Abstract
Objective
This retrospective, cohort study aims to assess the changing characteristics of peritonsillar abscess (PTA).
Method
Data were obtained from PTA patient records admitted to a secondary hospital over a 10-year period.
Results
A total of 427 patients, aged 31.6 ± 15.2 years (range, 3–91), were treated for PTA, reflecting an incidence of 0.9/10 000/y. Forty-seven (11%) patients had more than one episode. There was no sex, seasonal, or side predominance. Thirteen (3%) patients developed complications. One hundred four (24.4%) patients were 40 years or older, had a longer hospital stay, and were prone to complications. One hundred two (23.8%) patients did not have an anteceding pharyngotonsillitis. Smoking was more common among patients with PTA as compared with the general population and was associated with more complications. A total of 283 (66.2%) patients developed PTA in spite of prior antibiotic therapy; 51.1% of smokers that received prior antibiotics had a higher incidence of Streptococcus viridans isolates.
Conclusion
Peritonsillar abscess may have changed its characteristics: affecting more older patients having a worse and longer course and PTA evolvement without anteceding tonsillitis or in spite of a prior adequate antibiotic therapy. Smoking may be a predisposing factor.
1
Introduction
Peritonsillar abscess (PTA) is considered a suppurative complication of acute tonsillitis, which is usually treated with drainage and antibiotics. Most cases are reported among older children, adolescents, and young adults .
Epidemiology of PTA is not vastly discussed in the literature. Although its yearly incidence in the United States was estimated at 1 in 6500, in Northern Ireland, it was reported as 1 per 10 000 patients per year, with an average age of 26.4 years . Peritonsillar abscess was more commonly described in children older than 10 years . Anecdotal reports of older individuals having PTA described worse morbidity rates .
Recently, the highest incidence of PTA was found in adults 20 to 40 years of age . In addition, the usual causative bacteria seemed to alter from gram-positive cocci (mainly Streptococcus β -hemolytic group A) to anaerobes and gram-negative rods . A recent study reported an increased incidence along with a more aggressive presentation of PTA among the pediatric population .
Our impression was that during recent years, we have encountered more patients with PTA without an anteceding tonsillitis, a higher incidence of older patients, and abscess evolvement despite adequate antibiotic therapy.
The purpose of this retrospective study was to examine some of the possible changing trends of PTA during a 10-year period.
2
Patients and methods
The population of this study included all patients having PTA (International Classification of Diseases 9 [ICD9] code 475), hospitalized and treated between January 1, 1998, and December 31, 2007, in a secondary care urban medical center. The work has been approved by the institutional review board.
Medical records were retrospectively reviewed for age, sex, duration of symptoms, abscess side, prior antibiotic therapy, hospital stay, history of recurrent tonsillitis, previous PTA, culture results, comorbidities, smoking habits, and complications. Patients were further divided into 2 age groups (≥40 years or younger), which were then compared.
Incision and drainage were performed for all patients with PTA, usually upon arrival. A microbiological culture was routinely obtained with a standard swab or a syringe aspiration. Antibiotic therapy (mostly amoxicillin/clavunate) was commenced after drainage, along with fluid resuscitation, analgesics, and antiseptic mouthwash.
Statistical analysis was performed with SPSS for Windows version 10.0 software. χ 2 Analysis, Pearson exact test, and 2-tailed t tests were used. P < .05 was considered significant.
2
Patients and methods
The population of this study included all patients having PTA (International Classification of Diseases 9 [ICD9] code 475), hospitalized and treated between January 1, 1998, and December 31, 2007, in a secondary care urban medical center. The work has been approved by the institutional review board.
Medical records were retrospectively reviewed for age, sex, duration of symptoms, abscess side, prior antibiotic therapy, hospital stay, history of recurrent tonsillitis, previous PTA, culture results, comorbidities, smoking habits, and complications. Patients were further divided into 2 age groups (≥40 years or younger), which were then compared.
Incision and drainage were performed for all patients with PTA, usually upon arrival. A microbiological culture was routinely obtained with a standard swab or a syringe aspiration. Antibiotic therapy (mostly amoxicillin/clavunate) was commenced after drainage, along with fluid resuscitation, analgesics, and antiseptic mouthwash.
Statistical analysis was performed with SPSS for Windows version 10.0 software. χ 2 Analysis, Pearson exact test, and 2-tailed t tests were used. P < .05 was considered significant.
