\documentclass[10pt]{article}

\usepackage{fullpage}
\usepackage{CJKutf8} 
\usepackage[utf8]{inputenc}
\usepackage{setspace}
\usepackage{parskip}
\usepackage{titlesec}
\usepackage[section]{placeins}
\usepackage{xcolor}
\usepackage{breakcites}
\usepackage{lineno}
\usepackage{hyphenat}





\PassOptionsToPackage{hyphens}{url}
\usepackage[colorlinks = true,
            linkcolor = blue,
            urlcolor  = blue,
            citecolor = blue,
            anchorcolor = blue]{hyperref}
\usepackage{etoolbox}
\makeatletter
\patchcmd\@combinedblfloats{\box\@outputbox}{\unvbox\@outputbox}{}{%
  \errmessage{\noexpand\@combinedblfloats could not be patched}%
}%
\makeatother


\usepackage{natbib}




\renewenvironment{abstract}
  {{\bfseries\noindent{\abstractname}\par\nobreak}\footnotesize}
  {\bigskip}

\titlespacing{\section}{0pt}{*3}{*1}
\titlespacing{\subsection}{0pt}{*2}{*0.5}
\titlespacing{\subsubsection}{0pt}{*1.5}{0pt}


\usepackage{authblk}


\usepackage{graphicx}
\usepackage[space]{grffile}
\usepackage{latexsym}
\usepackage{textcomp}
\usepackage{longtable}
\usepackage{tabulary}
\usepackage{booktabs,array,multirow}
\usepackage{amsfonts,amsmath,amssymb}
\providecommand\citet{\cite}
\providecommand\citep{\cite}
\providecommand\citealt{\cite}
% You can conditionalize code for latexml or normal latex using this.
\newif\iflatexml\latexmlfalse
\providecommand{\tightlist}{\setlength{\itemsep}{0pt}\setlength{\parskip}{0pt}}%

\AtBeginDocument{\DeclareGraphicsExtensions{.pdf,.PDF,.eps,.EPS,.png,.PNG,.tif,.TIF,.jpg,.JPG,.jpeg,.JPEG}}

\usepackage[utf8]{inputenc}
\usepackage[english]{babel}



\usepackage{float}








\begin{document}
\begin{CJK}{UTF8}{gbsn}

\title{Admission avoidance in tonsillitis and peritonsillar abscess: a
prospective national audit during the initial peak of the COVID-19
pandemic}



\author[1]{Matthew Smith}%
\affil[1]{Addenbrooke's Hospital}%


\vspace{-1em}



  
  \date{April 25, 2026}


\begingroup
\let\center\flushleft
\let\endcenter\endflushleft
\maketitle
\endgroup





\selectlanguage{english}
\begin{abstract}
Objectives To report changes in practice brought about by COVID-19 and
the implementation of new guidelines for the management of tonsillitis
and peritonsillar abscess (PTA), and to explore factors relating to
unscheduled re-presentations for patients discharged from the emergency
department (ED). Design Prospective multicentre national audit over 12
weeks from 6th April 2020. Setting UK secondary care ENT departments
Participants Adult patients with acute tonsillitis and PTA Main outcome
measures Re-presentation within 10 days for patients discharged from the
ED. Results 83 centres submitted 765 tonsillitis and 416 PTA cases.
54.4\% (n=410) of tonsillitis cases and 45.3\% (187/413) of PTA were
discharged directly from the ED. 9.6\% (39/408) of tonsillitis and
10.3\% (19/184) of PTA discharges re-presented within 10 days, compared
to 9.7\% (33/341) and 10.6\% (24/224) for those initially admitted from
ED. The subsequent admission rate of those initially discharged from ED
was 4.7\% for tonsillitis and 3.3\% for PTA. IV steroids were given to
67.0\% of tonsillitis patients (n=505/754) and 73.6\% of PTA
(n=304/413). 77.2\% of PTA patients underwent drainage during their
initial presentation (n=319/413), but there was no significant
difference in re-presentation rate in those drained Vs not-drained
(10.6\% vs 9.5\%, n=15/142 vs 4/42, p=0.846). Univariable logistic
regression showed no significant predictors of re-presentation within 10
days. Conclusions Management of tonsillitis and PTA was affected during
the initial peak of the pandemic, with a shift towards outpatient care.
Some patients who may previously have been admitted to hospital may be
safely discharged from the ED.%
\end{abstract}%



