Peritonsillar abscess: bacteriological evaluation

The pus from a series of 41 peritonsillar abscesses was examined bacteriologically. In the majority of the abscesses a mixed bacterial flora was found. The specimens yielded 0-7 different bacterial species per abscess (mean 3.0). One species alone was isolated only in five cases (12.5%). Both anaerobic and aerobic bacteria were isolated from the specimens of 25 patients (61%), only anaerobes from two specimens (4.9%), and only facultative bacteria from 12 specimens (29%). Beta haemolytic streptococci were cultured in 43.9% of the cases, but Streptococcus pyogenes group A in only 10 cases (24.4%). Thus, the pus of the peritonsillar abscess seems to be caused by a mixed bacterial infection, where anaerobic bacteria play a significant role. Indications of tonsillectomy in cases with peritonsillar abscess are discussed.     

Peritonsillar abscess: the treatment options

Peritonsillar abscess is the second most common ENT emergency admission at our hospital. The optimal management has been a subject of discussion for years. This paper reviews 51 patients and the literature to question the traditional medical/surgical managements.     

Peritonsillar abscess: a study of 724 cases in Japan

We reviewed the records of 724 patients diagnosed with peritonsillar abscess who had been admitted to our hospital between January 1988 and December 1999. We analyzed their clinical features, disease course, and treatment. The male:female ratio was 3:1, and approximately two-thirds of these patients were between 20 and 39 years of age. The most common aerobic bacteria cultured from patients' pus were alpha-hemolytic streptococci. Severe complications---including deep neck infections and mediastinitis--were seen in 13 patients (1.8%). This complication rate suggests that patients with peritonsillar abscess should undergo immediate incision and drainage rather than needle aspiration.     

Peritonsillar abscess with parapharyngeal involvement: incidence and treatment

In 2.3% of 217 patients with peritonsillar abscess, the clinical picture was atypical, with inflammatory swelling of the pharyngeal wall below and behind the tonsil, oedema of the epiglottis and a diffuse swelling on the side of the neck. The typical signs of peritonsillar abscess, i.e. trismus, a medially displaced tonsil and displacement of the uvula toward the opposite side, were either completely lacking or less pronounced than usual. The abscesses were all located in the peritonsillar space at the lower pole or behind the tonsil. To ensure rapid, uncomplicated recovery in such cases with parapharyngeal involvement, it is essential that abscess tonsillectomy under antibiotic cover with penicillin is not postponed.     

Peritonsillar abscess: the rationale for interval tonsillectomy

Although peritonsillar abscess (quinsy) and peritonsillitis are common ENT emergencies, management strategies in the United Kingdom still vary among otolaryngologists. In order to obtain data on the success of the various strategies, we conducted two surveys--one concerned itself with patient outcomes, while the other sought information on physician preferences. The survey of 571 practicing ENT surgeons revealed that 83% advise interval tonsillectomy only for patients who have a history of tonsillitis; they prefer to take a wait-and-see approach for a single attack of quinsy. Conversely, 15% advise a routine interval tonsillectomy following even a single isolated attack of quinsy/peritonsillitis. Only 6.8% still perform a quinsy tonsillectomy in selected cases. Survey responses from 192 adults and 15 children who had been hospitalized for the treatment of quinsy/peritonsillitis revealed that the vast majority of patients who did not undergo an interval tonsillectomy were still asymptomatic 2 to 8 years later. These results indicate that a wait-and-see policy is indeed suitable for most patients who present with an isolated attack of quinsy/peritonsillitis without a history of tonsillitis. We recommend that tonsillectomy be performed as a definitive treatment for quinsy/peritonsillitis in patients who have a history of tonsillitis. Such a history is a reliable indicator of recurrent quinsy or tonsillitis following an attack of quinsy/peritonsillitis in both children and adults. Quinsy tonsillectomy should be reserved for those few patients who do not respond to conservative measures.     

Peritonsillar abscess: remember to always think twice

Peritonsillar abscess (PTA) is the most common complication of acute tonsillitis resulting in fever, unilateral sore throat, odynophagia and trismus. This retrospective study was undertaken to analyze the clinical courses of 775 patients with two different methods of the first-line treatment. Abscess tonsillectomy (TAC) including contralateral tonsillectomy was preferably performed between 2007 und 2010 (group A; n = 443). After that, incisional drainage (ID) was chosen as first-line treatment between 2010 and 2013 (group B; n = 332). The data of the patients were pooled from the individual charts to evaluate the prevalence of smoking habits, the incidence of the recurrence/complication rates and the number/types of surgical procedures associated with each therapy modality. Replacing TAC by ID as first-line treatment of PTA resulted in a significant decrease of days of inpatient treatment (4 vs. 7 days) and hemorrhage rate (0.3 vs. 5.1 %). A second, third and fourth surgical revision procedure was performed with comparable rates in group A (21.6; 2.4; 0.5 %) and B (21; 4.9; 0.3 %). Smoking habits were reported by almost every second patient. ID as first-line treatment of PTA is capable to reduce the hemorrhage rate and length of inpatient observation significantly. To suggest ID as first-line PTA treatment mandates a close follow-up to indicate repeated drainage of residual pus at an early stage. Further analysis is warranted to verify whether a better surveillance in an academic teaching hospital or surgical modification of the ID is followed by a higher success rate. Smoking habits are overrepresented in PTA patients.     

