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The Laryngoscope
C 2013 The American Laryngological,
V
Rhinological and Otological Society, Inc.
Corticosteroids in Peritonsillar Abscess Treatment: A Blinded
Placebo-Controlled Clinical Trial
Jason K. M. Chau, MD, MPH; Hadi R. Seikaly, MD, FRCSC; Jeffery R. Harris, MD, FRCSC;
Cristina Villa-Roel, MD, MSc; Craig Brick, BSc; Brian H. Rowe, MD, MSc
Objectives/Hypothesis: Sore throat is a common, benign emergency department (ED) presentation; however, peritonsillar abscess (PTA) is a complication that requires aggressive management. Use of systemic corticosteroids (SCSs) in PTA is
occurring without clear evidence of benefit. This study examined the efficacy and safety of SCS treatment for patients with
PTA.
Study Design: Randomized, double-blind, placebo-controlled trial.
Methods: A controlled trial with concealed allocation and double-blinding was conducted at two Canadian EDs. Following written informed consent, eligible patients received 48 hours of intravenous clindamycin and a single dose of the study
drug (dexamethasone [DEX] or placebo [PLAC], intravenously [IV]). Follow-up occurred at 24 hours, 48 hours, and 7 days.
The primary outcome was pain; other outcomes were side effects and return to normal activities/diet.
Results: A total of 182 patients were screened for eligibility; 41 patients were enrolled (21 DEX; 20 PLAC). At 24 hours,
those receiving DEX reported lower pain scores (1.4 vs. 5.1; P 5.009); however, these differences disappeared by 48 hours
(P 5.22) and 7 days (P 5.4). At 24 hours, more patients receiving DEX returned to normal activities (33% vs. 11%) and dietary intake (38% vs 25%); however, these differences were not significant and disappeared by 48 hours and 7 days. Side
effects were rare and did not differ between groups (P >.05).
Conclusions: Combined with PTA drainage and IV antibiotics, 10 mg IV DEX resulted in less pain at 24 hours when
compared to PLAC, without any serious side effects. This effect is short-lived, and further research is required on factors associated with PTA treatment success.
Key Words: Peritonsillar abscess, sore throat, corticosteroids, relapse, randomized controlled trial.
Level of Evidence: 1b
Laryngoscope, 124:97–103, 2014
INTRODUCTION
Classically called “quinsy” (derived from the Greek
term kynanche, meaning “dog-strangle”) peritonsillar
abscess (PTA) is regarded as the suppurative endpoint
in the infectious continuum of pharyngitis, acute tonsilli-
From the Department of Otolaryngology, University of Manitoba,
Winnipeg, Manitoba, Canada (J.K.M.C.), Department of Surgery, Division
of Otolaryngology–Head and Neck Surgery (H.R.S., J.R.H.), University of
Alberta, Edmonton, Alberta, Canada, Department of Emergency Medicine
(C.V.-R., C.B., B.H.R.), University of Alberta, Edmonton, Alberta, Canada,
School of Public Health (C.V.-R., B.H.R.), University of Alberta, Edmonton,
Alberta, Canada, University College Cork, Cork, Ireland (C.B.).
Editor’s Note: This Manuscript was accepted for publication June
6, 2013.
Presented at the 66th Annual Meeting of the Canadian Society of
Otolaryngology–Head & Neck Surgery, Toronto, Ontario, Canada, May
20–22, 2012.
The authors have no other funding, financial relationships, or conflicts of interest to disclose.
Funding support for this project was generously provided by the
University Hospital Foundation and the Department of Emergency Medicine Research Group at the University of Alberta (C.V.-R., C.B.). C.V.-R. is
supported by the Canadian Institutes of Health Research (CIHR) in
partnership with the Knowledge Translation branch. B.H.R. is supported
by the CIHR as Tier I Canada Research Chair in Evidence-Based Emergency Medicine (Government of Canada).
