OBJECTIVE: Peritonsillar abscess (PTA) is a common pediatric infection requiring drainage. Conscious Sedation (CS) can facilitate drainage in uncooperative children. However, it carries risks, especially if the airway is compromised. Moreover, evidence on its safety and efficacy is limited. This study examined the safety, pain reduction, and anxiety management of hospitalized pediatric patients treated for PTA under CS.
METHODS: We performed a prospective observational case series of 118 children aged 2-15 years with 155 PTA episodes, managed from 2016 to 2023. Conscious sedation was used in 42 episodes. Outcomes were compared among CS and non-CS (local anesthesia only). Complications assessed safety. Efficacy was evaluated by the amount of pus, hospitalization parameters, pain scores, and recurrence.
RESULTS: No significant differences were found regarding the demographic and presentation parameters except for younger age among the CS group (9 vs 11 years p = 0.001). One minor oxygen desaturation (2 %) event occurred with CS. Abscess drainage amount was greater with CS than non-CS, 4.9±4 mL vs. 3.2±2 mL, respectively (p = 0.03). Hospitalization stays were similar among groups. Maximum pain scores were lower with CS than non-CS, 1.4 ± 2 vs 4.2 ± 3 (p < 0.001); similarly, IV pain medication was used less frequently, 0.9 ± 1 vs. 1.6 ± 3 (p = 0.045), and the need for re-aspiration was less common 14 % vs. 28 % (p = 0.04), with CS than non-CS, respectively. The three-month recurrence rate was numerically lower with CS (5 % vs. 14 % non-CS).
CONCLUSIONS: Conscious sedation facilitates PTA drainage with excellent safety and improved efficacy compared to local anesthesia in children. Pain scores are reduced both during drainage and hospitalization. Our prospective data add to the limited evidence supporting CS as a viable option for abscess drainage in uncooperative pediatric patients. Further study is warranted to confirm potential long-term reductions in recurrence.

UNASSIGNED: This article describes a case of polymicrobial Arcanobacterium haemolyticum pharyngitis and sinusitis complicated by intracranial complications and reviews similar cases in the literature.
UNASSIGNED: A 21-year-old immunocompetent male presented with symptoms of sore throat, rhinorrhoea, lethargy, headache, and rash. Imaging demonstrated sinusitis, pre-septal sinusitis, peritonsillar abscess formation, subdural empyema and cerebritis. He was managed with endoscopic sinus surgery, craniotomy for evacuation of subdural empyema and antibiotics. Microbiological samples demonstrated growth of A. haemolyticum, strep. anginosus, and fusobacterium necrophorum. He subsequently developed a cerebral abscess requiring stereotactic needle drainage. After a prolonged course of antibiotics, the patient was discharge and made a good recovery.
UNASSIGNED: A. haemolyticum is an uncommon cause of non-streptococcal pharyngitis that may occur alongside other microorganisms and is rarely associated with severe intracranial complications. This organism and its antibiotic susceptibility patterns should be considered in complicated upper respiratory tract infections in immunocompetent hosts. Penicillins and macrolide antibiotics form the mainstay of therapy for A. haemolyticum.

Intratonsillar abscess (ITA) is rarely reported. Here, we present an uncommon case of acute ITA in an adult, discuss the evaluation and treatment plan, and review the ITA literature.  The abscess reported in the present study was diagnosed through a combination of clinical findings and computed tomography imaging, and treatment included drainage, intravenous (IV) clindamycin, and IV dexamethasone. The literature reports 72 ITA cases with specified treatments: 21 (29.2%) in adults, 19 (26.4%) in children, and 32 (44.4%) in patients of unspecified ages. Among them, 25 (34.7%) responded to antibiotics alone, 11 (15.3%) to needle aspiration and antibiotics, and 36 (50.0%) needed further intervention. Based on the presented case and literature review, we suggest the use of IV antibiotics with needle aspiration as the primary treatment for acute ITA. Incision and drainage (I&D) with antibiotics should be reserved for cases unresponsive to initial measures, and tonsillectomy is recommended for recurrent post-I&D cases.

OBJECTIVE: To systematically review the literature regarding previously described peritonsillar abscess (PTA) drainage simulation.
METHODS: PubMed, Scopus, Web of Science, Ovid, and Cochrane.
METHODS: A search of the abovementioned databases was performed in August 2022 using the terms \"peritonsillar abscess/quinsy,\" \"incision/drainage/aspiration,\" and \"simulation.\" No time restrictions were applied. We included studies that clearly described how their PTA models were built and underwent validation from experts and/or evaluation from trainees. Articles describing a model only without any evaluation and reports in languages other than English were excluded.
RESULTS: Our search initially yielded 80 articles after duplicate removal, 10 of which met our criteria and were included. Two studies trained participants on both needle aspiration and incision and drainage (I&D), four studies on I&D only, and four on needle aspiration only. 87.5% to 100% of junior residents reported minimal exposure to PTA prior to simulation. Five studies provided some form of validation to their models. The value of the simulators to train participants on skills received better appreciation than their anatomical fidelity. The perceived confidence level of trainees in managing PTA, which was assessed in 7 studies, substantially improved after training.
CONCLUSIONS: PTA simulation improves the confidence of trainees to perform PTA drainage. There is, however, a lack of standardization and evidence regarding transfer validity among PTA simulators. The development of a standardized PTA simulator could allow for more widespread use and increase resident comfort with this procedure in a pre-clinical setting.
METHODS: NA Laryngoscope, 134:2495-2501, 2024.

