Efficacy of three therapeutic methods for peritonsillar abscess
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《中华医药杂志》英文版
[Abstract] Objective To explore the most effective therapeutic method of peritonsillar abscess.Methods A hundred and twenty-six patients were divided into three groups. In group A,there were 28 cases who were operated in abscess stage, 23 cases in group B were operated selectively, and 75 cases in group C were conservatively treated.The effects of three therapeutic methods were analyzed.Results In group A, the average bleeding volume of unilateral tonsil was 12 ml with the incidence of postoperative bleeding 3.8% and the mean hospitalization duration of 7 days. In group B, the average bleeding amount of unilateral tonsil was 23 ml with the incidence 8.9%, and the mean hospitalization of 15 days. There were significant differences between the two groups in these parameters (all P<0.05). In the two groups there was no postoperative wound infection or general infection. Patients in group A recovered to normalization in postoperative body temperature, restriction of mouth opening and hemogram 2 days after operation, and patients in group C recovered to normalization about 6 days after operation. There was significant difference between the two groups (P<0.05). In group C, 4 cases relapsed, and the recurrent rate was 5.0%.Conclusions If patients' has no contraindication, the tonsillectomy is an appropriate method for peritonsillar abscess without relapse.
[Key words] peritonsillar abscess; tonsillectomy;therapy
INTRODUCTION Peritonsillar abscess (PTA), a common disease in clinic pratice, is one of emergencies in otorhinolaryngologic department and easy to relapse. If the patients with peritonsillar abscess were treated by different methods, the curative effects would be different. To enhance the therapeutic effects for peritonsillar abscess, three methods' effectiveness,surgery in abscess stage, selective surgery and conservative treatment are reported as follows.
MATERIALS AND METHODS
Materials
One hundred and twenty-six PTA patients from 1994 to 2004 in our department were divided into 3 groups. In group A,28 cases who were operated in abscess stage, including 20 males and 8 females, aging 16~60 years. In group B,23 cases who were operated in selectively, including 18 males and 5 females, aging from 14~66 years. In group C there were 75 cases who were conservatively treated, including 62 males and 13 females, aging from 8 to 72 years old. The patients were all with unilateral abscess, including 56 patients in the left and 70 patients in the right. The formative pura had been testified by paracentesis. Among them, 30 cases were testified the abscess formation in the peritonsillar tissue by B-mode ultrasound. There were symptoms, such as unilateral sorethroat, restriction of mouth opening and deglutition, lallation, salivation, fervescence, pharyngeal foreign body sensation, etc. And there were signs.including congestion of throat in the affected lateral, knuckle above the palatopharyngeal arch that presses the tonsil downward insider; unilateral and bilateral submandibular lymph nodes tumefaction, cervical immobilization, even compulsive rhebocrania.
Criteria of Diagnosis
(1) Sore throat, restriction of mouth opening, fervescence, pharyngeal foreign body sensation. (2) The significant knuckle around the above tonsil. (3) The history of repeated attack by the acute chronic tonsillitis, whose duration of illness is above 3~7 days. (4) Pura could be abstracted by paracentesis around the tonsil. (5)By B -mode ultrasound or CT, abscess can be testified.
Department of EENT(Eye,Ear,Nose and Throat),The 302th Hospital,Anshun 561000,Guizhou Province,China
Therapeutic Methods
Twenty-eight cases of group A were intravenously administered large dose sensitive antibiotics and hormone by drip after hospitalization. Among them, 8 cases were incised and drained, and 20 cases were paracentesed and drained. All patients underwent tonsillectomy 1~4 days after drainage.Twenty-three cases of group B were operated when the clinical symptoms and the local inflammation were removed after paracentesis and drainage, general anti-inflammatory therapy for 10 days. The patients who once had the history of repeated attack by tonsillitis were operated with bilateral tonsillectomy, and those wh had not the history or repeated attack of tonsillitis were operated unilateral tonsillectomy. The patients of group A and group B were all operated the tonsillectomy under local anesthesia, and were given the normal anti-inflammatory and hemostatic treatment after operation. Seventy-five cases of group C were paracentesed and drained after confirmed diagnosis by paracentesis and abstracting pura. These patients had being opened and drained by hemostatic forceps for 1~2 times everyday until there were no pura, and combined with the general anti-inflammatory treatment. Most of them were discharged after 2-week conservative anti-inflammatory treatment.
Statistical Methods
SPSS 10.0 statistical software pack was employed to analyse the data. T-test was used to compare the amount of bleeding and hospita stay of the two groups, and chi-square test was used to compare the incidence of postoperative bleeding of the two groups.