3
Results
In the 10-year period studied (1998–2007), 451 patients were hospitalized with the diagnosis of PTA. However, only 427 medical records were fully retrieved. For the purpose of epidemiologic analysis, only the data from the first PTA occurrence were accounted in all the patients (N = 427). However, for microbiological assessment, all available culture results obtained from all PTA episodes were considered (n = 349). For the purpose of this study, we subdivided the 10-year period to 2 groups: “early years” (1998–1002) and “late years” (2003–2007).
3.1
Age
The patients were aged 31.6 ± 15.2 years (mean ± SD; range, 3–91 years). Age frequency distribution is shown in Fig. 1 .
3.2
Sex
There were 234 (54.8%) male and 193 (45.2%) female patients.
3.3
Side
A total of 220 (51.5%) patients had a left side PTA, 206 (48.3%) patients had a right side PTA, and 1 patient had a simultaneous bilateral PTA.
3.4
Seasonal presentation
Seasons were defined as follows: winter (December to February), spring (March to May), summer (June to August), and autumn (September to November). Peritonsillar abscess was equally distributed along the year: winter (116 patients, 27.2%), spring (118 patients, 27.6%), summer (98 patients, 23%), and autumn (95 patients, 22.2%).
3.5
Symptoms duration
Upon arrival, patients were questioned about their symptoms, that is, fever, odynophagia, sore throat, prior antibiotic therapy, oral intake difficulties, and course of illness. The period between symptoms onset and hospital admission was 4 ± 2.6 days (mean ± SD; range, 1–21 days).
3.6
Smoking
A total of 144 (33.7%) patients were smokers. This rate was significantly higher than the smoking rate in the general population, which was reported to be 25.5% by the Israeli Health National Registry in 2004 ( P = .04). Among the smokers, 129 cultures were available for review.
3.7
Peritonsillar abscess recurrence
There were 47 (11%) patients who were hospitalized more than once having different recurrent episodes of PTA: 36 patients had 2 different episodes, 10 patients had 3 episodes, and 1 patient was admitted 4 times. A significant male predominance was observed (63%, P = .023). Among these patients, smoking rate was similar to the general population (24.7% vs 25.5%, respectively; P = .98).
3.8
Hospital stay
The patients stayed in the hospital in a range of 1 to 11 days (mean ± SD, 3.42 ± 1.3 days). Hospital stay of smokers was similar to that of nonsmokers.
3.9
Comorbidities
Seventy-nine (18.5%) patients had comorbidities; cardiovascular disease, diabetes, and asthma being the most frequent. Other comorbidities were drug abuse, alcohol abuse, thyroid disease, neurologic disease, liver disease, and pregnancy. None of the comorbidities were identified as a significant risk factor for having a PTA ( P = .71).
3.10
Complications
Thirteen (3%) patients had complications, namely, parapharyngeal cellulitis or supraglottic edema, and they required a longer hospital stay. Patients who received antibiotic therapy before admission did not have a significantly increased complication rate, as compared with patients who were untreated ( P = .166). Although 6 of 13 complicated patients were smokers, this observation did not reveal a significant predisposition for smokers to have PTA complications more than nonsmokers (4.1% vs 2.5%, respectively; P = .354).
3.11
Patients 40 years or older
This age group, consisting of 104 (24.4%) patients with an average age of 52.6 ± 11.9 years (mean ± SD; range, 40–91 years), was assessed separately and compared with the younger group, whose average age was 24.8 ± 8.4 years (mean ± SD; range, 3–39 years). There were 72 (65.3%) males and 36 (34.6%) females in the older age group, similar to the sex partition in the younger group, both groups having a significant male predominance ( P = .024). Seasonal distribution and symptom duration were similar in both age groups. However, older patients had a longer hospital stay as compared with younger patients (3.7 ± 1.7 vs 3.3 ± 1.1 days, respectively; P = .047), and the smoking rate in this age group was significantly higher than in younger patients (42.3% and 30.9%, respectively; P = .02). Complication rate was also significantly higher as compared with younger patients (2.3% and 0.7%, respectively; P < .001). Although not statistically significant, the relative proportion of older patients was higher in the last 5 years (2003–2007) than in the first 5 years (1998–2002) of the study (26.1% and 22.3%, respectively; P = .11) ( Table 1 ).
