Peritonsillar abscess: a study of 724 cases in Japan. (Original Article).

Abstract

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.

Introduction

Even though improvements in antibiotic therapy have lowered the mortality rate among patients with peritonsillar abscess, serious complications--including deep neck infection (1,2) and mediastinitis (3)--still occur. Therefore, otolaryngologists should continue to pay close attention to this possibility.

The emergency medical center at our university hospital covers one-third (population: 3.5 million) of the Tokyo metropolitan area, and a large number of patients with peritonsillar abscess have been treated at our clinic. This study was undertaken to analyze all cases we encountered during a recent 12-year period and to review the current clinical and therapeutic aspects of this disease in both Japan and the West.

Patients and methods

We reviewed the charts of 724 patients who were admitted to Kyorin University Hospital with a diagnosis of peritonsillar abscess between January 1988 and December 1999. Details regarding sex, age, clinical history, laboratory findings, and clinical courses were obtained for all patients.

A diagnosis of peritonsillar abscess was established when the presence of an abscess was confirmed by needle aspiration or surgical drainage. During aspiration, pus was collected from the affected peritonsillar space with an 18-gauge needle mounted on an evacuating syringe for bacteriologic sampling. For the bacteriologic study, aerobic bacteria only were examined in 453 patients, and both aerobic and anaerobic bacteria were examined in 13 patients.

Results

The group of 724 patients was made up of 541 males and 183 females, aged 7 to 92 years (mean: 32.6 [+ or -] 13.2). Approximately two-thirds of these patients were between 20 and 39 years of age (figure 1). The abscess was unilateral in 718 patients (left: 346; right: 372) and bilateral in six. There was no clear pattern with respect to the particular month during which patients were admitted (figure 2).

By far, the most common chief complaint was sore throat, which was reported by 614 patients (84.8%) (table 1). Some 75 patients (10.4%) had a history of tonsillar disease, including 48 who had had a previous peritonsillar abscess. Seven patients (1.0%) had a deep neck infection as a complication of their abscess. Dental disease was suspected as the primary infection in six patients (0.8%).

Data on both body temperature and white blood cell count at the initial consultation were available for 718 patients, and measurements of C-reactive protein for 699 (table 2). Temperature was elevated (<37.5[degrees] C) in 363 of 718 patients (50.6%), leukocytosis (<10,000/[cm.sup.2]) was found in 580 of 718 patients (80.8%), and the serum Creactive protein level was abnormally high (>0.4 mg/dl) in 661 of 699 patients (94.6%).

Among the 466 patients who were examined for aerobic bacteria, 386 cultures were positive and 80 were negative (table 3). The most common pathogens were [alpha]-hemolytic streptococci. Among the 13 patients who were examined for both aerobic and anaerobic bacteria, eight were positive and five were negative.

Incision and drainage was performed on 675 of the 724 patients (93.2%), and the remaining 49 patients (6.8%) underwent only needle aspiration. All patients received intravenous antibiotics, mostly penicillin or a cephalosporin. Additional surgical therapies were performed on patients who had deep neck infection (7 patients), epiglottic edema (4 patients), or mediastinitis (2 patients).

The mean duration of hospitalization was 9.9 days ([+ or -]2.6), excluding those patients with a deep neck infection. There were no peritonsillar abscess-related deaths in this study.

Discussion

Several studies have reported results similar to our findings-specifically, that peritonsillar abscess usually affects young adults and that it is more common in males than in females. (4-11) We found no clear seasonal predominance, but some Western studies have. However, there is no consensus on this because the seasonal predominances that have been reported vary so greatly; various authors have reported that the incidence is higher in spring and autumn, (5) in spring and winter, (8) and in June and winter. (11)

The percentage of patients in our study who had a history of peritonsillar abscess (10.4%) was clearly lower than the percentages (23 to 74%) reported in the aforementioned Western studies. (5,8,11) The incidence of bilateral peritonsillar abscess in our study (0.8%) was comparable with rates seen in some studies, (7,12) but less than those reported in others. (4,5,13) The low rate of bilateral disease can be attributed to the effective use of antibiotics.

In our study, [alpha]-hemolytic streptococci were the most common aerobic bacteria cultured from patients' pus (63.9%), while [beta]-hemolytic streptococci were isolated in only 10.3% of our patients. By contrast, most Western studies have found that 13-hemolytic streptococci were the most common isolates (20 to 50%). (5,9-11,13,14) One possible explanation for this difference is the widespread use of antibiotics in Japan. In Japan, antibiotics such as penicillin and cephalosporins are almost routinely administered to patients who have a common cold in order to prevent secondary bacterial infection; most of our patients had a history of antibiotic use prior to this study. Ghaffar et al studied the effect of antibiotic therapy on bacterial colonization in the nasopharynx and concluded that it resulted in an increased isolation of nasopharyngeal [alpha]-hemolytic streptococci. (15) This perhaps explains the high rate of [alpha]hemolytic streptococci infection in our study. In fact, our study is the first to emp hasize the importance of [alpha]hemolytic streptococci in peritonsillar abscess.

