Aetiology of Peritonsillar Abscess : Role of Minor Salivary Glands

Peritonsillar abscess (PTA) is the most common deep head and neck infection. PTA is considered to be a purulent complication of acute tonsillitis (AT), although the correlation between these two has not been proven. In recent decades, infection of minor peritonsillar salivary glands has been proposed to be behind the development of PTA. Smoking has been known to predispose patients to PTA, and poor dental hygiene has been hypothesised to control the course of the disease. Clarifying the aetiology of PTA would help physicians differentiate better the subtypes of PTA and plan the best treatment for the patient. Diagnostic tools to achieve this are lacking. Diagnosis of PTA is clinical and is based on a patient’s symptoms and clinical examination. No blood tests or imaging has been used routinely. Bacterial culture is a slow method and is not used in clinical decision-making. In the first study of this thesis, we compared bacterial findings of PTA between patients who had had a renewal and those who had not. Streptococcus anginosus group (SAG) was detected more often in the patients with renewal, compared to those without; however, no group A streptococcus was reported in patients with renewal. In addition, male patients over 40 years old had renewal episodes after a shorter period than other patients. In the second study, we histologically analysed the presence of peritonsillar minor salivary glands and inflammation patterns from the removed tonsils. In most (67.5%) of the tonsil specimens, minor salivary glands were identified, and we observed a greater periductal inflammation in patients with PTA compared to AT and chronic tonsillitis groups. In the third study, we collected AT and PTA patients and found a subgroup of PTA patients without any clinical signs of AT. PTA patients without tonsillar findings had significantly lower C-reactive protein (CRP) levels than PTA patients with tonsillar findings. They were also older than other patients suffering from PTA. In the fourth study, we compared salivary samples of the patients with AT, peritonsillitis, and PTA between themselves, and with healthy volunteers. No differences between groups were observed which could imply that the composition of oral bacterial microbiota may not have a significant effect on the development of PTA. Alcohol consumption, oral hygiene and smoking had no significant effect either on numbers or distribution of saliva bacteria. Our studies suggest that tonsillar infection is not always a pre-stage of PTA and support the hypothesis that infection of minor salivary glands, in some cases, causes PTA. We also showed that SAG predicts renewal of PTA, and it is found in older male patients with rapidly proceeding disease. By understanding the aetiology of PTA better, we could also identify patients with different aetiological factors and target treatment more accurately.Kurkkupaise on yleisin pään ja kaulan alueen syvä infektio. Perinteisesti kurk- kupaisetta on pidetty akuutin nielurisatulehduksen märkäisenä komplikaationa, mutta tieteellistä näyttöä näiden kahden taudin yhteydestä ei ole. Viimeisten kahden vuosikymmenen aikana on tutkittu pienten peritonsillaarisesti sijaitsevien sylkirauhasten roolia kurkkupaiseen taustalla. Tupakan tiedetään altistavan kurkkupaiseen kehittymiselle, ja myös huonolla hammashygienialla saattaa olla vaikutusta taudinkuvan. Taudin etiologian tunteminen auttaisi kliinikkoa erottamaan taudin erilaiset alatyypit ja valitsemaan parhaan mahdollisen hoidon potilaalle. Kliinikot tarvitsisivat myös diagnostisia menetelmiä kurkkupaiseen aiheuttajan selvittämiseen. Kurkkupaiseen diagnoosi on kliininen ja perustuu potilaan oireisiin sekä lääkärin suorittamaan tutkimukseen. Verikokeita tai kuvantamistutkimuksia ei rutiininomaisesti tarvita. Bakteeriviljelynäytteistä ei hoitoa suunniteltaessa ole hyötyä menetelmän hitauden vuoksi. Väitöskirjan ensimmäisessä osatyössä vertasimme kurkkupaiseiden märkäeritteen bakteerilöydöstä ”uusijoiden ja ei-uusijoiden” välillä. Streptococcus anginous –ryhmän (SAG) bakteereita tavattiin enemmän ”uusijoilla”, kun taas A-ryhmän streptokokkia (GAS) ei ”uusijoilla” todettu lainkaan. Lisäksi havaitsimme, että yli 40 vuotiailla miehillä kurkkupaise uusii muita potilaita nopeammin. Toisessa osatyössä mikroskopoimme histologisesti nielurisaleikkauksessa poistettua peritonsillaari- ja nielurisakudosta, ja osoitimme, että valtaosalla potilaista (67.5%) on pieniä sylkirauhasia peritonsillaaritilassa. Lisäksi havaitsimme, että kurkkupaisepotilailla on pienen sylkirauhasen tiehyen ympärillä huomattavasti enemmän tulehdusta kuin niillä potilailla, joiden nielurisat on poistettu äkillisen tai pitkäaikaisen nielurisatulehduksen vuoksi. Kolmannessa osatyössä osoitimme ryhmän kurkkupaisepotilaita, joilla ei ollut merkkejä akuutista nielurisatulehduksesta. Havaitsimme, että kurkkupaisepotilailla, joilla ei havaittu nielurisoissa infektion merkkejä oli selvästi matalampi CRP- arvo kuin potilailla, joiden nielurisoissa oli infektion merkkejä. Potilaat, joilla ei nielurisoissa havaittu tulehduksen merkkejä olivat myös selvästi vanhempia kuin muut kurkkupaisepotilaat. Neljännessä osatyössä vertasimme terveiden vapaaehtoisten, äkillisestä nielurisatulehduksesta, peritonsilliitista ja kurkkupaiseesta kärsivien potilaiden sylkinäytteitä. Ryhmien välillä ei havaittu eroja, joka voisi viitata siihen, ettei suun mikrobiston muutoksilla ole vaikutusta kurkkupaiseen kehittymiseen. Myöskään alkoholinkäytöllä, hammashygienialla tai tupakoinnilla ei havaittu olevan merkit- tävää vaikutusta syljen bakteerien määrään. Tutkimuksessamme osoitimme, ettei nielurisatulehdus aina edellä kurkkupaisetta. Tutkimuksemme tukee vahvasti hypoteesia, jonka mukaan osa kurkkupaiseista aiheutuu pienten sylkirauhasten tulehduksesta. Lisäksi osoitimme, että SAG ennustaa kurkkupaiseen uusiutumista ja on yleensä vanhempien miesten taudin- aiheuttajana. Ymmärtämällä kurkkupaiseen etiologiaa voimme jatkossa paremmin tunnistaa eri etiologiset tekijät ja valita hoidon tarkemmin

