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5ТАКТИКА ЛЕЧЕНИЯ ПАЦИЕНТА С ПЕРИТОНСИЛЛЯРНЫМ АБСЦЕССОМ
TREATMENT TACTICS OF PATIENT WITH PERITONSILLAR ABSCESS
Махамадалиев Е.Ю. Маматова Т.Ш. Арифов С.С.
Ташкентский институт последипломного медицинского образования
Makhamadaliev E.Yu. Mamatova T.Sh. Arifov S.S.
Tashkent institute of postgraduate medical education
E-mail:
Резюме
Целью исследования явился ретроспективный анализ показаний к горячей тонзиллэктомии, ее эффективности и безопасности.
Перитонзиллярный абсцесс (ПТА) - одно из наиболее частых осложнений острого тонзиллита и причина неотложной
ларингологической консультации. В некоторых случаях необходимо выполнить горячую тонзиллэктомию.
Материалы и методы. В период 2018-2019 гг. в стационар поступили 32 пациента (в возрасте от 18 до 55 лет) с
первоначальным диагнозом перитонзиллярный абсцесс. Среди них 18 женщин и 14 мужчин. Всем выполнена горячая
тонзиллэктомия.
Результаты. Большинство пациентов были в возрасте от 19 до 50 лет. Наиболее частыми симптомами были боль в горле, тризм и дисфагия. Во всех случаях производили разрез абсцесса, у 10 больных имелось гнойное отделяемое. У всех пациентов не было облегчения симптомов после инцизии и антибактериальной терапии. В 19 случаях без дренирования после первичного разреза гной был удален после тонзиллэктомии. В остальных 13 случаях были дополнительные резервуары гноя, которые были дренированы после операции у 7 пациентов. У 9 пациентов имелось более одной локализации абсцесса. Проблем с интубацией не было, осложнений в раннем и позднем послеоперационном периоде не было. Средняя
Заключение. Отсутствие улучшения после начального лечения ПТА является показанием к горячей тонзиллэктомии. Эта процедура не связана с повышенным риском осложнений. Эвакуация гнойного содержимого не исключает наличия другого абсцесса, необычной локализации или абсцесса парафарингеального пространства.
Ключевые слова: перитонзиллярный абсцесс (ПТА); Тонзиллэктомия; горячая тонзиллэктомия; острый тонзиллит;
Summary
The aim of this study was retrospective analysis of indications to hot tonsillectomy, its effectiveness and safety. Peritonsi llar abscess (PTA) is one of the most common complications of acute tonsillitis and the cause of emergency laryngological counselling. In some cases, it is necessary to perform hot tonsillectomy.
Material and Methods: In between 2018-2019, 32 patients (aged between 18 to 55 years old) with an initial diagnosis of peritonsillar abscess were admitted. Among them, 18 were women and 14 were men. All underwent hot tonsillectomy.
Results: Most of the patients were between 19 - 50 years old. The most common symptoms were pain in the throat, trismus and dysphagia. In all cases incision of an abscess was made, in 10 patients purulent discharge was present. In all patients there was no relief of symptoms after in-cision and antibiotic therapy. In 19 cases without drainage after initial incision, pus was drained after tonsillectomy. In the remaining 13 cases there were additional reservoirs of pus, which were drained after surgery in 7 patients. In 9 patients there was more than one localization of an abscess. There were no problems with intubation and no complicat ions in the early and late postoperative periods occurred. The average time of stay in hospital was 10 days.
Conclusion: Lack of improvement after initial treatment of PTA is an indication to hot tonsillectomy. This procedure is not connected with an increased risk of complications. Evacuation of purulent content does not exclude presence of another abscess, unusual localization or parapharyngeal space abscess.
Key words: peritonsillar abscess (PTA); tonsillectomy; hot tonsillectomy; acute tonsillitis; complication; parapharyngeal space abscess
References to the article
Makhamadaliev E.Yu., Mamatova T.Sh., Arifov S.S. Tactics of treatment of a patient with peritonsillar abscess //Innova. -2019.-No. 4(17). - P.10-15.
DOI: 10.21626/innova/2019.4/02
Библиографическая ссылка на статью
Махамадалиев Е.Ю., Маматова Т.Ш., Арифов С.С. Тактика лечения пациента с перитонсиллярным абсцессом // Innova. - 2019. - № 4 (17). -С.10-15.
