Local cultures are interesting, and variety is the spice of life. So let’s look at the ripened Quinsy fruit, shall we?
It is entirely imaginable that local practice at one tertiary care center is to perform an ED needle aspiration under endocavitary ultrasound guidance for a peritonsillar abscess and discharge the patient, while another within 100 miles may consult ENT to perform an aspiration at bedside and admit the patient. Likewise, one community center may perform aspiration, admit the patient overnight and consult ENT in the AM, while another community ED may transfer to a nearby tertiary care center because “this patient needs ENT.”
Ultimately, none of the above is necessarily wrong, it just depends on your level of comfort; but perhaps an understanding of the patients likely disease course may change your sentiment a bit.
This is a review of data from multiple sources – the National Ambulatory Health Care Survey of Emergency Departments, the national Emergency Department Sample, and the National Inpatient Sample – to evaluation the treatment outcomes of patients with a Quinsy – also known as a peritonsillar abscess. Ultimately, they find that only 20% of patients had an incision and drainage in the ED, 73% of ED patients were discharged, (5.9% transfer, 21.6% admit) yet, only a 5% revisit rate.
Importantly, medical failure occurred only 12.4% of the time, and surgical failure (a needle aspiraton was considered a surgical intervention) occurred only 3.5% of the time. There was a 2% re-admit rate, with a <2% complication rate for both medically and surgically treated patients.
Rather than transferring patients for ENT evaluation, and providing them with quite the bill for an ambulance, its entirely reasonable to attempt ED aspiration given the low likelihood of surgical failure. Likewise, its also reasonable to have a risk benefit discussion and explain to the patient that they have about a 10-15% chance of medical failure if they elect to not undergo an invasive procedure, provided you’ve adequately explained indications for returning to the ED; 90% likelihood of success is still quite high and you dont even have to get stabbed in the throat!
In the next post, we’ll discuss ways to optimize your patient, and red flags that aught to trigger an overnight stay. But for now, you should feel comfortable either medically treating the patient or attempting aspiration before considering transfer.