Send correspondence to Dr. Jason K. M. Chau, Department of
Otolaryngology, University of Manitoba, GB421 Health Sciences Center,
820 Sherbrook Street, Winnipeg, Manitoba, Canada R3A 1R9.
E-mail: [email protected]
DOI: 10.1002/lary.24283
Laryngoscope 124: January 2014
tis, and peritonsillar cellulitis.1 Despite widespread antibiotic use to treat these infectious states, PTA remains
the most common deep space infection of the head and
neck in young adults.2,3 The incidence of PTA in the
USA is approximately 30 cases per 100,000 people per
year, with associated annual health care expenditures of
$150 million.4 Its yearly peak incidence occurs in
November to December and April to May, which parallels the incidence of streptococcal pharyngitis and acute
tonsillitis.5,6 PTA occurs most commonly in those aged
20 to 40 years and affects males and females with equal
frequency.2
Although PTA remains a common clinical entity
encountered in various disciplines, significant debate
exists with respect to the best methods of diagnosis,
acute drainage, medical therapy, treatment setting, and
indications for tonsillectomy, either urgent or elective.
Management strategies vary,7 specifically with respect to
the most effective method of abscess drainage and
whether adjunctive systemic corticosteroids (SCSs) are
beneficial. There is currently only one published report
that has assessed the efficacy of adjunctive steroids in
PTA treatment. Ozbek et al.8 found that patients who
received corticosteroid therapy had improved recovery,
as measured by several outcomes, over patients who
received placebo. Despite this evidence, further studies
are needed before recommendations for the routine use
Chau et al.: Dexamethasone in PTA
97
of corticosteroids in PTA treatment can be made.9 We
present a double-blind, placebo-controlled clinical trial
comparing single-dose intravenous (IV) dexamethasone
to placebo that further addresses this question.
MATERIALS AND METHODS
appearing vials for both dexamethasone and placebo. Vials were
only administered to trial patients once enrollment had
occurred and the abscess had been drained by needle aspiration. The use of identically looking vials for both the treatment
drug and placebo also allowed for blinding of treatment group
assignment and blinding of the outcome assessment and datahandling processes.
Research Questions
The primary research question addressed by this study
was whether single-dose IV dexamethasone (10 mg), administered after needle drainage of a unilateral PTA, results in
decreased pain levels when compared to placebo as measured
with a validated subjective pain scale. Secondary questions
included the effect of single-dose IV dexamethasone (10 mg) on
mouth opening, body temperature, time to painless oral (per os
[PO]) intake, and time to return to “normal” activity as compared to placebo.
Setting
This was a two-site trial including a single tertiary-level
care academic referral center and a single community-based
emergency clinic.
Patient Recruitment and Enrollment
Patient recruitment was achieved via telephone or pager
referral to research staff by attending Emergency Physicians
and Otolaryngology–Head & Neck Surgery residents. Consent
was obtained by affiliated clinical research nursing staff from
patients who met the following eligibility criteria: 1) age > 17
years, 2) PTA confirmed by needle aspiration of frank pus, 3)
ability to comprehend and complete a written questionnaire, 4)
English-speaking, and 5) competent to provide informed
consent.
Patients were excluded if they had received SCS treatment within 72 hours of presentation, had documented PTA
within the previous 30 days (considered recurrent PTA), had a
“dry tap” needle aspiration (no pus expressed), had bilateral
PTA, or had complicated PTA requiring admission (e.g., severe
dehydration, airway compromise, or involvement of another
deep neck space).
Treatment Groups, Randomization,
Concealment, and Blinding
Patients were assigned into either intervention or control
groups after inclusion criteria were satisfied and the patient
provided signed informed consent to participate in the trial.
The a priori randomization strategy occurred at the level of the
pharmacy and was to be by random computer number generation in blocks of 10, stratified by center. One hundred brown
opaque vials, labeled with numerals ascending from 1 through
100, were prepared with either dexamethasone (10 mg of IV
preparation) or placebo. These vials were delivered to the trial
sites and kept in a designated locked area of the respective
emergency department (ED) with access only available to
study-affiliated nurses and assistants. Vials were used sequentially in order of ascending number starting at vial #1.
The control intervention contained 10 ml of sterile saline,
and the intervention consisted of 10 mg of dexamethasone
phosphate (Sabex, Cassola, Italy; bin #00664227) with methylparaben (0.15%) and propylparaben (0.02%) preservative. The
shelf life of both agents was 1 year. Concealment of allocation
was achieved by keeping all randomization information solely
at the involved dispensary pharmacy and by using identically
Laryngoscope 124: January 2014
98
Study Protocol
The PTA management included surgical and medical
treatments as follows.
Surgical. The surgical site was anesthetized with local
injection of 0.5 to 1.0 mL of 1% Xylocaine with epinephrine, if
no allergy history was present. Needle aspiration was performed with an 18-gauge needle mounted on an empty 10-mL
syringe, without ultrasound guidance. The needle aspirate was
sent for Gram stain as well as culture and sensitivity microbial
analysis.
