ORL specialists and that only severe cases, which require more aggressive treatment, are referred to hospitals. The timing and indications for TE also varied greatly. A TE costs around e2500 in our clinic and results in 2 weeks of sick leave [12,13]. In particular, older patients with no previous tonsil infections could benefit from a wait-and-see-strategy, because only 13% of conservatively treated patients older than 30 eventually undergo a TE in the 5 years after PTA [9]. Whether TE should be immediate or carried out after a recovery period (i.e. interval TE) remains controversial. According to Page et al., performing abscess TE is beneficial [14]. Interval TE is recommended only for cases in which personnel and facilities are unavailable for abscess TE [15,16]. Local
tradition and the financial systems of each clinic likely play major roles in the choice of treatment protocol. Every patient is entitled to the best practice available; although universal treatment decisions are unlikely, some local changes to replace current practices with more effective ones could prove beneficial. Data were collected and pooled automatically via Webropol survey software, which proved suitable for this kind of research; the software was quick, and the error-prone tabulation procedure occurred digitally. One limitation of this study was that it was not blinded; also, the questionnaire was directed to only one physician per clinic even though the choice of treatment between physicians may vary. On the other hand, the coverage of the PTA treatment in these 4 countries across 73 hospitals was extensive.
Conclusion PTA, the most common ORL infection requiring special health care, is treated differently in Finland, Sweden, Norway, and Denmark, especially among adults requiring hospitalization and antibiotic treatments. Further studies could identify means to develop more uniform treatments and propose common guidelines for the most effective, cost-beneficial therapy, and best clinical practice for each patient. Declaration of interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.
References [1] Rusan M, Klug TE, Ovesen T. An overview of the microbiology of acute ear, nose and throat infections requiring
Treatment variations for peritonsillar abscess
[2]
[3]
[4]
[5]
[6]
[7]
[8]
hospitalisation. Eur J Clin Microbiol Infect Dis 2009;28: 243–51. Risberg S, Engfeldt P, Hugosson S. Incidence of peritonsillar abscess and relationship to age and gender: retrospective study. Scand J Infect Dis 2008;40:792–6. Mehanna HM, Al-Bahnasawi L, White A. National audit of the management of peritonsillar abscess. Postgrad Med J 2002;78:545–8. Herzon FS. Harris P. Mosher Award thesis. Peritonsillar abscess: incidence, current management practices, and a proposal for treatment guidelines. Laryngoscope 1995;105: 1–17. Kieff DA, Bhattacharyya N, Siegel NS, Salman SD. Selection of antibiotics after incision and drainage of peritonsillar abscesses. Otolaryngol Head Neck Surg 1999;120:57–61. Hanna BC, McMullan R, Gallagher G, Hedderwick S. The epidemiology of peritonsillar abscess disease in Northern Ireland. J Infect 2006;52:247–53. European Observatory on Health Systems and Policies. Health Care in Transition; Finland, 2008; Norway 2006. Available at www.euro.who.int/observatory. Schraff S, McGinn JD, Derkay CS. Peritonsillar abscess in children: a 10-year review of diagnosis and management. Int J Pediatr Otorhinolaryngol 2001;57:213–18.
817
[9] Wiksten J, Hytönen M, Pitkäranta A, Blomgren K. Who ends up having tonsillectomy after peritonsillar infection? Eur Arch Otorhinolaryngol 2012;269:1281–4. [10] Gavriel H, Lazarovitch T, Pomortsev A, Eviatar E. Variations in the microbiology of peritonsillar abscess. Scand J Infect Dis 2009;28:27–31. [11] Ehlers Klug T, Rusan M, Fuursted K, Ovesen T. Fusobacterium necrophorum: most prevalent pathogen in peritonsillar abscess in Denmark. Clin Infect Dis 2009;49:1467–72. [12] Hoddeson EK, Gourin CG. Adult tonsillectomy: current indications and outcomes. Otolaryngol Head Neck Surg 2009;140:19–22. [13] Wikstén J, Blomgren K, Roine RP, Sintonen H, Pitkäranta A. Effect of tonsillectomy on health-related quality of life and costs. Acta Otolaryngol 2013;133:499–503. [14] Page C, Chassery G, Boute P, Obongo R, Strunski V. Immediate tonsillectomy: indications for use as first-line surgical management of peritonsillar abscess (quinsy) and parapharyngeal abscess. J Laryngol Otol 2010;124:1085–90. [15] Albertz N, Nazar G. Peritonsillar abscess: treatment with immediate tonsillectomy – 10 years of experience. Acta Otolaryngol 2012;132:1102–7. [16] Berry S, Pascal I, Whittet HB. Tonsillectomy a chaud for quinsy: revisited. Eur Arch Otorhinolaryngol 2008;265:31–3.