Smoking or poor oral hygiene do not predispose to peritonsillar abscesses via changes in oral flora

Aim: The purpose of this prospective study was to determine if there is a difference in number and distribution of salivary bacteria between patients with tonsillar infection and healthy volunteers. Background: The etiology of peritonsillar abscess (PTA) is unclear. Smoking, periodontal disease, and infection of minor salivary glands have been suggested as predisposing factors for PTA. Material and methods: Patients with acute tonsillitis (AT) (n = 54), peritonsillitis (PT) (n = 36), PTA (n = 58), and healthy volunteers (n = 52) were prospectively recruited and evaluated. Saliva bacteria were analyzed with flow cytometry. Patients and their treating physicians completed a questionnaire about patients' current disease, smoking habits, alcohol consumption, and oral health. Results: There were no differences in the total number of saliva bacteria between patients with acute throat infection and healthy volunteers (p = .104) or between AT, PT, and PTA patients (p = .273). Smoking habits, alcohol consumption, oral hygiene, or prior antibiotics had no effect on total amount of salivary bacteria in patients with acute throat infection. Conclusions: The effects of smoking on salivary bacteria do not seem to be the mechanism that promotes development of PTA in smokers.Peer reviewe

Peritonsillar abscess may not always be a complication of acute tonsillitis: A prospective cohort study

The present study aimed to specify diagnostics for peritonsillar abscesses (PTAs) and to clarify the role of minor salivary glands. This prospective cohort study included 112 patients with acute tonsillitis (AT) and PTA recruited at a tertiary hospital emergency department between February and October 2017. All patients completed a questionnaire concerning their current disease. Serum amylase (S-Amyl) and C-reactive protein (S-CRP) levels, tonsillar findings, and pus aspirate samples and throat cultures were analyzed. Eight of 58 PTA patients (13.8%) had no signs of tonsillar infection. The absence of tonsillar erythema and exudate was associated with low S-CRP (pPeer reviewe

