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PubMed2003

An evidence-based review of the treatment of peritonsillar abscess.

OBJECTIVE: Peritonsillar abscess (PTA) is commonly seen but still controversial. We performed an evidence-based review to answer 3 questions: Are steroids beneficial? Which is the best technique for acute surgical management? When is tonsillectomy indicated? STUDY DESIGN: We performed a MEDLINE search of the published literature using appropriate search terms to identify pertinent articles, which were reviewed and graded according to the evidence quality. RESULTS: Forty-two articles were analyzed. There are no published studies on steroids in PTA. There were 5 level I clinical studies on surgical technique, which indicated that needle aspiration, incision and drainage, and quinsy tonsillectomy are all effective for initial management. The overall PTA recurrence rate is 10% to 15%. CONCLUSIONS: Overall, grade C evidence indicates that several methods of initial surgical drainage are equally effective, and the recurrence rate is low. The literature does not specifically address different treatments for children and adults.

Drainage↗
PubMed1994

Diagnosis of peritonsillar abscess: value of intraoral sonography.

OBJECTIVE: Clinical differentiation of peritonsillar abscess from peritonsillar cellulitis can be difficult and often relies on blind needle aspiration of the tonsillar fossa to locate pus. The objective of this study was to establish a noninvasive and reliable sonographic technique for differentiating peritonsillar abscess from peritonsillar cellulitis in equivocal cases and to thereby avoid unnecessary needle aspiration. SUBJECTS AND METHODS: The study population included three healthy volunteers and 18 patients with clinically suspected peritonsillar abscess. The tonsils were assessed by using transcutaneous and intraoral sonography. RESULTS: The tonsils were visualized on both transcutaneous and intraoral sonograms in all three volunteers and in 16 patients. In one patient, the tonsils were not visualized on transcutaneous imaging; intraoral imaging showed cellulitis. In another patient, the intraoral examination was unsuccessful, whereas transcutaneous sonograms showed normal tonsils. On the basis of findings on transcutaneous sonograms, tonsils were considered normal in seven patients. Subsequent intraoral sonograms showed peritonsillar abscesses in four and peritonsillar cellulitis in two. Intraoral imaging was unsuccessful in one patient. On the basis of findings on transcutaneous sonograms, nine patients were thought to have peritonsillar cellulitis. Subsequent intraoral sonograms confirmed cellulitis in four and showed peritonsillar abscess in five. Transcutaneous sonography showed one peritonsillar abscess that was confirmed by findings on intraoral sonography. Surgical confirmation of sonographic findings was obtained in 12 of 18 patients; nine of 10 peritonsillar abscesses had surgical drainage, and three of seven cases of peritonsillar cellulitis had a dry, blind needle aspiration. CONCLUSION: These results show that enlarged tonsils can be visualized with transcutaneous sonography, but intraoral sonography is necessary to adequately define the heterogeneous or cystic nature of a peritonsillar abscess. Intraoral sonography is a useful, simple, and well-tolerated noninvasive technique that can be used to accurately differentiate peritonsillar abscess from peritonsillar cellulitis in clinically equivocal cases. This technique eliminates the need for blind needle aspiration of the tonsillar fossa before surgical drainage. Intraoral sonography also can be used to monitor patients' responses after treatment.

Adult↗
PubMed1994

Pathogenesis of peritonsillar abscess.

The pathogenesis of peritonsillar abscess is described in textbooks as being a direct communication and progression of acute exudative tonsillitis. Little study has been done on the true etiology and pathogenesis of peritonsillar abscess. This paper focuses on the pathogenesis of peritonsillar abscess. A group of salivary glands (Weber's glands) proven to be located in the supratonsillar space have been shown to be implicated in the pathogenesis of peritonsillar abscess. A review of peritonsillar abscess has been undertaken, and evidence has been presented to support the premise that the true cause for peritonsillar abscess is not necessarily an extension of an acute exudative tonsillitis, but an abscess formation of Weber's salivary glands in the supratonsillar fossa.

Adolescent↗
PubMed1996

Peritonsillar abscess following tonsillectomy.

