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Reprinted by permission of Laryngoscope. 2015; 125(12):2799-2804.

The Laryngoscope V C 2015 The American Laryngological, Rhinological and Otological Society, Inc.

Transcervical Ultrasonography in the Diagnosis of Pediatric Peritonsillar Abscess

M. Taylor Fordham, MD; Alex N. Rock, BA; Anjum Bandarkar, MD; Diego Preciado, MD, PhD; Michelle Levy, PA-C; Joanna Cohen, MD; Nabile Safdar, MD; Brian K. Reilly, MD

Objectives/Hypothesis: Pediatric peritonsillar abscess (PTA) is a common infection, particularly in the adolescent popu- lation. Physical examination alone is not always sufficient to diagnose this pathology, and thus, computed tomography is often utilized as a diagnostic adjunct. With growing concern over radiation exposure in the pediatric population, we conducted a prospective study to investigate the use of ultrasonography in the detection of pediatric PTA. Study Design: Prospective single arm cohort study. Methods: Pediatric patients examined in consultation for concern for PTA were prospectively enrolled in the study. Patients were managed based on clinical symptoms and presentation. Transcervical ultrasonography of the peritonsillar region was performed on all patients. Clinical outcomes were reviewed retrospectively and compared to ultrasound findings. Results: Forty-three patients (age range, 2–20 years) were enrolled in the study. The sensitivity and specificity of trans- cervical ultrasound when compared to clinical outcomes were 100% and 76.5%, respectively. The positive and negative pre- dictive values were 52.9% and 100%, respectively. Fisher exact test showed a statistically significant association ( P < .01) between negative ultrasonography and successful medical management, and multivariate regression analysis showed a strong correlation between ultrasound findings and presence/absence of purulence during surgical intervention ( P 5 .01). Conclusions: Transcervical ultrasonography is a useful tool in diagnosing pediatric PTA. This imaging modality not only avoids undue radiation exposure, but it also proves to be an excellent tool at identifying patients who will not need surgical intervention. To our knowledge, this is the first study to explore this technique for the diagnosis of pediatric PTA. Key Words: Pediatric peritonsillar abscess, ultrasound, transcervical, pediatric head and neck infection. Level of Evidence: 2b Laryngoscope , 125:2799–2804, 2015

INTRODUCTION Peritonsillar abscess (PTA) is a commonly occurring and potentially life-threatening suppurative infection located between the palatine tonsil capsule and the more lateral pharyngeal constrictor muscle. PTA affects chil- dren and adults but is more common in adolescents, with an estimated incidence of between 14 and 40 per 100,000 in patients younger than 18 years old. 1 Both medical and surgical management are frequently cura- tive. Inadequate treatment of PTA can result in rare but serious consequences, such as sudden rupture with aspi- ration of purulent exudate, extension of the infection into the mediastinum, acute airway obstruction, and/or From the Department of Pediatric Otolaryngology ( M . T . F ., D . P ., M . L ., B . R . K .), Department of Radiology ( A . B ., N . S .), and Department of Emer- gency Medicine ( J . C .), Children’s National Health System, Washington, DC; and George Washington University School of Medicine ( A . N . R .), Washington, DC, U.S.A. Editor’s Note: This Manuscript was accepted for publication April 1, 2015. Presented at the American Society of Pediatric Otolaryngology Meeting, Las Vegas, Nevada, U.S.A., May 16–18, 2014. The authors have no funding, financial relationships, or conflicts of interest to disclose. Send correspondence to M. Taylor Fordham, MD, Department of Pediatric Otolaryngology, Children’s National Health System, 111 Michigan Ave., Washington, DC 20010. E-mail: fordham@bcm.edu

sepsis. Therefore, appropriate diagnosis and manage- ment are crucial. 2,3 Treatment is based on differentiating among PTA, peritonsillar cellulitis (PTC), and tonsillitis (viral or bac- terial); however, distinguishing these entities may be challenging based on history and physical exam alone. A prior small study found the sensitivity and specificity of using clinical impression to diagnose PTA to be only 78% and 50%, respectively. 4 Computed tomography (CT) has been shown to be the most sensitive imaging modality for diagnosis (100% sensitivity) and provides the addi- tional benefit of identifying spread of infection beyond the peritonsillar tissues. 5 Although CT is an attractive option to assist in the diagnosis of a PTA, cost and increased awareness of radiation exposure prohibit this modality from being considered standard of care, espe- cially in the pediatric population. 6–9 Procedural inter- vention, such as incision and drainage, provides clarity of diagnosis as well as potential therapeutic benefit, but this management is obviously invasive and not without risk to the child. Ultrasound (US) has been shown to reliably distin- guish PTA from PTC in a number of small-scale studies with adult patients. 4,10–14 There is currently no litera- ture addressing the use of US for peritonsillar infection in an exclusively pediatric population. Thus, the primary objective of this study was to evaluate the efficacy of US in the diagnosis of pediatric PTA. We hypothesized that

DOI: 10.1002/lary.25354

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