\sloppy


\section*{Introduction}

{\label{introduction}}

The SARS-CoV-2 (COVID-19) pandemic led to necessary changes in the
management of common ENT emergency presentations internationally,
including tonsillitis and peritonsillar abscess (quinsy, PTA), two of
the most common emergency presentations to ENT.\textsuperscript{1} It
has been demonstrated that COVID-19 infection leads to high viral titres
in the nasal and oral cavities,\textsuperscript{2} with virus
transmission thought to be predominantly via aerosols or droplet
formation.\textsuperscript{3,4} Aspects of the management of tonsillitis
and PTA, including oral examination, PTA drainage and flexible
nasendoscopy, were considered to represent a potential route of
transmission of COVID-19.\textsuperscript{5,6}

In March 2020, new UK guidelines were issued for the management of
tonsillitis and PTA presenting to emergency departments (ED), in light
of COVID-19.\textsuperscript{7} The major shifts in practice proposed
were: the avoidance of oral examination; the routine discharge of
patients who could swallow fluids and medications; the routine
administration of intravenous (IV) medications to effect this; and the
avoidance of PTA drainage if possible. These changes aimed to minimise
the personnel involved in managing the acute presentation, reduce oral
instrumentation, and to reduce admission rates, thus preserving hospital
bed capacity for the anticipated COVID-19 demand.

The implementation of these relatively untested guidelines resulted in
significant changes to established practices that had been shown to be
safe over many years. This article aims to:

\begin{enumerate}
\tightlist
\item
  Report the findings of a 12-week prospective audit of acute
  tonsillitis and PTA care, conducted during the initial peak of
  COVID-19 in the UK.
\item
  Explore factors relating to unscheduled re-presentation to hospital in
  tonsillitis and PTA patients discharged from the ED.
\end{enumerate}

\section*{Methods}

{\label{methods}}

The protocol for this study was published in advance
at\emph{https://entintegrate.co.uk}. This manuscript has been prepared
with reference to the STROBE~checklist for cohort
studies.\textsuperscript{8}

\subsection*{Ethical considerations}

{\label{ethical-considerations}}

The Health Research Authority decision tool determined the study design
to fall under the remit of audit, and so no ethical approval was
required (available
at:\emph{http://www.hra-decisiontools.org.uk/research/}).

\subsection*{Study design and setting}

{\label{study-design-and-setting}}

A national prospective audit of the hospital management of tonsillitis
and PTA by UK secondary care ENT departments was conducted, in parallel
to an audit of acute epistaxis emergency care.\textsuperscript{9} The
audit was developed and run by INTEGRATE, the UK ENT Trainee Research
Network. All UK ENT departments were invited to participate via
advertisement, and registration with local audit and Clinical Governance
Departments was required. Sites could open at any point during the
prospective data collection period.

\subsection*{Participants}

{\label{participants-1}}

Consecutive patients with tonsillitis and PTA, aged 18 years and older,
and referred to ENT secondary care, were eligible for inclusion, whether
managed by telephone advice or face-to-face review.

\subsection*{Data collection}

{\label{data-collection}}

Eligible cases were identified over a 12 week period, between 6th April
and 29th June 2020. Each case was followed-up for 10 days. A
standardised electronic case report form was created using Excel
software (Microsoft Corporation, Washington, USA) and made available
online (Supplementary material ***), incorporating data validation to
encourage valid data entry and completeness. Data were initially held
offline at each centre, and patient identifiable data were removed prior
to submission to the project management team. Data were collected on:
patient demographics; COVID-19 status; reviewing clinicians; IV
medications and their effect; discharge medications; examinations
performed; and PTA drainage.

