Improving Outcomes

Optimizing the Quinsy

So a few days ago, we discussed management of a peritonsillar abscess; while admit rates from 2012 were roughly 22% with transfer rates at 5.9%, and its probably a tough sell that rates of transfer for on-call specialties such as ENT are down significantly from, say, this 2008 paper from EMRAP paper-chaser Mike Menchine (among others).

So what can we do to optimize these patients?

For one, choosing amoxicillin-clavulanate or cefuroxime/flagyl over amoxicillin might help; as it is associated with decreased failure rates, and a decreased rate of requiring additional procedures.

Likewise, this study, found that despite having more ominous clinical findings (more likely to have trismus, peritonsillar bulges, muffled voice, uvular deviation, dysphagia, etc), as well as having radiographically larger abscesses (2.6cm vs 1.3cm), surgically treated patients were less likely to be admitted (20% vs 11%) –  with high levels of success (97% surgical success vs 95% for those treated medically). Now, perhaps this was because of more aggressive treatment in the surgical arm – they were more likely to have antibiotics in the ED (and yes, they were more frequently dosed with IV antibiotics), as well as steroids (yep, more likely to have IV steroids too), as well as fewer repeat visits. Admittedly, repeat visits were quite high (20% medical treatment vs 14% surgical treatment) – which was higher than in the previous paper discussed, which estimated a 5% repeat visit rate nationally.

So who should stay, who should go, and what to do?  I think to avoid an admission or transfer, it’s my belief that we should be maximally aggressive with Quinsy’s – IV fluids, steroids (10mg dexamethasone seems to be a reasonable), antibiotics (likely a dose of either ceftriaxone or clindamycin), and some form of analgesia (ketorolac, opiates, etc).  While medical management has significant success, it still appears somewhat suboptimal compared to surgical treatment (ie, aspiration or I&D).  Generally, I have not been a believer in IV treatments being better than PO treatments, but this seems to be one of those rare instances where it might matter; particularly if you’re trying to stave off a transfer or admission. Likewise, the immunocompromised, those with poor airways (think those with sleep apnea), the extremes of age (with older than 40 years of age having a prolonged disease course in one study!) , intractable pain, vomiting, or persistent bleeding all should be considered for observation.

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