Peritonsillar abscess is an unusual complication following tonsillectomy. A series of five such patients is herein reported. Proper treatment begins with the initial tonsillectomy ensuring complete removal of the tonsils. Should a late peritonsillar abscess following tonsillectomy be found, the patient may be treated with needle aspiration of the affected area plus antibiotics. Removal of the remaining tonsillar tissue and surgical capsule of the tonsil is also advocated.

Adolescent↗
PubMed1988

A clinical prospective study of peritonsillar abscess in children.

Distinguishing peritonsillar abscess from cellulitis is an important clinical problem, particularly in children, who may require a general anesthetic for drainage of these abscesses. In order to identify those clinical factors most significant for peritonsillar abscess, we did a prospective study of 21 patients who presented with sore throat, fever, trismus, and tonsillar bulge; all symptoms that are consistent with the diagnosis of peritonsillar abscess. On admission, the following parameters were recorded: patient age, duration of sore throat, fever, white blood cell count, drooling, the degree of trismus (measured exactly as incisor-incisor distance), the degree of pharyngotonsillar bulge, and change in voice. After 24 to 48 hours of parenteral antibiotics, 12 patients (57%) had improved sufficiently and were continued on antibiotics until resolution (cellulitis group). Nine patients (43%) had no improvement and underwent surgery for drainage of the peritonsillar abscess (abscess group). At the end of the 18-month study period, the cellulitis and abscess groups were compared. On admission, no significant difference was found in age, duration of sore throat, fever, or white blood cell count. The pharyngotonsillar bulge was mild in 58% and moderate in 42% of the cellulitis group, while in the abscess group, the pharyngotonsillar bulge was mild in only 33% and moderate in 67%. After 24 to 48 hours of parenteral antibiotics, all patients in the cellulitis group had improvement of at least one symptom; whereas, all patients in the abscess group had no change or worsening of at least one symptom, including trismus, dysphagia, voice change, drooling, or pharyngotonsillar bulge. On admission, the precise measurement of trismus was not significantly different in the two groups (24.7 mm in cellulitis group vs. 22.5 mm in abscess group). However, after 24 hours of antibiotics, trismus averaged 7 mm more in the abscess group versus the cellulitis group (p less than 0.05).

Adolescent↗
PubMed2005

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.

Anti-Inflammatory Agents↗
PubMed1999

Selection of antibiotics after incision and drainage of peritonsillar abscesses.

Despite the fact that peritonsillar abscess is the most common complication of acute tonsillitis, the treatment of peritonsillar abscess remains controversial. One element of controversy is the choice of antibiotics after drainage of the abscess. In an attempt to assess the effect of antibiotic choice on the treatment of peritonsillar abscess, we conducted a retrospective review of records from patients with peritonsillar abscess treated with incision and drainage. Our review identified 103 patients, comprising two groups: 58 patients treated with broad-spectrum intravenous antibiotics and 45 patients treated with intravenous penicillin alone. These patients were hospitalized after incision and drainage, and therefore their clinical courses and responses to therapy could be rigorously assessed. Characterization of illness based on patient age, temperature, and white blood cell count revealed similar severity of illness between the two groups. Comparison of clinical outcomes with respect to hours hospitalized (mean 44.3 +/- 6.6 and 38.3 +/- 7.1 hours, 95% confidence interval, for broad-spectrum and penicillin groups, respectively) and mean hours febrile (16.9 +/- 5.0 and 13.3 +/- 4.2 hours, 95% confidence interval) were not statistically significantly different (p = 0.222 and 0.269, respectively) between groups, indicating that broad-spectrum antibiotics failed to show greater efficacy than penicillin in the treatment of these patients. The microbiologic characteristics of these infections, failures of therapy, and complication rates were similar to those reported in the literature. These results suggest that intravenous penicillin remains an excellent choice for therapy in cases of peritonsillar abscess requiring parenteral antibiotics after drainage.

Adolescent↗
PubMed1995

Computed tomographic findings in peritonsillar abscess and cellulitis.