\subsection*{Interim reports}

{\label{interim-reports}}

The 12 week audit was divided into three 4-week periods. Two interim
reports were produced (after periods 1 and 2) allowing for rapid
feedback of management and preliminary outcomes to the UK ENT community.
Both interim reports were disseminated electronically via ENTUK mailouts
within 10 days of data submission and hosted online
at\emph{https://entuk.org} and\emph{https://entintegrate.co.uk}.

\subsection*{Data analysis}

{\label{data-analysis}}

The primary outcome was unscheduled re-presentation to hospital within
10 days for ED discharges. This intended to assess the safety of the
lower rates of admission anticipated.

Univariable binary logistic regression analysis was used to identify
significant determinants of the primary outcome measure. The level of
significance was set at \textless{}0.05 with Bonferroni corrections
applied, where applicable. Analysis was performed using R statistical
software (R Foundation, Vienna, Austria).

\section*{Results}

{\label{results-1}}

\subsection*{Centres}

{\label{centres}}

Data were submitted by 83/86 UK centres who registered to take part (72
in England, 5 in Scotland, 3 in Wales and 3 in Northern Ireland). 2/83
centres submitted data covering the first period only. The dates centres
opened are shown in figure 1, alongside the median rates of tonsillitis
and PTA cases referred per centre per week.

\subsection*{Submissions}

{\label{submissions}}

1,181 cases met the prespecified eligibility criteria across the three
periods (765 tonsillitis cases {[}276, 212 and 277 cases respectively{]}
and 416 PTA cases {[}131, 129 and 156 cases respectively{]}).
Characteristics of both populations are shown in tables 1 and 2. Data
completeness was 99.2\% (n=592/597) of cases having data for the primary
outcome.

\subsection*{COVID-19}

{\label{covid-19}}

Figure 1 shows the number of patients with suspected or confirmed
COVID-19, at the time of presentation and following testing, for the
three audit periods, alongside the UK incidence of COVID-19.

\subsection*{Acute management of ED
patients}

{\label{acute-management-of-ed-patients}}

An oral examination was performed in 91.0\% of tonsillitis patients and
91.7\% of PTA patients (n=678/745 and n=376/410). FNE was performed in
4.6\% of tonsillitis patients and 9.5\% of PTA patients (n=34/745 and
n=39/410).

The rates of use of IV medications are shown in tables 1 and 2. IV
antibiotics were given in 79.6\% of tonsillitis patients (n=600/754) and
89.6\% of PTA patients (n=370/413). IV steroids were given in 67.0\% of
tonsillitis patients (n=505/754) and 73.6\% of PTA patients (n=304/413).

Suspected PTA underwent attempted drainage in 77.2\% of cases
(n=319/413). Needle aspiration was used in 78.6\% of these cases
(n=246/313) and produced pus in 54.4\% (n=134/246). Incision and
drainage was used in 21.4\% (n=67/313) and produced pus in 82.1\%
(n=55/67). Using either method, pus was obtained in 60.4\% (n=189/313).

Telephone advice only was given by way of remote management in 6.6\% of
tonsillitis cases (n=50/759) and 3.6\% of PTA cases (n=15/413).

For tonsillitis cases, when seen face to face (n=709), the majority of
patients were reviewed by pre-specialty grade junior doctors (51.6\%,
n=366) followed by specialty grade junior doctors (40.2\%, n=285),
consultants (6.1\%, n=43), and nurse practitioners (2.1\%, n=15).

For PTA cases, when seen face to face (n=398), the majority of patients
were reviewed by pre-specialty grade junior doctors (48.2\%, n=192)
followed by specialty grade junior doctors (41.2\%, n=164), consultants
(7.8\%, n=31), and nurse practitioners (2.8\%, n=11).

\subsection*{Admission to hospital from
ED}

{\label{admission-to-hospital-from-ed}}

Tables 1 and 2 show the discharge rates for tonsillitis and PTA patients
reviewed by ENT after presenting to the ED. The overall discharge rate
was 54.4\% for tonsillitis (n=410/754) and 45.3\% for PTA (n=187/413).
These data are also visualised in Figures 3 and 4.