RESULTS
The comparative results of operation and postoperative situation between group A and group B were as in the Table 1.
Table 1 The comparative results of operation and postoperative situation between group A and group B
TP1
In the recovery situation of postoperative body temperature, hemograme and restriction of mouth opening, patients in group A recovered to normalization about 2 days later, and the patients in group C about 6 days. There were significant differences between group A and group B in the bleeding amount of unilateral tonsil,the postoperative bleeding incidence and mean hospitalization duration (P<0.05). Patients of group A recovered to normalization more fastly than those of group C. All patients had been followed-up for 2 months to 2 years, there were no recurrent patients in group A and group B, and there were 4 recurrent patients (recurrent rate 5%). There were no septicemic, pneumonia and nephritis patients in group A.
DISCUSSION
PTA,a suppurative inflammation in circumtonsillar space, usually occur following acute tonsillitis. Inflammation, in tonsillar crypts, especially in supratonsillar fossa will destroy the epithelial tissue by bacteria or inflammation for crypt entrance's obstruction,develop toward crypt deep part, penetrate tonsillar capsule, enter tonsillar space, and generate phlegmon and secondly abscess[1].Children are seldom attacked by this disease, because children tonsillar capsule is thick and compact, tonsillar crypt is slit and its branches are short and superficial, which makes bacteria uneasily collect and diffuse. ZW Xue et al[2] reported a 53-day-old infant patient of unilateral peritonsillar abscess treated by tonsillectomy under general anesthesia in abscess stage.
Severe PTA is lethal, as a serious pharynx deep part infective disease. According to the abroad reports, the incidence rate of PTA is 0.03%[3]. According to MH Meng's[4] description about peritonsillar space's Weber's gland, they found the invasion of PTA is related to infection of Weber's gland by cutting tissue of normal palatum tonsil and abnormal palatum tonsil. PTA patients partly once had history of repeated attack by acute tonsillitis, and their inflammation of acute and chronic tonsillitis involves Weber's gland in crypt, which will lead to PTA because inflammation affects tonsillar fossa for inadequate drainage. The symptom includes pharyngodynia, which occurs 4~5 days after invasion, restriction of mouth opening, significant local eminence, and tender localization. The most reliable diagnostic method is to abstract pura by paracentesing from the most eminent spot of soft palate. In the study, 126 patients were all abstracted pura by paraentesis. At present, the method is recommended to clarify causes of disease, abscess's dimension and scope by B-mode ultrasound or CT, chose chieri or Thompson pot to paracentese, and acupuncture or drain by cutting many spots and attempt to paracentese[5]. The best spot of paracentesis and drainage is the most eminence of abscess or conjunction among tonsillar upper side, uvular radicle paralleling pharyngopalatine arch, and the third molar teeth, which can avoid damaging external carotid artery.
PTA is caused by bacteria infection, usually including hemolytic streptococcus, staphylococcus, etc.Otherwise, anaerobic bacteria can lead to this disease. The anterosuperior type is common in clinic. PTA must be identified with parapharyngeal abscess, wisdom tooth pericoronitis, Ludwig's anginairitis, and tonsillar malignant tumor. If PTA was not treated in time appropriately, there would generate a series of complications, often including cervical deep lymphnoditis, parapharyngeal infection and hemorrhage, laryngeal edema, deep abscess of neck and pyotoxinemia, seldom including cervical necrotic fasciitis and descending necrotic mediastinitis.
PTA therapeutic methods include conservative treatment, selective surgery and operation in abscess stage. The conservative treatment, mainly including abstracting pura by paracentesis, cutting and drainage, etc, is with less pain.But patients treated by this method recovered more slowly and partly could relapse. During selective surgery,conditions that tonsil adheres to peripheral tissue and scar generates,which makes passive separation diffcult, and often need sharp separation. In selective procedure, when adhesive band is separated, constrictor pharyngis fiber is damaged easily, and tonsil is difficult in extirpating entirely and can leave residual body, with long operative time, generating tunice albuginea, and high hemorrhage incidence. In abscess stage operation, tonsil is separated from peripheral tissue by abscess and easy to be dissected without scar generation and adhension, and with little damage to peripheral tissue and less bleeding. After operation, patients' tunica albuginea format soon with low hemorrhage incidence, quick recovery,short hospitalization duration and no restriction of mouth opening,and the operation can be done immediately after cutting and drainage.KY Wen[6] recommended that patients should be operated 2~3 days after abstracting pura and controlling infection if hatch is less than 2.5 cm;patients should be operated that day if hatch is more than 2.5cm; patients should be operated in selectively if they are in poor general condition or have systemic complications. WN Jin[7] thought that tonsillectomy in abscess stage is beneficial in three aspects as follows. (1) In early stage tonsil has slight adhension, which is easy to be separated and does not leave residual body. (2) The operation in abscess stage can drain entirely in time, which is benefit to inflammatory resolution. (3) This operation hammper the excretion of Weber's gland secretion and get rid of the cause of infection,thus cure this disease radically.