Aerosol Generation During Otologic Surgery

Objective To assess whether aerosol generation occurs during otologic surgery, to define which instruments are aerosol generating, and to identify factors that enhance safety in protection against airborne pathogens, such as severe acute respiratory syndrome coronavirus 2. Study Design An observational prospective study on aerosol measurements during otologic operations recorded between August and December 2020. Setting Aerosol generation was measured with an Optical Particle Sizer as part of otologic operations with anesthesia. Particles with a size range of 0.3 to 10 mu m were quantified. Aerosol generation was measured during otologic operations to analyze aerosols during drilling in transcanal and transmastoid operations and when using the following instruments: bipolar electrocautery, laser, suction, and cold instruments. Coughing is known to produce significant concentration of aerosols and is commonly used as a reference for high-risk aerosol generation. Thus, the operating room background concentration and coughing were chosen as reference values. Patients Thirteen otologic operations were included. The average drilling time per surgery was 27.00 minutes (range, 2.00-71.80 min). Intervention Different rotation speeds during drilling and other instruments were used. Main Outcome Measures Aerosol concentrations during operations were recorded and compared with background and cough aerosol concentrations. Results Total aerosol concentrations during drilling were significantly higher than background (p < 0.0001, d = 2.02) or coughing (p < 0.0001, d = 0.50). A higher drilling rotation speed was associated with higher particle concentration (p = 0.037, eta(2) = 0.01). Aerosol generation during bipolar electrocautery, drilling, and laser was significantly higher than with cold instruments or suction (p < 0.0001, eta(2) = 0.04). Conclusion High aerosol generation is observed during otologic surgery when drill, laser, or bipolar electrocautery is used. Aerosol generation can be reduced by using cold instruments instead of electric and keeping the suction on during aerosol-generating procedures. If drilling is required, lower rotation speeds are recommended. These measures may help reduce the spread of airborne pathogens during otologic surgery.Peer reviewe

Mental Well-being of Healthcare Workers in 2 Hospital Districts During the First Wave Ofthe Covid-19 Pandemic in Finland a Cross-sectional Study

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"As protective gear began to run low, guidance on protection became looser" - Healthcare workers' perspectives on infection prevention and control during the COVID-19 pandemic

ObjectivesThe COVID-19 pandemic has posed several risk factors to healthcare workers' (HCWs') emotional distress. The purpose of the study was to enhance understanding of the experiences and feelings of HCWs during the COVID-19 pandemic, with specific reference to infection prevention and control (IPC) practices and guidance, focusing on the quality and availability of personal protective equipment (PPE), guidelines, and management. With a qualitative approach, we aimed to enable a wider narrative; to gain a more detailed understanding related to PPE use and identify experiences that can be overlooked in forced-choice questionnaires. MethodsAn online questionnaire was conducted among HCWs of the City of Helsinki and Helsinki University Hospital between 12.6.2020 and 5.4.2021. Altogether 1,580 HCWs participated in the study, from whom 579 shared 1,666 free-text responses. These responses were analyzed qualitatively, and the results were combined with statistical data on the participants' working conditions and backgrounds. ResultsWe identified problems in PPE availability and changing guidelines as factors causing the most distress in the participants. Regarding availability, running out of masks and respirators emerged as the most worrying issue, and inadequate PPE was associated with the excessive workload (OR 1.51, CI 95% 1.01-2.25). The results also highlight the importance of transparent and clear communication regarding IPC instructions and guidance, and clear IPC guidance was associated with better levels of reported recovery from work (OR 1.51, CI 95% 1.06-2.14). ConclusionsOur study highlights the importance of adequate PPE provision, transparent communication, clear guidance, and supportive supervisory work in this ongoing pandemic and potential new ones. We suggest more rigorous preparation, with crisis communication planning and emergency storage of PPE.Peer reviewe

