INTRODUCTION

Tonsillites are frequent infectious processes in the world population, both in children and adults. It is a highly painful condition, causing malaise and compromising the quality of life. Diagnosis and treatment are easily managed. The most common etiological agent is group A beta hemolytic Streptococcus. Inadequate management may result in progression to complications, especially the frequent peritonsillar abscess. The most common clinical presentation includes odynophagia, fever, malaise, halitosis, toxemia, painful cervical ganglions, irradiated pain to the ear, salivation because of incapacity to swallow, bending of the head to the affected side, and trismus. At pharyngoscopic examination, we observe bulged soft palate and uvula displaced to the contralateral side.

Peritonsillar abscess is a collection of purulent secretion localized in the soft palate, in the supra-tonsillar region, in the soft tissue between the tonsil and the muscle wall, present after acute tonsillitis, whose etiological agent is group A beta hemolytic Streptococcus.

After an acute episode of tonsillitis, in which the dose of antibiotics was insufficient or its administration was shorter than necessary, the patient starts to experiment pain, unilateral dysphagia, irradiated pain to the ear, salivation because of incapacity to swallow, cervical ganglions, painful facial expression, saburral tongue and bending of the head to the affected side. Upon examination, we normally notice that the patient has toxemia, soft palate asymmetry, swelling on the affected side and uvula displaced to the contralateral side. Trismus (owing to the proximity of pterygoid muscle) is also found in all patients.

Treatment of peritonsillar abscesses is controversial. The world literature has shown proven efficacy with different therapeutic approaches, such as clinical treatment3, aspiration punch associated with antibiotics, surgical drainage associated with antibiotics, and tonsillectomy' in the acute phase and associated with antibiotics.

The present study carried out a retrospective analysis of 23 patients who had clinically diagnosed peritonsillar abscess submitted to hospital and ambulatory treatment, with success rates of 86.96%.

Pathophysiology of peritonsillar abscess

Abscess is a collection of purulent secretion confined to a tissue, organ or space. The most common sites of an abscess are the dermis, lungs, brain, liver, kidney - or cysts.

Abscesses are normally caused by irritation processes that remain localized and later are diffusely spread.

After the establishment of an infectious focus, there is accumulation of neutrophils (leukocytes) that produce phagocytosis and digest the necrotic and damaged tissue, converting it in mucus-purulent secretion.

Thus, an abscess consists of a mucopurulent collection, surrounded by inflammatory tissue with marked presence of neutrophils.

While there is the permanence of the irritating factor, more leukocytes will come, there will be more liquefied tissue and more purulent secretion.

Proteolysis results from the formation of large molecules, increasing osmolarity of the liquid and extracting liquid from the adjacent tissues. Occasionally, the purulent collection reaches the surface and there is spontaneous drainage. The formation of pus involves permanent destruction of tissues, which may be restored by normal scarring.

Sometimes, the irritation element (bacteria) disappears, thanks to the action of defense, before the purulent material reaches the surface. Under such circumstances, the abscess may be absorbed or remain as a sterile liquid collection (cyst) or dehydrate and remain as capsular fibrotic tissue.

A group of salivary glands located in the supra-tonsillar region - the so-called minor salivary glands of Weber, has been involved in the pathogenesis of peritonsillar abscess. Upon investigating patients who suffered a post-abscess tonsilectomy, we found inflammatory or fibrotic processes, reaching the minor salivary glands of Weber, raising the suspicion that the peritonsillar abscess could be an infectious process of these glands. The exsudative process does not necessarily have to extend as far as the glands, but usually the formation of the abscess started in these glands6.

Infection of His duct, located between the superior laryngeal constrictor and the tonsil, has been considered responsible for peritonsillar abscess. Therefore, not resecting it during tonsillectomy has normally led to recurrences.

MATERIAL AND METHOD

We carried out a retrospective analysis of the database information stored in the computer system of the private practice Instituto de Otorrinolaringologia e Fonoaudiologia NAKAO, in the city of Campo Grande/ MS, and of patients seen at Hospital Universitário, Universidade Federal de Mato Grosso do Sul, between 1996 and 1999, comprising 23 subjects.

Diagnosis of peritonsillar abscess was mainly clinical, including trismus, fever, toxemia, painful cervical ganglions, halitosis, incapacity to swallow, presentation longer than five days, bulging of soft palate and deviation of the uvula to the contralateral side.

The medical prescription for hospitalized patients was 500 ml glucose sterile solution at 5% + dexamethasone 10 mg + rifamicyn 500 mg + dipirone 2 ml, rapidly infused (approximately one hour).

Next, we infused the same drugs but at a rate of 14 drops/minute.

Hospital discharge was given when there was no further swelling, uvula deviation and trismus. Patients were hospitalized for approximately 3 days.

For patients who preferred ambulatory treatment, we infused approximately in one hour 500 ml glucose sterile solution at 5% + dexamethasone 10 mg + dipirone 2 ml + rifamicyn 500 mg BID.

Approximately eight hours after the administration of the drugs, pain returned in patients at ambulatory treatment, differently from the patients who were hospitalized and under continuous therapy.

Patients who did not meet the criteria of the protocol (peritonsillar abscess with palate bulging, uvula deviation and trismus) were rejected.

RESULTS

The 23 patients were divided into 11 female and 12 male patients, aged from 7 years to 45 years, mean age of 24.7 years. The highest incidence was noticed in the age range 11 to 30 years (16 patients, 69.57%).