The bilateral presentation of peritonsillar abscess is uncommon. Its management is controversial and it has been argued whether a quinsy tonsillectomy or an interval tonsillectomy should be performed. Here we describe the case of a 14-year-old boy with sore throat, trismus, and fever. He had bilateral tonsillar hypertrophy, convex arches, and soft palate edema. Computed tomography: bilateral tonsillar hypertrophy, with post-contrast enhancement, both with collection, edema with moderate pharyngeal stenosis. The patient was hospitalized for intravenous therapy and tonsillectomy with bilateral drainage resulting in a complete resolution of his condition and discharge at 48 hours. In the presence of a peritonsillar abscess, an unsuspected contralateral abscess should be considered. It should be diagnosed and managed adequately to prevent complications. Quinsy tonsillectomy could be safe and should be considered in patients who will undergo anesthesia for abscess drainage. The final decision should be made for each patient on an individual basis.
La presentación bilateral del absceso periamigdalino es poco frecuente. Su abordaje es controversial y se discute si realizar amigdalectomía en caliente versus diferida. Se presenta el caso de un paciente de sexo masculino, de 14 años, con odinofagia, trismo y fiebre. Presentaba hipertrofia amigdalina bilateral, pilares abombados y edema de paladar blando. Tomografía computada: hipertrofia amigdalina bilateral, con realce poscontraste, ambas con colección, edema con moderada estenosis faríngea. Se decidió internación para tratamiento endovenoso y amigdalectomía con drenaje bilateral. Resolución completa del cuadro con alta a las 48 horas. Ante la presencia de un absceso periamigdalino, debe considerarse la posibilidad de un absceso contralateral oculto. Debe ser diagnosticado y tratado adecuadamente para prevenir complicaciones. La amigdalectomía en caliente podría ser un tratamiento seguro y debería ser considerado en pacientes que serán sometidos a anestesia para drenaje. La decisión final debe ser determinada para cada caso en particular.

BACKGROUND: Peritonsillar abscess is a localised infection in the peritonsillar space. Pus from the abscess can contain anaerobes. Many clinicians prescribe metronidazole in addition to penicillin, but evidence to support this is limited. This review assessed the evidence of benefit of metronidazole for the treatment of peritonsillar abscess.
METHODS: A systematic review was conducted of the literature and databases including Ovid Medline, Ovid Embase, PubMed and Cochrane library. Search terms included all variations of peritonsillar abscess, penicillin and metronidazole.
RESULTS: Three randomised, control trials were included. All studies assessed the clinical outcomes after treatment for peritonsillar abscess, including recurrence rate, length of hospital stay and symptom improvement. There was no evidence to suggest additional benefit with metronidazole, with studies suggesting increased side effects.
CONCLUSIONS: Evidence does not support the addition of metronidazole in first-line management of peritonsillar abscess. Further trials to establish optimum dose and duration schedules of oral phenoxymethylpenicillin would benefit clinical practice.

Distinguishing peritonsillar abscess (PTA) from peritonsillar cellulitis using clinical assessment is challenging as many features overlap for both conditions, and physical examination is only about 75% sensitive and 50% specific for diagnosing PTA. The primary objective of this systematic review was to determine the test characteristics of ultrasound for diagnosing PTA when compared to a reference standard of computed tomography or acquisition of pus via needle aspiration or incision and drainage.
This systematic review was performed in accordance with the Preferred Reporting Items for a Systematic Review and Meta-analysis of Diagnostic Test Accuracy (PRISMA-DTA) guidelines. We searched seven databases from 1960 to November 2022. Two independent reviewers completed study selection, data extraction, and QUADAS-2 risk-of-bias assessment. We used a bivariate random-effects model to calculate pooled sensitivity, specificity, positive likelihood ratio (LR+), and negative likelihood ratio (LR-). We also conducted subgroup analyses on radiology ultrasound compared to point-of-care ultrasound (POCUS) and intraoral compared to transcervical scanning techniques.
From 339 citations, we identified 18 studies for inclusion. Because one study only reported positive cases of PTA (thereby preventing the calculation of specificity), it was excluded from the analysis, so the analysis included a total of 17 studies with 812 patients, of whom 541 had PTA. Pooled bivariate sensitivity was 86% (95% confidence interval [CI] 78%-91%), specificity 76% (95% CI 67%-82%), LR+ 3.51 (95% CI 2.59-4.89), and LR- 0.19 (95% CI 0.12-0.30). On subgroup analysis, radiology-performed ultrasound had a sensitivity and specificity of 89% and 71%, compared to POCUS, which had a sensitivity and specificity of 74% and 79%. Comparing the two different techniques, intraoral had a sensitivity and specificity of 91% and 75% while transcervical had a sensitivity and specificity of 80% and 81%.
Ultrasound demonstrates high sensitivity for ruling out PTA, but it only has moderate specificity for ruling in the diagnosis.

