The usefulness of abscess tonsillectomy followed by intraoral drainage for parapharyngeal abscess concomitant with peritonsillar abscess in the elderly

Parapharyngeal abscess (PPA) may cause life-threatening complications and peritonsillar abscess (PTA) and tonsillitis frequently precede PPA. The optimal management of PPA caused by PTA has been the subject of debate with respect to the surgical approach. We present three cases of PPA concomitant with PTA in elderly patients. In two cases, the abscesses in parapharyngeal space were drained by abscess tonsillectomy followed by intraoral incision of the tonsillar bed. On the other hand, the third case did not undergo abscess tonsillectomy because of his refusal of surgery and needed extraoral drainage after the aggravation of PPA. Based on the experience of those three cases, it was suggested that abscess tonsillectomy followed by intraoral incision of the tonsillar bed might be a useful surgical approach for the drainage of PPA concomitant with PTA, especially in elderly patients.     

Parapharyngeal abscess: diagnosis and treatment

To study the circumstances of diagnosis, predisposing factors, bacteriology and therapeutic management of parapharyngeal abscesses. This retrospective study over a period of 7 years concerned 16 patients hospitalized in an ENT and Head and Neck surgery department for parapharyngeal abscess. All patients were treated by intravenous antibiotics and steroids for 5–7 days. The length of hospital stay was 6–15 days. Parapharyngeal abscesses associated with peritonsillar and retropharyngeal abscess were all initially aspirated transorally for evacuation and bacteriologic examination. Five patients underwent surgical drainage (two via cervical incision, three by immediate tonsillectomy techniques and one by intra-oral drainage). Two patients presented jugular vein thrombosis. No life-threatening complication was observed. Patients were considered to be cured when cervical CT scan performed on D21-45 was normal. Parapharyngeal abscess is the second most common deep neck abscess after peritonsillar abscess. The diagnosis is both clinical and radiologic. CT scan is the best imaging examination for diagnosis and follow-up of parapharyngeal abscess. Non-complicated parapharyngeal abscesses require first-line medical management (intravenous antibiotics (amoxicillin and clavulanic acid) combined with steroids) and follow-up CT scan.     

An evidence-based review of peritonsillar abscess

Clin. Otolaryngol. 2012, 37 , 136–145 Objective of review:  We present the current literature surrounding peritonsillar abscess management highlighting areas of controversy. Type of review and search strategy:  Literature review using Medline and Embase databases (search terms ‘peritonsillar abscess’, ‘peritonsillar infection’ and ‘quinsy’) limited to articles published from 1991 to 2011 (English language). Results:  (i) Investigations: Intraoral ultrasound has a sensitivity and specificity of between 89–95% and 79–100%, respectively, for correctly diagnosing peritonsillar abscess and is underutilised currently. (ii) Medical management: Steroids can effectively aid recovery, reducing hospitalisation time and improving symptom relief; however, further study is needed, especially related to risk and cost benefit. Penicillin and metronidazole are an effective combination in 98–99% of cases of peritonsillar abscess. (iii) Surgical management: Overall, there is no convincing evidence in favour of either aspiration or incision & drainage. Quinsy tonsillectomy is subject to great geographical variation, however, is a safe procedure and reduces overall recovery time when compared with interval tonsillectomy. (iv) Admission: peritonsillar abscess can be effectively managed as an outpatient in many cases. (v) Further management: Overall, the recurrence rate of peritonsillar abscess is poorly defined but estimated as 9–22% based on current evidence. Interval tonsillectomy may be indicated in selected groups of patients at high risk of recurrence. Conclusions:  Peritonsillar abscess is a common condition with increasing incidence. We demonstrate the potential for evidence‐based modifications in clinical management. However, lack of national consensus may mean that this evidence base is not being adequately exploited in current practice. A national audit of peritonsillar abscess management, in particular looking at recurrence rates and patient experience with different management strategies, appears indicated.     

Tonsillectomy <Emphasis Type="Italic">à chaud</Emphasis> for quinsy: revisited

In a prospective study involving 16 patients over a 12 month period, we determined whether tonsillectomy à chaud is an acceptable alternative to interval tonsillectomy for patients with quinsy. Guidelines for the acute surgical management of quinsy (or peritonsillar abscess) were established following a departmental audit. Sixteen patients were admitted with a quinsy plus an indication for tonsillectomy; 12 were evaluated prospectively. Each was treated either by incision and drainage or needle aspiration, rehydration, analgesia and intravenous antibiotic therapy, followed by a tonsillectomy à chaud (immediate tonsillectomy) within 30 h of the acute admission. Despite initial drainage, a high incidence of pus was detected intra-operatively. A much larger group of patients had peritonsillitis rather than peritonsillar abscess. Of the 16 patients admitted with a quinsy and indication for tonsillectomy over a 12 month period, 12 consented to tonsillectomy à chaud. Aspiration was used to confirm the presence of a quinsy in seven patients (58%), and incision and drainage in the remaining five. There were no complications, and further hospitalisations were avoided thus reducing patient morbidity and costs. We propose that tonsillectomy à chaud remains a justifiable alternative to interval tonsillectomy for such patients when personnel and theatre facilities permit.     

