I made a comment about the peritonsillar abscess at the otohns list. Recently read that comment again and cannot resist the urge to re-publish on this blog here.

Here comes:

Regards all!

So up to now we saw a rich doctor’s approach to peritonsillar abscess, thereafter somebody from a not so developed country etc.

So, let’s see mine experience working in Zimbabwe (15 year in the government-run Mpilo Central Hospital).

First of all the patient should be dealt with in a single visit (no money for transport, medication, stay in the hospital, CT scan, US etc).

Secondly, the doctor is very tired and busy and does not have time to go around the wards, check the treatments, etc.

Thirdly, the abscess is usually obvious because the patient waited for a long time (no money for transport, etc).

If there is a trismus so the mouth cannot be opened a little bit for a long and narrow forceps – then abx, steroids and I and D in the main theatre.

If able to open the mouth – then Xylocain spray.

If the abscess is pointing then cut, closed forceps in – open out in one direction perpendicular to the original incision, again closed forceps in – open out in the direction parallel to the original incision. Home on antibiotics.

If the abscess is not pointing – then spray again, inject 1-2 mL of 1% Xylocain just in the mucosa and then I and D. And then home on antibiotics.

I saw my first one as a student of dentistry in 1977. I did my first one as an ENT resident in 1986.
In the last 20+ years I did maybe two in theatre.
From 1994 to 1998 – did approximately not less than one a month and not more than one a week. Only once did an I and D on a tumour, converted the procedure to Bx, ie, removed a piece of tissue with a cupped forceps and sent to histology instead of pushing in the closed forceps etc.

On not more than half a dozen occasions, put inside a huge needle, don’t know the number but something that is used for blood transfusion or a large cannula, got myself a lot of pus and sent the patient away. Didn’t understand the benefit because with similar pain to the patient and effort for everybody can perform a more reasonable drainage.

Main problem: pus under pressure is going to spray the unfortunate ENT surgeon!!!

Inadvertent finding of a carotid artery should not be a possibility for a person doing tonsillectomies regularly, aint’t it!!!

It is true that the carotid artery was described in the bed of the tonsil on several occasions and I know of at least one case where it went through the tonsil itself – but that is the problem for tonsillectomy, in theatre, etc.

I and D done “my way” certainly is not going to endanger the carotid.

Small problem is the possibility of an aneurysm – I saw one coming from the base of the skull, to one parapharyngeal space and basically behaving like a huge parapharyngeal or peritonsillar abscess and wisely decided not to touch. The patient passed away several days later because of a CVA. So this thing was in the brain also…

The benefit of abx and steroids (without cutting or aspiration) is probably for non-developed cases where one would like to reverse the process of abscess formation. So all the developing abscess contents are being absorbed back to the body instead of being thrown out in a kidney dish!!!

The benefit of needle aspiration is irefutable in the hands of a person who does not normally do tonsillectomies.

If you have ultrasound, work in ER, never saw an ENT patient in anger – fair enough – do US!!!

If you have a CT scan available – fair enough – put your own child under it – if you want to irradiate somebody – then irradiate one of your own!!! (And doing that don’t forget to think of us people who cannot afford to CT scan endocranial pathology…).

And not to forget – a SINGLE peritonsillar abscess is an ABSOLUTE indication for tonsillectomy at a later date – not earlier than six weeks after more-or-less complete resolving of the present infection. The other ABSOLUTE indication has something to do with tumours of the tonsil. And the OTHER indications are to make people happy (mothers, headmasters, bank managers, frustrated ENT doctors etc).

Hot tonsillectomy (so called a chaud!) is good in this space and time if you believe in the weapons of mass destruction, ie, like to do an unnecessary dangerous thing in the enemy territory …

Regards and hope this helps!

Maks.