International Journal of Medical and Health Research

International Journal of Medical and Health Research

ISSN: 2454-9142
Received: 16-08-2018; Accepted: 20-09-2018
www.medicalsciencejournal.com
Volume 4; Issue 10; October 2018; Page No. 149-152

Peritonsillar abscess: Pattern and treatment intervention in a tertiary health institution in

Sokoto metropolis
Stanley B Amutta1, Mohammed Abdullahi2, Daniel Aliyu3, Joshua C Okoro4
1-4
Department of Otorhinolaryngology, Usmanu Danfodiyo University Teaching Hospital, Sokoto, Nigeria

Abstract
Background and Objectives: Peritonsillar abscess is the collection of pus between the capsule of the tonsil and the superior
constrictor muscle of the pharynx. It is a common suppurative complication of acute tonsillitis. The peritonsillar abscess occurs
worldwide and affects people of all ages. Medical treatment consists of fluid rehydration, analgesic, and antibiotic therapy.
Surgical techniques of drainage of the peritonsillar abscess remained controversial. This study aims to describe the pattern and
management of peritonsillar abscess in Sokoto metropolis.
Methods: This study was a retrospective review of the patients managed for the peritonsillar abscess at the Ear, Nose and Throat
Department of Usmanu Danfodiyo University Teaching Hospital, Sokoto, Nigeria from 2006 to 2018. The case files retrieved from
the Medical Record Department and reviewed for the following variables: Biodata, symptoms, signs and the management. Data
analyzed with SPSS version 21.0.
Results: Of the 17 patients analyzed the mean age was 22.5 years (Range 5-43 years), 5 (29.4%) Males and 12 (70.6%) Females
with a male to female ratio of 1:2.4. Right tonsil accounted for 7 (41.2%) and left tonsil 10 (58.8%). The peritonsillar abscess was
most common between 11-40 years of age. All the patients hospitalized and given intravenous fluid rehydration, analgesic, and
empirical antibiotic therapy. Surgical drainage comprised needle aspiration in 7 (41.2%), followed by incision and drainage in 4
(23.5%), incision and drainage plus interval tonsillectomy in 1 (5.9%) and spontaneous rupture in 5 (29.4%). One of the patients
with spontaneous rupture had a parapharyngeal abscess.
Interpretation and Conclusion: In this study, the peritonsillar abscess was most common in adolescent and young adults between
11-40 years of age. Complications observed were spontaneous rupture of the PTA and a parapharyngeal abscess. All the patients
hospitalized, and Needle aspiration was the most frequent surgical drainage technique.

Keywords: peritonsillar abscess, pattern, management

Introduction PTA was high in the era of pre-antibiotic therapy [5]. The
Peritonsillar abscess (PTA) is the collection of pus between treatment outcome has significantly improved, but the choice
the capsule of the tonsil and the superior constrictor muscle of of first-line antibiotics and technique of surgical drainage
the pharynx [1, 4]. The collection of the pus is usually in the (incision and drainage, per mucosal needle aspiration, quinsy
area lateral to the superior pole of the tonsil [1, 5]. Nevertheless, tonsillectomy or interval tonsillectomy) remained
the site of pus collection may be localized to the middle controversial [1, 6, 9, 11].
portion or lower pole of the tonsil [5]. PTA is a common This study aims to describe the pattern and management of
suppurative complication of acute tonsillitis [1, 3]. In 1995, the peritonsillar abscess in Sokoto metropolis.
published incidence of PTA in the United States and Puerto
Rico among patients 5 to 59 years of age was 30.1/100, 000 Materials and Methods
people annually, and accounted for an estimate of 45,000 This study was a retrospective review of the patients managed
cases yearly [6]. The reported annual incidence of PTA in the for the peritonsillar abscess at the Ear, Nose and Throat
west of Ireland population in 2014 ranged 11-17/100, 000 Department of Usmanu Danfodiyo University Teaching
among patients 9 to 56 years [7]. We did not come across the Hospital, Sokoto, Nigeria from 2006 to 2018. The case files
incidence of PTA in Nigeria in our literature search. retrieved from the Medical Record Department and reviewed
Moreover, an earlier report [8] from Nigeria highlighted the for the following variables: Biodata, symptoms including
absence of the incidence among the Nigerian population. dysphagia, odynophagia, drooling, inability to open the
Clinically, PTA presents as an emergency with pyrexia, sore mouth, fever, dehydration, and History of previous tonsillitis,
throat, otalgia, dysphagia, odynophagia, inability to while physical features comprising trismus, asymmetry of the
swallow/drooling of saliva, while physical features include oropharynx due to swollen, erythematous, oedematous tonsil
trismus, asymmetry of the oropharynx due to swollen, and the ipsilateral soft palate pushing the uvula to the opposite
erythematous, oedematous tonsil and the ipsilateral soft palate side. Unilateral or bilateral PTA, previous PTA, medical
pushing the uvula to the opposite side [1, 2]. The mortality from treatment, needle aspiration, incision and drainage, quinsy