扁桃体周围脓肿的治疗和病理观察

本文分析 153例扁桃体周围脓肿的临床治疗过程 ,治疗方法包括广谱抗生素 ,反复针穿刺排脓及扁桃体摘除术。 153例中经穿刺排脓治愈者 79例 (51.6 % ) ;最后行扁桃体摘除术者 72例(4 7.1% )。对 56例扁桃体周围脓肿的扁桃体进行病理观察 ,发现扁桃体周围脓肿的扁桃体中 Weber's腺普遍呈萎缩表现 ,提示扁桃体周围脓肿发病机理可能与 Weber's腺感染有一定关系。     

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.     

A randomized trial for outpatient management of peritonsillar abscess

In order to compare the efficacy of permucosal needle drainage with that of incision and drainage in the outpatient management of peritonsillar abscess, 52 patients with aspiration-proven peritonsillar abscess were entered into a randomized, prospective protocol. A symptomatic scale scoring system was employed to evaluate treatment results. In the needle drainage group, 92% (22/24) were cured with a single aspiration. Ninety-three percent (26/28) of the patients in the incision and drainage group were cured on the initial attempt. The remainder of the patients in both groups were cured with a single retreatment. Only one patient required hospitalization, and no patients required tonsillectomy to resolve the abscess. These data indicate that outpatient permucosal needle drainage of peritonsillar abscess is an acceptable, inexpensive treatment comparing favorably with incision and drainage.     

Peritonsillar abscess. II. Cases treated with tonsillectomy à chaud

The treatment of a peritonsillar abscess by tonsillectomy à chaud obviously offers advantages over the more conservative treatment with incision, daily dilatations and possibly a later tonsillectomy. The patient avoids the painful drainage of the abscess with daily dilatations. Technically, the operation is easier to perform than later on when fibrosis has developed. The operative complications are not greater than in elective tonsillectomy, and there is no risk of spread of the infection when the patient is treated with antibiotics.     

Peritonsillar abscess in children in the southern district of Israel

Objective

Peritonsillar abscess is the most common deep neck infection and still provides a challenge to care givers in terms of diagnosis and treatment in the pediatric population. This study reviews our experience over the years 2004-2007 at the Soroka University Medical Center in the southern district of Israel in treating children with peritonsillar abscess. We compared our results with data regarding peritonsillar abscess in adults.

Methods

We performed a retrospective chart review of 126 children diagnosed and proved to have a peritonsillar abscess. Data regarding: age, sex, ethnicity, number of patients per year, seasonality, prior history of tonsillar infection, prior antibiotic treatment, length of hospitalization, surgical treatment, bacterial results and in hospital antibiotic treatment was collected from the medical charts of the patients.

Results

The average age of children with peritonsillar abscess was 12.8 years. 92 patients (73%) were above 10 years of age. We did not find an increase in the number of children with peritonsillar abscess per year over the time period of the study. The number of patients with peritonsillar abscess was significantly higher in the autumn and spring, 79 (62.6%) patients did not have prior history of tonsillar infections and 64 (67.4%) children were treated with antibiotics prior to the diagnosis of an abscess. In 95 (75.4%) patients the drainage method was needle aspiration, in 30 (28.3%) patients incision and drainage was performed and only one patient underwent bilateral quinsy tonsillectomy (0.8%). The bacterial culture was negative in 37 (36.7%) patients. In 29 patients (45% of positive cultures) the causative organism was Streptococcus group A. Mixed culture was present in 10 (15.6%) patients, nine cultures (14%) were positive for anaerobes, alone or in combination with other pathogens. Eighty-one patients (64.2%) were treated with amoxicillin-clavulanate potassium, 24 (19%) received cefuroxime and 17 (13.5%) were treated with cefuroxime+ metronidazole. The average hospital stay was 3 days.

Conclusion

Peritonsillar abscess, a potentially life threatening infection, is similar in presentation and bacteriology in the pediatric and the adult population. Based on our review we conclude that peritonsillar abscess in children can be effectively treated by the same methods used in the adult population.     