Tonsillectomy is the best treatment for PTA to avoid recurrence since PTA recurrent rate is very high[8]. In the past, people thought that operation should be done 2~3 weeks after acute inflammation resolution. But after 2~3 weeks, scar has already generated in tonsillar capsule, which makes tonsillar dissection difficult and tonsil destroyed heavily followed by heavy hemorrhage and residual body. Tonsillectomy factually not only relieve infection, but also eliminate abscess because antibiotic can control inflammation effectively. In abscess-stage tonsillectomy, tonsil is exposed absolutely and the operation is entirely accordance with surgical treatment discipline. In group A and group B, all patients have no postoperative infection of wound surface and systemic infection. Tonsillectomy in abscess stage, however, has some shortage as follows. Tissue becomes swellen and more fragile because this operation is in acute inflammatory stage and residual body is often left if surgeon is careless because the operation is more difficult than othe s. Nowadays, there are some related reports about tonsillectomy in home. In a word,abscess-stage operation is more effective for PTA than operation in selective surgery and conservative treatment if patient's organ has no contraindication without recurrence, the tonsillectomy is an appropriate method to treat peitonsillar abscess.
REFERENCES
1.黄选兆，汪吉宝.实用耳鼻咽喉科学.北京：人民卫生出版社，1999.376-377.
2.薛章伟，方文旭.婴幼儿扁桃体周围脓肿1例.耳鼻咽喉-头颈外科杂志，2001，8(4)：244.
3.Herzon Fs.Peritonsillar absecss：incidenie，current management practices and aproposal for treatment guidelines. Largngoescope，1995(Suppl 74)：1-17.
4.孟敏华，王卫.扁桃体周围脓肿的治疗和病理观察.耳鼻咽喉头颈外科杂志，2000，7(5)：273-275.
5.陈洪.超声对诊断扁桃体周围脓肿的价值.临床耳鼻咽喉科杂志，2000，10(10)：469.
6.闻克银.扁桃体周围脓肿扁桃体切除术36例.中国耳鼻咽喉颅底外科杂志，1997，3(4)：238.
7.靳维娜.扁桃体周围脓肿55例临床分析.中国基层医药，2004，11(9)：1128.
8.Fagan JJ，wonnald PJ.Quinsy tonsillectomy.Interval tonsil-ectomy:a prospective randornised trial.S Afr Med J，1994，84(10)：689-690.
(Editor Jaque)(CHENG Fang-ming)
[Key words] peritonsillar abscess; tonsillectomy;therapy
INTRODUCTION Peritonsillar abscess (PTA), a common disease in clinic pratice, is one of emergencies in otorhinolaryngologic department and easy to relapse. If the patients with peritonsillar abscess were treated by different methods, the curative effects would be different. To enhance the therapeutic effects for peritonsillar abscess, three methods' effectiveness,surgery in abscess stage, selective surgery and conservative treatment are reported as follows.
MATERIALS AND METHODS
Materials
One hundred and twenty-six PTA patients from 1994 to 2004 in our department were divided into 3 groups. In group A,28 cases who were operated in abscess stage, including 20 males and 8 females, aging 16~60 years. In group B,23 cases who were operated in selectively, including 18 males and 5 females, aging from 14~66 years. In group C there were 75 cases who were conservatively treated, including 62 males and 13 females, aging from 8 to 72 years old. The patients were all with unilateral abscess, including 56 patients in the left and 70 patients in the right. The formative pura had been testified by paracentesis. Among them, 30 cases were testified the abscess formation in the peritonsillar tissue by B-mode ultrasound. There were symptoms, such as unilateral sorethroat, restriction of mouth opening and deglutition, lallation, salivation, fervescence, pharyngeal foreign body sensation, etc. And there were signs.including congestion of throat in the affected lateral, knuckle above the palatopharyngeal arch that presses the tonsil downward insider; unilateral and bilateral submandibular lymph nodes tumefaction, cervical immobilization, even compulsive rhebocrania.
