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Process for sifting search results and selecting studies for inclusion.
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Figure 1

Process for sifting search results and selecting studies for inclusion.

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'Risk of bias' summary: review authors' judgements about each risk of bias item for each included study.
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Figure 2

'Risk of bias' summary: review authors' judgements about each risk of bias item for each included study.

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Comparison 1 Needle aspiration versus incision and drainage, Outcome 1 Rate of recurrence.
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Analysis 1.1

Comparison 1 Needle aspiration versus incision and drainage, Outcome 1 Rate of recurrence.

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Summary of findings for the main comparison. Needle aspiration versus incision and drainage for the treatment of peritonsillar abscess

Needle aspiration versus incision and drainage for the treatment of peritonsillar abscess

Patient or population: patients older than 8 years with peritonsillar abscess
Setting: inpatients and outpatients
Intervention: incision and drainage
Comparison: needle aspiration

Outcomes

Anticipated absolute effects* (95% CI)

Relative effect

№ of participants
(studies)

Quality of the evidence
(GRADE)

Comments

Risk with incision and drainage

Risk with needle aspiration

Primary outcome: recurrence rate

Study population

RR 3.74, 95% CI 1.63 to 8.59

612

(10 RCTs)

⊕⊝⊝⊝
very low1,2

—

47 per 1000

245 per 1000

Primary outcome: adverse effects/events associated with the interventions

One study reported post‐procedural bleeding in 1 patient (3.6%) in the incision and drainage group, with no adverse effects/events reported in the needle aspiration group. Two studies stated that no complications were seen in either group.

—

226

(3 RCTs)

⊕⊝⊝⊝
very low2,3

Adverse effects/events were not mentioned as a pre‐specified outcome measure in any of the studies.

Secondary outcome: time to resumption of normal diet

One study found no difference in the time to resumption of normal diet (mean 3.7 days in both groups, no confidence intervals provided). Another study found that a similar percentage of patients returned to solid food within 4 days (87%: needle aspiration, 88%: incision and drainage).

—

124

(2 RCTs)

⊕⊝⊝⊝
very low2,4

—

Secondary outcome: complications of the disease process

One study described a complication of 2 patients requiring admission to hospital for dehydration in the incision and drainage group and no complications in the needle aspiration group. One study stated that no complications were seen in either group.

—

170

(2 RCTs)

⊕⊝⊝⊝
very low2,5

Complications of the disease process were not mentioned as a pre‐specified outcome measure in any of the studies.

Secondary outcome: symptom scores
(Multiple different outcome scales used)

Procedural pain

Study 1

Pain was less in the needle aspiration group: MD ‐0.8, 95% CI ‐1.16 to ‐0.44 (10‐point scale)

Study 2

Reported less pain in the needle aspiration group

Pain resolution

Study 3

Pain resolution was similar between groups at 5 days post‐intervention

Other symptoms

Study 4

Reported comparable symptom scores between groups at presentation and 48 hours

—

Study 1

110 participants

Study 2

56 participants

Study 3

62 participants

Study 4

52

participants

⊕⊝⊝⊝
very low2,6

—

*The risk in the intervention group (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI).

CI: confidence interval; MD: mean difference; RCT: randomised controlled trial; RR: risk ratio

GRADE Working Group grades of evidence
High quality: We are very confident that the true effect lies close to that of the estimate of the effect
Moderate quality: We are moderately confident in the effect estimate: The true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different
Low quality: Our confidence in the effect estimate is limited: The true effect may be substantially different from the estimate of the effect
Very low quality: We have very little confidence in the effect estimate: The true effect is likely to be substantially different from the estimate of effect

1Downgraded once due to serious risk of inconsistency (unexplained heterogeneity).

2Downgraded twice due to very serious risk of bias (limitations in study design).

3Adverse event (post‐procedural bleeding) was not well described.

4Incomplete data (no standard deviations or confidence intervals provided).

5Admission to hospital for rehydration is inherently subjective and depends on multiple clinical variables.

6Downgraded once due to imprecision and differences in data reporting.

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Summary of findings for the main comparison. Needle aspiration versus incision and drainage for the treatment of peritonsillar abscess
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Table 1. Definition of recurrence and timing

Study ID

Definition of recurrence or criteria for re‐intervention described

Timing of assessment of recurrence

Spires 1987

No

2, 7 days (2x returned day 1)

Stringer 1988

"Failure to improve symptom scale score; visual evidence of a persistent abscess"

1, 2 days (24, 48 hours)

Maharaj 1991

"reaccumulation of pus"

1, 7 days

Nwe 2000

"patients in whom the trismus and pyrexia persisted 48 hours after the initial treatment"

2 days (48 hours)

Rafi 2007

No

Not stated

Khan 2011

No

Not stated

Khan 2012

No

Not stated

Sheikh 2012

Yes*

0, 1, 2 days

Chi 2014

No

Not stated

Khokhar 2015

No

"during the course of the study", 7, 14 days

Younas 2015

N/A

N/A

* "Improvement in patients was determined by examining the patient the next day after the procedure, a reduction in supra tonsillar swelling along with decrease in pain and also improvement in odynophagia were taken as criteria of improvement and termination of surgical attempts."

N/A: not available
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Table 1. Definition of recurrence and timing
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Comparison 1. Needle aspiration versus incision and drainage

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Rate of recurrence Show forest plot

10

612

Risk Ratio (M‐H, Random, 95% CI)

3.74 [1.63, 8.59]
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Comparison 1. Needle aspiration versus incision and drainage
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