Introduction common complications of acute tonsillitis and cause
Peritonsillar abscess (PTA) is one of the most of emergency laryngological counselling. It is also
l0
the most common deep neck infection. The incidence is estimated to be 30 out of 100,000 people per year. Factors predisposing to the development of peritonsillar abscess described in the literature are bad periodontal status and smoking. Treatment is always connected with an abscess incision, drainage of purulent content, rehydration with subsequent antibiotic therapy. In some cases, it is necessary to perform immediate tonsillectomy. Otherwise infection may spread into surrounding tissues such as parapharyngeal space. This procedure is potentially connected with an increased risk of complications, such as problems with intubation, intra- and post-operative haemorrhage and spread of the infection to surrounding tissues especially to the parapharyngeal space.Immediate tonsillectomy has also been reported in pediatric cases for airway obturation [18].
Materials and methods
Between 2018-2019 in In the ENT department of TIPME 32 patients with an initial diagnosis of
peritonsillar abscess were admitted, who underwent hot tonsillectomy. The ages of the patients ranged from 18 to 55 years old (middle 34 years), 18 women and 14 men.
Retrospective analysis of data from medical history, according to age, symptoms, signs and methods of treatment was made. Inclusion criteria were peritonsillar abscess recognized in clinical examination requiring tonsillectomy within 24 hours after admission to the hospital. Symptoms were asymmetry of oral pharynx and palatoglossal arch, dislocation of the tonsil. Age, stay in the hospital, history of recurrent tonsillitis and peritonsillae abscesses, C-reactive protein (CRP) level and type of treatment were analyzed. The day of discharge from hospital was assumed as the end of treatment. Patients left hospital after healing of tonsillar niche and relief of local and general symptoms.
Results
The age range of the patients is shown. The largest group of patients in this study were aged between 23 and 45 years.
Age in study group
80
18-23 23-45 45-55 >60
The number of men and women in the study were similar (M:W 44%/56%). Symptoms reported by patients are shown in Table 1, the most common symptom was pain in the throat and problems with swallowing.
Table 1. Symptoms reported by patients.
Symptom Number Perce
of patients ntage
Fever 13 40.6%
Trismus 29 90.6%
Pain in the throat 32 100%
Dysphagia 19 59.3%
Ear pain 4 12,5%
>3 acute tonsilitis in i5/32 46.8%
the previous 1 year
1-2 acute tonsilitis in 3/32 9.35%
the previous 1 year
Peritonsillar abscess (previous year) i8(i5) 56.2% (46.8 %)
In the history of previous upper respiratory tract infections more than half of the patients had at least 4 episodes of acute tonsilitis in the previous year and 15 had peritonsillar abscess in the past.
Upon admission to the hospital the patients were in good general condition. Following laryngological examination, swelling in the
peritonsillar area and pain with enlargement of lymph nodes on the affected side were stated together with signs of acute tonsillitis.
Blood tests was performed in all patients on the days of admitting and discharges from the hospital. Results of the blood tests are shown in Table 2,3. In all patients, levels of inflammatory parameters decreased at the day of discharge.
Table 2. Blood tests results.
The concentration of CRP The number of patients
with PA
Absolute Relative
less than 10 mg / l i person 3,i2 %
10 - 50 mg/l i3 pers. 40,62 %
50 - 100 mg/l i i pers. 34,37 %
100 - 200 mg/l 7 pers. 2i,87 %
In total: 32 pers. i00,0 %
Table 3. Blood tests results.
ESR The number of patients
with PA
Absolute Relative
1-10 mm / h 7 pers. 2i,87%
11-20 mm / h 8 pers. 25,00 %
21-30 mm / h i i pers. 34,37 %
31-40 mm / h 6 pers. i8,75 %
In total: 32 pers. i00,0 %
All patients at the day of admission had undergone incision of PTA. In 13 there was purulent drainage (40.6%). The algorithm of treatment is show in Figure 2.
In all patients indication for surgery, hot tonsillectomy, was lack of improvement within the following 48 hours, independent of purulent drainage after initial incision.
All 32 patients had immediate/hot tonsillectomy. In 7 it was on one side and in 25 bilateral. Indications for bilateral tonsillectomy were recurrent
acute tonsillitis and history of PTA in the previous year (12 cases) and signs of chronic tonsillitis (7 cases). During surgery in 86% of patients purulent content was drained and among those cases half of them were parapharyngeal space abscesses. Table 3 gives detailed information about recognized abscesses during surgery.
Table 3. Postoperative diagnosis.