Criteria of Diagnosis
(1) Sore throat, restriction of mouth opening, fervescence, pharyngeal foreign body sensation. (2) The significant knuckle around the above tonsil. (3) The history of repeated attack by the acute chronic tonsillitis, whose duration of illness is above 3~7 days. (4) Pura could be abstracted by paracentesis around the tonsil. (5)By B -mode ultrasound or CT, abscess can be testified.
Department of EENT(Eye,Ear,Nose and Throat),The 302th Hospital,Anshun 561000,Guizhou Province,China
Therapeutic Methods
Twenty-eight cases of group A were intravenously administered large dose sensitive antibiotics and hormone by drip after hospitalization. Among them, 8 cases were incised and drained, and 20 cases were paracentesed and drained. All patients underwent tonsillectomy 1~4 days after drainage.Twenty-three cases of group B were operated when the clinical symptoms and the local inflammation were removed after paracentesis and drainage, general anti-inflammatory therapy for 10 days. The patients who once had the history of repeated attack by tonsillitis were operated with bilateral tonsillectomy, and those wh had not the history or repeated attack of tonsillitis were operated unilateral tonsillectomy. The patients of group A and group B were all operated the tonsillectomy under local anesthesia, and were given the normal anti-inflammatory and hemostatic treatment after operation. Seventy-five cases of group C were paracentesed and drained after confirmed diagnosis by paracentesis and abstracting pura. These patients had being opened and drained by hemostatic forceps for 1~2 times everyday until there were no pura, and combined with the general anti-inflammatory treatment. Most of them were discharged after 2-week conservative anti-inflammatory treatment.
Statistical Methods
SPSS 10.0 statistical software pack was employed to analyse the data. T-test was used to compare the amount of bleeding and hospita stay of the two groups, and chi-square test was used to compare the incidence of postoperative bleeding of the two groups.
RESULTS
The comparative results of operation and postoperative situation between group A and group B were as in the Table 1.
Table 1 The comparative results of operation and postoperative situation between group A and group B
TP1
In the recovery situation of postoperative body temperature, hemograme and restriction of mouth opening, patients in group A recovered to normalization about 2 days later, and the patients in group C about 6 days. There were significant differences between group A and group B in the bleeding amount of unilateral tonsil,the postoperative bleeding incidence and mean hospitalization duration (P<0.05). Patients of group A recovered to normalization more fastly than those of group C. All patients had been followed-up for 2 months to 2 years, there were no recurrent patients in group A and group B, and there were 4 recurrent patients (recurrent rate 5%). There were no septicemic, pneumonia and nephritis patients in group A.
DISCUSSION
PTA,a suppurative inflammation in circumtonsillar space, usually occur following acute tonsillitis. Inflammation, in tonsillar crypts, especially in supratonsillar fossa will destroy the epithelial tissue by bacteria or inflammation for crypt entrance's obstruction,develop toward crypt deep part, penetrate tonsillar capsule, enter tonsillar space, and generate phlegmon and secondly abscess[1].Children are seldom attacked by this disease, because children tonsillar capsule is thick and compact, tonsillar crypt is slit and its branches are short and superficial, which makes bacteria uneasily collect and diffuse. ZW Xue et al[2] reported a 53-day-old infant patient of unilateral peritonsillar abscess treated by tonsillectomy under general anesthesia in abscess stage.
Severe PTA is lethal, as a serious pharynx deep part infective disease. According to the abroad reports, the incidence rate of PTA is 0.03%[3]. According to MH Meng's[4] description about peritonsillar space's Weber's gland, they found the invasion of PTA is related to infection of Weber's gland by cutting tissue of normal palatum tonsil and abnormal palatum tonsil. PTA patients partly once had history of repeated attack by acute tonsillitis, and their inflammation of acute and chronic tonsillitis involves Weber's gland in crypt, which will lead to PTA because inflammation affects tonsillar fossa for inadequate drainage. The symptom includes pharyngodynia, which occurs 4~5 days after invasion, restriction of mouth opening, significant local eminence, and tender localization. The most reliable diagnostic method is to abstract pura by paracentesing from the most eminent spot of soft palate. In the study, 126 patients were all abstracted pura by paraentesis. At present, the method is recommended to clarify causes of disease, abscess's dimension and scope by B-mode ultrasound or CT, chose chieri or Thompson pot to paracentese, and acupuncture or drain by cutting many spots and attempt to paracentese[5]. The best spot of paracentesis and drainage is the most eminence of abscess or conjunction among tonsillar upper side, uvular radicle paralleling pharyngopalatine arch, and the third molar teeth, which can avoid damaging external carotid artery.