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tonsillectomy, interval tonsillectomy, microbial isolates,

outpatient or hospitalized patients care, duration of hospital
stay. Outcome and follow-up. Exclusion criteria: Those with
negative needle aspiration/cellulitis or missing data. Data
analyzed with SPSS version 21.0.

Results
Twenty-four patients managed for PTA during the study
period. Seven of them with either missing files or incomplete
records were excluded from the study. Of the 17 patients
analyzed the mean age was 22.5 years (Range 5-43 years), 5
(29.4%) Males and 12 (70.6%) Females with a male to female
ratio of 1:2.4. Right tonsil accounted for 7 (41.2%) and left
tonsil 10 (58.8%). Distribution of the PTA by age group in
Figure 1.
Fig 2: Surgical drainage and spontaneous rupture of the
peritonsillar abscess.

Of the 17 patients, three (16.6%) had two episodes of

peritonsillar abscess, and one of those recurrent peritonsillar
abscesses agreed and had interval tonsillectomy. It was only
one patient who had recurrent tonsillitis. All the patients were
hospitalized. Overall, the mean duration of hospital stay was
5.4 days (Range 1-21 days). The duration of hospitalization
varies for the technique of surgical drainage and those that
rupture spontaneously and is tabulated in Table 1.

Table 1: Duration of hospitalization for the different technique of

PTA drainage and spontaneous rupture
Fig 1: Distribution of the PTA by age group.
Type of surgical drainage of Duration of hospitalization
S/N
the PTA in days (Range)
The clinical presentation was characterized by fever, sore 1 Needle aspiration 3.7 (1-7)
throat, dysphagia, odynophagia, trismus and dehydration in 13 2 Incision and drainage 3 (2-6)
(76.5%) of the patients, while 4 (23.5%) of the patients Incision and drainage plus
presented with few of the clinical features. In addition, 5 3 6
interval tonsillectomy
(29.4%) patients had spontaneous rupture of PTA, and it was 4 Spontaneous rupture 9.8 (3-21)
the ruptured PTA that influenced their presentation to the
hospital. The mean duration of symptoms before the The outcome was good because there was a successful
hospitalization was 5.9 days (range 1-14 days). The clinical resolution of the PTA. However, the follow-up was not
signs elicited include hyperemia, tense, swollen tonsil and satisfactory because ten of the patients were lost to follow-up.
ipsilateral soft palate with a deviation of the uvula to the The mean follow-up was 0.8 month (Range 26.5 days – 8
opposite side in 12 (70.6%) patients, some of those signs in 4 months).
(23.5%) and parapharyngeal abscess in 1 (5.9%) patient.
Confirmation of the diagnosis of PTA was by test aspiration in Discussion
12 (70.6%) patients whose PTA did not rupture The symptoms and signs of PTA exhibited by the patients in
spontaneously. The mean volume of the pus aspirated or this study are similar to the previous report [1, 3, 12, 13]. In this
drained by incision and drainage was 6.9ml (Range 3-20ml). study, PTA was most common between 11-40 years of age.
Streptococci species was isolated in 2 (11.8%) patients, and Therefore, it supports earlier studies which documented PTA
sensitive to Ceftriaxone and Ciprofloxacin. No growth in as a disease not restricted to any age but predominant in
1(5.9%) and the microscopy, culture, and sensitivity (M/C/S) adolescent and young adults [1, 6, 14]. The number of PTA cases
results were not available in 14 (82.4%) patients. Therefore, in this study is small in comparison to many reports [7, 10, 15, 17].
M/C/S did not influence the administration of drugs in the The reason for the few PTA patients in this study is not
patients. apparent. Probably, treatment in nearby public or private
Medical treatment comprised intravenous fluid rehydration for hospitals or self-medication and treatment by quacks may be
all the patients. Intravenous Amoxicillin plus clavulanic Acid the reasons for the small size of patients in this cohort. A
and Metronidazole in 9 (52.9%) patients, while Ceftriaxone multi-centre study may likely unravel the real burden of PTA
and Metronidazole in 8 (47.1%) patients. Surgical drainage of in this environment. Delayed or late presentation contributed
the PTA and those that rupture spontaneously are depicted in to the complications observed in this study. The spontaneous
Figure 2.