SOURCES OF HEALTHCARE WORKERS' COVID-19 INFECTIONS AND RELATED SAFETY GUIDELINES

Objectives: To evaluate the effectiveness of safety guidelines in the workplace, the authors analyzed the work-related exposure to SARS-CoV-2 and the source of COVID-19 infections among healthcare workers (HCWs), together with the use of personal protective equipment (PPE). Material and Methods: A cross-sectional prospective study was conducted in tertiary hospitals in the Uusimaa region, Finland, with 1072 volunteers being enrolled in the study from among the HCWs at the Helsinki University Hospital. Overall, 866 (80.8%) HCWs (including 588 nurses, 170 doctors, and 108 laboratory and medical imaging nurses) completed the questionnaire by July 15, 2020, with 52% of the participants taking care of COVID-19 patients. The participants answered a structured questionnaire regarding their use of PPE, the ability to follow safety guidelines, exposure to COVID-19, and the source of potential COVID-19 infections. The participants with COVID-19 symptoms were tested with the SARS-CoV-2 real-time polymerase chain reaction method. All infected participants were contacted, and their answers were confirmed regarding COVID-19 exposure. Results: In total, 41 (4.7%) participants tested positive for SARS-CoV-2, with 22 (53.6%) of infections being confirmed or likely occupational, and 12 (29.3%) originating from colleagues. In 14 cases (63.6%), occupational infections occurred while using a surgical mask, and all infections originating from patients occurred while using a surgical mask or no mask at all. No occupational infections were found while using an FFP2/3 respirator and following aerosol precautions. The combined odds ratio for working at an intensive care unit, an emergency department, or a ward was 3.4 (95% CI: 1.2-9.2, p = 0.016). Conclusions: A high infection rate was found among HCWs despite safety guidelines. Based on these findings, the authors recommend the use of FFP2/3 respirators in all patient contacts with confirmed or suspected COVID-19, along with the use of universal masking, also in personnel rooms.Peer reviewe

Microdebrider is less aerosol-generating than CO2 laser and cold instruments in microlaryngoscopy

Objective COVID-19 spreads through aerosols produced in coughing, talking, exhalation, and also in some surgical procedures. Use of CO2 laser in laryngeal surgery has been observed to generate aerosols, however, other techniques, such cold dissection and microdebrider, have not been sufficiently investigated. We aimed to assess whether aerosol generation occurs during laryngeal operations and the effect of different instruments on aerosol production. Methods We measured particle concentration generated during surgeries with an Optical Particle Sizer. Cough data collected from volunteers and aerosol concentration of an empty operating room served as references. Aerosol concentrations when using different techniques and equipment were compared with references as well as with each other. Results Thirteen laryngological surgeries were evaluated. The highest total aerosol concentrations were observed when using CO2 laser and these were significantly higher than the concentrations when using microdebrider or cold dissection (p < 0.0001, p < 0.0001) or in the background or during coughing (p < 0.0001, p < 0.0001). In contrast, neither microdebrider nor cold dissection produced significant concentrations of aerosol compared with coughing (p = 0.146, p = 0.753). In comparing all three techniques, microdebrider produced the least aerosol particles. Conclusions Microdebrider and cold dissection can be regarded as aerosol-generating relative to background reference concentrations, but they should not be considered as high-risk aerosol-generating procedures, as the concentrations are low and do not exceed those of coughing. A step-down algorithm from CO2 laser to cold instruments and microdebrider is recommended to lower the risk of airborne infections among medical staff.Peer reviewe

Työolot perusterveydenhuollossa ja erikoissairaanhoidossa covid-19 pandemian aikana

Objectives: The COVID-19 pandemic has globally affected healthcare workers’ (HCWs) health and wellbeing. Most studies on COVID-19 have focused on tertiary healthcare. The aim of this study was to increase the knowledge on the effects of the pandemic on working conditions in tertiary and primary healthcare. Material and Methods: The comparative cross-sectional study consisted of an online questionnaire sent to HCWs of the City of Helsinki (primary healthcare) and Helsinki University Hospital (tertiary healthcare). Altogether 1580 HCWs with direct patient contact participated in the study: 895 from tertiary and 685 from primary healthcare. Statistical analysis used SPSS 25 from IBM. The tests used were the χ2 test, Fisher’s exact test, and binary logistic regression analysis. Results: Primary HCWs were less likely to treat COVID-19 patients (OR = 0.45, 95% CI: 0.37–0.56). However, both groups reported a similar number of COVID-19 infections, primary HCWs 4.9% and tertiary HCWs 5.0%, and work-related quarantine was significantly more prevalent (OR = 1.96, 95% CI: 1.38–2.79) among primary HCWs. In addition, work-related wellbeing was poorer among primary HCWs than tertiary HCWs in terms of feeling more stressed at work (OR = 3.20, 95% CI: 2.55–4.02), not recovering from work (OR = 0.49, 95% CI: 0.39–0.62), reported mental wellbeing below normal levels (OR: 1.59, 95% CI: 1.26–2.00), and increased working hours (OR = 1.63, 95% CI: 1.25–2.12). Conclusions: The study demonstrates how the pandemic has affected the wellbeing and working conditions of not only tertiary but also less studied primary HCWs. The authors’ findings suggest that the challenges identified during the COVID-19 pandemic in the health and wellbeing of healthcare workers are even greater in primary care than in tertiary care.Peer reviewe