Lely Rahayu, Arta Eka Putra and Sartika Sari

Department of Otorhinolaryngology, Medical Faculty of Udayana University, Sanglah Hospital, Denpasar, Indonesia.

Corresponding Author E-mail: madelelyrahayu@gmail.com

DOI : https://dx.doi.org/10.13005/bpj/1193

Abstract

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 abscess; microbiological culture; Streptococcus

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Copy the following to cite this article: Rahayu L, Putra A. E, Sari S. The Distribution of Peritonsillar Abscess Patients in Sanglah Hospital Denpasar at 2010 until 2017. Biomed Pharmacol J 2017;10(2).

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Introduction

Peritonsillar abscesses (PTA) are acute infection followed by collections of purulent material in loose connective tissue between faryngeal constrictor muscle with tonsil at fossa tonsil.^1,2 This infection penetrate tonsillar capsule near superior pole. Peritonsillar abscess (PTA) is the most common complication of acute tonsilitis.^3,4

Peritonsillar abscess (PTA) is one of the head and neck infections often in adults. The onset of peritonsillar abscess starting from superficial infections and progressively developing into tonsillar cellulitis. Peritonsillar abscess complications that may occur include expansion into parapharing infection, mediastinitis, dehydration, pneumonia, intracranial infections such as cavernous sinus thrombosis, meningitis, brain abscess and airway obstruction.³

The clinical symptoms such as sore throat, localized pain, high fever, weakness and nausea. The other symptoms are halitosis, vomiting, ear pain or otalgia and trismus.^5,6

There is no data shown patients with peritonsillar abscesses in Sanglah General Hospital at Denpasar. The authors are interested to research on the distribution of patients with peritonsillar abscesses in Sanglah General Hospital at period January 2010 to March 2017. This results are expected for evidence information of peritonsillar abscess that could be implemented in managemenet of PTA properly and optimally.

Methods

The study was observational retrospective by using the medical records of patients with peritonsillar abscess who came to ENT Departement and the laboratory results from Microbiology Departement Sanglah General Hospital. We use concecutive sampling for patients with peritonsillar abscess between January 2010 and March 2017. The incomplete medical records will exclude in this study. Further data were tabulated and presented descriptively in tables and narrative.

Results and Discussion

A total of 28 patients with peritonsillar absces at period January 2010 to March 2017 were included in this study with a ratio of 25 males (65.78%) and 13 females (34.22%) (Table. 1).

Table 1: The distribution of patients with peritonsillar abscess based on sex.

Sex	n (%)
Male	25 (65.78)
Female	13 (34.22)
Total	28 (100)

In United States the incidence is 1/6500 of the population or 30.1/40000 people per year.⁷ Salihoglu et all., reports a total of 26 patients with peritonsillar abscess are 92.4% males with an average age was 22.2 years old.⁴ Ozbek et all., reports from total 62 patients with peritonsillar abscess the ratio is 25 (40.33%) females and 37 (59.67%) males with average age was 27.9 years old.⁹ Naik and Naik reports from total 27 patients with peritonsillar abscess the ratio is 18 (66.67%) males and 9 (33.33%) females in average age was 30.4 years old.¹⁰ In this study, the male in patients with abscesses peritonsil is higher than female same as Salihoglu et all., Ozbek et all., Naik and Naik studies.

The distribution of patients with PTA is highest in group of age 41-50 year which 15 patients (39.48%). The lowest distribution by group of age is above 60 years which 1 patients (2.63%) (Table 2). The average age in this study was 38.76 years which is higher than Salihoglu et all., Ozbek et all., Naik and Naik studies. Peritonsillar abscess often seems in adults at the age of 20 to 40 years. It is rare in children, except on immunocompromise condition. In Northern Ireland, author reports 1 per 10.000 patients per year, with an average age of 26.4 years old.⁸ Salihoglu et all., reports the average age was 22.2 years old.⁴ Ozbek et al., reports the average age was 27.9 years old.⁹ Naik and Naik reports the average age was 30.4 years old.¹⁰

Table 2: The distribution of patients with peritonsillar abscess based on age.

Age (years)	n (%)
11-20	3 (7.89)
21-30	6 (15.79)
31-40	10 (26,32)
41-50	15 (39.48)
51-60	3 (7.89)
>60	1 (2.63)
Total	38 (100)

Sore  throat is the most major complaint in about 30 patients (78.95%) in this study. While the lowest is dysphagia in about 8 patients (21.05%) (Table 3). In anamnese mostly obtained progressive sore throat despite untreated, localized pain, high fever, weakness and nausea. Odinophagia can be a prominent complaint and the patient may difficult when eat and even swallowing.^11,12 Frequently  hypersalivation as a result can not cope salivary secretions and the saliva often dripping out. Other complaints are halitosis, vomiting until refered pain over to the ear (otalgia). Trismus occurs when the infection extends the pterigoidius muscles.¹² Kara and Spinou reports sore throat are common complaints in patients with peritonsillar abscess that is equal to 92%.¹³ Sore throat in our study is the most major complaint peritonsillar abscess similar with Kara and Spinou study.

Table 3: The distribution of patients with peritonsillar abscess based on major complaint.