Peritonsillar abscess: a comparison of a conservative and a more aggressive management protocol

A two-year prospective study was undertaken to compare acute treatment modalities for peritonsillar abscesses. The most widely used modality, incision and drainage, with subsequent hospitalization for intravenous antibiotics and hydration, was compared with incision and drainage, with subsequent oral antibiotics and oral hydration. The results in 27 randomized patients showed no difference in morbidity, recovery time, or recurrence rate between the two groups. The authors conclude that initial incision and drainage, and oral antibiotics, is an effective, safe and less expensive treatment modality for peritonsillar abscesses. These results suggest that with a compliant patient population, peritonsillar abscesses may be effectively treated in an outpatient setting.     

Peritonsillar abscess: recurrence rate and the indication for tonsillectomy

Two hundred ninety patients treated for peritonsillar abscess (PTA) between 1970 and 1982 were reviewed. The patients were divided into those with a history of recurrent tonsillitis prior to developing PTA (72 patients, 25%), and those without (218 patients, 75%). The patients in the first group had four times more recurrences than those in the second group (40% versus 9.6%). Patients older than 40 years were found to have a lower incidence of throat infections than younger patients, and no PTA recurrences were observed. Neither subsequent tonsillitis nor recurrent PTA was observed among 72 patients (25%) who underwent tonsillectomy 6 to 12 weeks after PTA. The pre-PTA history was found to be a dominant factor in determining the need for tonsillectomy. In patients who suffered from recurrent tonsillitis prior to PTA, tonsillectomy is recommended. In those with a single episode of PTA and no history of tonsillitis, tonsillectomy is not indicated.     

Peritonsillar abscess in children: a 10-year review of diagnosis and management

OBJECTIVE: peritonsillar abscess is the most common deep neck infection in adults and children. However, pediatric patients with their smaller anatomy and often inability to cooperate with exam and treatment, provide a challenge. This study reviews the experience over the last 10 years at a children's hospital in the diagnosis and treatment of pediatric peritonsillar abscess. METHODS: a retrospective chart review of 83 children diagnosed with a peritonsillar abscess by the Otolaryngology service over a 10-year period (March 1989-February 1999) were reviewed. Presenting signs and symptoms, physical findings, age, season of presentation, prior pharyngitis history, and prior treatment was collected from the charts. Additionally, diagnostic studies (if any), treatment performed, bacteriology, and outcome/complications were noted. RESULTS: due to either an inability to cooperate fully for examination and treatment, or because of an earlier history of significant recurrent pharyngitis or obstructive tonsillar hypertrophy, half of the children required treatment in the operating room. Twenty-six out of 83 (31%) underwent a quinsy tonsillectomy. Length of stay was relatively short (0.9 days). There were no recurrent PTAs in our series, although four children initially treated with incision and drainage required tonsillectomy for persistent symptoms or residual abscess. Ten of those not treated with tonsillectomy (19%) required interval tonsillectomy for recurrent pharyngitis. CONCLUSION: limited by the ability to cooperate with treatment, children often require different treatment plans. We offer a treatment algorithm for managing children with PTAs that takes into account their age, level of cooperativeness, co-morbidities and prior history of pharyngitis, PTA or obstructive sleep disorder.     

Peritonsillar abscess: Tonsil antibiotic levels in patients treated by acute abscess surgery

