# 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.