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rupture and parapharyngeal abscess presented late in the interval tonsillectomy in this study supports many authors [8,
22]
second week of onset of the symptoms of the PTA. who favoured tonsillectomy for recurrent PTA.
The spontaneous rupture of PTA encountered in this study is In this study, the average duration of hospitalization was 3.7
one of the dreadful complications of PTA [14]. Spontaneous days for needle aspiration, three days for incision and drainage
rupture of PTA carries potential risks of aspiration, aspiration and longest in those complicated by spontaneous rupture and
pneumonia, lung abscess, and deep neck space infection. In parapharyngeal abscess. The prolonged hospitalization for the
this study, none of the patients who had the spontaneous complicated cases was due to the time required for the
rupture of the PTA was complicated by aspiration or lung resolution of the complications. Comparatively, In Ireland,
infection. However, one of them had a parapharyngeal mean hospital stay was four days [7] and two to four days in
abscess, which was drained via an external approach. another report [1]. The poor compliance to follow-up in this
Similarly, there was an earlier report in another study where study may mean the complete resolution of the PTA because
parapharyngeal abscess occurred as a complication of PTA many patients in this environment often do not come for
[18]
. In contrast, no record of complications in a retrospective follow-up whenever their symptoms resolved.
chart review of 577 cases of PTA in England [16].
The microorganisms commonly implicated as an aetiology in Limitation of this study
PTA is Gram-positive cocci, especially group A beta It was a retrospective study and hospital-based. Secondly, the
haemolytic streptococcus [1, 3, 6, 7, 14, 16, 17]. Anaerobes are often number of patients analyzed is small. Therefore, it may not
implicated, and some report mentioned gram negative represent the actual pattern of PTA in Sokoto metropolis.
microbes like Pseudomonas species [14]. In this study,
Streptococci species was isolated in only two patients. M/C/S Conclusion
was not available for most of the patients. Therefore, In this study, the mean age for peritonsillar abscess was 22.5
antibiotic therapy was not dependent on M/C/S. The fact that years (Range 5-43 years), 5 (29.4%) Males and 12 (70.6%)
M/C/S did not influence the choice of antibiotics in this series Females with a male to female ratio of 1:2.4. It was most
supports earlier reports that discourage routine M/C/S in the common in adolescent and young adults between 11-40 years
management of PTA [6, 14, 16]. of age. Complications observed were spontaneous rupture of
In this study, medical treatment consisted of intravenous the PTA and a parapharyngeal abscess. These complications
rehydration, antibiotics, and anti-pyretic/analgesics. All the were associated with a prolonged hospital stay. All the
patients were managed as in-patients against the out-patient patients were managed as in-patients and medical treatment
management recommended by numerous reports [1, 6, 19] comprised intravenous fluid rehydration and empirical
because of significant moderate to severe dehydration due to antibiotic therapy. Needle aspiration was the most frequent
dysphagia and odynophagia. The patients in this series could surgical drainage technique of draining the PTA. There was a
not swallow both liquid and solid diets for a considerable satisfactory resolution of the abscess, although, follow-up was
length of time exceeding 24-hours in some of the patients as at poor.
the time of hospitalization. The two concurrent administered
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