Peritonsillar Abscess: Recurrence Rate and Treatment

Abstract

\s=b\ In 161 patients treated for a peritonsillar abscess by stab incision as the only surgical procedure, a follow-up study was conducted after 3\m=1/2\to eight years. Of all the patients examined, 51% had experienced no throat symptoms, 22% had had recurrent peritonsillar abscesses, 20% had had recurrent episodes of tonsillitis with fever, and 7% had had symptoms resembling episodic pharyngitis in varying degrees. The age of the patient and the patient's history of previous throat infections were found to have prognostic value. Older patients (older than 40 years) had a lower incidence of new throat infections (peritonsillar abscess, tonsillitis, or both) than younger patients. Patients without previous throat symptoms had a lower incidence of new throat infections than patients with a history of throat infection before the peritonsillar abscess, which in itself might indicate the need for tonsillectomy. (Arch Otolaryngol 1981;107:540-542) It is a common conception that one peritonsillar abscess is an indica¬ tion for tonsillectomy, either immedi¬ ately or after an interval of six to 12 weeks. This conception is based on the premise that a peritonsillar abscess will lead to recurrent tonsillitis, peritonsillitis, or peritonsillar abscess in a considerable number of patients. However, as also pointed out by Doyle1 and Templer et al,2 this assumption seems to be based on a general impression rather than on facts. To our knowledge, the preva¬ lence of recurrent throat infections after a peritonsillar abscess has not been recorded in the literature. The present study explores the prognosis of peritonsillar abscess with regard to the development of new peritonsillar group of patients observed during a period of four to eight years after a peritonsillar abscess that was treated by stab incision. PATIENTS AND METHODSAt the Ear, Nose, and Throat Depart¬ ment of Glostrup University Hospital, stab incision without routine interval tonsillec¬ tomy was the standard treatment of peri¬ tonsillar abscess in the five-year period from 1971 to 1975. The treatment included antibiotics, in most cases with penicillin G sodium, for a period of six to ten days. The diagnosis was based on the typical clinical signs and was verified by the presence of pus at stab incision or at subsequent dila¬ tions of the incision.A total of 256 patients were treated operatively. Sixty-two of these were excluded from the study because they either had had an interval tonsillectomy (17 patients) or abscess tonsillectomy (45 patients)-in most cases because of repeated episodes of peritonsillar abscess, frequently recurrent tonsillitis, or both. This group preponder¬ antly included patients younger than 20 years. Follow-up information was obtained from 166 of the remaining 194 patients (follow-up rate, 85.5%).These 166 patients included 103 men and 63 women. Median age was 26 years, rang¬ ing from 7 to 70 years (interquartile range, 18 to 36 years). Follow-up was performed from 3'/2 to eight years after the peritonsil¬ lar abscess (median, five years)...

Indications for tonsillectomy stratified by the level of evidence

“…Already in 1859, Chaissaignac reported on his experiences with abscesstonsillectomy [347], later recommended by Winckler as standard therapy for PTA [348], confirmed by a first study of Virtanen in 1949 [349]. Arguments for abscesstonsillectomy include: definitive removal of the abscess focus, removal of an occult contralateral abscess, only one inpatient treatment, diagnosis of a previously undetected malign disease, avoiding painful secondary drainage, needle aspiration and treatment of retrotonsillar spreading of the abscess [345], [350]. Occult malignomas are very rare (0.3%), the diagnosis depends on histopathologic examination [351], [352], [353], [354], [355] and is therefore impossible after NA or ID.…”

“…Among those 42 publications, there were only 5 level I trials [263], [304], [345], [363], [364], the remainder were classified as level IV including 13 case series with only one treatment modality [301], [302], [303], [305], [314], [343], [358], [374], [375], [376], [377], [378], [379], 12 case series comparing different therapies [261], [264], [307], [308], [366], [380], [381], [382], [383], [384], [385], [386], and one economic analysis [301]. Concerning recurrence rates and indication, the authors found 2 level II studies [309], [313] and 13 level IV trials [301], [303], [310], [311], [312], [314], [343], [350], [361], [372], [387], [388], [389]. From the 5 randomized trials, 3 compared the outcome after NA vs. ID in cohorts of 5 [304], 60 [363], and 62 patients [345] and could not reveal a significant difference.…”

“…Rarely, a second NA becomes necessary [303], [305], [306], [307], ,[358] [375], [396]. In different studies, NA and ID proved to have a comparable outcome [304], [345]; in the study by Wolf et al [308] ID was initially more successful than NA and in the study by Savolainen et al [306] it was better in the following course.Recurrence rate: The recurrence rate was given with 0% to 23% in the literature analyzed by Herzon [261], [302], [303], [304], [305], [307], [308], [309], [310], [311], [313], [314], [350], [358], [378], [383], [386], [397]. An age <30 years [398], previous PTA [306], and a history of recurrent tonsillitis episodes [309] proved to be risk factors for the development of PTA recurrences, mostly within 2 to 12 months [306], [309].…”

“…Recurrence rate: The recurrence rate was given with 0% to 23% in the literature analyzed by Herzon [261], [302], [303], [304], [305], [307], [308], [309], [310], [311], [313], [314], [350], [358], [378], [383], [386], [397]. An age <30 years [398], previous PTA [306], and a history of recurrent tonsillitis episodes [309] proved to be risk factors for the development of PTA recurrences, mostly within 2 to 12 months [306], [309].…”

“…The recurrence rates were significantly different (p<0.001) ranging between 0% to 22%. Interestingly, a recurrence rate of only 10% was calculated for studies from the USA vs. 15% for studies from outside the USA [261], [302], [303], [304], [305], [306], [307], [308], [309], [310], [311], [313], [314], [350], [358], [376], [378], [379], [383], [386], [397]. …”