Discussion

The profound impact of the Covid-19 pandemic on healthcare services resulted in rapid and widespread changes to local ENT service provision, requiring continual evaluation to ensure safety and effectiveness. Our results suggest that the emergency management of suspected quinsy using the updated guidelines is associated with: fewer in-patient hospital admissions, fewer nasendoscopies, reduced corticosteroid use, increased frequency of aspiration or drainage under local anaesthetic, increased virtual follow-up appointments, and no increase in mortality or re-admission rates. Although the mean length of stay was longer for those patients requiring in-patient admission, this represents a significant cost saving overall, as the proportion of suspected quinsy referrals requiring in-patient admission are significantly reduced.

Any reduction in in-patient hospital admissions is of added importance during the pandemic. Avoidable admissions to hospital are thought to increase the risk of viral exposure to shielding patients and prematurely exhaust the hospital surge capacity.^{Reference Moghadas, Shoukat, Fitzpatrick, Wells, Sah and Pandey1,Reference Bann, Patel, Saadi, Gniady, Goyal and McGinn4} Anecdotally, patients’ priorities during the pandemic may have also changed to reflect this, with greater preference to avoid hospital admission where possible.

Patients still requiring admission were more likely to be more systemically unwell in group 2 (post-implementation of the new standard operating procedures), which may explain the increased mean length of hospital stay observed, although data on physiological parameters or laboratory indicators were not collected. Co-morbidity data are also omitted, and so important risk factors are not identified. Bird et al. list the following criteria for admission of tonsillitis cases: immunocompromise, diabetes and features of breathlessness, severe dehydration, or septic shock.^{Reference Bird, Biggs and King18} Additional data are thus necessary in future, to develop predictors of re-admission and standardised criteria for admitting these patients to hospital.

However, the unchanged rates of re-admission and mortality that we observed suggest that the management of suspected acute sore throat, tonsillitis or peritonsillar abscess using the updated standard operating procedures is safe. Although complications experienced in the community may be missed in this study, it is likely that any significant problems would re-present to the hospital.

Interestingly, our data support the role of peritonsillar abscess drainage. We observed an increased frequency of aspiration or surgical drainage under local anaesthetic in group 2. Unsurprisingly, a greater proportion of these were ‘dry taps’, suggesting a greater willingness to attempt aspiration or drainage in any suspected case. However, although we did not perform further subgroup analysis of confirmed cases of quinsy, recent evidence indicates no significant difference in outcomes between medical management and surgical drainage of peritonsillar abscess.^{Reference Forner, Curry, Hancock, MacKay, Taylor and Corsten19} Similarly, conservative medical management is reported as an effective treatment for co-existent peritonsillar abscess and Covid-19.^{Reference Sideris, Ghosh, Lam and Mackay20}

Given the relative contraindication of corticosteroids in those at higher risk of Covid-19, we recorded more cases of suspected quinsy in group 2 that were managed with antibiotics alone. Traditionally, this is an effective treatment for simple acute bacterial throat infections.^{Reference Centor, Witherspoon, Dalton, Brody and Link21–Reference Harris, Hicks, Qaseem and High23} Corticosteroids are conventionally used in more severe cases and in those with suspected peritonsillar abscess, primarily for symptomatic relief.^{Reference Chau, Seikaly, Harris, Villa-Roel, Brick and Rowe11–Reference Sadeghirad, Siemieniuk, Brignardello-Petersen, Papola, Lytvyn and Vandvik13,Reference Hardman, McCulloch and Nankivell24} The unwanted effects of corticosteroids on immunity, in the context of uncertain viral exposure in the community, were considered with caution early on in the pandemic.^{Reference Chau, Seikaly, Harris, Villa-Roel, Brick and Rowe11,Reference Johnson and Vinetz25,26} However, widespread use of steroids in these cases appears to have continued during the pandemic, as reported in the ‘Integrate’ (the UK ENT Research Trainee Network) Covid-19 ENT emergency care audit.^{Reference Smith27} Although the survival benefit of dexamethasone in Covid-19 has also been demonstrated, this relates to a different patient group, and there is no suggestion that corticosteroid use prior to coronavirus infection has any protective effects.^{Reference Mahase28,Reference Horby, Lim, Emberson, Mafham and Bell29} Large prospective studies of adverse outcomes from corticosteroid use during the pandemic are needed to address this contentious topic.

Notably, coronavirus status screening and testing in our centre was low. Given that symptoms of throat infection often met the criteria for suspected coronavirus infection, a greater proportion of tests were expected. Indeed, coronavirus status screening is now a prerequisite for any patient requiring admission to hospital, and rates of coronavirus testing in suspected peritonsillar abscess cases were higher nationally.^{Reference Smith27}

As throat examination, flexible nasendoscopy and quinsy drainage are all considered high-risk procedures for aerosol and droplet generation, full PPE is advised for the treating clinicians, regardless of the patient's coronavirus status.^{Reference Patel, Hardman, Yang, Robson, Putnam and George30,31} The Liverpool Peritonsillar Abscess Score has undergone modification to support the triage of suspected cases without oral examination, thereby limiting clinicians’ risk of exposure.^{Reference Selwyn, Yang, Heward, Kerai, Thompson and Shommakhi32} However, adequate access and supply of appropriate PPE, as well as improved patient testing, must be ensured to protect both patients and staff, and to avoid compromising patient care.

The expedited uptake of telemedicine has increased the availability of virtual follow-up consultations for patients, and has allowed remote working for staff to deliver healthcare, whilst minimising non-essential travel. This highlights the need for continual optimisation and allocation of resources to deliver safe and cost-effective care.

Ultimately, our data support the evidence base for out-patient management of quinsy.^{Reference Al Yaghchi, Cruise, Kapoor, Singh and Harcourt8,Reference Stringer, Schaefer and Close33–Reference Ophir, Bawnik, Poria, Porat and Marshak35} The findings are comparable to those of the national Covid-19 ENT emergency care audit,^{Reference Smith27} where approximately 45–55 per cent of patients with suspected tonsillitis or quinsy were discharged without admission, and only 10 per cent re-presented to hospital, with 3–5 per cent subsequently re-admitted. Therefore, developing a sustainable out-patient treatment protocol for peritonsillar abscess is an important next step,^{Reference Lamkin and Portt36} with consideration of bacteriological studies to support local antimicrobial policies.^{Reference Cherukuri and Benninger37}

Importantly, Covid-19 also impacted the workforce. In our centre, specialty registrars in ENT were required to act down as resident on-call, responding to emergency referrals directly, in place of junior colleagues who were temporarily redeployed to other hospital services. Although this exclusively affected our Covid-19 dataset, the implemented changes in quinsy care are protocol-driven, and rarely require senior-led technical skills or clinical decision-making. Therefore, effective induction processes are needed to allow optimal clinical skills acquisition and familiarity with updated treatment guidelines amongst all treating clinicians. Further evaluation will be needed when services and staffing return to the pre-coronavirus levels, to ensure the sustainability of these results.

Further research could include the use of patient-related outcome measures in out-patient quinsy care, and assessment of correlation with objective markers of disease severity, so as to establish predictors of re-presentation or re-admission.

Our constantly changing understanding of Covid-19, a new clinical entity, and its associated risks, will undoubtedly continue to affect ENT services and hence require continued service evaluation. By comparing outcomes following changes in practice during the first wave of the pandemic to those immediately prior to the pandemic, studies such as ours are limited in terms of sample size and widespread reproducibility; nevertheless, they provide important insights into local service provision and present suggestions for further improvement.