AIBSCESSES AND QUINSY

Transcription

1 BILATERAL PERITONSILLAR AIBSCESSES AND QUINSY TONSILLECTOMY Randall E. Dalton, MD, Esrafil Abedi, MD, and Aristides Sismanis, MD, FACS Richmond, Virginia Two patients presented with history, symptoms, and clinical findings suggesting unilateral peritonsillar abscesses. At the time of quinsy tonsillectomy, the patients were found to have pus present in the contralateral peritonsillar spaces. These findings prompted a review of the literature to determine the actual frequency of bilateral peritonsillar abscesses and to reassess the approach to treatment of patients presenting with peritonsillar abscesses. Peritonsillar abscess frequently develops following the onset of acute tonsillitis, and it is possible that this process occurs bilaterally with the developmental stages of the abscesses being different on each side. Intensive antibiotic treatment, incision and drainage of the obvious abscess probably suppresses the development of and masks the presence of the abscess on the opposite side. Quinsy tonsillectomy has been indicated previously for patients not responding to intravenous antibiotic treatment and incision and drainage of their peritonsillar abscess. The possibility of a subclinical contralateral peritonsillar abscess being present is an additional indication for proceeding with a quinsy tonsillectomy, especially in patients who remain febrile after apparent satisfactory drainage of the clinically evident abscess. Peritonsillar abscess develops as the most frequent complication of acute tonsillitis when the infection spreads from the crypts to the loose alveolar peritonsillar tissues.' Early, adequate drainage of the abscess to prevent serious complications always has been recognized as being important. The methods of accomplishing this drainage, however, have been varied, and the appropriate approach to the definitive treatment of peritonsillar abscess continues to generate controversy. The authors' experience with two patients with bilateral peritonsillar abscesses prompted a review of the literature to determine the actual frequency of this clinical entity and to reassess the approach to treatment of patients with peritonsillar abscesses. Both patients presented with history, symptoms, and clinical findings suggestive of unilateral peritonsillar abscesses, and at the time of quinsy tonsillectomy pus was found in the contralateral peritonsillar spaces. Presented at the 89th Annual Convention and Scientific Assembly of the National Medical Association, Montreal, Canada, August 1, Requests for reprints should be addressed to Dr. Randall E. Dalton, Department of Otolaryngology, Medical College of Virginia, Virginia Commonwealth University, Richmond, VA CASE REPORTS Case I. T.B. is a seven-year-old black girl who was referred from pediatrics to the clinic to be evaluated for a possible left peritonsillar abscess. JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 77, NO. 10,

2 She had onset of a sore throat ten days prior to presentation and was being treated with oral penicillin. Despite that treatment, the sore throat persisted and worsened. Her appetite was poor, but she was having no trouble swallowing and no breathing difficulty. The child's mother denied any history of frequent sore throats or tonsillitis in the past. Pertinent findings of the physical examination were: oral temperature of F, pulse 104 beats per minute, respiratory rate 20 per minute, and blood pressure 100/40 mmhg. General inspection revealed a well-developed, well-nourished black female child in no apparent acute distress. Her voice was normal; she exhibited no drooling or trismus. On pharyngeal examination she was noted to have 31/2+ enlarged, exudative tonsils. There was erythema, bulging and fullness of the left anterior tonsillar pillar and soft palate. The uvula was edematous but in the midline. White blood count was 12,500 mm3 with 71 segmented neutrophils, 27 lymphocytes, and 2 monocytes. Treatment was initiated with intravenous (IV) antibiotics, hydration, humidified mist, saline gargles, and IV dexamethasone. On the following morning the peritonsillar edema had decreased, making the marked left anterior tonsillar pillar bulging more apparent. A quinsy tonsillectomy was carried out under general anesthesia. Nine ml of pus was drained from the left peritonsillar space and an unsuspected 3 ml of pus was encountered in the right peritonsillar space. Estimated blood loss for the procedure was 60 ml. The postoperative course was benign and unremarkable. Case 2. J.O. is a 19-year-old black man who presented to our clinic with a history of onset of a sore throat of one week's duration. He had been seen initially in a local emergency room and was treated with oral penicillin V, 500 mg, four times daily. Despite that treatment, his sore throat progressed to the point where he was unable to swallow solids. He was seen by a local physician and had what was described as incision and drainage of a right peritonsillar abscess and received an intramuscular penicillin injection. He presented at the clinic three days after the incision and drainage procedure, unable to swallow even liquids. He denied any history of frequent sore throats in the past. Physical examination revealed a welldeveloped, well-nourished, young, black man in obvious discomfort, with a "hot potato" voice, drooling saliva, and demonstrating a moderate amount of trismus. Oral temperature was F, pulse 100 beats per minute, respiratory rate 24 per minute, and blood pressure 124/80 mmhg. Pharyngeal examination revealed bilateral erythematous tonsils with bulging of the right anterior pillar and soft palate with displacement of the uvula to the left of midline. His white blood count was elevated to 21,000 mm3. Eight ml of pus was drained from the right peritonsillar space in the clinic. The trismus improved but the patient continued to be febrile. The trismus recurred and again pus was drained from the right side of the incision and drainage site. When trismus and dysphagia again recurred, he was subjected to a quinsy tonsillectomy, at which time unsuspected pus was encountered in the left peritonsillar space. Operative estimated blood loss was 100 ml. The postoperative course was unremarkable. HISTORICAL PERSPECTIVES Quinsy is an old English word that described any throat infection until about 1800 when the term began to be more specific for peritonsillar abscess. Incision and drainage was considered a method of treatment of this entity during the 14th century. In 1859, Chassaignac,2 a French surgeon, performed the first complete "abscess tonsillectomy." Prior to antibiotics there were many fatalities secondary to peritonsillar abscess, attesting to the inadequacy of incision and drainage alone as treatment. Records reveal 226 deaths in England in 1875 with the cause indicated as "quinsy." Later it was recommended that tonsillectomy be used routinely for the adequate drainage of peritonsillar abscesses. Between 1890 and 1930 European and American surgeons continued to debate the merits of incision and drainage vs partial or complete tonsillectomy. During this period of time only two articles appeared in the American literature in favor of "quinsy tonsillectomy." 808 JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 77, NO. 10, 1985