Medical. All patients received an IV fluid bolus of 1 L of
normal saline over 1 hour, IV analgesia (usually ketorolac 30
mg), and IV antibiotics. Ketorolac was preferentially administered as part of a narcotic sparring strategy of the regional
EDs. If allergic sensitivity to ketorolac had been documented or
reported by the patient, morphine was administered (2.5–5.0
mg IV). Most patients received IV clindamycin (600 mg every 8
hours) for 48 hours, with the first dose being delivered in the
ED and subsequent doses administered in a dedicated outpatient IV clinic. If a history of an allergy to clindamycin was
present, then IV cefazolin (Ancef 1 g every 8 hours) and metronidazole (Flagyl 500 mg IV every 8 hours) were administered.
Following at least 48 hours of IV clindamycin, patients were
converted to equivalent-dose oral preparations (e.g., clindamycin 300 mg three times daily) for 12 days to ensure a total duration of antibiotic therapy of 14 days. In patients who had a
history of allergy to clindamycin, Clavulin (amoxicillin–clavulanic acid/Augmentin 875 mg PO twice daily) was prescribed.
Data Collection
At presentation and following informed consent, the
patient’s history was documented, with demographic (e.g., sex,
age), chief complaint, and associated upper aerodigestive tract
symptom data being recorded. Associated symptoms of PTA were
recorded, including progressive dysphagia, odynophagia, voice
alteration, malaise, and lethargy. Social history and allergic history were also recorded in addition to any recent prescription
antibiotic or steroid use. One of the study investigators performed and documented a physical examination, which included
general appearance, vital signs including temperature, voice
quality, trismus (poor mouth opening recorded using interincisor
distance), and important oropharyngeal findings.
Outcomes, Outcome Measures, and Follow-up
The primary outcome in this trial was that of subjective,
patient-reported levels of pain. This was measured on a 10-point
visual analog scale (VAS) that has been well validated for measuring subjective pain levels in the ED patient population.10,11
Based on Gallagher et al. and Bijur et al.’s reports, a change
score of 1.3 on a 10-point VAS in ER patients was chosen as the
minimal clinically important difference (MCID) that would drive
a subsequent change in PTA management protocols.10
Secondary outcomes included mouth opening (in centimeters), body temperature (in degrees Celsius), and time to
painless PO intake (in hours). Mouth opening, as recorded as
interincisor distance, was measured with a standard 12-cm
Chau et al.: Dexamethasone in PTA
Fig. 1. CONSORT diagram showing the flow of participants through each stage of a randomized trial. F-U 5 follow-up; PTA 5 peritonsillar
abscess.
ruler, with the smallest increments of measure being millimeters. The incisal surfaces of the mesial upper and lower incisors were used as reference measuring points in all patients.
Body temperature was measured with a standard oral thermometer in units of degrees Celsius, with precision to the nearest 10th of a degree. Time to painless PO intake was measured
in hours and subjectively reported by patients in a take-home
diary.
Follow-Up
Data collection for the first 48 hours was achieved with
self-reported patient diaries. The diaries required a grade 7
reading level (Canada) and were completed at enrollment and
at each subsequent outpatient IV clinic visit for a total of 6
data collection points. A patient’s clinical progress was reviewed
and examined by blinded research staff at the 24- and 48-hour
time points in the outpatient IV clinic. Subjective patientreported diaries were checked for completeness and collected at
the last IV outpatient clinic visit. Follow-up at the 7-day time
point was performed by phone. Patients were given the on-call
staff otolaryngologist’s office contact details to arrange follow-up
for reassessment and possible tonsillectomy.
Statistics
Descriptive data included proportions and means with
standard deviations or medians with interquartile range,
as appropriate. Bivariate analyses for dichotomous and for
continuous variables were performed by v2 tests, t tests, or
Laryngoscope 124: January 2014
Mann–Whitney tests. Analyses for continuous variables over
time were performed using analysis of variance. All analyses
(including sample size and post hoc power calculations) were
performed using STATA statistical software (release 10.0; (Stata
Corporation, College Station, TX).
Ethics
The Health Research Ethics Board of the University of
Alberta approved this trial. Informed written consent was
obtained from each patient prior to enrollment.
RESULTS
Participants
One hundred eighty-two patients were screened for
eligibility, with 122 being deemed ineligible. Of these, 41
patients were enrolled (21 dexamethasone; 20 placebo).
