Does smoking increase the risk of peritonsillar abscess formation?
The latest Paper of the Month from The Journal of Laryngology & Otology is ‘Analysis of smoking behaviour in patients with peritonsillar abscess: a prospective, matched case-control study’ by D Schwarz, P Wolber, M Balk, and J C Luers.
In this post, the Senior Editors of The Journal of Laryngology & Otology introduce the topic.
Although previous retrospective studies have identified a link between smoking and peritonsillar abscess formation, this has not been tested in a prospective study. In September’s issue of The Journal of Laryngology & Otology, Schwarz et al investigate whether smoking increases the risk of peritonsillar abscess formation.1 The authors of this study identified a statistically significant association between peritonsillar abscess formation and smoking (p = 0.025), in agreement with previous retrospective studies.2 Of the 325 cases of peritonsillar abscess in the National Prospective Quinsy Audit, 17% of patients had a smoking history, although a smoking history was not independently predictive of a 30-day adverse event.3 The authors of this latest study postulate that smoking leads to injury to the oropharyngeal mucosa, thereby increasing the likelihood of developing abscess formation. Smoking may also increase the risk of abscess formation by altering the tonsillar bacterial flora and/or the local and systemic immunological milieu.
Waiting lists for elective surgery are a topical issue in many publicly funded healthcare systems. In order to reduce waiting times for surgery, McLaren et al introduced a pathway for audiologists to directly schedule children for grommet insertion, meeting National Institute for Health and Care Excellence Clinical Guideline 60 (‘CG60’).4 Prior to implementation of the new pathway mean duration between the first audiology appointment and grommet insertion was 294.5 days. Implementation of the new pathway led to a significant reduction in the time interval between the first audiology appointment and surgery (mean duration 232 days, a reduction of 62.5 days; p = 0.024). The authors stress that the ultimate decision regarding surgery still rests with ENT specialists. In addition, the new pathway places greater responsibility on the audiology team regarding surgical based treatments. Indeed, this may account for the low number of patients adopting the new pathway. Alternatively the low numbers being referred directly for grommets by the audiology team may reflect a tighter adherence to NICE guidelines by audiologists following a strict protocol. Other ENT departments may choose to adopt such a pathway in order to improve service provision, following consultation with their local audiology departments.
Finally, Noor et al review the indications for panendoscopy in the work-up of patients with newly diagnosed head and neck squamous cell carcinoma.5 Obtaining a tissue diagnosis was still the most common indication for panendoscopy.6 However, the authors conclude that panendoscopy remains paramount in the assessment of suitability for transoral robotic surgery and in the investigation of the unknown primary.7 Interestingly, the authors identified only a 1.1% risk of synchronous second primary tumour, of which all were P16 negative, suggesting that the increase in HPV-related disease is responsible for this reduction.8,9
1 Schwarz D, Wolber P, Balk M, Luers JC. Analysis of smoking behaviour in patients with peritonsillar abscess: a prospective, matched case-control study. J Laryngol Otol 2018;132:pp
2 Klug TE, Rusan M, Clemmensen KK, Fuursted K, Ovesen T. Smoking promotes peritonsillar abscess. Eur Arch Otorhinolaryngol 2013;270:3163-7
3 ENT Trainee Research Collaborative – West Midlands. Mitchell-Innes A, Abdelrahim A, Muzaffar J, Douglas J, Walton J, Hardman J et al. National prospective cohort study of peritonsillar abscess management and outcomes: the Multicentre Audit of Quinsies study. J Laryngol Otol 2016;130:768-76
4 McLaren O, Toll EC, Easto R, Willis E, Harris S, Rainsbury J. Streamlining grommet pathways for otitis media with effusion and hearing loss in children: our experience. J Laryngol Otol 2018;132:pp
5 Noor A, Stepan L, Kao SS, Dharmawardana N, Ooi EH, Hodge JC et al. Reviewing indications for panendoscopy in the investigation of head and neck squamous cell carcinoma. J Laryngol Otol 2018;132:pp
6 Roland N, Porter G, Fish B, Makura Z. Tumour assessment and staging: United Kingdom National Multidisciplinary Guidelines. J Laryngol Otol 2016;130:S53-8
7 Mackenzie K, Watson M, Jankowska P, Bhide S, Simo R. Investigation and management of the unknown primary with metastatic neck disease: United Kingdom National Multidisciplinary Guidelines. J Laryngol Otol 2016;130:S170-5
8 Jain KS, Sikora AG, Baxi SS, Morris LG. Synchronous cancers in patients with head and neck cancer: risks in the era of human papillomavirus-associated oropharyngeal cancer. Cancer 2013;119:1832-7
9 Hamilton D, Khan MK, O’hara J, Paleri V. The changing landscape of oropharyngeal cancer management. J Laryngol Otol 2017;131:3-7
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