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Three Part Question

In [adults and adolescents with peritonsillar abscess (quinsy)] is [needle aspiration or incision and drainage more effective] at [reducing symptoms and preventing recurrence]?

Clinical Scenario

A 23 year old man presents to Accident and Emergency with a 3 day history of painful swallowing and feeling unwell. On examination he is pyrexial and has trismus. Oropharyngeal examination confirms the clinical suspicion of right sided quinsy. You wonder whether needle aspiration or incision and drainage is the best initial treatment.

Search Strategy

MEDLINE database (OVID 1966 - Sept week 4 2004)
{exp peritonsillar abscess OR peritonsillar abscess.mp OR quinsy.mp} AND {exp treatment OR treatment.mp OR aspiration.mp OR incis$.mp}
LIMIT to Human AND English

Search Outcome

202 papers found of which 185 irrelevant and 12 of insufficient quality for inclusion. (Leaving 5 papers)

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Spires JR et al 1987 USA	62 patients with confirmed peritonsillar abscess. I+D vs. needle aspiration	PRCT	Time to return to eating meal comfortably	Identical recovery rate for 2 procedures (3.7 days). 2 patients had recurrence following I+D	Low number of patients
Stringer S et al 1988 USA	52 patients with confirmed peritonsillar abscess. I+D vs. needle aspiration	PRCT	Resolution of symptoms using 1-5 scale	92% of needle aspiration, 93% of I+D patients cured following initial treatment	Low number of patients
Maharaj D et al 1991 South Africa	60 patients with confirmed peritonsillar abscess. I+D vs. needle aspiration	PRCT	Failure rate (reaccumulation of abscess)	Failure rate 13% for needle aspiration, 10% for I+D	Low number of patients, no statistical analysis
Wolf et al 1994 Israel	Case notes of all patients treated for peritonsillar abscess over 4 year period reviewed (n=160)	Retrospective case series	Recurrence rate	23.3% of needle aspiration group and 4.1% of I+D group had recurrence	Low patient numbers, retrospective study design
Johnson R et al 2003 USA	Not a clinical study but a review of the literature on treatment of quinsy	Meta-analysis	Pooled data from previous studies	Initial success rate 93.7% for I+D, 91.6% for needle aspiration. NNT 47.6 in favour of I+D	Even combined studies had low power (ie high chance of type II error)

Comment(s)

These papers compare the two treatment techniques using two different outcome measures - resolution of symptoms or recurrence of the peritonsillar abscess. None has sufficient power to show a significant difference between the techniques for either of the outcome measures. Note that a third technique for treatment of peritonsillar abscess, 'quinsy tonsillectomy', was not included in this BET.

Clinical Bottom Line

On the evidence available, both incision and drainage and needle aspiration appear to be effective methods of reducing the symptoms and preventing recurrence of a peritonsillar abscess.

References

1. Spires JR, Owens JJ, Woodson GE, Miller RH Treatment of Peritonsillar Abscess Arch Otolaryngol Head Neck Surg Sept 1997; 113, 984-6
2. Stringer SP, Schaefer SD, Close LG A Randomized Trial for Outpatient Management of Peritonsillar Abscess Arch Otolaryngol Head Neck Surg March 1988; 114, 296-8
3. Maharaj D, Rajah V, Hemsley S Management of Peritonsillar Abscess Journal of Laryngology and Otology Sept 1991; 105, 743-5
4. Wolf M, Even-Chen I, Kronenberg J Peritonsillar Abscess: Repeated Needle Aspiration Versus Incision and Drainage Ann Otol Rhinol Laryngol 1994; 103, 554-7
5. Johnson RF, Stewart MG, Wright CC An Evidence-Based Review of the Treatment of Peritonsillar Abscess Otolaryngology Head and Neck Surgery Mar 2003; 128, 332-43