peritonsilar infection

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ARTICLE IN PRESS+Model

Acta Otorrinolaringol Esp. 2012; xxx(xx):xxx---xxx

www.elsevier.es/otorrino

ORIGINAL ARTICLE

Peritonsillar Infections: Prospective Study of 100 ConsecutiveCases

Mara Costales-Marcos, Fernando Lpez-lvarez, Faustino Nnez-Batalla,Carla Moreno-Galindo, Csar lvarez Marcos, Jos Luis Llorente-Pends

Servicio de Otorrinolaringologa, Hospital Universitario Central de Asturias, Oviedo, Principado de Asturias, Spain

Received 25 October 2011; accepted 2 January 2012

KEYWORDSPeritonsillarinfection;Abscess;Cellulitis;Tonsillitis

AbstractIntroduction: Peritonsillar infection is the most frequent complication of acute tonsillitis. Peri-tonsillar infections are collections of purulent material, usually located between the tonsillarcapsule and the superior constrictor of the pharynx. Peritonsillar infection can be divided intoabscess and cellulitis.Material and methods: We prospectively analysed the clinical data from 100 patients with peri-tonsillar infection from 2008 to 2010. The diagnosis of abscess or peritonsillar cellulitis wasprimarily based on obtaining pus through ne-needle aspiration.Results: Seventy-seven percent of patients had no history of recurrent tonsillitis and 55%werereceiving antibiotic treatment. Sixty-two cases were peritonsillar abscess and the rest werecellulitis. Trismus , uvular deviation and anterior pillar bulging were statistically associated withperitonsillar abscess (P


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after 5 days, were changed to a combination of clindamycinand gentamicin as described above. In all cases, antibiotictreatment was carried out empirically and duration of intravenous therapy varied between 1 day (only 1 case wastreated for 24 h) and 7 days. Most patients (82%) receivedintravenous antibiotic treatment for at least 3 days. Allpatients were given a dose of intravenous corticosteroids(methylprednisolone 1 mg/kg) upon admission, as well as

intravenous analgesia. All patients evolved satisfactorilyand we did not observe progress of the infection to moreserious complications.

All patients received oral antibiotic therapy at dischargefor 7 days. Treatment consisted in amoxicillin/clavulanate1000 mg/62.5 mg, in 2 tablets every 12 h in 83%of cases andclindamycin 300 mg every 6 h in 17%of cases.

These cases of peritonsillar infection were the rst col-lected during the time of study in 95% of patients, whilst1%experienced a new episode and 4%presented 2 consec-utive episodes. In 26 cases (26%) we suggested performingtonsillectomy after the episode of peritonsillar infection.

Discussion

Most studies published in current literature are based on aretrospective analysis of cases. Thus, their results reectthe management of this condition in 10---15 years evolution.In order to reduce the heterogeneity inherent to most ret-rospective series, we have chosen to analyse prospectively100 consecutive cases treated at our hospital according tothe same diagnostic and therapeutic protocol.

In our series, 55% of patients were receiving antibi-otic therapy for the treatment of pharyngotonsillitis. Thisnding is more consistent with the classical concept that

peritonsillar infection is due to a torpid evolution of bac-terial tonsillitis. However, this percentage is higher thanthat described in the literature, where prior pharyngoton-sillar infection was only reported in between 11% and 45%of cases. 12,13 The absence of prior tonsillar infection wouldsupport the theory that the origin of peritonsillar infectionis cellulitis of Webers salivary glands. These small mucousglands are located in the superior pole of the tonsillar bedand the soft palate. When cellulitis of these glands takesplace and inammation progresses, it leads to symptomswhich are clinically indistinguishable from those causedwhen a tonsillar infection does not evolve favourably. Thisobservation would also justify the development of peri-tonsillar infections in patients who had undergone priortonsillectomy. 14,15

The diagnosis of this entity is simple and is based onclinical data and physical exploration. 1 It is characterisedby the presence of unilateral inammatory signs and symp-toms, even in the absence of febrile syndrome. The presenceof trismus, bulging of the anterior pillar and deviation of the uvula to the contralateral side can help to distinguishbetween a phlegmonous early stage and peritonsillar abscesswithout requiring puncture. While this datum conrms thereports published by Kilty et al., 16 it should be taken withcaution since, as seen in our study, up to 23%of cases do notpresent signicant trismus. Some authors advocate the useof ultrasound for diagnosis and to conduct guided punctures,

as well as computed tomography (CT) in uncooperative pae-diatric patients. 1

One of the hypotheses which we considered at the begin-ning of the study was that an inappropriate use of antibioticsin the treatment of pharyngitis favoured the developmentof complications, specically the use of macrolides, due tothe high rate of resistance among the Spanish population.However, although most patients were taking antibiotics at

the time of diagnosis of peritonsillar infection, we foundthat only 3% of patients who had taken antibiotics previ-ously had taken a macrolide and most were being treatedadequately with amoxicillin/clavulanate. Nevertheless, webelieve that not taking the appropriate dosage or failureto adequately comply with the correct antibiotic patterncould be a favouring factor since most authors report ahigher rate of peritonsillar infections in patients treatedwith macrolides. 9 In our series we found no relationshipbetween a history of repeated pharyngotonsillitis and thedevelopment of peritonsillar infection. This coincides withthe ndings in other series. 2 However, we did observe a rela-tionship between suffering repeated pharyngotonsillitis andsuffering more than one episode of phlegmon/abscess.

