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Biomedical & Pharmacology Journal

Vol. 10(2), 979-984 (2017)

The Distribution of Peritonsillar Abscess Patients

in Sanglah Hospital Denpasar at 2010 until 2017

Department of Otorhinolaryngology, Medical Faculty of Udayana University,

Sanglah Hospital, Denpasar, Indonesia.
*Corresponding author E-mail:

(Received: May 13, 2017; accepted: May 30, 2017)


Peritonsillar abscesses (PTAs) are collections of purulent material that usually develop
outside the tonsillar capsule near the superior pole. Peritonsillar abscess (PTA) is the most common
complication of tonsil infections in adults. To know the distribution of patients with peritonsillar abscess
in Sanglah Hospital Denpasar at period 2010-2017. This is an observational retrospective study
using medical records of patients with peritonsillar abscess in Sanglah Hospital Denpasar during
January 2010 until March 2017. 38 patients with peritonsillar abscess were male 65.78%, mean of
age 38.76 years, 78.95% with sore throat, 100% unilateral, most common aerob culture detected
Streptococcus viridans (63.16%) that 100% sensitive to cefuroxime, cefepime, meropenem and
linezolid. The most length of hospital stay was 4 days (65.78%) with average 4.5 days, mostly found
without difficulting factors and there is no complication in this study. This study revealed male more
frequent than female, with sore throat is the frequent symptoms, mostly unilateral and Streptococcus
viridans is the most bacteria in microbiological culture and 100% sensitive to cefuroxime, cefepime,
meropenem and linezolid. There is no difficulting factors and complication in this study.

Keywords: peritonsillar absces, microbiological culture, Streptococcus.

INTRODUCTION infection, mediastinitis, dehydration, pneumonia,

intracranial infections such as cavernous sinus
Peritonsillar abscesses (PTA) are acute thrombosis, meningitis, brain abscess and airway
infection followed by collections of purulent material obstruction.3
in loose connective tissue between faryngeal
constrictor muscle with tonsil at fossa tonsil.1,2 This The clinical symptoms such as sore throat,
infection penetrate tonsillar capsule near superior localized pain, high fever, weakness and nausea. The
pole. Peritonsillar abscess (PTA) is the most common other symptoms are halitosis, vomiting, ear pain or
complication of acute tonsilitis.3,4 otalgia and trismus.5,6

Peritonsillar abscess (PTA) is one of the There is no data shown patients with
head and neck infections often in adults. The onset peritonsillar abscesses in Sanglah General Hospital
of peritonsillar abscess starting from superficial at Denpasar. The authors are interested to research
infections and progressively developing into tonsillar on the distribution of patients with peritonsillar
cellulitis. Peritonsillar abscess complications that abscesses in Sanglah General Hospital at period
may occur include expansion into parapharing January 2010 to March 2017. This results are
980 RAHAYU et al., Biomed. & Pharmacol. J., Vol. 10(2), 979-984 (2017)

expected for evidence information of peritonsillar old.8 Salihoglu et all., reports the average age was
abscess that could be implemented in managemenet 22.2 years old.4 Ozbek et al., reports the average
of PTA properly and optimally. age was 27.9 years old.9 Naik and Naik reports the
average age was 30.4 years old.10
Sore throat is the most major complaint in
The study was observational retrospective about 30 patients (78.95%) in this study. While the
by using the medical records of patients with lowest is dysphagia in about 8 patients (21.05%)
peritonsillar abscess who came to ENT Departement (Table 3). In anamnese mostly obtained progressive
and the laboratory results from Microbiology sore throat despite untreated, localized pain, high
Departement Sanglah General Hospital. We use fever, weakness and nausea. Odinophagia can be
concecutive sampling for patients with peritonsillar a prominent complaint and the patient may difficult
abscess between January 2010 and March 2017. when eat and even swallowing. 11,12 Frequently
The incomplete medical records will exclude in this hypersalivation as a result can not cope salivary
study. Further data were tabulated and presented secretions and the saliva often dripping out. Other
descriptively in tables and narrative. complaints are halitosis, vomiting until refered
pain over to the ear (otalgia). Trismus occurs when
RESULTS AND DISCUSSION the infection extends the pterigoidius muscles.12
Kara and Spinou reports sore throat are common
A total of 28 patients with peritonsillar complaints in patients with peritonsillar abscess that
absces at period January 2010 to March 2017 is equal to 92%.13 Sore throat in our study is the most
were included in this study with a ratio of 25 males major complaint peritonsillar abscess similar with
(65.78%) and 13 females (34.22%) (Table. 1). Kara and Spinou study.