3 Baum3 presented his enthusiastic and comprehensive paper in 1926 and Holinger's4 report in favor of acute abscess tonsillectomy was given in Although Virtanen5 reported, in the European literature, 3,000 cases of quinsy tonsillectomy without incidence in 1949, it was not until the 1960s that American surgeons "discovered" that immediate tonsillectomy was a practical and safe way to completely drain the pus of a peritonsillar abscess. In 1960 Volk and Brandow6 described their "acute tonsillectomy" results and pointed out that "if the surgery could be done safely prior to antibiotics, certainly, there should be no worry if the patient is covered with good blood levels of penicillin." DISCUSSION There continues to be an ongoing debate in this country about the ultimate, appropriate treatment of the patient with a peritonsillar abscess. A basic surgical tenet is that pus must be drained and there is little disagreement with this teaching, but the method of drainage has been the issue of debate. Pathophysiology The term peritonsillitis has been used to encompass both peritonsillar cellulitis and abscess, which are stages in the same disease spectrum.7 Exudative tonsillitis can lead to peritonsillar erythema and edema (peritonsillar cellulitis) and subsequent formation of microabscesses within the tonsillar crypts. This can progress to coalescence of pus within the tonsillar capsule, suppuration outside of the capsule in the peritonsillar space, and finally, spontaneous rupture or extension of the abscess. The individual's systemic response to infection, antibiotics, or surgical intervention may, of course, interrupt the progression of this disease at any stage. The amount of time involved in the progression from one stage to another in the formation of a frank abscess is highly variable and is surely dependent on many factors. As tonsillitis is an infection that in most instances involves both tonsils, it is probable that progression to peritonsillar abscess also occurs bilaterally, with the developmental stages of the abscesses being different on each side.8 With this scheme in mind, it is easy to imagine bilateral peritonsillar abscesses occurring fairly frequently. Adequate antibiotic treatment and incision and drainage of the obvious abscess probably suppresses the development and masks the presence of the abscess on the opposite side. Potential complications of an untreated (or inadequately treated) peritonsillar abscess includes airway compromise from epiglottis and/or laryngeal edema, parapharyngeal abscess, retropharyngeal space and mediastinal extension, jugular vein thrombophlebitis, and sepsis. Intracranial complications include cavernous sinus thrombosis, brain abscesses, meningitis, and osteomyelitis of the sella turcica. Spontaneous rupture of the abscess can result in aspiration pneumonia and lung abscess. Diagnosis The diagnosis of peritonsillar abscess is made on the basis of the history and physical findings. Typically the patient is a young adult (there is no evidence of male predominance, contrary to previous reports in the literature), aged 15 to 30 years. The patient usually has had a sore throat for three to ten days and already has been started on oral antibiotics. Progressive odynophagia, dysphagia, and ear pain prompt the individual to seek relief. The patient appears ill, is noted to be febrile, with trismus, oral pooling of saliva and drooling. There is a muffled "hot potato" voice and pharyngeal examination reveals bulging of an anterior tonsillar pillar and soft palate with uvula displacement contralaterally. Complete blood count will demonstrate a leukocytosis. Treatment Treatment of peritonsillar abscess consists of systemic antibiotics that cover group A B3-hemolytic streptococci, the most common offending organism,' and drainage of pus from the abscess cavity. The methods favored for accomplishing evacuation of the pus are incision and drainage or an immediate tonsillectomy. The site usually used for incision and drainage is located at the midpoint of a line drawn from the JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 77, NO. 10,

