Ultrasound in Emergency Medicine| Volume 59, ISSUE 5, P693-698, November 2020

Evidence-Based Medicine Improves the Emergent Management of Peritonsillar Abscesses Using Point-of-Care Ultrasound

  • Ryan C. Gibbons
    Reprint Address: Ryan C. Gibbons, md, Department of Emergency Medicine, Lewis Katz School of Medicine at Temple University, 1017 Jones Hall, 1316 West Ontario Street, Philadelphia, PA 19140
    Department of Emergency Medicine, Lewis Katz School of Medicine at Temple University, Philadelphia, Pennsylvania
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  • Thomas G. Costantino
    Department of Emergency Medicine, Lewis Katz School of Medicine at Temple University, Philadelphia, Pennsylvania
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      Physical examination for peritonsillar abscess (PTA) has limited sensitivity. Traditional management involves blind needle aspiration, which has a false negative rate of 10–24%. A randomized controlled trial by Costantino et al. demonstrated that point-of-care ultrasound (POCUS) improves PTA management.


      Compare the use and impact of POCUS between patient cohorts prior to and after the trial by Costantino et al.


      Retrospective cohort study of adult patients diagnosed with PTA. Cohort 1 presented to the emergency department (ED) January 2007–December 2008. Cohort 2 presented between January 2013 and December 2014. Data were separated into those with POCUS vs. without ultrasound (NUS). Primary endpoint was POCUS utilization. Secondary endpoints were successful aspiration, otolaryngology (ear, nose, and throat [ENT]) consultation, computed tomography (CT) imaging, unscheduled return visits, and length of stay (LOS). The Fisher's exact and t-tests analyzed data.


      Cohort 1 enrolled 48 patients, vs. 114 patients for cohort 2. Twelve patients in cohort 1 had a POCUS (25%) vs 89 in cohort 2 (78%) (p < 0.0001; odds ratio [OR] 0.09 (95% confidence interval [CI] 0.04–0.20). Emergency physician (EP) successful aspiration: 89.1% POCUS vs. 24.5% NUS (p < 0.0001; OR 25 [95% CI 10–59]). Combined EP/ENT successful aspiration: 99.0% POCUS vs. 80.3% NUS (p < 0.0001; OR 24 [95% CI 3–193]). ENT consultation:12.9% POCUS vs. 65.6% NUS (p < 0.0001; OR 0.07 [95% CI 0.03–0.17]). CT usage: 23.8% POCUS vs. 37.7% NUS (p = 0.07; OR 0.51 [95% CI 0.25–1.02]). Return visits: 3.96% POCUS vs. 18.0% NUS (p = 0.004; OR 0.18 [95% CI 0.05–0.61]).


      POCUS use has increased for PTA treatment, improves aspiration, and decreases consultations, CTs, return visits, and LOS.


