Steroids in peritonsillar abscess treatment: A controlled clinical trial'

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Steroids in peri-tonsillar abscess treatment A
controlled clinical trial.

• Brian H. Rowe, MD, MSc, CCFP(EM)
• Canada Research Chair in Emergency Airway
  Diseases
• Department of Emergency Medicine
• University of Alberta

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Disclosure

• The research team does not have any affiliation
  with a commercial organization that may have a
  direct or indirect connection to the content of
  this presentation.

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Collaborators

• ENT Program
• PI Chau JKM
• Co-I Seikaly HR, Harris JR.
• Department of Emergency Medicine
• Brick C, Willis V, Villa-Roel C.
• EMeRG research nurses/staff.

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Introduction

• Sore throat is a common ED presentation
• 1-2 of all ED presentations in the US
• Most cases of sore throat have a viral etiology,
  are benign, and self-limited.
• Group A beta-hemolytic streptococcus (GABHS)
  occurs in
• 15 of adults
• 30 of children.

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PTA

• Peri-tonsillar abscess (PTA) is perhaps the most
  common complication of GABHS infection and
  requires aggressive management
• ID
• Antibiotics.
• Research suggests that corticosteroids are
  effective in sore throat treatment.
• CS are used without firm evidence of benefit in
  PTA.

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Rationale/objectives

• One major controversies surrounding PTA
  management is the efficacy and safety of
  adjunctive corticosteroids.

To examine the efficacy and safety of systemic
corticosteroids treatment for patients with PTA.
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Methods

• Controlled clinical trial with concealed
  allocation, central randomization, and double
  blinding.
• Two Canadian EDs (Edmonton, AB).
• Selection criteria
• Age gt 18 years
• Physician diagnosis of PTA
• Abscess needle aspiration/drainage attempted
• Physician-based criteria for discharge.

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Study flow chart
Emergency Department discharge
?
IV DEXAMETHASONE 10 mg in 50 cc saline
Emergency DepartmentTreatment
Clindamycin 600 mg IV TID X 48 hours
A
Clindamycin 600 mg po TID X 5 days
Clindamycin 600 mg IV TID X 48 hours
Screening and consent
IV Placebo in 50 cc saline
Days 0 1 2 7 Data ED Visit Diary Clinic
Visit Telephone
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Results
Most common exclusion was coexisting CS treatment
(19)
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Results
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Results
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Results
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Results
Pain score at discharge was 6.1 2.6.
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Results
Back to normal diet
38
25
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Results
Back to normal activity level

33
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p0.05
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Results
Side effects at 48 hours
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Limitations

• Small sample size
• Study stopped due to funding and enrollment
  issues
• Clinician are using this therapy frequently and
  enrollment of more patients became impossible.
• No valid outcome measure for the trial apart from
  pain relief.
• Long-term follow-up was not possible given the
  level of funding provided.

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Discussion

• This is only the second controlled clinical trial
  of systemic corticosteroids vs placebo in the
  treatment of acute PTA following a drainage
  attempt.
• Excellent follow-up of patients and significant
  results despite not reaching SS.
• The other (Turkish) PTA CS trial revealed
• RCT IM MP (n34) vs. placebo (n28) in admitted
  pts
• Difference in trismus severity, dysphagia,
  temperature, and hospital LOS favoring
  corticosteroids without any increased
  complications.

Ozbek C, et al. J Laryngol Otol. 2004
118(6)439-42.
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Conclusion

• Combined with PTA needle aspiration and IV
  antibiotics, 10 mg IV DEX resulted in less pain
  at 24 hours when compared to placebo.
• No serious side effects were observed however,
  the sample is small and the duration of follow-up
  was short.
• The benefits of systemic corticosteroids appear
  small and the decision regarding their use likely
  still requires a larger RCT.

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Acknowledgements

• Funding
• UAH Foundation for providing funding for this
  study.
• Investigators and Research Nurses at UAH and
  NECHC sites.
• In-kind resources
• Department of Emergency Medicine, University of
  Alberta.

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Thank you!

• Questions?