In United States the incidence is 1/6500 Most patients with peritonsillar abscess
of the population or 30.1/40000 people per year.7 occur unilateral 100% in this study. This results
Salihoglu et all., reports a total of 26 patients with shown a higher quantity than Papacharalampous
peritonsillar abscess are 92.4% males with an et all., and Edinger et all., case studies. Physical
average age was 22.2 years old.4 Ozbek et all., examination of the tonsil found unilateral swelling,
reports from total 62 patients with peritonsillar because rarely both tonsils are infected at the same
abscess the ratio is 25 (40.33%) females and 37 time. If both are infected when the oposite tonsil
(59.67%) males with average age was 27.9 years become swelling after the infected tonsil getting
old.9 Naik and Naik reports from total 27 patients with better. When swelling occurs simultaneously, the
peritonsillar abscess the ratio is 18 (66.67%) males symptoms of sleep apnea and airway obstruction
and 9 (33.33%) females in average age was 30.4 will be worsed.12 Papacharalampous et all., reports
years old.10 In this study, the male in patients with a case of bilateral peritonsillar abscess in 19
abscesses peritonsil is higher than female same as years female.2 Naik and Naik10 and Wang et all.,
Salihoglu et all., Ozbek et all., Naik and Naik studies. reports there were no differences site of location in
peritonsillar abscess.14 Edinger et all., reports a case
The distribution of patients with PTA is of bilateral peritonsillar abscess in 24 years female.15
highest in group of age 41-50 year which 15 patients
(39.48%). The lowest distribution by group of age is Based on microbiological culture,
above 60 years which 1 patients (2.63%) (Table 2). Streptococcus viridans is highest about 24 patients
The average age in this study was 38.76 years which (63.16%), while Enterococcus sp is the lowest
is higher than Salihoglu et all., Ozbek et all., Naik about 1 patient (2.63%). Eighteen point fourty three
and Naik studies. Peritonsillar abscess often seems percent shows no growth of in microbiology culture
in adults at the age of 20 to 40 years. It is rare in (Table 4). This results is supported by Sakae et all.,
children, except on immunocompromise condition. and Repanos et all., studies which are Streptococcus
In Northern Ireland, author reports 1 per 10.000 viridans is highest in patients with peritonsillar
patients per year, with an average age of 26.4 years abscess. Microbiological culture was done to
RAHAYU et al., Biomed. & Pharmacol. J., Vol. 10(2), 979-984 (2017) 981

growing population of aerobic bacteria as much as our study the resistancy of Streptococcus viridans
the mix of flora that involves microorganisms Gram- to clindamycin and erythromycin was low. Some
negative and Gram-positive. Some studies reports authors suggested second or third generation
Streptococcus viridans is the most common cause cephalosporins administration compared with group
of peritonsillar abscess, followed by Streptococcus penicillin .6
pyogenes. Streptococcus sp and anaerobic bacteria
have been identified as causative agents. 6,16 The distribution of patients with peritonsillar
Sakae et all., found 32% Streptococcus viridans in abscess is highest obtain for 4 days about 25 patients
peritonsillar abscess culture in Brazil.17 Repanos et (65.78%) in this study. Only 1 patient (2.63%) was
all., reports 43.7% Streptococcus sp in peritonsillar treated for 6 days (Table 6). In our study, the length
abscess culture.18 of hospital stay inpatient with peritonsillar abscess is
longer than Repanos et all., Wang et all., Kara and
Streptococcus viridans was obtained the Spinou, Naik and Naik studies. The average length
most sensitive to the antibiotic cefuroxime, cefepime, of treatment peritonsillar abscess obtained in this
meropemen, and linezolid respectively by 100% in study is 4.5 days. Repanos et all., reports an average
this study. Streptococcus viridans mostly resistance to treat patient with peritonsillar abscess requires
to the antibiotic ampicillin established at 62.5% (Table for 2.4 days inpatient.18 Naik and Naik reports the
5). Repanos et all., reports 0.84% Streptococcus average for hospital stay is 3.5 days.10 Kara and
sp resistance to the antibiotic group penicillin .18 The Spinou reports the average for hospital stay is 2.2
resistancy of Streptococcus viridans to ampicillin is days.13 Wang et all., reports the average for hospital
higher in our study than Repanos et all., studies. stay is 4.2 days.14
Takenaka et all., in their study reports all Gram-
positive bacteria sensitive to the antibiotic penicillin
group and cephalosporin.19 Sowerby et all., reports
Table 2: The distribution of patients
32% Streptococcus sp resistance to clindamycin
with peritonsillar abscess based on
and 41% resistant to erythromycin.20 However, in