Figure 1 summarizes the screening process and shows
the flow of participants through each stage of the trial
according to the CONSORT guidelines for reporting
randomized control trials. Figure 1 also outlines the various reasons for ineligibility and exclusion. The most
common reason for patient exclusion was their receiving
corticosteroids within 72 hours prior to presentation
(23%). This trend became more prominent as the time
course of the trial went on and resulted in the study
being terminated early.
Chau et al.: Dexamethasone in PTA
99
TABLE I.
Comparison of Patient Demographics, Symptoms, and Clinical
Characteristics.
PLAC,
n 5 20
DEX,
n 5 21
Age, yr, median (IQR)
29 (21–37)
22 (19–29)
.138
Male sex, No. [%]
Marital status, No. [%]
14 [70]
14 [66.7]
.819
10 [50]
13 [61.9]
.524
7 [35]
3 [14.3]
15 [75]
11 [52.4]
.21
3 [15]
5 [25]
7 [33.3]
8 [38.1]
.035
9 [45]
7 [33.3]
.662
5 (3–6)
5 (3–6)
.957
18 [90]
20 [95.2]
.606
.218
Characteristic
P
Demographics
Single
Married
Work status, No. [%]
Working
School
University education,
No. [%]
Smoker, No. [%]
Symptoms at presentation
Length of symptoms,
d, median (IQR)
Dysphagia, No. [%]
Current diet, No. [%]
Fluids only
NPO
Soft diet and DAT
Currently on antibiotics,
No. [%]
Prior history of PTA, No. [%]
6 [30]
12 [57.1]
7 [35]
6 [28.6]
6 [30]
15 [75]
3 [14.3]
12 [57.5]
.228
6 [30]
5 [23.8]
.655
37.1 6 0.7
37.3 6 0.7
.729
2.8 (2–3.5)
3.1 (2.5–4.0)
.175
1.2 (0.2–4.5)
3.0 (1.1–5.5)
.094
663
662
.573
Clinical characteristics
Body temperature, C,
mean 6 SD
Interincisor distance, cm,
median (IQR)
Amount of pus drained, mL,
median (IQR)
Pain score, /10 on VAS 6 SD
DAT 5 diet as tolerated; DEX 5 dexamethasone; IQR 5 interquartile
range; NPO 5 nothing by mouth; PLAC 5 placebo; PTA 5 peritonsillar
abscess; SD 5 standard deviation; VAS 5 visual analogue scale.
Primary Outcome
Subjective pain scores. Analysis of patientreported pain scores at the 24-hour, 48-hour, and 7-day
time points revealed significant differences between
treatment groups exclusively at the 24-hour endpoint
(Fig. 2). The dexamethasone treatment group had
median pain scores of 1.4 after 24 hours versus the control group’s median score of 5.1. This significant difference of 3.7 disappeared at the 48-hour and 7-day time
points. Intragroup analysis of change over time was performed and revealed a statistically significant change
over time in the dexamethasone group but not the control group. Analysis of analgesic and anti-inflammatory
use after 48 hours and 7 days revealed no significant differences between the treatment groups (Table II).
Secondary Outcomes
Body temperature was found to significantly differ
at the 24-hour time point but not at the 48-hour
measurement (Table II). Trismus, measured as interincisor distance, was not significantly different between
groups; however, there was a trend to statistical significance at the 48-hour time point favoring dexamethasone
(Table II). In terms of subjectively reported return to
normal activity, significant differences between groups
were noted at the 24-hour time point; however, these
differences were nonsignificant at the 48-hour and 7-day
measurements (Fig. 3). There were no significant differences found between groups in subjectively reported
return to normal diet (Fig. 4).
Complications and Side Effects
Side effect profiles of both treatment arms were
also recorded. Important side effects collected included
nausea, vomiting, drowsiness, restlessness, muscle
spasms, and diarrhea. As given in Table II, there were
no significant differences noted in side effects at the 48hour and 7-day time points.
Dropouts/Withdrawals
Overall, only 1 patient from each group failed to
provide 7-day follow-up; however, not all patients were
captured at each follow-up. For example, at 48 hours 4
patient outcomes could not be ascertained (1 placebo, 3
dexamethasone).
Patient Characteristics
Demographic details of both treatment groups are
compared in Table I. There were no significant differences noted except in level of educational achievement.