Abscess tonsillectomy for acute peritonsillar abscess

Peritonsillar abscess (PTA) is a common but potentially serious complication of acute exudative tonsillitis. Several treatment guidelines have been described including needle aspiration, incision and drainage or abscess tonsillectomy. From January 1996 to September 2000 145 patients (53 female and 92 male, age range 3-95 years) were treated for PTA at the Department of Otorhinolaryngology, Head and Neck Surgery of the MLU Halle-Wittenberg, Germany. The highest incidence of PTA was observed in the second and third decades of life. Immediate abscess tonsillectomy was performed in 105 cases. This procedure, considered as safe and easy, has a lot of advantages. Compared with other treatments, it removes the abscess with amelioration of the trismus and dysphagia. Needle aspiration as the initial and only treatment was performed in 13 patients. In 20 patients without clinical improvement after aspiration, abscess tonsillectomy was undertaken. We conclude that immediately performed abscess tonsillectomy is an effective and safe treatment for peritonsillar abscess.     

Routine abscess tonsillectomy: late results.

The late results of abscess tonsillectomy as a routine treatment of peritonsillar abscess were investigated. The material comprises 113 patients. Follow-up was performed two to five years after the operation (bilateral dissection tonsillectomy under general anesthesia). Symptoms of pharyngitis, recurrent or chronic, were present in 17 percent of the patients, in most cases without major objective changes in the throat. The incidence of these symptoms was highest--70 percent--in patients past middle age without any history of trouble from the throat before the peritonsillar abscess. Tonsil remnants were seen in 28 percent, but only 6 percent of the patients had new episodes of febrile throat infections. The results are discussed. A reserved attitude to abscess tonsillectomy (and to interval tonsillectomy) is recommended for peritonsillar abscess in elderly patients without previous trouble from the throat.     

Absceso parafaríngeo secundario a un absceso periamigdalino en la infancia

We report a case of parapharyngeal abscess in a five-years-old girl, secondary to a local extension of a peritonsillar abscess. The typical signs of peritonsillar abscess, medially displaced tonsil and displacement of the uvula toward the oposite side, were either less pronunced than usual. In this case, with parapharyngeal involvement, the treatment was abscess tonsillectomy under intravenous anti     

Peritonsillar abscess: Treatment with immediate tonsillectomy - 10 years of experience

Abstract Conclusion: Immediate tonsillectomy in patients with peritonsillar abscess is a safe and effective treatment that should be considered as an alternative to conventional incision and drainage. Objective: To assess the efficacy, safety, and microbiology of immediate tonsillectomy over 10 years, in patients with peritonsillar abscess. Methods: This was a retrospective study. We reviewed the clinical charts of patients diagnosed with peritonsillar abscess in Clínica Las Condes from September 2000 to August 2010, who were treated with immediate unilateral or bilateral tonsillectomy. The patients' epidemiological information, antibiotic therapy, laterality of the surgery, results of microbiological cultures, complications, and recurrences were recorded. Results: A total of 112 patients were studied, with a mean age of 24 years. There were no events of sepsis, and there were only four cases (3.6%) of postoperative bleeding, two of which resolved spontaneously. Only 29% of the patients required morphine pump-based analgesia in the postoperative period. The mean length of hospital stay was 3.4 days. Among the 28 unilateral tonsillectomies, 4 (14.2%) developed streptococcal tonsillitis and 2 (7.1%) were readmitted with a contralateral peritonsillitis: one cellulitis and one abscess that required drainage and tonsillectomy. The most frequently isolated microorganisms were gram-positive bacteria (Streptococcus pyogenes and other streptococci) and anaerobic bacteria (mainly Bacteroides spp. and Fusobacterium nucleatum).     

Peritonsillar abscess: risk of disease in the remaining tonsil after unilateral tonsillectomy à chaud

The occurrence of disease in the remaining tonsil after unilateral tonsillectomy à chaud in the treatment of peritonsillar abscess, was studied in 536 patients. No patient had a history of previous severe tonsillitis at the time of the unilateral tonsillectomy, 6.1 per cent of the patients were readmitted for surgery of the remaining tonsil during the follow-up period. Ninety-seven per cent of these patients were younger than 30 years of age. Previous investigations have shown increasing frequency by age of pharyngitis after bilateral tonsillectomy. We suggest bilateral tonsillectomy in all cases of patients younger than 30 years old who suffer from peritonsillar abscess irrespective of previous tonsillar disease. Patients older than 30 should be treated with unilateral ablation, unless there is a clear indication for bilateral tonsillectomy.     