The differentiation of a peritonsillar abscess from peritonsillar cellulitis, although difficult on physical examination, is required in order to determine the appropriate treatment. Peritonsillar cellulitis can be treated with antibiotics alone, while a peritonsillar abscess should be drained. Computed tomography (CT) of the neck is often performed to identify the formation of a deep abscess in the neck, but is rarely used to diagnose peritonsillar infections. We report a patient in whom CT was a useful diagnostic tool for distinguishing peritonsillar abscess from peritonsillar cellulitis.

Adult↗
PubMed1999

[Therapeutic approach to peritonsillar abscesses].

The treatment of peritonsillar abscesses is debated. A retrospective study was made of 19 patients diagnosed as peritonsillar abscess who were treated by incision, drainage, and intravenous antibiotics. The surgical, medical and diagnosis factors that affect the management of peritonsillar abscesses are discussed.

Abscess↗
PubMed1994

The role of ultrasound in the management of peritonsillar abscess.

A distinction between a peritonsillar abscess and peritonsillitis is useful clinically, as the former requires surgical drainage while the latter merely requires treatment with antibiotics. To evaluate the diagnostic implications of performing ultrasonography of the tonsils in patients with clinically diagnosed peritonsillar abscess, 27 patients underwent ultrasound examination before needle aspiration of the abscess was performed. Ultrasound was able to detect peritonsillar abscess in 91 per cent of the cases (sensitivity rate), with a false negative rate of nine per cent and a false positive rate of 20 per cent. The specificity of the test was 80 per cent, and was able to differentiate abscess from peritonsillitis in 88.9 per cent. On the basis of these results we conclude that ultrasonography of the tonsils in patients thought to have peritonsillar abscess is a useful adjunct, enhancing diagnostic accuracy and reducing unnecessary surgical drainage.

Adult↗
PubMed2004

Corticosteroids and peritonsillar abscess formation in infectious mononucleosis.

Peritonsillar abscess formation is an uncommon complication of infectious mononucleosis (IM). Early case reports implicated corticosteroids in the development of such abscesses, however, subsequent studies suggested that these drugs do not promote the formation of abscesses at several sites outside the central nervous system. It has recently been demonstrated that zwitterionic polysaccharides, in bacterial capsules, form complexes with CD4(+) T lymphocytes leading to abscess formation. A patient is presented who developed peritonsillar abscess a few days after initiation of corticosteroid therapy for IM; the medical literature was reviewed in respect of this subject. It appears that the occurrence of these abscesses in IM is not strongly linked to corticosteroid treatment. The authors, therefore, recommend that steroids should not be withheld from patients with severe IM on the basis that they may precipitate the development of peritonsillar abscess.

Administration, Oral↗
PubMed1981

Bilateral peritonsillar abscesses.

A case of bilateral peritonsillar abscesses is reported. The patient was a 31-year-old male presenting with a severe sore throat, dysphagia, trismus and bilateral swelling of the soft palate causing no displacement of the uvula. Incision and drainage (I and D) and an interval tonsillectomy cured this condition. On review of the literature, it was noted that bilateral peritonsillar abscesses are not uncommon. Peritonsillar abscesses possibly occur bilaterally, but as the developmental stages of the abscesses are not simultaneous, immediate tonsillectomy or intensive antibiotic treatment following I and D controls the formation of the opposite side abscess in most cases.

Adult↗
PubMed2001

[Clinical significance of the Streptococcus milleri group in peritonsillar abscesses].