4 9~~~~~~~~~~~~ -, ia-anterior U.P-Upper Pole M-M idport ion L.P-Lower Pole P-Posterior Figure 1. Possible abscess sites within the peritonsillar space UPPER POLE RMIDPORTION I LOWER POLE Figure 2. ~~~~~~~BILATERAL MULTILOCULATED Possible locations of peritonsillar abscess second upper molar tooth, on the involved side, to the base of the uvula. Unfortunately this approach is only successful in draining pus that is located behind the upper pole of the tonsil. That is the situation 60 to 70 percent of the time but in the remaining situations the pus persists.9 The abscess may be located in the midportion, lower pole, or posteriorly, as well as in the upper-pole area. There is also the possibility of multiloculation and bilateral peritonsillar abscesses in addition to the other sites (Figures 1 and 2). Tonsillectomy, which involves excision of the entire medial wall of the abscess cavity, -always accomplishes adequate and dependent drainage. CONCLUSIONS Throughout the literature, those who favor tonsillectomy, either immediately or scheduled in the future, cite the need to prevent a recurrent abscess. Those who favor only incision and drainage will state that the recurrence rate has not been determined and imply that it is low and insignificant. From several series,10-22 the authors have determined that the reported frequency of recurrent peritonsillar abscess is 5.9 to 22.7 percent (Table 1). The incidences were determined prospectively or retrospectively, depending on the particular series. The length of time in following patients for 810 JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 77, NO. 10, 1985

5 TABLE 1. INCIDENCE OF RECURRENT PERITONSILLAR ABSCESS No. of Patients No. of with Recurrent Source Abscess Abscesses* Percentage Bonding' Nielsen and Greisen" Schecter, et al Holt and Tinsley' McCurdy' Templer, et all Lee, et all Brandow Holt Herbild and Bonding Muller Harma, et al2l Beeden and Evans *Incidence determined prospectively or retrospectively TABLE 2. INCIDENCE OF BILATERAL PERITONSILLAR ABSCESSES* No.- of Quinsy No. of Tonsillec- Bilateral Source tomies Abscesses Percentage Yung and Cantrell Maisel' Sumner Bateman, et a Beeden and Evans Lee, et al ** 24.1 Bonding Templer, et al' Brandow' Leek Trzcinski *Unsuspected contralateral abscesses found at quinsy tonsillectomy **Plus two additional patients who had undergone incision and drainage of an abscess contralateral to the abscess found during surgery recurrence varied widely. These figures are, of course, also skewed by the fact that patients treated after their first peritonsillar abscess with immediate or interval tonsillectomy had only a rare opportunity of developing a recurrent abscess. Although there are only two papers in the English language literature that specifically address the subject of bilateral peritonsillar abscesses,8'23 their occurrence was recognized in several of the series reporting quinsy tonsillectomies. The authors have determined that the incidence of bilateral peritonsillar abscesses, with the unsuspected contralateral abscess being discovered at quinsy tonsillectomy, as determined from these series, is from 1.9 to 24.1 percent (Table 2). The cases of all JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 77, NO. 10,

