Journal of Population Therapeutics

& Clinical Pharmacology

Original Research
DOI: 10.15586/jptcp.v26i2.616

A NEW TREATMENT MODALITY TO REDUCE ACUTE TONSILLITIS HEALING TIME

Huseyin Keskin, MD1 and Oguz Guvenmez, MD2
1
Department of Otorhinolaryngology, Bor State Hospital, Nigde, Turkey
2
Independent Researcher, Internal Medicine and Traditional Medicine, Adana, Turkey

Corresponding author: oguzguvenmez001@hotmail.com

Submitted: 31 May 2019. Accepted: 14 June 2019. Published: 10 July 2019.

ABSTRACT
Background and Objective
Acute tonsillitis is one of the most common reasons for application to otorhinolaryngology clinics. In
the treatment of acute tonsillitis, supportive therapies are mostly used. As antibiotic therapy, penicillin
or erythromycin can be used. The aim of this study is to decrease the clinical recovery time of acute
tonsillitis by providing parenteral treatment and daily cleaning of tonsillar lesions.
Material and Methods
Patients with an age range of 15–60 years were included in the study. The patients were divided into two
groups. The first group used an i.v. combination of ampicillin + sulbactam and the tonsillar membranes of
patients were cleaned daily. The second group used only the i.v. combination of ampicillin + sulbactam.
Results
Patients who received antibiotherapy and debridement had a clinical improvement of 90% on the 2nd
treatment day and 95% on the 5th treatment day. The patients receiving only antibiotics had a clinical
improvement of 65% on the 5th treatment day and 75% on the 7th treatment day. The recovery time of
both groups was significantly different (p < 0.05).
Conclusion
The solution and technique used in this clinical study showed that patients with acute tonsillitis could
recover in a very short time without any complications.
Keywords: acute tonsillitis, treatment, healing time, recovery, otorhinolaryngology

J Popul Ther Clin Pharmacol Vol 26(2):e14–e19; July 10, 2019.

This article is distributed under the terms of the Creative Commons Attribution-Non
Commercial 4.0 International License. ©2019 Keskin and Guvenmez.

e14
A new treatment modality to reduce acute tonsillitis healing time

INTRODUCTION prolonged hospital stay. It is necessary to shorten

the length of stay in otorhinolaryngology clinics
Acute tonsillitis is one of the most common
with clinical improvement and increase the
reasons for application to otorhinolaryngology
­quality of life of the patients in a short time.
clinics. The infectious factors of acute tonsillitis
We  hypothesize that the membranes on tonsils
have been shown in detail in previous studies (1).
should be cleaned daily to decrease the clinical
Viral agents are responsible for 50–80% of all
recovery time.
acute tonsillitis. Viral infections are frequently
The aim of this study is to accelerate the clini-
caused by rhinovirus, coronavirus, and parainflu-
cal recovery by providing parenteral treatment
enza virus. Rarely, unusual organisms such as
and daily cleaning of tonsillar lesions in patients
herpes simplex virus can be detected. In addition,
with acute tonsillitis who are admitted to the oto-
the Epstein–Barr virus (EBV) is responsible for
rhinolaryngology clinics.
approximately 1–10% of all cases (also called
mononucleosis or glandular fever) (1). EBV also METHODS
causes contagious infections. The most common
Study period
bacterial microorganisms causing acute tonsillitis
This study was conducted in Nigde Bor State
are A group beta-hemolytic Streptococci (most
Hospital in Turkey between February 2017 and
frequent), Chlamydia pneumoniae, Mycoplasma
February 2019.
pneumoniae, Haemophilus influenzae, Candida,
Neisseria meningitis, and Neisseria gonorrhoeae Sample and design
(2). The treatment of viral tonsillitis depends on The patients with acute tonsillitis who were
the symptoms. However, the treatment of bacte- admitted to the Department of Otolaryngology
rial tonsillitis is directed to the bacterial agent. Clinic in Nigde Bor State Hospital in Turkey were
The symptoms of acute tonsillitis are sore included in the study.
throat, headache, fever, malaise, muscle and joint The inclusion criteria were as follows: an age
pain, and swallowing difficulty (3). In viral tonsil- range of 15–60 years, grade 2–3 tonsil hypertro-
litis, fever continues as sub-febrile. In bacterial phy, exudation and membrane formation on ton-
tonsillitis, fever becomes apparent. On physical sils, fever (>37.3°C), severe weakness, no previous
examination, tonsil hypertrophy and hyperemia oral antibiotic use, and difficulty in breathing and
are usually seen. In young and adult patients, there speaking. In addition, throat swab samples were
may be white or gray membranes on tonsils. taken from the tonsils of the patients and sent
Nowadays, in the treatment of acute tonsilli- to  the microbiology laboratory. A rapid antigen
tis, supportive therapies (analgesic therapy and detection test (Strep A Optical Immune Assay
corticosteroid therapy) are mostly used (4, 5). As [BioStar]) was studied.
a first option of antibiotic therapy, penicillin is It was decided to give intravenous antibiotics
generally used. If there is an allergic situation, to the patients who were positive, and so they
erythromycin or second-generation cephalospo- were hospitalized. Rapid antigen test negative
rin can be used (6, 7). The risk of transmission patients were given outpatient symptomatic treat-
can reduce in 24 hours after the use of antibiotics ment, and these patients were not included in the
(8). The recovery period of acute tonsillitis does study. Other swab samples taken from the patients
not change with different antibiotic use (9). The were incubated in sheep blood agar for 48 hours
average healing time varies between 7 and 14 days. at 37°C. The culture plates were checked every
This causes long-term parenteral medication and 24 hours. Culture positive patients were noted.