Few researchers have microbiologically studied peritonsillar abscesses in detail, and their results have been conflicting. Although Streptococcus pyogenes (Group A beta-streptococcus) is commonly considered an important pathogen in this infection, recent studies have demonstrated the recovery of many other streptococci mainly consisting of alpha-streptococci. Few studies have identified these streptococci at the species level, however. We studied details of bacteriology in 31 cases of peritonsillar abscess treated between 1991 and 2000. The Streptococcus milleri group was most frequently isolated (25.8%), followed by Eikenella corrodens (9.7%), Staphylococcus aureus (6.5%), and S. pyogenes (3.2%). The S. milleri group, consisting of 3 species of Streptococcus constellatus, S. intermedius, and S. anginosus, forms part of the normal flora most commonly found in the mouth, throat, gastrointestinal tract, and genital tract. These species have become known as an important pathogen in abscess disease but little attention has been paid to their role in peritonsillar abscesses. To adequately culture the S. milleri group, incubation in air containing carbon dioxide or in an anaerobic condition is required, and then the differentiation of the 3 species requires the biochemical reactivity tests. Since hemolytic patterns of the S. milleri group vary, we studied the population of alpha-, beta-, and gamma-hemolytic strains among 36 strains of this group. We found 32 (88.8%) to be alpha-hemolytic. Although not all alpha-hemolytic strains belong to the S. milleri group, a considerable number of this group could be missed among alpha-streptococci isolated from the peritonsillar abscess. As antibiotics began being used widely, normal flora such as the S. milleri group may have become an important pathogen in peritonsillar abscesses due to an imbalance between organisms and host defense.

Adolescent↗
PubMed2002

Peritonsillar abscess: diagnosis and treatment.

Peritonsillar abscess, the most common deep infection of the head and neck that occurs in adults, is typically formed by a combination of aerobic and anaerobic bacteria. The presenting symptoms include fever, throat pain, and trismus. Ultrasonography and computed tomographic scanning are useful in confirming a diagnosis. Needle aspiration remains the gold standard for diagnosis and treatment of peritonsillar abscess. After performing aspiration, appropriate antibiotic therapy (including penicillin, clindamycin, cephalosporins, or metronidazole) must be initiated. In advanced cases, incision and drainage or immediate tonsillectomy may be required.

Adult↗
PubMed1995

The microbiology and antibiotic treatment of peritonsillar abscesses.

Pus from 53 peritonsillar abscesses was cultured and associations between the microbiological results and clinical data were investigated with the aim of developing a clinical protocol for treatment. A positive culture grew in 85% of quinsies and of these 16% produced aerobes and 84% anaerobes. Penicillin-resistant organisms were grown from 32% of patients and all but one of these organisms (Haemophilus influenzae) was sensitive to metronidazole. There was no association between clinical presentation and cultured organism which could guide treatment, hence we recommend penicillin and metronidazole as the antibiotic regimen of choice in the treatment of peritonsillar abscesses because of its effectiveness in 98% of patients.

Adolescent↗
PubMed1995

[A case of deep neck abscess and acute mediastinitis, secondary to peritonsillar abscess].

A 60-year-old female visited a hospital complaining of fever and pharyngeal pain. She was diagnosed as peritonsillar abscess. Initial conservative treatment was not curative, and deep neck and mediastinal abscess developed. After cervical drainage, she was referred to our hospital. Drainage tube was inserted via epigastrium into anterior mediastinum upwardly under local anesthesia. Postoperative course was uneventful, and she was cured and discharged after about 1 month of hospitalization. We stressed the importance of recognition of the mediastinitis as a complication of cervical infections. And immediate drainage procedure is required as soon as the diagnosis is established.

Abscess↗
PubMed1981

Peritonsillar abscess.

In 161 patients treated for a peritonsillar abscess by stab incision as the only surgical procedure, a follow-up study was conducted after 3 1/2 to eight years. Of all the patients examined, 51% had experienced no throat symptoms, 22% had had recurrent peritonsillar abscesses, 20% had had recurrent episodes of tonsillitis with fever, and 7% had had symptoms resembling episodic pharyngitis in varying degrees. The age of the patient and the patient's history of previous throat infections were found to have prognostic value. Older patients (older than 40 years) had a lower incidence of new throat infections (peritonsillar abscess, tonsillitis, or both) than younger patients. Patients without previous throat symptoms had a lower incidence of new throat infections than patients with a history of throat infection before the peritonsillar abscess, which in itself might indicate the need for tonsillectomy.

Adolescent↗
PubMed1981

Bilateral peritonsillar abscess: an unusual presentation.

Bilateral peritonsillar abscess is uncommon. We have described a patient in whom it was misdiagnosed as bilateral hypertrophy of the tonsils. Direct palpation of the tonsils, which helped in the diagnosis in our patient, should be done routinely in patients with suspected peritonsillar abscess.

Child↗