6 of the series were combined and resulted in an incidence of 4.9 percent (55/1,115). 1,8-10,15-17,22,24-26 The advantages of immediate tonsillectomy in the treatment of peritonsillar abscess are that total evacuation of pus is assured, an unsuspected contralateral abscess may be revealed, and there is prompt relief of trismus and pain. Furthermore, it is a one-stage curative operation that is technically simple to perform, especially on the involved side, as the dissection is partially completed by the abscess. In contrast, the disadvantages of incision and drainage are that it is a very unpleasant, awkward procedure for both surgeon and patient; the drainage of pus is often incomplete and the patient's symptoms subside slowly. If an interval tonsillectomy is planned, there is the need for an additional period of discomfort and convalescence, and the procedure is technically more difficult after fibrosis of the tonsillar bed has been allowed to de- velop. Also, the risk of recurrent symptoms from the tonsils remains until tonsillectomy. Modem anesthetic techniques have contributed to making immediate quinsy tonsillectomy a safe, reliable, and economical method of treatment for peritonsillar abscess.2024 Experience has proven that the feared complications of sepsis, excessive bleeding, and airway obstruction that could occur when operating during the acute stage are more theoretical than real.11 Quinsy tonsillectomy previously has been indicated for patients not responding to intravenous antibiotic treatment and incision and drainage of their peritonsillar abscess, to assure that the pus is completely drained. The possibility of a subclinical contralateral peritonsillar abscess being present is an additional indication for proceeding with a quinsy tonsillectomy, especially in patients who remain febrile after apparent satisfactory drainage of the clinically evident abscess. Literature Cited 1. Maisel RH. Peritonsillar abscess: Tonsil antibiotic levels in patients treated by acute abscess surgery. Laryngoscope 1982; 92: Chassagnac E. Traite pratique de la suppuration et du drainage. Chirurgical, vol 2. Paris: Masson, Baum HL. The radical cure of peritonsillar abscess. Ann Otol Rhinol Laryngol 1926; 35: Holinger J. The removal of tonsils in the presence of a peritonsillar abscess. Ann Otol Rhinol Laryngol 1921; 30: Virtanen VS. Tonsillectomy as treatment of acute peritonsillitis, with clinical and statistical observations. ACTA Otolaryngol [Suppl] (Stockh) 1949; 80:1. 6. Volk BM, Brandon EC. Bilateral tonsillectomy for peritonsillar abscess. Laryngoscope 1960; 70: Fried MP, Forrest JL. Peritonsillitis: Evaluation of current therapy. Arch Otolaryngol 1981; 107: Kanesada K, Mogi G. Bilateral peritonsillar abscesses. Auris Nasus Larynx (Tokyo) 1981; 8: Yung AK, Cantrell RW. Quinsy tonsillectomy. Laryngoscope 1976; 86: Bonding P. Tonsillectomy a chaud. J Laryngol Otol 1973; 87: Neilsen VM, Greisen 0. Peritonsillar abscess. I. Cases treated by incision and drainage: A follow-up investigation. J Laryngol Otol 1981; 95: Schechter GL, Sly DE, Roper AL, Jackson RT. Changing face of treatment of peritonsillar abscess. Laryngoscope 1982; 92: Holt RG, Tinsley PP Jr. Peritonsillar abscesses in children. Laryngoscope 1981; 91: McCurdy JA Jr. Peritonsillar abscess: A comparison of treatment by immediate tonsillectomy and interval tonsillectomy. Arch Otolaryngol 1977; 103: Templer JW, Hollinger LD, Wood RP II, et al. Immediate tonsillectomy for the treatment of peritonsillar abscess. Am J Surg 1977; 134: Lee KJ, Traxler JH, Smith HW, Kelly JH. Tonsillectomy: Treatment of peritonsillar abscess. Trans Am Acad Ophthalmol Otolaryngol 1973; 77: Brandow EC Jr. Immediate tonsillectomy for peritonsillar abscess. Trans Am Acad Ophthalmol Otolaryngol 1973; 77: Holt GR. The management of peritonsillar abscesses in military medicine. Mili Med 1982; 147: Herbild 0, Bonding P. Peritonsillar abscess: Recurrence rate and treatment. Arch Otolaryngol 1981; 107: Muller SP. Peritonsillar abscess: A prospective study of pathogens, treatment, and morbidity. Ear Nose Throat J 1978; 57: Harma RA, Juola E, Rnoppi P, Vartiainen E. Abscess tonsillectomy a tiede. Acta Otolaryngol [Suppl] (Stockh) 1979; 360: Beeden AG, Evans JN. Quinsy tonsillectomy-a further report. J Laryngol Otol 1970; 84: Brook I, Shah K. Bilateral peritonsillar abscess: An unusual presentation. South Med J 1981; 74: Sumner E. Quinsy tonsillectomy: A safe procedure. Anesthesia 1973; 28: Leek JH. Stat tonsillectomy for peritonsillar abscess. Minn Med 1980; 63: Trzcinski WK. Peritonsillar abscess: A rationale for treatment. Northwest Med 1973; 72: JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 77, NO. 10, 1985