Chief complaint	n (%)
Sore throat	30 (78.95)
Dysphagia	8 (21.05)
Total	38 (100)

Most patients with peritonsillar abscess occur unilateral 100% in this study. This results shown a higher quantity than Papacharalampous et all., and Edinger et all., case studies. Physical examination of the tonsil found unilateral swelling, because rarely both tonsils are infected at the same time. If both are infected when the oposite tonsil become swelling after the infected tonsil getting better. When swelling occurs simultaneously, the symptoms of sleep apnea and airway obstruction will be worsed.¹² Papacharalampous et all., reports a case of bilateral peritonsillar abscess in 19 years female.² Naik and Naik¹⁰ and Wang et all., reports there were no differences site of location in peritonsillar abscess.¹⁴ Edinger et all., reports a case of bilateral peritonsillar abscess in 24 years female.¹⁵

Based on microbiological culture, Streptococcus viridans is highest about 24 patients (63.16%), while Enterococcus sp is the lowest about 1 patient (2.63%). Eighteen point fourty three  percent shows no growth of in microbiology culture (Table 4). This results is supported by Sakae et all., and Repanos et all., studies which are Streptococcus viridans is highest in patients with peritonsillar abscess. Microbiological culture was done to growing population of aerobic bacteria as much as the mix of flora that involves microorganisms Gram-negative and Gram-positive. Some studies reports Streptococcus viridans is the most common cause of peritonsillar abscess, followed by Streptococcus pyogenes. Streptococcus sp and anaerobic bacteria have been identified as causative agents.^6,16 Sakae et all., found 32% Streptococcus viridans in peritonsillar abscess culture in Brazil.¹⁷ Repanos et all., reports 43.7% Streptococcus sp in peritonsillar abscess culture.¹⁸

Table 4: The distribution of patients with peritonsillar abscess based on microbiology culture.

Microbiology culture	n (%)
Streptococcus viridans	24 (63.16)
Streptococcus pyrogens	3 (7.89)
Klebsiella Pneumonia	3 (7.89)
Enterococcus sp	1 (2.63)
No growth	7 (18.43)
Total	38 (100)

Streptococcus viridans was obtained the most sensitive to the antibiotic cefuroxime, cefepime, meropemen, and linezolid respectively by 100% in this study. Streptococcus viridans mostly resistance to the antibiotic ampicillin established at 62.5% (Table 5). Repanos et all., reports 0.84% Streptococcus sp resistance to the antibiotic group penicillin .¹⁸ The resistancy of Streptococcus viridans to ampicillin is higher in our study than Repanos et all., studies. Takenaka et all., in their study reports all Gram-positive bacteria sensitive to the antibiotic penicillin group and cephalosporin.¹⁹ Sowerby et all., reports 32% Streptococcus sp resistance to clindamycin and 41% resistant to erythromycin.²⁰ However, in our study the resistancy of Streptococcus viridans to clindamycin and erythromycin was low. Some authors suggested second or third generation cephalosporins administration compared with group penicillin .⁶

Table 5: The resistancy pattern for Streptococcus viridans in peritonsillar abscess.

Type of antibiotic	Name of antibiotic	n=24 (%)
		S	I	R
Ampicillin	Ampicillin	9 (37.5)	0 (0)	15 (62.5)
	Amoxicillin/ clavulanic acid	14 (58.3)	1 (4.2)	9 (37.5)
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)

The distribution of patients with peritonsillar abscess is highest obtain for 4 days about 25 patients (65.78%) in this study. Only 1 patient (2.63%) was treated for 6 days (Table 6). In our study, the length of hospital stay inpatient with peritonsillar abscess is longer than Repanos et all., Wang et all., Kara and Spinou, Naik and Naik studies. The average length of treatment peritonsillar abscess obtained in this study is 4.5 days. Repanos et all., reports an average to treat patient with peritonsillar abscess requires for 2.4 days inpatient.¹⁸ Naik and Naik reports the average for hospital stay is 3.5 days.¹⁰ Kara and Spinou reports the average for hospital stay is 2.2 days.¹³ Wang et all., reports the average for hospital stay is 4.2 days.¹⁴

Table 6: The distribution of patients with peritonsillar abscess based on lengt of hospital stay.

Length of stay (days)	n (%)
3	2 (5,26)
4	25 (65.78)
5	10 (26.33)
6	1 (2.63)
Total	38 (100)

Twenty eight patients (73.69%) in this study without difficulting factors. Trismus shown in 9 patients (23.68%). This results shown lower than Salihoglu et all., studies. Only one patient (2.63%) found with diabetes mellitus (Table 7), which is higher in Wang et all., studies.  Several difficulting factors that affect peritonsillar abscess including trismus and systemic diseases, especially diabetes melitus.²¹ Wang et all., reports 3.5% of patients with peritonsillar abscess found with diabetes mellitus.¹⁴ Salihoglu et all., reports 88.46% of patients with peritonsillar abscess accompanied by trismus.⁴

Table 7: The distribution of patients with peritonsillar abscess based on difficulting factors.

Difficulting factor	n (%)
Trismus	9 (23.68)
Diabetes mellitus	1 (2.63)
None	28 (73.69)
Total	38 (100)

A total 38 patients in this study found wihout any complications. In our study, we found without any complications same as in Ozbek et all., studies. Immediate complications can occur in the form of dehydration due to less food intake. Spontaneous rupture of the abscess with blood or pus aspiration pneumonitis or abscess can cause infection to the pulmonary area.^1,8,22 Expansion to parapharing, may result in an abscess parapharing, spreading into the mediastinum may result in  mediastinitis.²² Ozbek et all., in their studies did not obtained any complications of peritonsillar abscess such as abscess in the deep neck spaces or mediastinis.²³

Conclusion

A total 38 patients with peritonsillar abscess who came into Sanglah General Hospital between January 2010 and March 2017 were predominant male. The mean of age was 38.76 years old. Sore throat is the most symptoms when came into the hospital. Mostly cases occur are unilateral. The most common microbiological culture was Streptococcus viridans. The most length of hospital stay was 4 days with average 4.5 days. In this study, mostly found without difficulting factors and there is no any complication occurs.

Acknoledgement and Conflict of Interest

There is no conflict of interest

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