Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Throat pain 
Treatment: Inpatient admission 

The inpatient admission was medically necessary. 

The patient is a female child. She presented to the ED with four-day history of worsening throat pain, now with difficulty speaking due to pain, and muffled voice, but able to swallow saliva. She was being treated with acetaminophen and ibuprofen. She had been seen by her primary care practitioner and referred to the ED for evaluation to rule out strep pharyngitis and peritonsillar abscess. 

The patient's vital signs included temperature 37.9, heart rate 118, respiratory rate 22, and blood pressure 117/80. Pain was rated 10/10 (ten out of ten). Examination was significant for no acute distress, right soft palatal swelling/erythema with uvular deviation to contralateral side, no stridor or drooling, moist mucous membranes, shotty submandibular lymphadenopathy, clear lungs, and good perfusion. Laboratory evaluation revealed leukocytosis (WBC [white blood count] 16.1K) with left shift (82.8%), and unremarkable metabolic panel. She was treated with two normal saline boluses due to tachycardia. She was diagnosed with peritonsillar abscess versus cellulitis, and prepped in the ED for needle aspiration. However, despite intranasal Versed and Cetacaine spray, she refused the procedure half-way through the lidocaine/epinephrine injection. ENT (otolaryngology) was subsequently consulted for further management. CT scan with contrast was recommended, taking a long time to obtain, and revealing a right peritonsillar abscess measuring 1.6 x 1.7 x 1.9 cm. ENT recommended admission for Unasyn and possible surgery later in the day. 

Admission orders included nothing by mouth pending surgical drainage, Unasyn, IV (intravenous) fluids, cardiopulmonary monitoring, and possible testing for strep infection. She was taken to the OR (operating room) for drainage. Cultures were obtained at the time of surgery. Post-operatively, pain was managed with routine acetaminophen. Her diet was advanced as tolerated. She was subsequently deemed stable for discharge to complete a course of antibiotics with Augmentin and follow-up in the outpatient clinic. 

There are two main treatment options for management of peritonsillar abscess, needle aspiration and incision and drainage. Studies have looked at which modality produces the best results with the lowest morbidity. Currently, there is weak evidence that needle aspiration is less painful and weak evidence that incision and drainage has lower risk of recurrence. At this time, both procedures are considered reasonable and standard of care. Antibiotic therapy and supportive care complete the management strategy for peritonsillar abscess. Empiric antibiotic coverage should include activity against streptococcus and oral anaerobic bacteria. While most patients can be treated as outpatients, some may require admission. Usual reasons for admission include dehydration, difficulty managing oral fluid intake, airway concerns, failure of outpatient management, and comorbid conditions (diabetes mellitus, immunosuppressant medication use, signs of sepsis). For those patients appropriate for outpatient therapy, post-drainage observation is necessary to ensure adequate fluid intake and pain management. 

In the case of this patient, she failed treatment in the ED because she was unable to tolerate needle aspiration despite Versed and topical anesthetic. She was subsequently admitted, treated with Unasyn, and taken to the OR the same day for incision and drainage. She did well, and was discharged home the following day on Augmentin. Although she remained hemodynamically stable throughout, with no evidence of airway obstruction or sepsis or significant dehydration, she required acute inpatient management because she could not have been safely managed at a lower level of care.