TYAG/ Vet

Collcut Medical Journal 2011 9;3,:e

Original article:
Treatment of Peritonsillar Abscess-
A prospective study of Aspiration verses incision and drainage
V. Tyagi, A Kaushal, Deeplca Garg, Samistha De, P. Nagpure
Department of ENT & Head Neck Surgery
Mahatma Gandhi Institute of Medical sciences,
Sevagran. Wardha, Maharashtra, India

Objective: The study was conducted to find the various clinical presentations and
to evaluate efficacy of permucosal needle drainage with that of incision and
drainage in the management of peritonsillar abscess Study design Prospective,
randomized study Methods: This investigation included 71 cases with unilateral
peritonsillar abscess. They were divided in 2 groups, one group was treated with
aspiration and other treated with incision and drainage, effects of these therapeutic
methods were evaluated. Results: Age ranged from 14 years to 56 years (mean
40.59 years). Mate predominance was seen in the ratio of 1:0.78. A triad of
'symptoms comprising pain, fever and peritonsiliar swelling was observed in 29
(90-62 %) cases. Bacterial culture was positive in 59 (83 %) cases. Most common
aerobic organism isolated was Group A beta hemolytic streptococcus (GABHS)
seen in 16 (27%) cases: Anaerobic culture was positive in 11 (50 %) cases out of
22 cases, in which anaerobic culture was done_ In the needle drainage group_
86% (31!36) were cured with a siny:a aspiration. 97 percent (34135) of the
patients in the incision and drainage group were cured on the initial attempt The
remainder of the patients in both groups were cured with a single retreatment.
Only 1 patient proceeded to incision and drainage after failure of aspiration and no
patients required tonsillectomy to resolve the abscess. Conclusion; Permucosal
needle drainage of peritonsillar abscess was found to be acceptable, inexpensive
treatment comparing favorably with incision and drainage.
Keywords: Peritonsillar Abscess(PTA), Aspiration, Incision & Drainage

Introduction
The most commonly encountered abscess in the upper aero digestive tract is the
Peritonsillar Abscess (PTA) and it usually spreads from a contiguous focus in the
tonsils or the parapharyngeal area. Progression of the suppurative process with the
development of a purulent collection between the capsule of the tonsil and the
fascia of the superior constrictor muscle result in the so called peritonsillar
abscess or quinsy. History tells us that President George Washington succumbed
to a peritonsillar abscess'. The generally accepted classic treatment consists of
permucosaf aspiration or incision and drainage with systemic antibiotics followed
by interval tonsillectomy.
Debate continues regarding optimal therap/ in terms of morbidity and cost
effectiveness.
The prospective study was carried out in Ent & Head Neck Surgery Department
of our rural teaching institute. It includes 71 patients with unilateral PTA
diagnosed between 1st August 2008 and 31st July 2010_ The group comprised of
40 males and 31 females with average age of 40.59. All cases diagnosed
underwent a detailed history taking followed by a thorough general physical
examination with, special reference to the examination of Throat, Nose and Ear.
Patients were divided into two groups randomly. In first group aspiration was
done and in the other incision and drainage was done followed by systemic
antibiotic. if the patient was not relieved in 3 days, a repeat procedure was done.
Aerobic and anaerobic culture of the pus sample was sent in most of the cases.
Inclusion criteria for cases: All the patients attending to our OPD with clinical
diagnosis of PTA were considered as cases. Aspiration was done using a 10mt
syringe and an 18 French Gauge (FG) needle Incision and drainage was done by a
standard incision in the superolaterat feudal arch after using 10% xylocaine spray
as a local anesthetic. All patients were started empirically on injection Crystalline
Penicillin (after sensitivity test) and injection Metronidazole according to the
recommended dosage.Antibiotic was changed according to the culture sensitivity
report subsequently. Statistical methods
Data were analyzed using WHO free domain software EPiinfo. Version
4.02.Wherever necessary statistical tests student't'- test were applied to assess the
significance.