J Popul Ther Clin Pharmacol Vol 26(2):e14–e19; July 10, 2019.

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A new treatment modality to reduce acute tonsillitis healing time

The exclusion criteria were as follows: a his- 5. Astragalus gummifer: 7 cc

tory of tonsillectomy, presence of a peritonsillar 6. Carthamus tinctorius: 7 cc
abscess (PTA), children under 15 years of age, 7. Povidone iodine: 20 cc
a  history of antibiotic allergy with penicillin 8. Ethyl alcohol: 15 cc
group, and patients previously treated for acute
tonsillitis.
Application of the solution and cleaning of
All patients were examined by an experienced
tonsillar membranes and exudates
otolaryngologist. Patients’ histories were noted.
The procedure was performed by an experi-
Patients who fulfilled the inclusion criteria were
enced otolaryngologist. The mixture was shaken
randomly included in the study. Participants were
before use. It was soaked with the previously pre-
randomly assigned following simple randomiza-
pared cotton swab. For both tonsils, the mem-
tion procedures (computerized random numbers)
branes, exudate, and crypts were removed. Then,
to one of the two treatment groups. Patients who
the solution was applied to the surface of cleaned
did not meet the inclusion criteria were treated in
tonsils. Oral intake of the patients was limited for
accordance with the treatment guidelines.
15 minutes. It was informed not to swallow the
The patients were divided into two groups.
solution.
The first group used an i.v. combination of ampi-
When the debridement was performed, signifi-
cillin + sulbactam and the tonsillar membranes
cant care was taken not to stimulate the pharyn-
were cleaned daily. The second group used only
geal reflex. In this way, the patient was able to
the i.v. combination of ampicillin + sulbactam.
tolerate the procedure. After the procedure, we
The number of patients included in the first
did not see any complications. Only three patients
group was 107. The number of patients included
had vomiting after the procedure.
in the second group was 98.
In order to evaluate the response of the
Preparation of tonsillar cleaning apparatus patients to the treatment, the Sore Throat Life
To clean the membrane on the tonsils, cotton Quality Scale (STQoL) was used (10). The scale
and sponge on a long curette tip were prepared was adapted to Turkish and applied to patients. It
with 0.5 × 0.5 cm dimensions. is a valid scale for evaluating patients with acute
tonsillitis for measuring the quality of life. With
Preparation of tonsillar cleaning solution
this scale, the patient can be evaluated in three
The prepared solution contained the herbal
different ways: social, physical, and environmen-
extracts commonly used in the community. In
tal. The questionnaire includes 21 questions and
addition, the contents and proportions of the
is rated from 1 to 5. Five possible answers are
mixture were determined according to the effec-
offered for each statement, in the form of Likert’s
tivity and tolerability of the patients. The herbal
scale: “not at all,” “a little,” “medium,” “a lot,”
extracts in the mixture had no toxic effects for the
and “extremely.” The answers are rated from 5
dose used.
(“not at all”) to 1 (“extremely”).
The content of the mixture was as follows for
All patients included in the study filled the
100 cc:
questionnaire before starting the treatment. The
1. Sodium bicarbonate: 30 cc (50% saline) questionnaire was repeated on the 2nd, 5th, and
2. Mentha piperita: 7 cc 7th days after the treatment. The mean scores of
3. Ocimum basilicum: 7 cc the questionnaire were compared separately for
4. Cichorium intybus: 7 cc each group.

J Popul Ther Clin Pharmacol Vol 26(2):e14–e19; July 10, 2019.

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A new treatment modality to reduce acute tonsillitis healing time

Sample Size RESULTS

According to the power analysis, for a study
A total of 205 patients were included in the
design with 0.05 type I error, 80% power, and a
study. Demographic data are explained in Table 1.
standard effect size of 0.41, a minimum of 93
The age range of the patients was 15–60 years.
subjects in each group was found to be required.
The first group included 107 patients, and the
Statistical Analysis ­second group included 98 patients. The sex distri-
Standard deviation, mean, median, lowest, bution in the first group was 54 females and 53
highest, frequency, and ratio values were utilized males, and in the second group, it was 46 females
in the descriptive statistics of the data. Categorical and 52 males.
variables were compared with the chi-square test. There was no significant difference in the
The distribution of the variables was assessed STQoL mean scores of all patients before treat-
with the Kolmogorov–Smirnov test. Independent ment (p > 0.05) (Table 2). The STQoL scores sig-
sample t-test and paired sample t-test were used nificantly increased compared to the pretreatment
for the analysis. The analysis of data is made use scores in Group I (p < 0.05) (Indicates that the
of with SPSS 21.0 program. disease is healed rapidly) (Table 2).
On the 2nd and 5th day after treatment, there
Ethical Approval and Reference Number was no significant increase in the STQoL score in
This study was conducted in accordance with Group II (p > 0.05). On the 7th day, the STQoL
the Declaration of Helsinki, and the ethics scores significantly increased in Group II (p < 0.05).
­committee approval was obtained from Adana On the 2nd, 5th, and 7th day after treatment,
City Hospital in Adana, Turkey. The reference the mean STQoL score of Group I was signifi-
number is 93/2018. Patients included in the study cantly higher than the mean STQoL score of
were informed and consent forms were obtained. Group II.