Management on an outpatient basis or hospitalisation of these patients is a source of disagreement between vari-ous authors (Table 3). While in countries such as the UnitedKingdom the vast majority of patients are admitted, in theUnited States they are mostly managed as outpatients. 24In our series, following the protocol at our service, weadmitted these patients in order to administer intravenousantibiotics and provide hydration and nutritional support.Nevertheless, we believe that, following the therapeuticregime of Al Yaghchi et al., 25 certain patients without riskfactors could benet from outpatient management.

Drainage of the purulent material is part of the treat-ment (Table 3). The most appropriate method for this task

remains controversial, although both puncture-aspirationand incision-drainage seem to be equally effective. 18,21 Inour action protocol, we use puncture-aspiration at the timeof diagnosis. According to the leakage or not of purulentmaterial, we classify the infection as phlegmon or abscess.The management guide for peritonsillar abscesses proposedby Herzon et al. 12 suggests that puncture-aspiration canbe used as the only drainage procedure, as it obtains aresolution rate of 96%, and leaves incision-drainage as analternative for cases of failure of the rst technique. Theseauthors emphasise the scarce discomfort, technical simplic-ity and low cost of the technique, as well as the fact that itdoes not require specialised equipment. Some authors advo-cate performing tonsillectomy immediately after drainingthe abscess (quinsy or hot tonsillectomy) due to the lowrate of complications and recurrences. 26 In our study, mostpatients evolved adequately without having to repeat thepuncture or perform an incision for drainage.

Antibiotic treatment was established empirically, withthe rst option being intravenous amoxicillin-clavulanateat high doses. This treatment progressed adequately in84% of cases, including those previously treated with thissame combination. From this we can conclude that mostresistances remain dose-dependent. We believe that a com-bination of clindamycin and gentamicin may be an adequatealternative in cases of -lactam allergy or unfavourable evo-lution with the rst option. Other authors advocate the


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Peritonsillar Infections: Prospective Study of 100 Consecutive Cases 5

Table 3 Comparative studies of drainage method and treatment regime.

Authors Treatment regime Numberof patients

Method Success, %

Mehanna et al. 17 94%hospital 101 48%punction 926% outpatient 52%incision 90

Ong et al. 13 100%hospital 185 66%incision 9334% punction 41

Stringer et al. 18 100%outpatient 24 Punction 9228 Incision 93

Herzon et al. 12 100%outpatient 41 100%punction 90Ophir et al. 19 92%outpatient 75 100% punction 52

8% hospitalSegal et al. 20 100%outpatient 126 75.4% punction 23.8%

incision 0.8% quinsy tonsillectomy

96

98100

Spires et al. 21 100%outpatient 41 Punction 9821 Incision 100

Maharaj et al. 4 100%outpatient 30 Punction 87

30 Incision 90Savolainen et al. 22 100%hospital 98 100%punction 91Wolf et al. 23 100%hospital 86 Punction 28

74 Incision 90

use of cefotaxime or penicillin alone or combined withmetronidazole, with similar results. 13,27 We believe thatadministration of a single dose of corticosteroids can bevery useful, having observed, like other authors, a fasterimprovement of symptoms such as dysphagia, pain andtrismus. 28

In accordance with other authors,29

we believe thatmicrobiological identication studies are unnecessary, sinceempirical therapy is generally effective before cultureresults are obtained. In addition, many patients take antibi-otics previously, so, very often, the results of the culture donot identify the causative agent. Conducting cultures andantibiograms would only be useful in cases of infectionswith very unfavourable evolution and in immunocompro-mised patients.

According to Wikstn et al. the risk of recurrence is10%---15% depending on the follow-up period. This rateincreases to 50% in patients younger than 40 years and inthose with a history of repeated infections. 30 Our recurrencerate was 5%, which would conrm the effectiveness of our

protocol.Regarding the indication for tonsillectomy after an

episode of peritonsillar infection, as described in theliterature, 9,31 we do not consider having suffered such anepisode as an absolute criterion for the intervention. How-ever, in patients with repeated pharyngotonsillitis and inthose cases with more than one peritonsillar event, we sup-port the indication of delayed tonsillectomy.

We have not collected any cases of serious complicationsduring this time period, since cases of mediastinitis, necro-tising fasciitis or septic embolisms are more common inseverely immunocompromised patients or in those who havesuffered a major delay in diagnosis. 32

Conclusions

Peritonsillar infection is the most common complication of bacterial pharyngotonsillitis. Although this entity is likelyto cause high morbidity and mortality, it has an excellentprognosis when properly treated.

Due to the absence of clinical practice guidelines forthe management of this disorder there are various treat-ment protocols. From our experience, we believe thatpuncture-aspiration in the most convex peritonsillar regionand administration of intravenous antibiotics represents asafe and effective protocol in the management of thesepatients. Further, controlled studies would be required inorder to determine the efcacy and safety of managementon an outpatient basis compared to hospital admission.

Conict of Interests

The authors have no conicts of interest to declare.

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