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        • Herzon F.S.
        • Harris P.
        Mosher Award Thesis. Peritonsillar abscess: incidence, current management practices, and a proposal for treatment guidelines.
        Laryngoscope. 1995; 105: 1-17
        • Blair A.B.
        • Booth R.
        • Baugh R.
        A unifying theory of tonsillitis, intratonsillar abscess and peritonsillar abscess.
        Am J Otolarygol. 2015; 36: 517-520
        • Klug T.E.
        • Rusan M.
        • Fuursted K.
        • et al.
        Peritonsillar abscess: complication of acute tonsillitis or Weber’s glands infection?.
        J Otolaryngol Head Neck Surg. 2016; 155: 199-207
        • Farmer S.J.
        • Khatwa M.A.
        • Zeitoun H.M.
        Peritonsillar abscess after tonsillectomy: a review of the literature.
        Ann R Coll Surg Engl. 2011; 93: 353-357
        • Johnson R.F.
        • Stewart M.G.
        • Wright C.C.
        An evidence-based review of the treatment of peritonsillar abscess.
        J Otolarygol Head Neck Surg. 2003; 128: 332-343
        • Mazur E.
        • Czerwińska E.
        • Korona-Głowniak I.
        • Grocholwalska A.
        • Kozioł-Montewka M.
        Epidemiology, clinical history and microbiology of peritonsillar abscess.
        Eur J Clin Microbiol Infect Dis. 2015; 34: 549-554
        • Klug T.E.
        Peritonsillar abscess: clinical aspects of microbiology, risk factors, and the association with parapharyngeal abscess.
        Dan Med J. 2017; 64: B5333
        • Powell E.L.
        • Powell J.
        • Samuel J.R.
        • et al.
        A review of the pathogenesis of adult peritonsillar abscess: time for a re-evaluation.
        J Antimicrob Chemother. 2013; 68: 1941-1950
        • Georgalas C.
        • Kanagalingam J.
        • Zainal A.
        • et al.
        The association between periodontal disease and peritonsillar infection: a prospective study.
        J Otolaryngol Head Neck Surg. 2002; 126: 91-94
        • Lehnerdt G.
        • Senska K.
        • Fischer M.
        • Jahnke K.
        Smoking promotes the formation of peritonsillar abscesses.
        Laryngorhinootologie. 2005; 84 ([in German]): 676-679
        • Powell J.
        • Wilson J.A.
        An evidence-based review of peritonsillar abscess.
        Clin Otolaryngol. 2012; 37: 136-145
        • Scott P.M.
        • Loftus W.K.
        • Kew J.
        • Ahuja A.
        • Yue V.
        • van Hasselt C.A.
        Diagnosis of peritonsillar infections: a prospective study of ultrasound, computed tomography, and clinical diagnosis.
        J Laryngol Otol. 1999; 113: 229-232
        • Snow D.G.
        • Campbell J.B.
        • Morgan D.W.
        The management of peritonsillar sepsis by needle aspiration.
        Clin Otolaryngol. 1991; 16: 245-247
        • Spires J.R.
        • Ownes J.J.
        • Woodson G.E.
        • Miller R.H.
        Treatment of peritonsillar abscess: a prospective study of aspiration vs incision and drainage.
        Arch Otolaryngol Head Neck Surg. 1987; 113: 984-988
        • Buckley A.R.
        • Moss E.H.
        • Blokmanis A.
        Diagnosis of peritonsillar abscess: value of intraoral sonography.
        AJR Am J Roentgenol. 1994; 162: 961-964
        • Costantino T.G.
        • Satz W.A.
        • Dehnkamp W.
        • Goett H.
        Randomized trial comparing intraoral ultrasound to landmark-based needle aspiration in patients with suspected peritonsillar abscess.
        Acad Emerg Med. 2012; 19: 626-631
        • Strong E.B.
        • Woodward P.J.
        • Johnson L.P.
        Intraoral ultrasound evaluation of peritonsillar abscess.
        Laryngoscope. 1995; 105: 779-782
        • Blaivas M.
        • Theodoro D.
        • Duggal S.
        Ultrasound guided drainage of peritonsillar abscess by the emergency physician.
        Am J Emerg Med. 2003; 21: 155-158
        • Lyon M.
        • Blavias M.
        Intraoral ultrasound in the diagnosis and treatment of suspected peritonsillar abscess in the emergency department.
        Acad Emerg Med. 2005; 12: 85-88
        • Nogan S.
        • Jandali D.
        • Cipolla M.
        The use of ultrasound imaging in evaluation of peritonsillar infections.
        Laryngoscope. 2015; 125: 2604-2607
        • Araujo Filho B.C.
        • Sakae F.A.
        • Sennes L.U.
        • Imamura R.
        • de Menezes M.R.
        Intraoral and transcutaneous cervical ultrasound in the differential diagnosis of peritonsillar cellulitis and abscesses.
        Braz J Otorhinolaryngol. 2006; 72: 377-381
        • American College of Emergency Physicians
        Policy Statement. Ultrasound guidelines: emergency, point-of-care, and clinical ultrasound guidelines in medicine.
        (Available at:)
        • Secko M.
        • Sivitz A.
        Think ultrasound first for peritonsillar swelling.
        Am J Emerg Med. 2015; 33: 569-572
        • Mazonakis M.
        • Tzedakis A.
        • Damilakis J.
        • Gourtsoyiannis N.
        Thyroid dose from common head and neck CT examinations in children: is there an excess risk for thyroid cancer induction?.
        Eur Radiol. 2007; 17: 1352-1357