PTA is caused by bacteria infection, usually including hemolytic streptococcus, staphylococcus, etc.Otherwise, anaerobic bacteria can lead to this disease. The anterosuperior type is common in clinic. PTA must be identified with parapharyngeal abscess, wisdom tooth pericoronitis, Ludwig's anginairitis, and tonsillar malignant tumor. If PTA was not treated in time appropriately, there would generate a series of complications, often including cervical deep lymphnoditis, parapharyngeal infection and hemorrhage, laryngeal edema, deep abscess of neck and pyotoxinemia, seldom including cervical necrotic fasciitis and descending necrotic mediastinitis.
PTA therapeutic methods include conservative treatment, selective surgery and operation in abscess stage. The conservative treatment, mainly including abstracting pura by paracentesis, cutting and drainage, etc, is with less pain.But patients treated by this method recovered more slowly and partly could relapse. During selective surgery,conditions that tonsil adheres to peripheral tissue and scar generates,which makes passive separation diffcult, and often need sharp separation. In selective procedure, when adhesive band is separated, constrictor pharyngis fiber is damaged easily, and tonsil is difficult in extirpating entirely and can leave residual body, with long operative time, generating tunice albuginea, and high hemorrhage incidence. In abscess stage operation, tonsil is separated from peripheral tissue by abscess and easy to be dissected without scar generation and adhension, and with little damage to peripheral tissue and less bleeding. After operation, patients' tunica albuginea format soon with low hemorrhage incidence, quick recovery,short hospitalization duration and no restriction of mouth opening,and the operation can be done immediately after cutting and drainage.KY Wen[6] recommended that patients should be operated 2~3 days after abstracting pura and controlling infection if hatch is less than 2.5 cm;patients should be operated that day if hatch is more than 2.5cm; patients should be operated in selectively if they are in poor general condition or have systemic complications. WN Jin[7] thought that tonsillectomy in abscess stage is beneficial in three aspects as follows. (1) In early stage tonsil has slight adhension, which is easy to be separated and does not leave residual body. (2) The operation in abscess stage can drain entirely in time, which is benefit to inflammatory resolution. (3) This operation hammper the excretion of Weber's gland secretion and get rid of the cause of infection,thus cure this disease radically.
Tonsillectomy is the best treatment for PTA to avoid recurrence since PTA recurrent rate is very high[8]. In the past, people thought that operation should be done 2~3 weeks after acute inflammation resolution. But after 2~3 weeks, scar has already generated in tonsillar capsule, which makes tonsillar dissection difficult and tonsil destroyed heavily followed by heavy hemorrhage and residual body. Tonsillectomy factually not only relieve infection, but also eliminate abscess because antibiotic can control inflammation effectively. In abscess-stage tonsillectomy, tonsil is exposed absolutely and the operation is entirely accordance with surgical treatment discipline. In group A and group B, all patients have no postoperative infection of wound surface and systemic infection. Tonsillectomy in abscess stage, however, has some shortage as follows. Tissue becomes swellen and more fragile because this operation is in acute inflammatory stage and residual body is often left if surgeon is careless because the operation is more difficult than othe s. Nowadays, there are some related reports about tonsillectomy in home. In a word,abscess-stage operation is more effective for PTA than operation in selective surgery and conservative treatment if patient's organ has no contraindication without recurrence, the tonsillectomy is an appropriate method to treat peitonsillar abscess.
REFERENCES
1.黄选兆，汪吉宝.实用耳鼻咽喉科学.北京：人民卫生出版社，1999.376-377.
2.薛章伟，方文旭.婴幼儿扁桃体周围脓肿1例.耳鼻咽喉-头颈外科杂志，2001，8(4)：244.
3.Herzon Fs.Peritonsillar absecss：incidenie，current management practices and aproposal for treatment guidelines. Largngoescope，1995(Suppl 74)：1-17.
4.孟敏华，王卫.扁桃体周围脓肿的治疗和病理观察.耳鼻咽喉头颈外科杂志，2000，7(5)：273-275.
5.陈洪.超声对诊断扁桃体周围脓肿的价值.临床耳鼻咽喉科杂志，2000，10(10)：469.
6.闻克银.扁桃体周围脓肿扁桃体切除术36例.中国耳鼻咽喉颅底外科杂志，1997，3(4)：238.
7.靳维娜.扁桃体周围脓肿55例临床分析.中国基层医药，2004，11(9)：1128.
8.Fagan JJ，wonnald PJ.Quinsy tonsillectomy.Interval tonsil-ectomy:a prospective randornised trial.S Afr Med J，1994，84(10)：689-690.
(Editor Jaque)(CHENG Fang-ming)