Clinical data comparisons with respect to patient symptoms at the time of presentation to the ER are presented
in Table I. There were no significant differences between
groups noted. Baseline clinical measurements are also
presented in Table I. There were no significant differences found between treatment groups.
Laryngoscope 124: January 2014
100
Fig. 2. Comparison of subjectively reported pain scores at 24
hours, 48 hours, and 7 days in peritonsillar abscess patients
receiving dexamethasone (dark boxes) or placebo (white boxes).
Chau et al.: Dexamethasone in PTA
TABLE II.
Measurement of ED and Post-ED Cointerventions and Outcomes.
PLAC,
n 5 20
Intervention/Outcome
DEX,
n 5 21
P
9 (42.9)
5 (23.8)
.606
.734
.867
1
Medication administered in the ED, No. (%)
Analgesic
Anti-inflammatory
7 (35)
6 (30)
Medication taken within 48 hours, No. (%)
Analgesic
Anti-inflammatory
11 (55)
1 (5)
11 (52.4)
1 (4.8)
Body temperature, C,
mean 6 SD
.004*
.001*
Baseline
37.1 6 0.7
37.3 6 0.7
.729
24 hours
48 hours
36.7 6 0.8
36.3 6 0.6
36.0 6 0.5
36.3 6 0.7
.008†
1
Fig. 4. Comparison of subjectively reported return to normal diet
in peritonsillar abscess patients receiving dexamethasone (black
bars) or placebo (gray bars).
3.1 [2.5–4.0]
3.9 6 1.3
.175
.059
DISCUSSION
.509
.35
Trismus, interincisor distance, cm
Baseline, median [IQR]
48 hours, mean 6 SD
2.8 [2.0–3.5]
3.3 6 1.2
Side effects at 48 hours, No. (%)
Nausea
Vomiting
4 (20)
2 (10)
2 (9.5)
3 (14.3)
Drowsiness
8 (40)
6 (28.6)
.66
Restlessness
Muscle spasms
2 (10)
2 (10)
3 (14.3)
2 (9.5)
.651
.844
0
0
Diarrhea
Side effects at 7 days, No. (%)
Nausea
Vomiting
Drowsiness
Restlessness
Muscle spasms
Diarrhea
0
2 (9.5)
.107
0
1 (4.8)
.356
1 (5)
0
2 (9.5)
1 (4.8)
.505
.356
0
2 (9.5)
.107
2 (10)
4 (19)
.287
*Analysis of variance.
†
Statistically significant.
DEX 5 dexamethasone; ED 5 emergency department; IQR 5 interquartile
range; PLAC 5 placebo; SD 5 standard deviation.
Fig. 3. Comparison of subjectively reported return to normal activity in peritonsillar abscess patients receiving dexamethasone
(black bars) or placebo (gray bars).
Laryngoscope 124: January 2014
Despite widespread use of antibiotics for treating
tonsillitis and pharyngitis, PTA remains a common clinical entity encountered in the ED. Although any age
group can be affected, PTA is most common in adolescents and young adults between the ages of 20 and 40
years.2 The bacteriology has remained relatively constant during the past half century, with Streptococcus
species being the most common organisms cultured.12,13
Despite its frequency, significant debate exists regarding
PTA management7; specifically, the method of abscess
drainage and the role of adjunctive corticosteroids. The
use of systemic corticosteroids as adjunctive therapy has
been reported as safe and effective, and has become
more commonplace in recent years.14–16
This methodologically rigorous trial evaluated the
effectiveness of dexamethasone compared to placebo. A
statistically significant difference in subjective pain
scores was found at the 24-hour post-treatment time
point. An overall effect size of 3.7 was noted between
treatment groups in favor of dexamethasone. This is 2.7
times the a priori chosen MCID of 1.3 that has been well
validated in our target setting. This large effect size,
emerging despite lower than expected enrollment, is
undoubtedly clinically important and is certainly compelling evidence to advocate for a change in practice.
Using a comprehensive search strategy, only one
other published study was identified that assessed the
efficacy of adjunctive steroids in PTA treatment. Ozbek
et al.8 compared intramuscular methylprednisolone to
placebo in a randomized prospective fashion. Patients
were admitted to hospital and received either intramuscular (IM) methylprednisolone or placebo, along with
abscess drainage by needle aspiration and intravenous
antibiotics (which were continued for at least 2 days and
until the patient improved). Specific outcomes assessed
included hours hospitalized, throat pain, time to oral
intake, fever, and trismus. The authors found a statistically significant difference in trismus severity, dysphagia
levels, body temperature, and hours hospitalized favoring the use of steroids without noting any increase in
frequency of complications.