All patients presented significant relief of pain after the first infusion of sterile solution.

Patients who chose ambulatory treatment referred that the presentation of dysphagia returned 6 to 8 years after the administration of the drugs. Twelve hours after the first administration, the second dose was administered.

Painful facial expression disappeared within two hours after the first drug administration.

Patients who preferred hospitalization remained in venous infusion of antibiotics associated with dexamethasone and dipirone and did not experience return of pain. Seven patients remained in hospital for 48 to 72 hours.

We also prescribed 500 mg amoxicillin TID and 5 mg prednisone TID for seven days.

Two patients (8.69%) presented recurrence and were submitted to tonsillectomy after the acute episodes. Three patients (13.04%) presented spontaneous drainage of the abscess during hospitalization.

DISCUSSION

Appropriate documentation of patients is essential for retrospective studies and medicolegal issues. The inappropriate description of the clinical picture may compromise later assessments. Incomplete documentation in medical files, failing to report the essential signs and symptoms, prevents us from confirming a diagnosis previously made. It has been a common mistake both in private practices and in university settings.

Treatment of abscesses, regardless of the location, is preferably surgical. Peritonsillar abscesses, in turn, are approached differently, from clinical treatment4, to drainage associated with clinical treatment2 (either outpatient or in-patient procedure7), to aspiration of the abscess associated with clinical treatment. Sexton and Babin (1987) demonstrated that there were no differences between in-patient and outpatient procedures concerning drainage and venous antibiotic therapy.

Pain is a significant symptom reported by patients with peritonsillar abscess, preventing them from carrying out simple daily activities. Painful facial expression is invariably present. Pain should be immediately relieved, regardless of the method, in order to improve patients' quality of life.

We decided to adopt clinical treatment in the present study because it has shown to be effective and quick in relieving pain and the infectious condition. It provides high compliance, low morbidity, low percentage of recurrence; it is non-invasive, does not require general or local anesthesia and may be performed in the ambulatory or as an in-patient procedure.

We treated 23 patients with peritonsillar abscesses between 1996 and 2000. Treatment consisted of venous infusion of antibiotics, analgesics and corticoids with anti-inflammatory drugs. Patients who used the drugs every 12 hours reported recurrence of pain after the 8-hour post-infusion. Those who remained under continuous infusion of drugs and were hospitalized did not experience aggravation of pain. One hundred percent of the patients reported significant improvement of the pain in the first two hours after venous infusion, which was the key aspect to make us continue to use the protocol throughout the years. In both in-patient and outpatient modalities, swelling of soft palate, uvula deviation and trismus disappeared within 48 to 72 hours. Spontaneous drainage was observed in three patients (13.04%) who were hospitalized. In these three patients, symptoms of odynophagia, painful facial expression, fever and trismus were not longer manifested when the spontaneous drainage happened.

For statistical purposes, we considered that these three patients presented clinical resolution as a result of drainage, classifying them as therapeutic failures. Surgical drainage was not considered because all patients reported significant regression of pain, accepting intake of liquid and paste foods in the first two hours after infusion.

Recurrence was present in two cases (8.69%), later submitted to tonsillectomy. Patients submitted to tonsillectomy were not the patients who had experienced spontaneous drainage.

CONCLUSION

Medical clinical treatment with venous infusion of antibiotics, analgesics and hormonal anti-inflammatory drugs was effective for the treatment of peritonsillar abscess in 86.96% of the cases.

REFERENCES

1. CANNON, C. R. & CHAMBERS, A. - Peritonsillar abscess in children. J. Miss State Med Associ, 40 (3): 78-80, 1999.
2. EPPERLY, T D. & WOOD, T C. - New trends in the management of peritonsillar abscess. Am. Fam. Physician. 42: (1): 102-12, 1990.
3. HARA, K.; BABA, S.; MATSUMOTO, F.; OOISHI, M.; KAWAADA, Y; ARATA, J.; SHINAGAWA, N.; SASSAKI, J.; HAYASHI, K.; SUGIHARA, T.; MATUSDA, S. - Clinical evaluation of biapenem in various infectious diseases, Jpn. J. Antibiotic, 52 (11): 629-60, 1999.
4. HARRIS, W E - Is a single quinsy an indication for tonsillectomy?, Clin. Otolaryngol. 16 (3): 271-3, 1991.
5. IEMMO, M.; MAURER, J.; RIECHELMANN, H. - HNO, 140 (3): 94-6, 1992.
6. PASSY, V - Pathogenesis of peritonsillar abscess, Laryngoscope, 104: 185-90, 1994.
7. SEXTON, D. G. & BABIN, R. W - Peritonsillar abscess: a comparison of a conservative and a more aggressive management protocol. Int. J. Pediatr Otorhinolaryngol., 14 (2): 129-32, 1987.

* Joint Professor, Master, Responsible for the Discipline of Otorhinolaryngology, Universidade Federal de Mato Grosso do Sul.
** Undergraduate, School of Medicine, Universidade Federal de Mato Grosso do Sul.
*** Ph.D.,, Professor, Discipline of Statistics, Universidade Federal de Mato Grosso do Sul.

Address correspondence to: Milton Nakao - Rua Marechal Cândido Mariano Rondon, 2372 -79002-201 Campo Grande/MS - Tel: (55 67) 783-4855/721-3166.
E-mail: nakao.ms@bol.com.br
Article submitted on January 18, 2001. Article accepted on March 27, 2001.