Number Percentage
antero-superior 19 59.37%
PTA
Posterior PTA 6 18.75%
Parapharyngeal 14 43.75%
space abscess
Among all patients with parapharyngeal space abscess only in 2 cases on initial incision drainage of pus was present. In 9 patients there was more than one localization of an abscess. In 4 patients PTA in antero-superior area and parapharyngeal space abscess were found and in 4 posterior PTA and parapharyngeal space were found simultaneously.
Loss of blood was on average 110 ml. The average time of surgery was 72 minutes. There were no problems with intubation, no complications in the early and late post-operative period occurred.
Discussion
PTA is a purulent reservoir localized between the superior pharyngeal sphincter and a tonsil which
Patients were treated with antibiotics and it was usually intravenous amoxycylin with clavulanic acid (3 times daily, 1,2 g in 29 out of 32 patients), in one case cefurixime with metroni-dazole was used and in another case cefotaxim with clindamycin was used.
The average time of stay in hospital was 10 days. None of the described patients required treatment on our clinic again.
is a complication of acute tonsillitis. This diagnosis requires immediate treatment because of the possibility of infection spread to the parapharyngeal space, retropharyngeal space and floor of the mouth. Continuation of disease leads to the
involvement of deep neck spaces and mediastinum, which is a life threatening condition. According to the literature progression of infection from throat to deep neck space occurs in 1.8% patients and from those spaces to mediastinum in 10%. Mortality in acute mediastinitis is still high and ranges from 30% to 40%.
In the group of patients analyzed in the study, most patients were young adults aged from 18 to 55 years old who are professionally active people. These data are consistent with those from the literature and that makes problem of PTA treatment economically important. The symptoms reported by patients were typical for throat infections.
Out of the whole group in 8, patients abscesses were present in more than one localization, for example PTA with abscess of parapharyngeal space. This means that even initial incision with drainage of pus from the peritonsillar area requires subsequent controls, especially in situations when there is no expected improvement in patient's clinical status or recurrence of symptoms after initial improvement. There are data in the literature concerning the spread of infection from peritonsillar area to deep neck spaces in similar cases.
Fine needle aspiration of PTA or incision with drain-age of pus with subsequent antibiotic therapy is the treatment of choice. Although, when there is a lack of expected improvement the next step that should be considered is hot tonsillectomy. This procedure is also called tonsillectomy "a chaud" or urgent ton-sillectomy and was described at the beginning of 20th century as typical treatment of PTA. Potentially increased risk of the procedure and intra-operative and post-operative complications led to the abandonment of this procedure by surgeons. However, on the basis of the results presented here, along with data from the literature we can suggest that this procedure is not connected with increased risk of complications such as haemorrhage during surgery or delayed haemorrhage. Albertz et al reported that describing their 10 years experience. The authors had cases of bleeding (3.6%) and single cases of edema, diarrhea, persisted odynophagia, panic attack, cutaneous rash. No problems with intubation or complications such as haemorrhaging occurred in any of our patients. These results confirm information from the literature according to Berry et al who estimated hot tonsillectomy to be easier than delayed tonsillectomy, especially on the side of PTA. Johnson suggested that if there is delayed tonsillectomy following abscess, this may be connected with higher costs of treatment as it may require another hospitalization and absence at work. The same author recommends hot tonsillectomy in all patients with recurrent PTA, as it may prevent recurrences. It is still controversial if this tonsillectomy should be performed on one side only or if it should be performed bilaterally. In our material bilateral tonsillectomy was made in all patients who
had indications for tonsillectomy, independent from PTA. According to the literature it seems to be the most common practice in another centres. However, Albertz et al recommend bilateral tonsillectomy in all cases as a prevention of recurrences, on the basis of their study. Immediate tonsillectomy is especially effective in cases of intratonsillar and posterior abscess, which was confirmed in our study.
It is recommended to administer antibiotics intravenously before hot tonsillectomy and to avoid analgesic drugs which inhibit aggregation of blood platelets and may influence blood coagulation.
In all of our patients improvement was achieved after surgery and antibiotic therapy with amoxicillin with clavulanic acid. Diagnostic imaging may include computer tomography but it seems that the main indication for hot tonsillectomy is lack of expected clinical improvement in spite of proper treatment. Diagnostic imaging may be useful in case of doubts.
Conclusion
Lack of improvement after initial treatment of PTA should make a consideration of performing hot tonsillectomy as an emergency. This procedure is not connected with increased risk of complications and postponing the decision may lead to infection spread into surrounding tissues. Evacuation of purulent content does not exclude the presence of another abscess in close, unusual localization or parapharyngeal space abscess.
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