Chau et al.: Dexamethasone in PTA
101
Our present study differs from Ozbek’s in several
aspects. First, we present a clinical trial on PTA management in an outpatient setting. Second, we compared
treatment groups based on a primary outcome of subjective pain. Third, we employed a pain scale and MCID
that have been well validated.10,11 Fourth, our trial
assessed subjective return to normal activity, which
although not a direct quality of life (QOL) measure, can
reasonably be interpreted as a surrogate for overall
QOL. Last, we compared IV dexamethasone, rather than
IM methylprednisolone, to placebo. Dexamethasone
administered intravenously was chosen because IM drug
administration may have affected pain score reports and
carries with it the potential complications of infection,
hematoma, and myonecrosis. Moreover, there is greater
support for use of dexamethasone in the published literature in our target population.14–16 Overall, we feel our
study represents high-quality evidence in a North American context.
No significant differences were noted in trismus
severity or dysphagia levels in this trial. These findings
contradict findings of the prior study.8 Whereas Ozbek8
noted significant improvement of trismus in the methylprednisolone group after 12 and 24 hours, we found
no such difference. The units of measure employed may
explain this difference. Interincisor distance measured
to the nearest 10th of a centimeter was used in our
trial, whereas percentage improvement scores are presented in Ozbek’s trial. Comparing change scores may
predispose to finding differences not found when comparing objective measurements. Similarly with dysphagia levels, we found no significant differences between
our treatment groups. This disparity from the prior
published trial may be due to the outcome measures
used. Objective assessment of ability to swallow water
(as performed in Ozbek’s trial) is certainly different
from subjective reports of time to return to a normal
diet.
Limitations
This study has several potential limitations. First,
the study was concluded prematurely due to increasing
difficulty enrolling patients. Over the time course of the
trial, patients received IV steroids prior to their presentation at the tertiary care ED more frequently, thus limiting our eligible patient pool. Despite the decision being
made to stop prior to data analysis, a large and statistically significant effect size was identified. Post hoc
power calculation confirmed that our sample of 41
patients was more than adequate to detect the observed
difference between treatment groups >80% of the time.
Second, with a small sample size, the groups were not
exactly balanced and adjustment was not possible; however, the majority of imbalances favored the placebo
group. Third, although it is likely that single-dose dexamethasone is relatively safe, it is important to point out
that this study did not follow patients beyond 7 days
and may have missed uncommon or delayed adverse
events. Given the frequency of sore throats and PTA,
additional studies may be required to assess the likeliLaryngoscope 124: January 2014
102
hood of rare or long-term adverse events such as PTA
recurrence or deep neck space infection. Fourth, the protocol required needle aspiration and IV antibiotics as the
minimal standard of care, and in a small proportion of
(excluded) cases the aspiration failed. Although these
patients were excluded (and therefore did not enter into
our analysis), some may argue that surgical blade drainage should have been employed rather than needle aspiration, as the degree of anatomic decompression that is
achievable is greater. It is possible that scalpel drainage
may have expressed pus where the needle aspiration did
not. Khayr’s work3 coupled with our own center’s experience led to the choice of needle aspiration, and we do
not believe this choice invalidates the results of the trial.
Finally, the allocation process, although concealed and
blinded, was controlled by a noninstitutional pharmacy.
This may have introduced uncontrolled bias; however,
we believe these possible biases do not invalidate the
observed results.
CONCLUSION
In the clinical setting of unilateral PTA treated
with needle aspiration and IV antibiotics, a single 10-mg
dose of IV dexamethasone administered following needle
aspiration results in reduced subjective pain levels and
improved patient QOL at 24 hours without any adverse
side effects or morbidity when compared to IV antibiotics
alone. This option should be considered in patients with
unilateral PTA who have severe pain in the ED; however, due to the short-term transient nature of the benefit, the treatment decision should be weighed against
possible later adverse events such as PTA recurrence or
deep neck space infection.
Acknowledgments
The authors thank the research coordinators for the study
at each site: Virginia Willis (University of Alberta
Hospital, Edmonton, Alberta, Canada) and Debbie
Boyko (Northeast Community Health Centre, Edmonton,
Alberta, Canada).
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