UNASSIGNED: to describe a case of severe sepsis and complicated bacteremia caused by Arcanobacterium haemolyticum and review similar cases in the literature.
UNASSIGNED: A 26-year-old gentleman with a history of epilepsy presented with symptoms of sore throat, productive cough, periumbilical abdominal pain, watery diarrhea, nausea and vomiting, subjective fevers along with progressive jaundice for seven days. The patient had acute fulminant liver failure, septic shock, and Multi-organ failure. He required vasopressors, underwent intubation, and had grown Arcanobacterium haemolyticum in the blood and Bronchoalveolar lavage samples. He developed a peritonsillar abscess and cavitary pneumonia and required chest tube drainage followed by thoracotomy for hemothorax. The patient improved on Ampicillin-Sulbactam treatment and was treated with a total antibiotic duration of 6 weeks. He fully improved on post-discharge follow-up.
UNASSIGNED: Arcanobacterium haemolyticum is a Gram-positive (sometimes Gram variable), catalase-negative facultatively anaerobic, non-motile, non-spore-forming, and variably β-hemolytic and is known to be a cause of pharyngitis and skin and soft tissue infections. Rarely A. Haemolyticum can be associated with severe systemic infections such as infective endocarditis, systemic abscesses, osteomyelitis, and septicemia. In previous literature reviews, the source of A. haemolyticum depended on the host, and pharyngeal and upper respiratory sources were likely to be associated with immunocompetent hosts.
UNASSIGNED: A. haemolyticum should be included in the differential diagnosis of bacterial pharyngitis complicated by severe systemic illness. Penicillins are the most commonly used antibiotics for treating A. haemolyticum bacteremia, and macrolides can be used for Penicillin\'s treatment failure.

OBJECTIVE: Post-tonsillectomy haemorrhage is an increasingly common cause of morbidity following tonsillectomy. Secondary post-tonsillectomy haemorrhage occurring more than 24 hours after an operation has long been attributed to post-operative infection; however, there is little evidence to support this hypothesis and the associated use of antibiotics in the current literature.
METHODS: This study looked at the aetiology and evidence-based management of post-tonsillectomy haemorrhage, and investigated the impact of bacterial infection and antimicrobials on the pathogenesis and clinical course of this complication.
RESULTS: A number of peri-operative risk factors for post-tonsillectomy haemorrhage exist, and infective pathologies, including recurrent or chronic tonsillitis and group A streptococcus on blood cultures, may predispose to bleeding. Very few studies have shown a link between post-tonsillectomy haemorrhage and objective markers of infection such as pyrexia, raised inflammatory markers or positive microbiology cultures. The role of antibiotics in secondary post-tonsillectomy haemorrhage remains controversial, and numerous randomised, controlled trials of peri-operative antibiotics have shown no significant difference in bleeding rates between antibiotics and controls.
CONCLUSIONS: Further trials investigating the role of antibiotics and more robust studies investigating the presence of bacterial infection at the time of bleeding may be required to determine the true role of infection in post-tonsillectomy haemorrhage.

UNASSIGNED: Patients with a peritonsillar abscess (PTA) often present to emergency departments as the first point of medical contact. Upper respiratory tract infections (URTIs) are more frequent in the winter. Therefore, we hypothesize that the incidence of PTAs will be more frequent in colder winter months as well. This is the first study assessing the seasonal variation and epidemiology of PTA presentations to an emergency department in Atlantic Canada, home to a unique maritime climate.
UNASSIGNED: A retrospective cohort study was conducted through a chart review of all patients who presented to the Saint John Regional Hospital Emergency Department from January 1, 2015, to December 31, 2020. Patient characteristics, treatment, and microbiology were reported. A chi-square goodness-of-fit test assessed the seasonal variation of PTA. Pearson correlations assessed PTA incidence per mean monthly temperature and humidity.
UNASSIGNED: A total of 75 patients were included. 57.3% were male and 42.7% were female, with a mean age (±SD) of 35.9 ± 14.0. Most patients presented afebrile (82.7%, cutoff ≥ 38.0°C). Approximately half of all patients had an elevated WBC count (49.3%, cutoff ≥ 10.9 × 109). The most common bacteria isolated were Streptococcus species followed by anaerobic bacteria (17.9%). No significant variation was found with respect to season (X2(3) = 1.0, P = .801), temperature (r(70) = 0.198, P = .096), or humidity, (r(70) = 0.063, P = .599).
UNASSIGNED: This study did not find a seasonal variation of PTA in a maritime climate. These findings question the anecdotal hypothesis that PTA is associated with progression from acute URTIs and therefore would be more common in the winter months.