Forty-five patients who had tonsillectomy in the acute phase of peritonsillar abscess were studied. All patients received intravenous penicillin or cephalosporin before surgery. Samples of tonsil from each side were evaluated for penicillin and cephalosporin as was a blood sample obtained during surgery. The tonsil tissue antibiotic levels were compared between the infected and non-abscess side. We expected to find less antibiotic on the inflamed side since less bleeding from the abscessed tonsil bed usually suggests less blood flow through this tonsil, and we also expected a low, satisfactory tissue level in patients under usual regimens of intravenous antibiotics. Our results indicate that 60% of the patients had evidence of streptococcal infections by culture or serum assay. All patients completed the treatment without complications. Eighty-five percent of abscesses were in the superior pole and 15% were located posteriorly and would be adequately drained only by tonsillectomy. There was no clear seasonal peak to the infection and no evidence of specific virulence of the streptococci found. Tissue antibiotic assay showed only 32% of the patients on penicillin had a measurable tissue level and 66% of the cephalosporin treated patients had detectable antibiotic levels in the tissue. The abscessed tonsil was equally as likely to have increased levels of penicillin as its uninflamed mate while in all cases, where detectable, the abscessed tonsil had increased concentrations of cephalosporin relative to the opposite side. We conclude that penicillin does not penetrate tonsil tissue very well and does not favor either the infected or uninfected side while the cephalosporins may have a specific reduced tissue barrier to penetration in the presence of inflammation. Therefore, we recommend medical treatment with 1 gm of penicillin intravenously every 4 hours or 1 gm of cephalosporin every 6 to 8 hours intravenously with an additional dose of the intravenous antibiotic at the time of tonsillectomy.     

Peritonsillar abscess with parotid and peripharyngeal extension. Report of a case

Peritonsillar abscess is the most frequent complication of a tonsillar infection. The purulent material can spread from peritonsillar space to the fascial neck spaces. These deep neck infections may be a life threatening complication. The correct treatment of these infections is an appropriate antimicrobial therapy and abscess drainage, most of the times by surgery. We present a clinical case of a large perypharyngeal, and parotid abscess originated from a peritonsillar abscess. It was necessary surgical treatment to drain it.     

Peritonsillar abscess with parapharyngeal and retropharyngeal involvement: incidence and intraoral approach

CONCLUSION: This study illustrates common sites of infection seen in peritonsillar abscesses with involvement of the pharyngeal space and retropharyngeal space. Abscesses behind and/or inferior to the tonsil were encountered more frequently than expected. In these cases, the drainage had to be placed in the inferior pole of the tonsil and these types were frequently seen in older patients. OBJECTIVES: The aim of this study was to assess to what extent abscesses spread in patients with peritonsillar abscess and to determine to what extent pus can be drained intraorally. PATIENTS AND METHODS: The clinical charts of 45 patients with peritonsillar abscess involvement of the parapharyngeal space and/or retropharyngeal space were retrospectively reviewed. RESULTS: In 45 cases, 21 patients were diagnosed with the superior type, and we could drain the pus intraorally in 90% of the patients. On the other hand, 24 cases were diagnosed with the inferior type and they were drained intraorally in 58% of the cases.     

Peritonsillar and parapharyngeal space abscess in the older adult

OBJECTIVE: To review the presentation and management of peritonsillar (PTA) and parapharyngeal space (PPSA) abscesses in older adults and compare this with the usual presentation and management in the younger patient. STUDY DESIGN: An 18-year retrospective review at a tertiary care hospital. METHODS: The patient database was searched by using the diagnosis codes for PTA and PPSA. The search included inpatient and outpatient visits of patients 50 years of age and older from 1983 to 2001. The charts were reviewed, and data regarding presentation, management, and outcome were recorded. Comparisons to the current literature were made. RESULTS: Fourteen patients were identified, 8 with PTA and 6 with PPSA. The most common symptoms in both groups were sore throat and dysphagia. Only 1 patient in either group was febrile. All vital signs were within normal limits in all other patients. Only 1 patient in each group experienced trismus, and no patients showed drooling. Five of the PTA patients required inpatient care, and 2 were taken to the operating room. CONCLUSIONS: PTA and PPSA are uncommon infections in the older adult, with only 14 patients identified at a tertiary care hospital over an 18-year period. Complaints of new onset sore throat and dysphagia of several days duration in patients over 50 years old should alert the evaluating physician to these 2 clinical entities, even in afebrile, nontoxic patients. PTA in this group may be more likely to require inpatient care along with surgical treatment in the operating room.     

Peritonsillar abscess in children and its indication for tonsillectomy

38 children aged 1-15 years treated for peritonsillar abscess (PTA) between 1976 and 1986 have been reviewed. The patients were divided into those with a history of recurrent tonsillitis prior to developing PTA (T+) (10 patients = 26.3%) and those without such history (T-) (28 patients = 73.4%). 19 patients were surgically drained, 2 abscesses ruptured spontaneously, 2 patients were treated by repeated needle aspirations and 15 patients were treated by medication only. Neither the pre-PTA history (T+ versus T-) nor the mode of treatment during the acute event showed any significant differences in comparing the recurrency rate of PTA or tonsillitis. Therefore, it seems that a single event of PTA among pediatric population should not be considered an indication for tonsillectomy.