Discharge rates from ED before and after \emph{statim} IV medications
were as follows: tonsillitis 17.6\% (n=133/754) and 44.6\% (n=277/754);
PTA 9.0\% (n=37/413) and 39.9\% (150/376), respectively.

Length of stay data were available for all eligible patients admitted to
hospital. Patients staying [?]1 day, [?]2 days and [?]3 days were as follows:
tonsillitis 61.9\%, 38.1\%, 14.2\% (n=213/344, 131/344, and 49/344) and
PTA 61.9\%, 38.1\%, 12.4\% (n=140/226, 86/226, and 28/226).

\subsection*{Planned follow up for ED
discharges}

{\label{planned-follow-up-for-ed-discharges}}

No follow-up was arranged in 71.7\% of tonsillitis patients (n=294/410)
with 5.9\% having face-to-face (n=81/410) and 19.8\% having telephone
appointments scheduled (n=81/410) (9 reported as `other', 2 directly
listed for tonsillectomy).

No follow-up was arranged in 50.3\% of PTA patients (n=94/187) with
8.6\% having face-to-face (n=16/187) and 38.5\% having telephone
appointments scheduled (n=72/187) (5 reported as `other').

\subsection*{Unscheduled re-presentation within 10
days}

{\label{unscheduled-re-presentation-within-10-days}}

Re-presentation rates and outcomes from re-presentation are shown in
table 3. Further detail for ED discharges, by patient and management
factors, are shown in tables 1 and 2.

Univariable logistic regression showed no significant predictors of
re-presentation within 10 days (tables 1 and 2). No deaths were
recorded.

\par\null

\section*{Discussion}

{\label{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.

\subsection*{COVID-19, tonsillitis and peritonsillar
abscess}

{\label{covid-19-tonsillitis-and-peritonsillar-abscess}}

Sore throat and pharyngeal inflammation are recognised manifestations of
COVID-19,\textsuperscript{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.\textsuperscript{11} Coronaviruses are not one of
the known viral pathogens frequently contributing to acute
tonsillitis.\textsuperscript{12} The only comparable pre-COVID-19
presentation data comes from the UK multicentre audit of quinsies
(MAQ),\textsuperscript{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,\textsuperscript{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.\textsuperscript{15}

\subsection*{Changes to care during the COVID-19
pandemic}

{\label{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,\textsuperscript{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,\textsuperscript{16,18} and only 8\% of PTA cases discharged from ED
in 2014.\textsuperscript{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.\textsuperscript{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.\textsuperscript{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.\textsuperscript{13}

\subsection*{Drivers of clinical decision
making}

{\label{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.\textsuperscript{16--18,23}Unsurprisingly, the inability to
swallow fluids and medications, especially after \emph{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.

\subsection*{Outcomes from outpatient
care}

{\label{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,\textsuperscript{16,17} and considerably lower than the 30-day
figure from MAQ.\textsuperscript{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.

\subsection*{Implications for clinical
practice}

{\label{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.

\subsection*{Strengths and limitations of the
study}

{\label{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.

\section*{Conclusion}

{\label{conclusion}}

Presentations with tonsillitis and PTA during the initial peak of the
COVID-19 pandemic were below previous rates. The management of these
cases was notably different, with high rates of IV steroid use,
avoidance of PTA drainage for some patients, and an overall shift
towards outpatient care. This national study highlights that many
patients who may previously have been admitted to hospital following
their acute assessment and management, may be safely discharged from the
ED.

\section*{References}

{\label{references}}

1 NHS Digital (2017) NHS Hospital Episode Statistics in England and
Wales. .

2 Harcourt J., Tamin A., Lu X., \emph{et al.} (2020) Severe Acute
Respiratory Syndrome Coronavirus 2 from Patient with Coronavirus
Disease, United States. \emph{Emerging Infect. Dis.} \textbf{26} ,
1266--1273.

3 Thamboo A., Lea J., Sommer D.D., \emph{et al.} (2020) Clinical
evidence based review and recommendations of aerosol generating medical
procedures in otolaryngology - head and neck surgery during the COVID-19
pandemic. \emph{J Otolaryngol Head Neck Surg} \textbf{49} , 28.