Observation and Resulte

A total of, 71 patients were admitted with the diagnosis of peritonsillar abscess
during two years of the study. Majority of the patients were adults, with youngest
of age 14 yrs and the oldest was of age 56 yrs with average being 40.59 years.
There was a mate preponderance 57% of total cases. (Table 1) Left tonsil was
affected in 69% of patients. All patients were from poor socioeconomic condition
and hygiene. Patients presented with majority of symptoms and sign as shown in
Table 2.
All 36 patients in first group underwent sub mucosal aspiration and 31 were cured
with a single aspiration. Four patients were cured with second aspiration done
after 3 days of antibiotic. Incision and drainage was done in t patient after failure
of repeated aspiration and 7 days of antibiotic treatment
In second group, out of 35 patients 34 approved with a single attempt of incision
and drainage. Incision and drainage was repeated after 3 days in one patient only.
The average hospital stay of aspiration group was 4.31 days while of incision and
drainage group, it was 4.26 days. Volume of pus ranged from 2ml to 18 mi.
Patient with more than 5 ml of pus mostly required repetition of procedure.
Bacterial culture was positive in 59 (83 %) cases. Most common aerobic organism
isolated was Group A beta hemolytic Streptococcus (GABHS) seen in 16 (27%)
cases. Anaerobic culture could be done in 22 cases only. it was positive in. 11 (50
%) cases. Commonest isolate was Peptostreptococcus species seen in 4 (18%)
cases. Other organisms isolated were Staphyloccocus aureus, Haemophillus
influenza, Neisseria species, Fusobacterium species.
During the study period of 2 years a total of 71 cases of PTA were seen
comprising 0.08 % of new OPD cases and 0.80% of ENT indoor admissions and it
formed the most common head neck absr.ess.
Our study is consistent with other studies in showing mate preponderance 2. Left
tonsil is significantly more involved (69%) than the fight tonsil similar to other
studies.3.16
General symptoms consist of fever, malaise, and toxemia and body ache 4. Local
symptoms consists of odynophagia seen in 92-51% to 100% cases, fever seen in
27% to 93.6%, trismus seen in 63% to72.38% and dysphagia seen in 48 to100%
cases5.6. Trismus is caused by the irritation of ptergoid and masseter muscle due to
suppurative infection of the pertonsillar space. This symptom may result in
dehydration4 . Referred otalgia may be present and this symptom is explained by
the shared sensory innervations of the ear and the tonsillar area by the
glossopharyngeal nerve. Tonsillar hypertrophy, palatal oedema and pharyngeal
irritation cause characteristic muffled or "hot potato voice n7.13. PTA usually
remains localized to the pertonsilfar space but, if untreated, may violate the
superior constrictor muscle and involved other deep spaces of the neck and
eventually the mediastinum.
lntraoral examination in peritonsillar abscess may be compromised by trsmus. The
distinguishing features are inferiomedial displacement of the infected tonsil,
possibly involving the soft palate and contralateral deflection of the uvula. On
palpation, this area may be fluctuant. Mucosa in oral cavity is generally inflamed
and erythematous4. Purulent exudates may cover or partially obscure the Tonsils
and tender cervical lymphadenopathy is present7.8.The head is kept tilted towards
the affected site. Aerobic bacteria were isolated predominated by Group A Beta
hemolytic streptococcus (GABHS), followed by

Coagulase +ve Staphylococci this was consistent with other studies 9.18.19.The
anaerobic isolate in PTA varies from 18% to 95% 6. 10. 11, and 12
. Proliferation of
anaerobes around the tonsil is probably one of the possible explanations for
peritonsiliar abscess formation more commonly in adults than children8.
The result of culture & sensitivity was little or of no use in. our series because of
delay in the report and most patient-, improved with empirical antibiotics. Culture
results did not affect individual patient treatment, but may have a potentially
useful role for selecting empirical antibiotic therapy. Penicillin has many
attractive attributes for this infection such as high penetration into the infected
tissues, activity against both aerobes and anaerobes and low cost14
In our study there was no significant difference in the average duration of
hospitalization. There were no failures in the incision and drainage group. 1
patient initially treated with aspiration had to be treated by subsequent incision
and drainage because of re accumulated pus. Incision and drainage and aspiration
have been found to be relatively safe and easy procedures. They offer rapid relief
of symptoms and can be performed with patient under local anesthesia on an
outpatient basis; however adequate local anesthesia may be difficult to obtain in
the presence of severe inflammation.
Incision and drainage has been noted to be a very painful and a difficult procedure
in a patient with severe trismus. Open drainage also carries a risk of aspiration of
purulent material. Careful patient positioning and availability of suction are
necessary to prevent this complication'. Another potential complication albeit rare,
is the injury to the internal carotid artery secondary to peritonsillar abscess15.
Compliance wit aspiration is more and it offers a benefit of collection of pus for
investigation. As there is no significant difference in duration of stay in both the
groups, aspiration seems to be a better alternative than incision and drainage in
patients with less amount of pus accumulation.
There was no complication in any patient. In our study there was not a single
recurrent abscess in follow-ups this was similar to other studies, again questioning
delayed tonsillectomy in patients with peritonsillar abscess17.

Acknowledgments
We are grateful to Kasturba health society and the patients.
Details of ethics approval
Ethics Committee's approval was taken. Informed consent was taken.