The therapeutic strategy for peritonsillar abscess is still controversial. Schechter et al wrote that incision and drainage followed by immediate tonsillectomy is not necessary to effect the complete resolution of a peritonsillar abscess. (8) Similarly, Savolainen et al reported that the therapeutic effects of needle aspiration were comparable with those of incision and drainage. (10) Ophir et al also pointed out the advantages of needle aspiration, not only in terms of therapeutic effect but cost reduction, as well. (14)

Other authors favor incision and drainage. Wolf et al reported that the recurrence rate among patients who were treated for peritonsillar abscess with needle aspiration was statistically higher than that seen with incision and drainage. (11) Nielsen et al reported a case of mediastinitis resulting from peritonsillar abscess, and they emphasized the importance of wide incision and drainage rather than needle aspiration. (3)

We performed incision and drainage on most of our patients (93.2%). Unfortunately, we were not able to systematically follow up these patients for a sufficient period (>2 yr), so it is not possible for us to determine which method is statistically better solely on the basis of this study. Nevertheless, because we have seen cases of serious complications of peritonsillar abscess, we believe that immediate drainage through surgical incision is the preferred method of treatment.

[FIGURE 1 OMITTED]

[FIGURE 2 OMITTED]

Table 1

Chief complaints, medical history, and complications among 724 patients
with peritonsillar abscess

Finding                  n (%)

Chief complaint
Sore throat            614 (84.8)
Odynophagia             41 (5.7)
Neck swelling           16 (2.2)
Swallowing difficulty   13 (1.8)
Neck tenderness          7 (1.0)
Other                   33 (4.6)

Medical history
Tonsillar disease       75 (10.4)
Hypertension            22 (3.0)
Asthma                  18 (2.5)
Viral hepatitis         16 (2.2)
Diabetes mellitus       12 (1.7)

Complication
Deep neck infection      7 (1.0)
Epiglottic edema         4 (0.6)
Mediastinitis            2 (0.3)
Other                    2 (0.3)
Table 2

Mean body temperature and laboratory findings at the initial
consultation

Test                    Results (mean [+ or -] SD)

Body temperature        37.5 [+ or -] 1 .5 [degrees] C
 (n = 718)
White blood cell count  14,500 [+ or -] 5,200/
 (n = 718)              [cm.sup.2]
C-reactive protein      8.6 [+ or -] 6.1 mg/dl
 (n = 699)
Table 3

Types of bacteria isolated

Finding                                  n (%) *

Aerobic (n = 466) +
 [alpha]-Hemolytic streptococci        298 (63.9)
 Neisseria spp.                        189 (40.6)
 [beta]-Hemolytic streptococci          48 (10.3)
 [gamma] Streptococci                   45 (9.7)
 Other                                  28 (6.0)
 Negative culture                       80 (17.2)

Aerobic and anaerobic (n = 13)
 Anaerobic gram-negative rods            5 (38.5)
 Porphyromonas spp.                      4 (30.8)
 Anaerobic gram-negative streptococci    1 (7.7)
 Negative culture                        5 (38.5)

* Some cultures yielded more than one isolate.

+ Total includes 453 patients who were examined for aerobic bacteria
only and 13 who were examined for both aerobic and anaerobic bacteria.

References

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(2.) Wenig BL, Shikowitz MJ, Abramson AL. Necrotizing fasciitis as a lethal complication of peritonsillar abscess. Laryngoscope 1984;94: 1576-9.

(3.) Nielsen TR, Clement F, Andreassen UK. Mediastinitis--a rare complication of peritonsillar abscess. J Laryngol Otol 1996;110: 175-6.

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(9.) Snow DG, Campbell JB, Morgan DW. The microbiology of peritonsillar sepsis. J Laryngol Otol 1991;105:553-5.

(10.) Savolainen S, Jousimies-Somer HR, Makitie AA, Ylikoski JS. Peritonsillar abscess. Clinical and microbiologic aspects and treatment regimens. Arch Otolaryngol Head Neck Surg 1993; 119:521-4.

(11.) Wolf M, Even-Chen I, Kronenberg J. Peritonsillar abscess: Repeated needle aspiration versus incision and drainage. Ann Otol Rhinol Laryngol 1994:103:554-7.

(12.) Kristensen S, Juul A, Nielsen F. Quinsy: A bilateral presentation. J Laryngol Otol 1985;99:401-2.

(13.) Litman RS, Hausman SA, Sher WH. A retrospective study of peritonsillar abscess. Ear Nose Throat J 1987;66:53-5.

(14.) Ophir D, Bawnik J, Poria Y, et al. Peritonsillar abscess. A prospective evaluation of outpatient management by needle aspiration. Arch Otolaryngol Head Neck Surg 1988:114:661-3.

(15.) Ghaffar F, Friedland IR, Katz K, et al. Increased carriage of resistant non-pneumococcal a-hemolytic streptococci after antibiotic therapy. J Pediatr 1999:135:618-23.

From the Department of Otolaryngology-Head and Neck Surgery, Kyorin University School of Medicine, Tokyo.

Reprint requests: Hidekazu Tanaka, MD, Department of Otolaryngology-Head and Neck Surgery, Kyorin University School of Medicine, 6-20-2, Shinkawa Mitaka City, Tokyo, 181-8611, Japan. Phone/fax: [phone].