4 Workman A.D., Welling D.B., Carter B.S., \emph{et al.} (2020)
Endonasal instrumentation and aerosolization risk in the era of
COVID-19: simulation, literature review, and proposed mitigation
strategies. \emph{Int Forum Allergy Rhinol} \textbf{10} , 798--805.

5 To K.K.-W., Tsang O.T.-Y., Yip C.C.-Y., \emph{et al.} (2020)
Consistent Detection of 2019 Novel Coronavirus in Saliva. \emph{Clin.
Infect. Dis.} \textbf{71} , 841--843.

6 Curran J., Calder N., Yaneza M., \emph{et al.} (2020) Reducing
potential aerosol generation in flexible nasolaryngoscopy: a novel
method. \emph{J Laryngol Otol} \textbf{ePub ahead of print} .

7 McNally G., Burgess A., Agrawal S., \emph{et al.} (2020) ENT UK
COVID-19 Adult Tonsillitis \& Quinsy Guidelines. .

8 von Elm E., Altman D.G., Egger M., \emph{et al.} (2008) The
Strengthening the Reporting of Observational Studies in Epidemiology
(STROBE) statement: guidelines for reporting observational
studies.\emph{J Clin Epidemiol} \textbf{61} , 344--349.

9 INTEGRATE (The UK ENT research trainee network) (2020) Admission
avoidance in acute epistaxis: a prospective national audit during the
initial peak of the COVID-19 pandemic. \emph{Clin
Otolaryngol}\textbf{Submitted} .

10 El-Anwar M.W., Elzayat S. \& Fouad Y.A. (2020) ENT manifestation in
COVID-19 patients. \emph{Auris Nasus Larynx} \textbf{ePub ahead of
print} .

11 Proenca-Modena J.L., Pereira Valera F.C., Jacob M.G., \emph{et
al.}(2012) High rates of detection of respiratory viruses in tonsillar
tissues from children with chronic adenotonsillar disease. \emph{PLoS
ONE} \textbf{7} , e42136.

12 Sidell D. \& Shapiro N.L. (2012) Acute tonsillitis. \emph{Infect
Disord Drug Targets} \textbf{12} , 271--276.

13 ENT Trainee Research Collaborative -- West Midlands (2016) National
prospective cohort study of peritonsillar abscess management and
outcomes: the Multicentre Audit of Quinsies study. \emph{J Laryngol
Otol} \textbf{130} , 768--776.

14 Klug T.E. (2014) Incidence and microbiology of peritonsillar abscess:
the influence of season, age, and gender. \emph{Eur. J. Clin. Microbiol.
Infect. Dis.} \textbf{33} , 1163--1167.

15 Hartnett K.P., Kite-Powell A., DeVies J., \emph{et al.} (2020) Impact
of the COVID-19 Pandemic on Emergency Department Visits - United States,
January 1, 2019-May 30, 2020. \emph{MMWR Morb. Mortal. Wkly.
Rep.}\textbf{69} , 699--704.

16 Bird J.H., Biggs T.C. \& King E.V. (2014) Controversies in the
management of acute tonsillitis: an evidence-based review. \emph{Clin
Otolaryngol} \textbf{39} , 368--374.

17 Ashman A. \& Harris R. (2017) Outpatient management of patients with
acute tonsillitis and peritonsillar abscess in ninety adult
patients.\emph{Clin Otolaryngol} \textbf{42} , 720--723.

18 Mohammed H., Jin X., Masterson L., \emph{et al.} (2017) Ambulant
management of acute tonsillitis in adult patients, a study on 330
patients. \emph{Clin Otolaryngol} \textbf{42} , 897--901.

19 Hardman J.C., McCulloch N.A. \& Nankivell P. (2015) Do
corticosteroids improve outcomes in peritonsillar
abscess?\emph{Laryngoscope} \textbf{125} , 537--538.

20 Ozbek C., Aygenc E., Tuna E.U., \emph{et al.} (2004) Use of steroids
in the treatment of peritonsillar abscess. \emph{J Laryngol
Otol}\textbf{118} , 439--42.