Table 1: Age and gender distribution (n-71)

Sex 0-15 yrs 16-30 yrs 31-45 46-60 yrs Percentage
yrs
Male 1 6 15 18 56
Female 0 3 17 11 44
Toal 1 9 32 29 100

T 1 2: Clinical resentation of eritonsillar abscess

SymptomJsign Number of patients Percentage(n=71)
Odynophagia 71 100
Fever 68 95.77
Muffled speech 65 91.54
Halitosis 63 88.73
Trismus 63 78.87
Dysphagia 56 35.21
Otalgia 25 32.39
Drooling of saliva 23 32.00
Lymphadenopathy 69 97.18
Pyrexia 40 56.33
Dehydration 13 18.30

References
1. Johnson JT. Abscess and deep space infection of the head and neck Infectious
Disease Clinic of North America 1992; 6:705-717.
2. Raut VV, Yung MW. Peritonsillar abscess: The rationale for interval
tonsillectomy. Ear Nose Throat J. 2000; 79: 206-209.
3. Cannon CR, Lampton LM. Peritonsillar abscess following tonsillectomy. J
Miss State Med Assoc 1996; 37:577-9.
4. Petruzzeli GJ, Jonson JT. Peritonsillar abscess: why aggressive management is
appropriate. Post graduate Medicine. 1990;88 99-106.
5. Holt GR, Mc Manus K Newman R, Potter JL, Tinsley PP. Computed
Tomography and surgical findings in deep neck infector s. Otolaryngology
Head Neck Surgery. 1982;693-696.
6. Maharaj D, Rajan V, Hemsley S. Management of peritunsillar abscess. Journal
of laryngology and Otology. 1991;105:743-745.
7. Hardingham M. Peritonsillar infection. Clinics Of North America.1 987;
20273-278.
8. Cowan DL, Hibbert J. Acute and chronic infections of pharynx and tonsils 6th
Ed; ed Hibbert j, Karr AG, oxford:Bitter Worth Heinmann 1997;5:3-6.
9. Kieff DA, Bhattacharyya N, Siegel NS, Salman SD, Selection of antibiotics
after Incision and drainage of peritonsillar abscesses. Otolaryngol Head Neck
Surg. 1999; 120:57-61.
10. Hallander HO, Floodstrom A, Holmberg K Influence of the collection and
transport of specimens on the recovery of bacteria from peritonsiltar abscess.
Journal of clinical microbiology. 1975,2.504-509.
11. Jokiph AMM, Jokippi L, Sipila P, Jokinen K Serniquantative Culture results
and pathologic significance of obligate anaerobes in Peritonsillar abscess.
Journal of Clinical Microbiology. 1988; 26: 957-961.
12. Brook I, Frazier E. Thompson DH_ Aerobic anerobic microbiology of
peritonsillar abscess. Laryngoscopel991; 101:289-292
13. Pillsburry HC,Donovan ML. Oral cavity, Oropharynx and oesophagous. In
Lees Essential Otolaryngology: Head Neck Surgery Aboard preparation and
concise reference. New York Elseviere Science Publishing. 1987:425-430
14. Gidley PW,Ghoryeb DY, Stiemberg CM. Contemporary management of deep
neck infections Otolaryngology Head Neck Surgery. 1997; 1 16:16-22.
15. Blum DJ. Septic necrosis of internal carotid artery: Acomplication of
peritonsillar abscess. Otolaryngology Head Neck Surgery.1 983; 91:114-118.
16. lqbal SM, Husain A, Mughal S, Khan iZ. Khan IA Peritonsillar celiutites and
quinsy, clinical presentation and management_ Pakistan armed forces medical
journal 2009;:110-112
17. Spire JR, Owens JJ, Woodson GE, Miter RH. Treatment of peritonsillar
abscess. A prospective study of aspiration vs incision and drainage. Arch
Otolaryngol Head Neck Surc. 1987 Sep; 113(9):984-986.
18. Snow DG,Campbeli JB,Morgan DW. The microbiology of peritonsillar sepsis.
J Laryngol and Oto.1991; 105:553-555
19. Savolainen S, Sourer JHR, Makitie AA, Yiikoshi JS. Peritonsitlar abscess:
Clinical and Micrologic aspect and treatment regimens. Arch Ototaryngol
Head Neck Surgery. 1993; 119:521-524.

Corresponding author: V. TYAGI

ENT & Head Neck Surgery Department
Mahatma Gandhi institute of Medical Sciences,
Sevagram, Wardha= 442102, Maharashtra, India.
Fax- 91-7152-284286,
E- mail- drvishaltyyagi@rediffmail.com
Phone- Residence- 00 91-7152-284005,
Institution:00 91-7152-284341-55 Ext. (o) 276