Table 1: The distribution of Age (years) n (%)

patients with peritonsillar abscess
based on sex 11-20 3 (7.89)
21-30 6 (15.79)
Sex n (%) 31-40 10 (26,32)
41-50 15 (39.48)
Male 25 (65.78) 51-60 3 (7.89)
Female 13 (34.22) >60 1 (2.63)
Total 28 (100) Total 38 (100)

Table 4:The distribution of patients

with peritonsillar abscess based on
Table 3: The distribution of patients microbiology culture
with peritonsillar abscess based on
major complaint Microbiology culture n (%)

Chief complaint n (%) Streptococcus viridans 24 (63.16)

Streptococcus pyrogens 3 (7.89)
Sore throat 30 (78.95) Klebsiella Pneumonia 3 (7.89)
Dysphagia 8 (21.05) Enterococcus sp 1 (2.63)
Total 38 (100) No growth 7 (18.43)
Total 38 (100)
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Twenty eight patients (73.69%) in this Salihoglu et all., reports 88.46% of patients with
study without difficulting factors. Trismus shown in peritonsillar abscess accompanied by trismus.4
9 patients (23.68%). This results shown lower than
Salihoglu et all., studies. Only one patient (2.63%) A total 38 patients in this study found wihout
found with diabetes mellitus (Table 7), which is any complications. In our study, we found without
higher in Wang et all., studies. Several difficulting any complications same as in Ozbek et all., studies.
factors that affect peritonsillar abscess including Immediate complications can occur in the form of
trismus and systemic diseases, especially diabetes dehydration due to less food intake. Spontaneous
melitus.21 Wang et all., reports 3.5% of patients with rupture of the abscess with blood or pus aspiration
peritonsillar abscess found with diabetes mellitus.14 pneumonitis or abscess can cause infection to the

Table 5: The resistancy pattern for Streptococcus viridans in peritonsillar


Type of Name of n=24 (%)

antibiotic antibiotic

Ampicillin Ampicillin 9(37.5) 0(0) 15(62.5)

Amoxicillin/ 14(58.3) 1(4.2) 9(37.5)
clavulanic acid
Cephalosporin Cephalothin 23(95.8) 0(0) 1(4.2)
Cefuroxime 24(100) 0(0) 0(0)
Cefotaxime 23(95.8) 0(0) 1(4.2)
Cefepime 24(100) 0(0) 0(0)
Carbapenem Imipenem 23(95.8) 1(4.2) 0(0)
Meropenem 24(100) 0(0) 0(0)
Glycopeptide Vancomycin 23(95.8) 0(0) 1(4.2)
Macrolide Erythromycin 12(50) 3(12.5) 9(37.5)
Tetracycline Tetracycline 12(50) 2(8.3) 10(41.7)
Lincosamide Clindamycin 12(50) 4(16,7) 8(33.3)
Oxazolidinones Linezolid 24(100) 0(0) 0(0)
Aminoglycoside Amikacin 14(58.3) 2(8.3) 8(33.3)
Gentamicin 14(58.3) 1(4.2) 9(37.5)
Fluoroquinolone Ciprofloxacin 15(62.5) 0(0) 9(37.5)
Levofloxacin 20(83.3) 0(0) 4(16.7)

Table 6: The distribution of patients with Table 7: The distribution of patients

peritonsillar abscess based on lengt of with peritonsillar abscess based on
hospital stay difficulting factors

Length of stay (days) n (%) Difficulting factor n (%)

3 2 (5,26) Trismus 9 (23.68)

4 25 (65.78) Diabetes mellitus 1 (2.63)
5 10 (26.33) None 28 (73.69)
6 1 (2.63) Total 38 (100)
Total 38 (100)
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pulmonary area.1,8,22 Expansion to parapharing, January 2010 and March 2017 were predominant
may result in an abscess parapharing, spreading male. The mean of age was 38.76 years old. Sore
into the mediastinum may result in mediastinitis.22 throat is the most symptoms when came into the
Ozbek et all., in their studies did not obtained any hospital. Mostly cases occur are unilateral. The most
complications of peritonsillar abscess such as common microbiological culture was Streptococcus
abscess in the deep neck spaces or mediastinis.23 viridans. The most length of hospital stay was 4
days with average 4.5 days. In this study, mostly
CONCLUSION found without difficulting factors and there is no any
complication occurs.
A total 38 patients with peritonsillar abscess
who came into Sanglah General Hospital between


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