Copyright of Acta Oto-Laryngologica is the property of Taylor & Francis Ltd and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
ORIGINAL ARTICLE
Variations in treatment of peritonsillar abscess in four Nordic countries JOHANNA WIKSTÉN1, KARIN BLOMGREN1, THOMAS ERIKSSON2, LIVIU GULDFRED3, METTE BRATT4 & ANNE PITKÄRANTA1 Department of Otorhinolaryngology – Head and Neck Surgery, Helsinki University Central Hospital, Helsinki University, Faculty of Medicine, Helsinki, Finland, 2Department of Otorhinolaryngology – Head and Neck Surgery, Sundsvall Hospital, Sundsvall, Sweden, 3Department of Otorhinolaryngology – Head and Neck Surgery, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark and 4Department of Otorhinolaryngology – Head and Neck Surgery, St Olav’s University Hospital, Trondheim, Norway
1
Abstract Conclusion: In four Nordic countries, peritonsillar abscess (PTA) patients are treated rather differently. Objectives: To study how such patients are treated in those countries. Methods: The 81 chief physicians of otorhinolaryngology departments of all central hospitals in Denmark (n = 15), Norway (n = 19), Sweden (n = 27), and Finland (n = 20) received a multiple-choice questionnaire. Results: A total of 73 physicians (90%) replied. The largest differences arose in treating patients with intravenous versus per oral antibiotics, and treating as inpatients versus outpatients. In Finland, 50% of PTA patients aged >16 years were treated as inpatients and 50% as outpatients, whereas the respective quotas in Sweden were 9 and 91%, Norway 19 and 81%, and Denmark 33 and 67%. Of Finnish physicians, 30% treated their patients primarily with oral antibiotics, 70% with intravenous antibiotics; in Sweden 91 vs 9%, Norway 53 vs 47%, and Denmark 18 vs 82%. In Denmark, almost all patients were operated on immediately, whereas in the other three countries, especially Sweden, operations more often were performed after a recovery period. Combining metronidazole with penicillin or cephalosporins was most common in Denmark: 58% reported usage, compared with 30% in Finland, 16% in Norway, and 4% in Sweden.
Keywords: Questionnaire, quinsy, practice guideline
Introduction Peritonsillar abscess (PTA), the most common complication of acute tonsillitis, is the most frequent otorhinolaryngological (ORL) infection requiring hospitalization [1]. One well-performed study shows an incidence of 37 per 100 000 [2]. No common clinical practice guidelines are available for the treatment of PTA. Various options for invasive management include incision and drainage, aspiration with a needle, and tonsillectomy (TE) au chaud. In the UK, most patients are inpatients, but in the USA, most physicians treat them as outpatients [3,4]. Antibiotic administration can be oral, intramuscular, or intravenous. In most cases, the antibiotic of choice is
oral procaine penicillin potentially combined with metronidazole or oral amoxicillin with clavulanic acid; inpatients usually receive intravenous benzylpenicillin, cefuroxime, or metronidazole [2,5,6]. Finland, Sweden, Norway, and Denmark are Nordic countries that closely resemble each other and are thus logical choices for comparison. Their similarities in health care, population, and relatively high levels of education, in addition to their similarly high standards of medicine make comparison both reasonable and interesting. Nevertheless, treatment for PTA differs even within these countries, as does the organization of public vs private health care between countries [7]. In the present study, we focused on PTA patients treated in public special health care
Correspondence: Johanna Wikstén MD, Department of Otorhinolaryngology – Head and Neck Surgery, Helsinki University Central Hospital, PO Box 220, FI-00290, Helsinki, Finland. Tel: +358 50 595 7227. Fax: +358 9 471 75010. E-mail: johanna.wiksten@hus.fi
(Received 31 October 2013; accepted 6 March 2014) ISSN 0001-6489 print/ISSN 1651-2251 online 2014 Informa Healthcare DOI: 10.3109/00016489.2014.905702
