Discussion
COVID-19 led to significant disruption of well-established standards of
care, but it is increasingly recognised that these changes may have
unveiled positive developments in our management of certain conditions.
This discussion focuses on lessons that can be learned from the
collective national experience regarding the management of acute
tonsillitis and PTA.
COVID-19, tonsillitis and peritonsillar
abscess
Sore throat and pharyngeal inflammation are recognised manifestations of
COVID-19,10 but a consistent association with acute
tonsillitis has not been described. Acute tonsillitis may have a viral
or bacterial aetiology, with acute bacterial tonsillitis often preceded
by a viral infection.11 Coronaviruses are not one of
the known viral pathogens frequently contributing to acute
tonsillitis.12 The only comparable pre-COVID-19
presentation data comes from the UK multicentre audit of quinsies
(MAQ),13 where the median number of cases of PTA alone
was 3 per month. This compares to approximately 4 combined tonsillitis
and PTA cases per month during the COVID-19 audit, with nearly twice the
number of tonsillitis cases compared to PTA. Given seasonal variation
has limited effect,14 this apparent drop in
presentations may be due to the reduced spread of common viral infection
with COVID-19 population measures, or a reduced willingness of patients
to present to ED.15
Changes to care during the COVID-19
pandemic
Acute management of tonsillitis and PTA in ED aims to reduce the
proportion of patients that require admission. This practice has been
advocated for several years,16,17 but COVID-19
provided further pressure to clinicians to only admit cases where
essential.
During the audit, clinicians discharged just over half of tonsillitis
patients, and just under half of those with PTA. This represents a
significant shift in practice, with historically high levels of
admission for tonsillitis presenting to ENT in the
UK,16,18 and only 8% of PTA cases discharged from ED
in 2014.13
The use of IV antibiotics and steroids in ED was common, with the
majority of both tonsillitis and PTA patients receiving both. The effect
of this treatment, and any concurrent analgesia, was dramatic. This
management approach doubled the proportion of patients able to swallow
fluids in the subgroup later deemed suitable for discharge, with a large
benefit also seen in those later admitted. This finding is in line with
previous small studies that suggest IV steroids may reduce pain and
trismus, facilitating earlier oral intake.19–21
Another COVID-19-provoked shift in practice has been a move away from
PTA drainage (cf MAQ), with the aim of reducing clinician exposure to
aerosol and droplets. Nearly a quarter of patients with suspected PTA
had no drainage performed, and this did not appear to influence the
decision to admit, nor did the presence or absence of pus on incision or
aspiration. There was also no difference in 10-day re-presentation rates
between those drained or managed conservatively. Inevitably milder or
borderline cases are more likely to have been managed conservatively in
our dataset, however a recent meta-analysis also demonstrated no
difference in outcomes between patients initially treated with
conservative or surgical interventions for PTA.22 This
audit, combined with ongoing emphasis on reducing clinician exposure to
oral secretions, should promote further exploration of the role of
conservative management of PTA, and outcomes associated with not
draining.
Some aspects of management did not change with the introduction of
COVID-19 guidelines. Avoidance of oral examination was recommended, yet
9 out of 10 patients still underwent an oral assessment. Furthermore,
once patients were admitted, the length of stay for both tonsillitis and
PTA was between 1 and 2 days, the same as previously
found.13
Drivers of clinical decision
making
The ENTUK COVID-19 guidelines suggested the decision to admit should be
primarily based on the patient’s ability to swallow fluids and
medication, with the initial triage focusing on airway concern and
sepsis, similar to other published criteria.16–18,23Unsurprisingly, the inability to swallow fluids and medications,
especially after statim IV medications, led to admission in
almost all cases. Physiological markers of sepsis were not recorded and
so it is uncertain what role these played in the decision to admit.
Outcomes from outpatient
care
Whilst discharging patients from ED can benefit patients and the
hospital, it must be balanced against the potential harm of
deterioration or complications occurring within the community. 10-day
re-presentation rates were similar to or below previously reported
data,16,17 and considerably lower than the 30-day
figure from MAQ.13 For both tonsillitis and PTA
cohorts, the readmission rate was low, and higher in the group initially
admitted from ED. Even in those patients re-presenting, many could
continue to be managed as an outpatient after further review in ED.
Enhanced management within ED and early discharge therefore appears
safe.
Implications for clinical
practice
The practice adopted across the UK during the COVID-19 epidemic has
reduced admissions, and to a lesser extent reduced possible clinician
exposure to patient secretions. While the decision-making process
currently adopted appears safe, it is difficult from the data to fully
characterise the optimal pathway or criteria for admission.
Looking for possible improvements in current management, in this audit
the 101 patients not examined did not demonstrate a higher
re-presentation rate. It could therefore be argued that the continued
use of patient examination by an ENT clinician is not justified, given
both the risk of COVID-19 transmission, and the existence of a common
management pathway for tonsillitis and PTA, with unclear benefit of PTA
drainage.
Given the observational nature of this study, it is not possible to
determine exactly which tonsillitis and PTA patients can be routinely
managed as outpatients, but the current guidance appears to provide a
sound basis for triage, probably incorporating a review of the presence
of physiological markers of sepsis. It has however been shown that a
greater proportion of patients with these conditions can be safely
managed at home than has traditionally been the case.
Strengths and limitations of the
study
This large prospective national study gives a comprehensive report of
tonsillitis and PTA management and is uniquely placed to learn from the
synchronous UK-wide changes in practice brought about by the initial
peak of the COVID-19 pandemic. Despite disruption to routine care,
extremely high levels of data completeness were seen.
To reduce the burden on data collection during a clinically challenging
time, data were not collected on physiological parameters,
laboratory/imaging results and past medical history. The classification
of patients as tonsillitis or PTA was solely based on clinician
judgement, and some PTA treated conservatively may have not re-presented
true abscesses. Re-presentations beyond 10 days and those to community
healthcare will have been missed, although these are unlikely to
represent severe complications. Finally, patient hospital-avoidance
behaviour at the height of the pandemic likely raised the threshold for
re-attending with milder complications.