INTRODUCTION
Peri tonsillar abscess is the most common deep infection of the head and neck
region that occurs commonly in adults and is typically caused by combination of Aerobic
and Anaerobic Bacteria.
A peritonsillar abscess (quinsy) is collection of pus between Fibrous capsule of
Tonsil usually at it upper pole and superior constrictor muscle of pharynx.
Two mechanisms have been proposed to explain development of peritonsilla r
abscess. One is by direct spread of an inadequately treated acute tonsillitis, where the
infection directly spreads to peritonsillar space and results in peritonsillar cellulitis and
abscess.
Second mechanism is an abscess formed in a group of salivary glands in
supratonsillar fossa known as WEBER GLANDS These group of salivary glands are
located in superior tonsillar pole and there ducts secrete through tonsillar fossa, If there is
tonsillar disease, chronic tonsillitis etc.There may be obstruction to ducts of Weber
glands that can lead to stasis of secretions which in turn lead’s to bacterial colonization
and bacterial infection.
There are different modes of treatment of peritonsillar abscess. The most common
mode of treatment is incision and Drainage followed by in interval tonsillectomy 4 to 6
wks later, this type of tonsillectomy is designated as “TONSILLECTOMY A FROID”
The other methods of treatment
are Needle aspiration and ABSCESS
TONSILLECTOMY/HOTTONSILLECTOMY/QUINSYTONSILLECTOMY, Which has
become popular during recent years. This method of doing tonsillectomy during acute,
Infective stage is also known as “TONSILLECTOMY A CHAUD”
The risks of abscess tonsillectomy are mainly theoretical and none of the studies
showed increased incidence of secondary hemorrhage and spread of infection.
This study aims at evaluating the advantages and disadvantages associated with
immediate abscess tonsillectomy.
Methodology
Source of data:
Patients and clinical material available at JSS hospital.
Methods of collection of data:
Data was collected in a pretested proforma which meets the objective of the study
30 cases was selected from the total number of cases by using simple random sampling
method.
The analysis will be done using parameters the mean, the standard deviation, standard
error, T-test and chi-square test.
5% or 0.5 and 1.1 or 0.01 levels of significance will be considered for the purpose of
comparison at the specified degree of freedom.
Inclusion criteria:
1) Patients with peritonsillar abscess only are included in study.
2) Patients above 6 yrs are included.
Exclusion criteria:
1) Patients below 6 yrs and above 45 yrs are excluded.
2) Patients with chronic ailments like diabetes mellitus, hypertension, asthma,
epilepsy and bleeding diathesis are excluded.
3) Patients having peritonsillar abscess associated with dental infections, nasal and
ear pathology are excluded.
Method of study:
1. To interview the patients before abscess tonsillectomy and case history collection.
2. To assess the general condition of patient and carry out all routine investigations.
3. To administer pre operative antibiotics that is Third generation cephalosporin’s
(Cefotaxim 30mg/kg) and metronidazole (500mg 8 th hourly) intravenously to
cover both aerobic and anaerobic infections and anti-inflammatory drugs and
analgesics to reduce pain and inflammation.
4. To carry out abscess tonsillectomy using dissection and snare method.
5. To measure preoperative bleeding and to look out for any post operative bleeding
from tonsillar fossa. To assess the pain following procedure.
6. Post operative pain is assessed on basis of Objective Pain Scale (OPS) which is a
validated 1-10 scale for assessment of post operative pain. The param eters used
for assessment are Blood pressure, movement, posture, verbal complaint and
agitation and in case of children’s crying is taken into account, According to OPS
post operative pain is classified as No pain, mild, moderate and severe.
7. 1 week and 4 weeks following procedure post operative follow up is done.
8. To take into account any complications associated with the procedure.
STASTICAL METHOD EMPLOYED.
Following statistical methods were employed in the present study
 Frequencies/Descriptives
 Chi-square test
 Contingency coefficient (Cross Tabs)
 One-way ANOVA (Analysis of variance)
RESULTS
Majority of the cases belonged to age group between 35-46yrs of age and the cases were
predominantly found in Males
The culture report of pus collected during the procedure showed Mixed growth in
majority of cases Indicating that complete evacuation of pus is not possible with single sitting of
incision and drainage and required repeated dilatations to evacuate pus completely.
The incidence of primary haemorrhage and reactionary haemorrhage was nil in the cases
studied, Even though the bleeding was more during surgery due to Acute inflammation but was
not alarming or uncontrollable (usually between 80-120ml).
Secondary haemorrhage was reported in only two cases usually between 4-6th day after
surgery and was treated conservatively. This study showed that incidence of secondary
haemorrhage is not as high as given in some literature.
Objective pain scale (OPS) showed that pain during post operative period was of
moderate degree and comparable with pain associated with regular and interval tonsillectomy.
The mean total period of hospitalization was 3.82 days indicating the cost-effectiveness
of treatment.
Overall results of study of Abscess tonsillectomy showed that the procedure can be
carried out safely without any greater risk of haemorrhage or other complications and was most
cost effective method of treatment in draining the Abscess completely, preventing recurrence and
decreasing total period of hospitalization.