814
J. Wikstén et al.
with the aim of learning how PTA is treated in these Nordic countries. The emergence of major differences would warrant further study to discover the optimal means to standardize predominant intervention practices and possibly to propose guidelines. Material and methods A questionnaire translated into the four Nordic languages was e-mailed to all ORL department chief physicians in all 20 central hospitals (including university hospitals) in Finland, 27 in Sweden, 19 in Norway, and 15 in Denmark. If the chief physician did not treat PTA patients, he or she was asked to forward the questionnaire to a colleague who did. The 23 multiple-choice questions enquired about TE treatment in each ORL clinic, such as how the abscess was opened, and if so, whether the management of distinct age groups differed, and whether the patient eventually underwent TE. Additionally, we explored inpatient or outpatient status, and the choice of antibiotic. Most questions were multiple-choice with from 2 to 12 answer alternatives. For some questions, more than one answer was possible. The questionnaire, created and distributed by web-based Webropol survey and analysis software, arrived by e-mail and took approximately 5 min to answer. The responses were automatically transferred to MS Excel and Webropol. No ethical approval was required. Statistical analysis We performed the statistical analysis with NCSS (Kaysville, UT, USA) 2009 statistical analysis 0%
Yes No
10 % 20%
software using Fisher’s exact test. p values < 0.05 were considered significant. Results Of the 81 physicians who received questionnaires, 73 replied, yielding a response rate of 90%. The eight nonrespondents included one Norwegian, four Swedes, and three Danes. Most (88%) respondents considered the treatment policy in their hospital uniform, and 68% felt that the treatment policy had not changed in the past 3 years. All agreed that PTA patients received treatment in referral clinics with oncall personnel rather than in primary health care; 15% had participated in PTA-related training in the previous 3 years. Of the 73 respondents, 4 (5%) always performed TE on PTA patients, and 27 (37%) did so in cases with bilateral PTA (Figure 1); 80% reopened the abscess cavity daily or every other day. Clearly, in most hospitals, children under 7 years underwent TE. Four respondents used aspiration or incision if the child’s co-operation permitted, and two chose inpatient treatment with intravenous antibiotics. As many as five respondents (7%) treated their pediatric patients with PTA under general anesthesia without removing the tonsils. The choice of treatment among 8–15-year-old patients seemed to depend on their degree of co-operation. The treatment of patients over age 16 with intravenous versus per oral antibiotics showed the most variation between countries (Figure 2). Clear differences also emerged in the treatment of patients as inpatients versus outpatients, with 50 vs 50% in 30%
40%
50%
60%
70%
80%
90% 100%
1. Always 2. Patient < 7 years 3. Patient 8–15 years 4. In cases with a second abscess 5. In cases with bilateral abscess 6. With history of tonsil infections 7. If healing has slowed down
8. If abscess cannot be opened at a polyclinic 9. Cases with simultaneous mononucleosis Figure 1. Question 7. ‘When do you perform a tonsillectomy on a patient with peritonsillar abscess?’
Treatment variations for peritonsillar abscess
815
100% 80% 60%
Peroral Intravenous
40% 20% 0% Finland
Sweden
Norway
Denmark
Figure 2. Question 14. ‘Do you treat a patient with peritonsillar abscess primarily with oral or intravenous antibiotics?’