21 Chau J.K.M., Seikaly H.R., Harris J.R., \emph{et al.} (2014)
Corticosteroids in peritonsillar abscess treatment: A blinded
placebo-controlled clinical trial: Dexamethasone in
PTA.\emph{Laryngoscope} \textbf{124} , 97--103.

22 Forner D., Curry D.E., Hancock K., \emph{et al.} (2020) Medical
Intervention Alone vs Surgical Drainage for Treatment of Peritonsillar
Abscess: A Systematic Review and Meta-analysis. \emph{Otolaryngol Head
Neck Surg} \textbf{ePub ahead of print} .

23 National Institute for Health and Clinical Excellence (2018) Clinical
Knowledge Summary: Sore throat - acute. .

\section*{Tables and figures}

{\label{tables-and-figures}}

\textbf{Table 1:} Characteristics of tonsillitis population, with
proportions admitted/discharged and re-presentation rates for ED
discharges (with univariable regression analysis).

\textbf{Table 2:} Characteristics of PTA population, with proportions
admitted/discharged and re-presentation rates for ED discharges (with
univariable regression analysis).

\textbf{Table 3:} Re-presentation rates and outcomes from
re-presentation by condition and admission status.

\textbf{Figure 1:} Combination graphic to communicate trends in data
over 12-week audit period: 1) The bar chart forming the background shows
sequential opening of centres across the UK as the audit period
progressed, 2) The box and whisker plots show the median, range and
interquartile range of tonsillitis and quinsy patients presenting per
centre per week for each of the three 4-week audit periods, 3) The
scatter plot and error bars are COVID-19 swab rates (\%) (diamonds) and
positive swab rates (\%) (crosses) with 95\% confidence intervals, 4)
The grey line chart is the 7-day rolling average of UK cases from 1st
March to 31st July (available
at:\emph{https://coronavirus.data.gov.uk/cases}).

\textbf{Figure 2:} Sankey chart visualising proportions of patients
being admitted or discharged from the ED, with rates of subsequent
re-presentation, stratified by A) IV steroid use for tonsillitis
patients and B) drainage for PTA patients.

\textbf{Table 1:} Characteristics of tonsillitis population, with
proportions admitted/discharged and re-presentation rates for ED
discharges (with univariable regression analysis).

\textbf{Variable}

\textbf{Status}

\textbf{ED admissions}

\% (n)

\textbf{ED discharges}

\% (n)

\textbf{Re-presentation rates of}

ED discharges

\% (n)

\textbf{Univariable logistic regression}

p value

Overall

-

45.6 (344/754)

54.4 (410/754)

9.6 (39/408)

-

Sex

Female

45.3 (196/433)

54.7 (237/433)

10.6 (25/236)

0.406

Male

46.1 (148/321)

53.9 (173/321)

8.1 (14/172)

Age in years

Cohort Median (Range) (Interquartile range)

26.5 (18 to 86) (21 to 34)

27 (18 to 86) (21 to 35)

Re-presented vs no 23 vs 27 (18 to 68) vs (18 to 86) (20 to 37) vs (21
to 34)

0.791

Previous course of oral antibiotics

No

48.3 (184/381)

51.7 (197/381)

8.1 (16/197)

0.342

Yes

42.9 (160/373)

57.1 (213/373)

10.9 (23/211)

Examinations

None

23.9 (16/67)

76.1 (51/67)

7.8 (4/51)

0.679

Yes (any)

47.8 (324/678)

52.2 (354/678)

9.7 (34/352)

Oral exam only

46.1 (297/644)

53.9 (347/644)

9.6 (33/345)

0.694

FNE only

(0/0)

(0/0)

(0/0)

-

Oral exam \& FNE

79.4 (27/34)

20.6 (7/34)

14.3 (1/7)

0.575

Swallowing fluids/medications \textbf{prior} to IV medications?

No

60.1 (291/484)

39.9 (193/484)

8.8 (17/193)

0.625

Yes

19.6 (53/270)

80.4 (217/270)

10.2 (22/215)

Swallowing fluids/medications \textbf{after} IV medications?