DISCUSSION
Of the 35 Cases studied, Most of the cases (17 accounting to 48.6%) were in the age
group of 26-36yrs and least only 2 cases accounting to 5.7% in the age group of 6-15yrs. The
mean age among Males Was 32.04 with a standard deviation of 8.46yrs and the mean age among
females was 27yrs with a standard deviation of 7.97yrs the minimum age was 9yrs in males and
13yrs in females and the maximum age was 45yrs in males and 35yrs in females. The mean age
of all the cases together was 30.46yrs with standard deviation of 8.53yrs. Out Of 35 cases 24
were males and 11 were females
Out of all the cases studied 22 cases had Lt sided peritonsillar abscess and 11 cases had
RT sided peritonsillar abscess. The routine investigations carried out in the patients showed
elevated Total leukocytic count other investigations were within limits. All the cases were treated
with pre operative antibiotics and analgesics and the surgery was carried out within 24hrs of
admission.
The incidence of primary and reactionary haemorrhage was Nil, Even though there was
excessive bleeding during the procedure as compared to regular tonsillectomy it was not drastic
or alarming and the amount of
Bleeding was usually between 90-120ml.
Secondary haemorrhage was seen in 2 out of 35 cases accounting to 5.7% and was
usually observed between 4-6th post operative days both the cases were treated conservatively.
Post operative pain assessment was done on basis of OPS (Objective pain scale) and
most of the cases that is 65.7% of cases (23cases) showed moderate degree of pain
Severe pain was seen in only in 11.4% of cases (4 cases) these cases were treated with
commonly used analgesics (NSAID’S).
The other minor complications such as injury to posterior pillar (2 cases) and
symptomatic lingual tonsil hypertrophy in 1case were seen.
The average total period of hospitalization was 3.82 days with 3 days seen in 42.9% of
cases and 4 days seen in 45.7% of cases the maximum period of hospitalization was of 8days
seen in 1case of peritonsillar abscess with neck space infection. There was Non significant
association between number of days of hospitalization and other parameters like haemorrhage,
pain, other complications, age and sex.
The culture analysis of the pus collected showed mixed growth in 20cases that is 57.1%
of cases and anaerobic growth in 7 cases accounting to 20% of cases gram positive cocci was
seen in about 17% of cases with B-hemolytic streptococci seen in most of the cases (11.4%).The
cases were treated with combination antibiotics of cephalosporin’s and metronidazole post
operatively.
The study showed that the procedure Abscess tonsillectomy can be carried out safely
without much complications and the incidence of secondary haemorrhage was not as high as
compared to literature.
BIBLIOGRAPHY
1) J. Laryngol Otol 1981 Aug; 95(8): 805-7.
Nielsen VM, Greisen O, Peritonsillar abscess II cases treated with tonsillectomy a
chaud.
2) Laryngoscope, 1981 Aug; 91(8): 1226-30.
Holt GR, Tinsley PP Jr. Peritonsillar abscess in children.
3) Acta Oto Rhinolaryngology Belg 2000; 54 (4): 459-64.
Brojendian S, Bisschop P. Clinical advantage of abscess tonsillectomy in
peritonsillar abscess.
4) Schweiz Med Wochenzchi 2000; Suppl 125; 175-195.
Clerc S, Soldati D, Socio economic aspects in therapy of peritonsillar abscess.
5) Auris Nasus Larynx 2001; Nov 28 (4): 323-7.
Jochen P, Windfuhr, Chen YS. Immediate abscess tonsillectomy – A safe
procedure?
6) Clinical otolaryngology 2003 Oct; 28 (5): 420-4.
Dunne AA, Granger O, Folz BJ, Sester Lenn A, Werner JA. Peritonsillar abscess –
critical analysis of abscess tonsillectomy.
7) J Laryngol Otoal. 1992 Nov; 106 (11): 986-8.
Chowdury CR, Bricknell MC. The management of quinsy – a prospective study.
8) Aurius Nasus Larynx 1999 Jul; 26(3): 299-304.
Suzuki M, Veyama T, Mogi G. Immediate tonsillectomy for peritosillar abscess.
9) BMJ 2001 322: 943-5.
Sculpher M, Drummond M, O’Brien B. Abscess tonsillectomy effectiveness and
efficiency.
10) J. Laryngol Otol 1995 Dec 97(12): 1105-9.
Mc Curdy JA Jr. Peritonsillar abscess – A comparison of treatment by immediate
tonsillectomy and interval tonsillectomy.
11) Acta otolaryngology suppl. 1979; 360:67-9.
Harma RA, Juola E, Ruoppi P, Vartiainen E.- Abscess tonsillectomy a tiede.
12) J. Otol 1990; 19: 226-9
Hall S.F-Peritonsillar abscess: The treatment options.
13) Laryngoscope 1995; 105: 1-17
Herzon F.S Peritonsillar abscess: incidence, current management practices and a
proposal for treatment guidelines.
Tables and Figures
a) Right Sided Quinsy
b) Pus coming out on incision
AGE -WISE DISTRIBUTION OF CASES
No. of patients
12
10
8
6
4
2
0
6-15
16-25
26-36
Age groups
36-45
Male
Female
INCIDENCE OF HEMORRHAGE
35
No. of patients
28
21
14
7
0
PH
RH
Complications
PH- Primary Hemorrhage
RH- Reactionary Hemorrhage
SH- Secondary Hemorrhage
SH
Present
Absent
Graph showing Objective pain scale
5.70%
2.90%
NIL
91.40%
INJURY TO
POST.PILLAR
LINGUAL TONSIL
HYPERTROPHY
Graph showing incidence of other complications
16
No. of patients
12
8
4
0
d3
d4
d5
Days
d7
Distribution of cases according to days of hospitalisation
d8