Finland, 9 vs 91% in Sweden, 19 vs 81% in Norway, and 33 vs 67% in Denmark, and in the administration of one versus multiple antibiotics, with 70 vs 30% in Finland, 96 vs 4% in Sweden, 82 vs 18% in Norway, and 42 vs 58% in Denmark. Penicillin, whether oral or intravenous, was the first choice for most (65%) respondents. Only one respondent identified an intramuscular dose as the first choice (Figure 3). Combining metronidazole with penicillin or cephalosporins was most common in Denmark, where 58% reported doing so, compared with 30% in Finland, 16% in Norway, and 4% in Sweden. In Denmark, nearly all (92%) TEs in this age group were performed immediately. In the three other countries, especially in Sweden, such operations were performed more often after a 1–6-month recovery period (Figure 4). Comparison of treatment protocols between large (over 10 ENT specialists, n = 22) and small (10 or fewer ENT specialists, n = 49) clinics showed no
3% 8%
significant differences. In both large and small clinics, 82% of the respondents reopened the abscess cavity. Patients were treated primarily as inpatients in 31% of the small clinics, but in only 18% (p = 0.386) of the large clinics. Immediate TE, carried out mostly in Denmark, was performed in 55% of the cases in large clinics, but in only 38% (p = 0.282) of cases in small clinics. Discussion Even in closely related Nordic countries, adult patients with PTA received markedly different treatment. Although some common trends in management emerged, treatment protocols varied widely even within countries, but especially between them. Respondent physicians followed guidelines when treating PTA in children, and the literature indeed describes such treatment well, taking into account
p.o. penicillin 40% 1% p.o. clindamycin 7%
1%
p.o. penicillin+metronidazole 13%
1%
40% i.v. penicillin 25% i.v. cephalosporins 1%
25%
i.v. clindamycin 1% i.v. penicillin+metronidazole 8% i.v. cephalosporins+metronidazole 3% 13%
7% i.m. penicillin 1% Figure 3. Question 16. ‘First-choice antibiotic (choose one).’
816
J. Wikstén et al. 100 %
80 % Depends on patient Within 6 months Within 3 months Within 1 month Within one to three days Within 24 h
60 % 40 %
20 %
0% Sweden
Finland
Norway
Denmark
Figure 4. Question 10. ‘If you decide on a tonsillectomy, how soon after diagnosing the peritonsillar abscess do you attempt to perform a tonsillectomy on a patient over 16?’
that the preferred protocol usually depends on patient co-operation [4,8,9]. The opposite was true among adult patients; outpatient vs inpatient differences were especially large. Long distances sometimes make it more convenient to follow up on a patient overnight in a ward instead of scheduling a separate follow-up visit. Most physicians (80%) reopened the abscess cavity within the next 1–2 days, although almost all patients (94%) actually heal well with a single opening [4]. The literature has thoroughly described the pathogens of PTA with only slight variations between studies; anaerobes and polymicrobial growth show a rising trend [10]. In the present study, penicillin was the antibiotic of choice (65%), which is in line with published treatment suggestions [4,5]. A recent Danish study reported that Fusobacterium necrophorum was the main pathogen [11]; it was thus surprising that Denmark had the highest percentage of metronidazole use, as well as a combination of antibiotics. Physicians in Denmark also perform immediate surgery more often and show a higher incidence of intravenous antibiotic use, which may indicate that less severe cases of PTA are treated by private ORL specialists and that only severe cases, which require more aggressive treatment, are referred to hospitals. The timing and indications for TE also varied greatly. A TE costs around e2500 in our clinic and results in 2 weeks of sick leave [12,13]. In particular, older patients with no previous tonsil infections could benefit from a wait-and-see-strategy, because only 13% of conservatively treated patients older than 30 eventually undergo a TE in the 5 years after PTA [9]. Whether TE should be immediate or carried out after a recovery period (i.e. interval TE) remains controversial. According to Page et al., performing abscess TE is beneficial [14]. Interval TE is recommended only for cases in which personnel and facilities are unavailable for abscess TE [15,16]. Local
tradition and the financial systems of each clinic likely play major roles in the choice of treatment protocol. Every patient is entitled to the best practice available; although universal treatment decisions are unlikely, some local changes to replace current practices with more effective ones could prove beneficial. Data were collected and pooled automatically via Webropol survey software, which proved suitable for this kind of research; the software was quick, and the error-prone tabulation procedure occurred digitally. One limitation of this study was that it was not blinded; also, the questionnaire was directed to only one physician per clinic even though the choice of treatment between physicians may vary. On the other hand, the coverage of the PTA treatment in these 4 countries across 73 hospitals was extensive.