No

97.6 (163/167)

2.4 (4/167)

0 (0/4)

0.991

Yes

38.8 (171/441)

61.2 (270/441)

7.8 (21/269)

Statim IV medications

None

7.6 (11/144)

92.4 (133/144)

13.5 (18/133)

0.125

Yes (any)

54.6 (333/610)

45.4 (277/610)

7.6 (21/275)

IV antibiotics only

60.0 (63/105)

40.0 (42/105)

12.7 (30/237)

0.146

IV steroids only

20.0 (2/10)

80.0 (8/10)

11.1 (1/9)

0.986

IV antibiotics \& steroids

54.1 (268/495)

45.9 (227/495)

7.1 (3/42)

0.126

Discharge medications

None

-

(16)

12.5 (2/16)

0.652

Yes (any)

-

(374)

9.1 (34/372)

Oral antibiotics only

-

(350)

8.6 (30/348)

0.595

Oral steroids only

-

(2)

50.0 (1/2)

0.225

Oral antibiotics \& steroids

-

(22)

13.6 (3/22)

0.919

\textbf{Table 2:} Characteristics of PTA population, with proportions
admitted/discharged and re-presentation rates for ED discharges (with
univariable regression analysis).

\textbf{Variable}

\textbf{Status}

\textbf{ED admissions}

\% (n)

\textbf{ED discharges}

\% (n)

\textbf{Re-presentation rates of}

ED discharges

\% (n)

\textbf{Univariable logistic regression}

p value

Overall

-

54.7 (226/413)

45.3 (187/413)

10.3 (19/184)

-

Sex

Female

58.5 (93/159)

41.5 (66/159)

6.2 (4/65)

0.178

Male

52.4 (133/254)

47.6 (121/254)

12.5 (15/120)

Age in years

Cohort Median (Range) (Interquartile range)

- 31 (18 to 91) (25 to 42.75)

- 31 (18 to 85) (23 to 42.5)

Re-presented vs no 31 vs 32 (18 to 76) vs (18 to 85) (25 to 51.5) vs (23
to 42)

0.407

Previous course of oral antibiotics

No

55.8 (121/217)

44.2 (96/217)

9.6 (9/94)

0.713

Yes

53.8 (105/195)

46.2 (90/195)

11.2 (10/89)

Examinations

None

32.4 (11/34)

67.6 (23/34)

8.7 (2/23)

0.770

Yes (any)

56.9 (214/376)

43.1 (162/376)

10.7 (17/159)

Oral exam only

55.2 (186/337)

44.8 (151/337)

10.1 (15/148)

0.830

FNE only

(0/0)

(0/0)

(0/0)

-

Oral exam \& FNE

71.8 (28/39)

28.2 (11/39)

18.2 (2/11)

0.431

Swallowing fluids/medications \textbf{prior} to IV medications?

No

63.2 (203/321)

36.8 (118/321)

11.2 (13/116)

0.609

Yes

25.0 (23/92)

75.0 (69/92)

8.8 (6/68)

Swallowing fluids/medications \textbf{after} IV medications?

No

89.8 (97/108)

10.2 (11/108)

20 (2/10)

0.439

Yes

47.9 (127/265)

52.1 (138/265)

11.6 (16/138)

Statim IV medications

None

7.5 (3/40)

92.5 (37/40)

2.9 (1/35)

0.140

Yes (any)

59.8 (223/373)

40.2 (150/373)

12.1 (18/149)

IV antibiotics only

66.7 (46/69)

33.3 (23/69)

4.3 (1/23)

0.762

IV steroids only

0 (0/3)

100 (3/3)

0 (0/3)

0.992

IV antibiotics \& steroids

58.8 (177/301)

41.2 (124/301)

13.8 (17/123)

0.105

Discharge medications

None

-

(17)

12.5 (2/16)

0.785

Yes (any)

-

(167)

10.3 (17/165)

Oral antibiotics only

-

(155)

1.4 (2/140)

0.734

Oral steroids only

-

(0)

(0/0)

-

Oral antibiotics \& steroids

-

(12)

60.0 (15/25)