Parapharyngeal abscess: diagnosis,complications and management in adults

Parapharyngeal abscess may cause life-threatening complications. Peritonsillar abscess and tonsillitis may result in parapharyngeal abscess. Since the introduction of antibiotics, the incidence of parapharyngeal abscess secondary to tonsillitis and peritonsillar abscess has decreased dramatically. We present five cases of parapharyngeal abscess resulting from tonsillitis and peritonsillar infection extending to the parapharyngeal space in adult patients. Two were complicated by mediastinitis despite early treatment by wide spectrum antibiotics. We believe that early diagnosis and aggressive antibiotic treatment with early surgical drainage in cases associated with pus collection are the key points in preventing serious and fatal complications. We emphasize the diagnostic role of computerized tomography (CT) scan and the importance of early and proper drainage of these abscesses.     

The contemporary approach to diagnosis and management of peritonsillar abscess

PURPOSE OF REVIEW: Peritonsillar abscess is a common problem, but some aspects of diagnosis and management remain controversial. We review the recent literature on peritonsillar abscess. RECENT FINDINGS: Intraoral ultrasound can be a helpful diagnostic tool for peritonsillar abscess. For management, needle aspiration, incision and drainage, and quinsy tonsillectomy all yield successful results. Recent reviews have still not established that one treatment is consistently preferred. A randomized, placebo-controlled trail found that the use of intravenous steroids seems to reduce many symptoms, when used along with abscess drainage. SUMMARY: The use of steroids may be beneficial in the treatment of peritonsillar abscess, and different techniques for abscess drainage are still used around the world, with consistently good results.     

Peritonsillar abscess. A prospective evaluation of outpatient management by needle aspiration

Outpatient management of peritonsillar abscess by needle aspiration and oral antibiotic therapy was evaluated for its effectiveness in providing rapid symptom relief and cure and in preventing recurrence. Between 1984 and 1987, 124 patients with peritonsillar infection were treated in our department, and 115 were included in this prospective study. Needle aspiration was not carried out in 11 patients because of young age, noncooperation, or severe trismus. The other 104 patients underwent permucosal aspiration and were followed up for periods of four months to three years. Of these, findings of aspiration were positive in 75 (72%). Only nine (12%) of the 75 patients with positive aspirates had to be hospitalized. In 64 (85%) of the 75 patients, the abscess resolved without further therapy. Aspiration of pus, along with oral administration of antibiotics, thus appears to be a reasonable alternative to incision and drainage or "hot" tonsillectomy in patients with peritonsillar abscess. This conservative approach obviates the need for hospital admission in most patients, thus enabling a significant cost reduction.     

Peritonsillar abscess. A comparison of treatment by immediate tonsillectomy and interval tonsillectomy.

The generally accepted therapeutic regimen for peritonsillar abscess consists of the administration of parenteral antibiotics with incision and drainage followed by interval tonsillectomy in four to six weeks. Treatment by immediate tonsillectomy, however, is practiced widely in Europe and has received recent attention in the American literature. This report compares the clinical course of patients treated by interval tonsillectomy and immediate tonsillectomy. Patient morbidity was lessened by immediate tonsillectomy, since two separate surgical procedures were avoided, and the total period of hospitalization was reduced by nearly 50%. Advantages and disadvantages of both methods of therapy are discussed.     

Health costs and consequences: have UK national guidelines had any effect on tonsillectomy rates and hospital admissions for tonsillitis?

Tonsillectomy is a common therapeutic option in the management of recurrent tonsillitis. In 1999, the Scottish Intercollegiate Guidelines Network (SIGN) introduced SIGN 34 outlining appropriate indications for tonsillectomy. Following concerns of increasing hospital admissions for tonsillitis, in 2009 ENT UK suggested that too few tonsillectomies were being undertaken. This study analyses the effect the SIGN guidelines have had on trends in population rates of tonsillectomy and hospital admissions for tonsillitis and peritonsillar abscess in England, Scotland and Wales. A retrospective study was undertaken using the health databases of England, Scotland and Wales between 1999 and 2010. Tonsillectomy, acute tonsillitis and peritonsillar abscess were identified using national classification codes. Changes in rate of tonsillectomy and hospital admissions for tonsillitis and peritonsillar abscess were assessed using a linear regression model. 699,898 tonsillectomies were undertaken in the three national cohorts over the study period. Linear regression analysis suggested that implementation of SIGN 34 significantly reduced the population rate of tonsillectomy in England (p = 0.005) and Wales (p = 0.003) but not in Scotland (p = 0.24), and indicated there had been an increase in hospital admissions for acute tonsillitis in all cohorts (England p = 0.000008, Scotland p = 0.03, Wales p = 0.000005) and peritonsillar abscess in England (p < 0.05) and Wales (p = 0.03). SIGN 34 has reduced tonsillectomy rates in England and Wales but not in Scotland. This finding is associated with increasing hospital admissions for acute tonsillitis in all national cohorts, which may suggest that the current stipulated guidelines miss patients who would benefit from surgical intervention.     

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.