TABLE 1 Demographic Variables and Clinical Characteristics of the Sample

Group I Group II
p*
Mean ± SD/N% Median Mean ± SD/N% Median
Age 40.4 ± 15.3 38.0 41.5 ± 14.8 39.0 0.624
p**
Gender Male 53 / 49.5% 46 / 46.9% 0.316
Female 54 / 50.5% 52 / 53.1%
*Independent sample t-test was used. **Chi-square test was used.

TABLE 2 The Comparison of Group I and Group II STQoL Scores

Group I Group II
p*
Mean ± SD Mean ± SD
STQoL Before treatment 25.7 ± 4.3 27.3 ± 4.5 0.821
After treatment (2nd day) 58.2 ± 8.4 33.1 ± 5.2 0.038
After treatment (5th day) 76.5 ± 13.2 40.4 ± 8.3 0.021
After treatment (7th day) 92.4 ± 16.7 67 ± 12.5 0.032
*Independent sample t-test was used. Paired sample t-test was used.

J Popul Ther Clin Pharmacol Vol 26(2):e14–e19; July 10, 2019.

This article is distributed under the terms of the Creative Commons Attribution-Non
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A new treatment modality to reduce acute tonsillitis healing time

DISCUSSION fasciitis (NF) which can progress very ­rapidly (18).

This may lead to mortality. Treatment of these
If acute tonsillitis is not treated effectively in a
complications is surgery (19). This causes great
short period, it will become chronic and cause
sociopsychological problems for the patient.
various complications (11). Therefore, it is effec-
PTA, PPA, RPA, or NF did not develop in any
tive to start treatment immediately. With appro-
of the patients included in our study. Patients
priate antibiotic therapy, acute bacterial tonsillitis
who received antibiotherapy and debridement
can usually heal without developing any compli-
had clinical improvement of 90% on day 2 and
cations within 7–10 days (12). However, the anti-
95% on day 5. Patients receiving only antibiotics
biotic given for this should be appropriate, the
had a clinical improvement of 65% on day 5 and
patient should use the drugs regularly, and the
75% on day 7. The recovery time of both groups
patient should not be in a state of immunosup-
was statistically significant (p < 0.05).
pression. These conditions are not considered in
This article should be considered with its lim-
the current treatment guidelines (13).
itations. A major limitation is that the STQoL is
The prevalence of antibiotic consumption, espe-
not validated in Turkish. The scale was adapted
cially in our country, prevents the treatment of
to Turkish and applied to patients by the authors.
many infections such as acute tonsillitis in a short
Another limitation is the lack of a placebo group.
time (14). In addition, according to our clinical
Including a placebo group would improve the
observations, the development of complications is
findings of the study.
inevitable, especially in young and adult patients,
without appropriate treatment methods. The CONCLUSIONS
accepted duration of antibiotic treatment is approx-
As a result, the solution and technique used in
imately 10 days (9). However, most patients do not
this clinical study showed that patients with acute
complete this period. The patients with complica-
tonsillitis could recover in a very short time with-
tions are hospitalized and treated parenterally (15).
out any complications. Thus, complications can
Our hypothesis is the basis of this study. If the
be prevented. Although i.v. antibiotic treatment
area of infection is mechanically removed, clini-
is effective, the recovery period is long. However,
cal recovery time will improve. Therefore, paren-
future placebo-controlled studies are needed to
teral treatment was started in all patients included
clarify these findings.
in our study. The combination of ampicillin +
sulbactam was started. This combination has AUTHORS’ CONTRIBUTIONS
proven effective in all patients. Unlike, in patients H.K. was responsible for the concept, litera-
who underwent tonsillar local debridement, ture, design, data collection, and manuscript
recovery time was shortened, and quality of life writing. O.G. was responsible for the literature,
increased in a short time. analysis, interpretation, and manuscript writing.
It is very important to prevent acute tonsillitis
complications, because complication develop- CONFLICT OF INTEREST
ment increases morbidity and mortality. The The authors have no conflict of interest to
most common complication is PTA. In addition, declare.
the parapharyngeal abscess (PPA) may develop a
FUNDING
retropharyngeal abscess (RPA) as a result of the
spread of infection to the hypopharynx (16, 17). The authors declare that there is no financial
The most serious complication is necrotizing support for this study.

J Popul Ther Clin Pharmacol Vol 26(2):e14–e19; July 10, 2019.

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A new treatment modality to reduce acute tonsillitis healing time

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