Introduction
A peritonsillar abscess or ‘quinsy’ forms as a result of the spread of infection from the superior pole of the tonsil into the potential space between the tonsillar capsule and its pharyngeal muscle bed, and is said to be the principal complication of bacterial tonsillitis.Reference Gleeson1 Thus, quinsy is one of the most common ENT emergencies,Reference Khayr and Taepke2 and the most prevalent presenting deep space infection of the head and neck.3
Clinically, those affected present with severe pharyngitis, usually lateralised to one side, voice change and trismus, often with marked associated lymphadenopathy. This results in a severe local and systemic illness that requires a combination of supportive treatment and antibiotic therapy, in addition to local drainage of the pus by aspiration through the supratonsillar fold.Reference Gleeson1
Peritonsillar abscess patients frequently feel markedly better following pus drainage; it is therefore paramount that these patients are treated quickly and safely. The location of the abscess at the back of the oropharynx, and the associated trismus caused by irritation to the medial pterygoid muscle, present an interesting challenge to the inexperienced clinician, as the procedure requires a certain degree of dexterity and skill.Reference Murphy, Murphy and Sama4 These patients are frequently assessed and managed by the junior resident ENT surgeon, who performs the drainage procedure in the emergency department or ENT treatment room. To ensure patient safety and optimum care, it is imperative that the clinician is adequately trained.
The implementation of the European Working Time Directive and Modernising Medical Careers training programme, necessitating cross-specialty cover and a short (four-month) duration of foundation posts,5 has resulted in an increasing number of inexperienced doctors rotating through otolaryngology departments and providing emergency care to ENT patients. As numerous acute ENT conditions require basic surgical or technical intervention, it is not surprising that effective and efficient simulation induction training has become paramount in providing a safe yet valuable educational environment for the junior clinician. Whilst simulation has developed over the years for numerous procedural-based ENT skills, and plays a pivotal role in induction programmes and introductory ENT courses around the country, there has not yet been a realistic and easily reproducible model for teaching the skills needed to manage quinsy.
There have been previous attempts to create a quinsy simulator. Murphy et al. described the ‘Quinsy Trainer’, using water balloons inserted into the oropharynx of a manikin.Reference Murphy, Murphy and Sama4 Following this, Taylor and Chang introduced a more realistic simulator.Reference Taylor and Chang6 Here, we suggest a simple, reusable and realistic simulation model for providing safe training in the drainage of quinsy.
Materials and methods
A simple silicone tonsil mould was developed by the in-house dental technicians for insertion into the oral cavity of the Laryngotech simulator (Ruislip, Middlesex, UK),7 or any other commonly used intubation manikin head. This mould was developed using a walnut impression to represent the irregular appearance of a tonsil with associated peritonsillar swelling (Figure 1a). A small fenestration in the mould was created in the superior pole to allow the insertion and removal of a cod liver oil capsule (Figure 1b and 1c).
Examples of the tonsil moulds: (a) tonsil mould with fenestration at superior pole, (b) cod liver oil capsule, (c) tonsil mould with capsule being inserted and (d) tonsil mould with capsule fully inserted.
A cod liver oil capsule is fully inserted into the mould to represent a pointing peritonsillar abscess (Figure 1d). The cod liver oil capsule (Figure 1b) replicates the abscess contents by providing a foul-smelling, discoloured material that can be easily aspirated with a needle and syringe (Figure 2).
Needle with aspirated contents of a cod liver oil capsule.
Once the capsule is inserted into the mould, the mould is then mounted to the oropharynx of the manikin via the oral cavity. This is accomplished using a sticky hook and loop pads to allow easy and repeatable insertion and removal (Figure 3). The manikin head can be used in any suitable training setting; patient position is represented by wall mounting at an appropriate height using suction cup attachment. The trainee can then attempt drainage in a safe environment with direct supervision from the trainer, who, in turn, can offer tips on optimum aspiration point, patient position and safe handling of instruments. At this stage, it is recommended gloves be worn as the aspirate contents are quite unpleasant.
Tonsil mould positioned in the manikin ready for aspiration.
Once the procedure has been completed, the silicone mould can simply be removed, the empty cod liver oil capsule discarded and a new capsule re-inserted, before being repositioned for the next attempt. This will give multiple trainees the opportunity to perform the procedure as frequently as required to become competent. As trainee confidence and ability improve, the scenario can be made more challenging by introducing varying degrees of trismus by simply applying tape around the lower jaw of the manikin with various degrees of tension (Figure 4).
Manikin with and without trismus: (a) without tape and (b) with tape to reduce mouth opening.
Discussion
We feel that this adaptation of the Laryngotech trainer closely represents a medialised tonsil and small peritonsillar abscess, allowing for safe and effective training. Whilst it is recognised that there is no substitute for clinical exposure, and that all simulation teaching comes with limitations, this trainer presents the junior doctor with opportunities to practice initial attempts safely, in a non-threatening and harm-free environment.
Murphy et al. described the ‘Quinsy Trainer’ using a water balloon, wrapped in tape and filled with water, which is placed in the oropharynx of a training manikin, but this was of relatively low fidelity and lacked true clinical resemblance.Reference Murphy, Murphy and Sama4 Taylor and Chang introduced a more realistic simulator, but this required specialist equipment to reproduce.Reference Taylor and Chang6
Our silicone mould gives a superior training opportunity that necessitates careful examination of the tonsillar region to identify the correct spot for aspiration, and requires accurate direction of the needle into and not beyond the capsule. The aspiration of a discoloured, foul-smelling substance in our model (rather than simply using water), and the ability to alter the degree of trismus, add to the realism of the model and the challenges faced in clinical practice. This makes the simulator a very powerful training tool that is not only realistic but also easily reproducible in any hospital with a dental department.
So far, the simulator has been used to good effect locally in the teaching of junior ENT staff at regular induction programmes, with well-received feedback.
Conclusion
The adaptation to the Laryngotech trainer has proved to be simple and affordable, and provides a safe training tool for the training of peritonsillar abscess drainage. This tool can be used widely and inexpensively in educating the inexperienced ENT doctor and helping provide better patient care.
Acknowledgements
We would like to thank the dental technicians at Shrewsbury and Telford Hospitals, in particular Samantha Bunn and Hilary Beeswick, for their valuable contribution in the production of the silicone tonsils.