Conclusion PTA, the most common ORL infection requiring special health care, is treated differently in Finland, Sweden, Norway, and Denmark, especially among adults requiring hospitalization and antibiotic treatments. Further studies could identify means to develop more uniform treatments and propose common guidelines for the most effective, cost-beneficial therapy, and best clinical practice for each patient. Declaration of interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.
References [1] Rusan M, Klug TE, Ovesen T. An overview of the microbiology of acute ear, nose and throat infections requiring
Treatment variations for peritonsillar abscess
[2]
[3]
[4]
[5]
[6]
[7]
[8]
hospitalisation. Eur J Clin Microbiol Infect Dis 2009;28: 243–51. Risberg S, Engfeldt P, Hugosson S. Incidence of peritonsillar abscess and relationship to age and gender: retrospective study. Scand J Infect Dis 2008;40:792–6. Mehanna HM, Al-Bahnasawi L, White A. National audit of the management of peritonsillar abscess. Postgrad Med J 2002;78:545–8. Herzon FS. Harris P. Mosher Award thesis. Peritonsillar abscess: incidence, current management practices, and a proposal for treatment guidelines. Laryngoscope 1995;105: 1–17. Kieff DA, Bhattacharyya N, Siegel NS, Salman SD. Selection of antibiotics after incision and drainage of peritonsillar abscesses. Otolaryngol Head Neck Surg 1999;120:57–61. Hanna BC, McMullan R, Gallagher G, Hedderwick S. The epidemiology of peritonsillar abscess disease in Northern Ireland. J Infect 2006;52:247–53. European Observatory on Health Systems and Policies. Health Care in Transition; Finland, 2008; Norway 2006. Available at www.euro.who.int/observatory. Schraff S, McGinn JD, Derkay CS. Peritonsillar abscess in children: a 10-year review of diagnosis and management. Int J Pediatr Otorhinolaryngol 2001;57:213–18.
817
[9] Wiksten J, Hytönen M, Pitkäranta A, Blomgren K. Who ends up having tonsillectomy after peritonsillar infection? Eur Arch Otorhinolaryngol 2012;269:1281–4. [10] Gavriel H, Lazarovitch T, Pomortsev A, Eviatar E. Variations in the microbiology of peritonsillar abscess. Scand J Infect Dis 2009;28:27–31. [11] Ehlers Klug T, Rusan M, Fuursted K, Ovesen T. Fusobacterium necrophorum: most prevalent pathogen in peritonsillar abscess in Denmark. Clin Infect Dis 2009;49:1467–72. [12] Hoddeson EK, Gourin CG. Adult tonsillectomy: current indications and outcomes. Otolaryngol Head Neck Surg 2009;140:19–22. [13] Wikstén J, Blomgren K, Roine RP, Sintonen H, Pitkäranta A. Effect of tonsillectomy on health-related quality of life and costs. Acta Otolaryngol 2013;133:499–503. [14] Page C, Chassery G, Boute P, Obongo R, Strunski V. Immediate tonsillectomy: indications for use as first-line surgical management of peritonsillar abscess (quinsy) and parapharyngeal abscess. J Laryngol Otol 2010;124:1085–90. [15] Albertz N, Nazar G. Peritonsillar abscess: treatment with immediate tonsillectomy – 10 years of experience. Acta Otolaryngol 2012;132:1102–7. [16] Berry S, Pascal I, Whittet HB. Tonsillectomy a chaud for quinsy: revisited. Eur Arch Otorhinolaryngol 2008;265:31–3.
Copyright of Acta Oto-Laryngologica is the property of Taylor & Francis Ltd and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