0.756

Drainage

None

54.3 (51/94)

45.7 (43/94)

9.5 (4/42)

0.846

Yes (any)

54.9 (175/319)

45.1 (144/319)

10.6 (15/142)

I\&D (any)

61.2 (41/67)

38.8 (26/67)

7.7 (2/26)

0.583

Needle aspiration (any)

52.8 (130/246)

47.2 (116/246)

11.4 (13/114)

I\&D, no pus

75.0 (9/12)

25.0 (3/12)

0 (0/3)

0.992

I\&D, Pus

58.2 (32/55)

41.8 (23/55)

8.7 (2/23)

0.912

Needle aspiration, no pus

50.9 (57/112)

49.1 (55/112)

16.4 (9/55)

0.333

Needle aspiration, Pus

54.5 (73/134)

45.5 (61/134)

6.8 (4/59)

0.616

No pus (either method)

53.2 (66/124)

46.8 (58/124)

15.5 (9/58)

0.130

Pus (either method)

55.6 (105/189)

44.4 (84/189)

7.3 (6/82)

\textbf{Table 3:} Re-presentation rates and outcomes from
re-presentation by condition and admission status.

\textbf{Cohort}

\textbf{Re-presentation rate}

\% (n)

\textbf{Drainage attempted}

after re-presentation

\% (n)

\textbf{Admission rate}

after re-presentation

\% (n)

\textbf{Admission rate after re-presentation as proportion of initial
presentation management}

\% (n)

Tonsillitis admissions

9.7 (33/341)

24.2 (8/33)

66.7 (22/33)

6.5 (22/341)

Tonsillitis discharges

9.6 (39/408)

7.7 (3/38)

50.0 (19/38)

4.7 (19/408)

PTA admissions

10.7 (24/224)

70.8 (17/24)

83.3 (20/24)

8.9 (20/224)

PTA discharges

10.3 (19/184)

63.2 (12/19)

31.6 (6/19)

3.3 (6/184)\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/image1/image1}

\end{center}
\end{figure}

\textbf{Figure 1:} Combination graphic to communicate trends in data
over 12-week audit period: 1) The bar chart forming the background shows
sequential opening of centres across the UK as the audit period
progressed, 2) The box and whisker plots show the median, range and
interquartile range of tonsillitis and quinsy patients presenting per
centre per week for each of the three 4-week audit periods, 3) The
scatter plot and error bars are COVID-19 swab rates (\%) (diamonds) and
positive swab rates (\%) (crosses) with 95\% confidence intervals, 4)
The grey line chart is the 7-day rolling average of UK cases from 1st
March to 31st July (available
at:\emph{https://coronavirus.data.gov.uk/cases}).\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/image2/image2}

\end{center}
\end{figure}

\textbf{Figure 2:} Sankey chart visualising proportions of patients
being admitted or discharged from the ED, with rates of subsequent
re-presentation, stratified by A) IV steroid use for tonsillitis
patients and B) drainage for PTA patients.

\textbf{Hosted file}

\verb`Table 1.docx`  available at \url{https://authorea.com/users/356700/articles/479543-admission-avoidance-in-tonsillitis-and-peritonsillar-abscess-a-prospective-national-audit-during-the-initial-peak-of-the-covid-19-pandemic}

\textbf{Hosted file}

\verb`Table 2.docx`  available at \url{https://authorea.com/users/356700/articles/479543-admission-avoidance-in-tonsillitis-and-peritonsillar-abscess-a-prospective-national-audit-during-the-initial-peak-of-the-covid-19-pandemic}

\textbf{Hosted file}

\verb`Table 3.docx`  available at \url{https://authorea.com/users/356700/articles/479543-admission-avoidance-in-tonsillitis-and-peritonsillar-abscess-a-prospective-national-audit-during-the-initial-peak-of-the-covid-19-pandemic}\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/TQ-Figure-1/TQ-Figure-1}

\end{center}
\end{figure}\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/TQ-Figure-2/TQ-Figure-2}

\end{center}
\end{figure}

\selectlanguage{english}
\FloatBarrier
\end{CJK}\end{document}

