Pediatric Peritonsillar Abscess : Outcomes and Cost Savings from Using Transcervical Ultrasound.

Caroline Blatcher, MS4

Article

Huang, et al. “Pediatric Peritonsillar Abscess : Outcomes and Cost Savings from Using Transcervical Ultrasound.” Laryngoscope 2017; 127 : 1924-1929.

Takeaway (TLDR)

PTA is a very common infection in the pediatric population, but the ability of ED physicians to diagnose it on the grounds of physical exam alone has been shown to be poor. Ultrasound is a suitable alternative to CT scan as an imaging study to aid in diagnosis of PTA – it is safer (less radiation exposure), reduces the rate of surgical intervention, and lowers length of stay compared to CT scan.

Background

Peritonsillar abscess (PTA) is the most common infection of the neck, and is most commonly seen in children and adolescents. Though there are clinical signs of PTA, physical exam alone has been shown to be insufficiently sensitive and specific to make the diagnosis. Many patients have been receiving CT scans for diagnosis of PTA, but ultrasound has emerged as a possible alternative imaging study that has lower cost and no radiation exposure, especially critical in the pediatric population. This study compares the use of ultrasound versus CT scan as the initial diagnostic imaging study in patients with suspected PTA and compares clinical outcomes.

The Study

Type : retrospective cohort study

Population : children with suspected PTA in the ED over a 2-year period

Clinical Setting : Emergency Department

Exclusion Criteria : <2 years old,  any suspicion for retropharyngeal or parapharyngeal abscess, hemodynamic instability, respiratory distress

Inclusion Criteria : children with suspicion for PTA determined by a certified physician in the ED based on physical exam findings such as tonsillar asymmetry, uvular deviation, and trismus

Methods : Transcervical ultrasound performed by a licensed ultrasound tech following guidelines provided by an experienced radiology attending. All exams were performed in 10 minutes or less. Ultrasound findings were then interpreted by a blinded radiologist and categorized into abscess, phlegmon, or tonsillitis. Additional data from a second cohort of patients found to have PTA prior to use of ultrasound was collected as a control group. Comparisons of outcomes were performed using statistical analysis.

Primary Endpoints : CT scans performed, procedures performed, type of procedure performed, length of stay >23 hours, ENT consult in the ED, readmission within 30 days

Secondary Endpoint : total cost

Results

Approximately 1/3 of patients presumed to have PTA by ED physicians were found to have findings of PTA on ultrasound. Several outcomes including length of stay >23 hours, need for surgical intervention, and need for CT scan were reduced significantly in the ultrasound group compared with the non-ultrasound group. The proportion of negative CT scans in the ultrasound and non-ultrasound group was not statistically significant. Several other outcomes, including difference in readmission rate, cost, and need for ENT consult, did not reach statistical significance.