JOURNAL READING Silvia Gita Aditama

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 JOURNAL IDENTITY
Title
Management of recurrent tonsillitis in children
Writer
Diaa El Din El Hennawi , Ahmed Geneid , Salah
Zaher, Mohamed Rifaat Ahmed
Publisher
American Journal of Otolaryngology–Head and
Neck Medicine and Surgery/2017
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 ABSTRACT
Objective:
To compare azithromycin (AZT) and benzathine
penicillin (BP) in the treatment of recurrent
tonsillitis in children.

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 METODE
Definition
Recurrent tonsillitis was defined as four or
more episodes of ton- sillitis per year (for
children of either gender) with two of the
episodes confirmed to be group A
streptococcal infection

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 METHODS
A randomized controlled clinical trial study created in the
otolaryn- gology department - Suez Canal University
Hospital – Ismailia – Egypt and Alexandria University
Children Hospital – Egypt from March 2005 to May 2012
The study comprised of 350 children with recurrent
streptococcal tonsillitis, 284 of whom completed the study
and 162 children received conventional surgical treatment.
The rest of the children, 122, were divided randomly into
two equal main groups.
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 METHODS
Group A children received a single
intramuscular BP (600,000 IU for children ≤
27 kg and 1,200,000 IU for ≥27 kg) every
two weeks for six months.
Group B children received single oral AZT
(250 mg for children ≤ 25 kg and 500 mg for
≥25 kg) once weekly for six months.

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 METHODS
The enrolled children were aged from five to 12.
The 350 children enrolled fulfilled the inclu- sion
criteria and did not have any significant co-
morbidities
Significant co morbidities included: rheumatic
heart disease, rheumatic fever, marked
anesthetic risk, sensitivity to AZT or BP, the
intake of drugs that might interfere with AZT or
BP, hepatic impairment, or long QT syndrome

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 METHODS
Randomization was performed prior to study commencement as
fol- lows: Opaque envelopes were numbered sequentially from
1 to 350. A computer-generated table of random numbers was
used for group assignment; if the last digit of the random
number was from 0 to 4, assignment was to group 1 (received
conventional tonsillectomy), and if the last digit was from 5 to 9,
assignment was to group 2 (re- ceived BP or AZT)
Group 2 was randomized again in similar manner in group A
and group B.
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POPULATION

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METHODS

• Data collected included complete medical histories with an empha- sis on

recurrent tonsillitis. Symptoms' severity was assessed using a vi- sual
analog scale for symptoms' severity (with 0 indicating no symptoms and
10 indicating the most severe symptoms).
• CBC, ASOT, and ESR data were collected from all children at the
beginning of the study and after six months.
• CBC: Complete blood count
• ASOT: A Streptococcus Test
• ESR: Eritrosit Sedimentasion test (non specific test for infections or autoimmune
disease)

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METHODS
• The outcomes were assessed through the following measures:
1. Medical history and clinical evaluation by the end of the trial.
2. ASOT and ESR levels were taken before the start of the study and six months
after it.
3. Symptoms' severity was assessed using the vi- sual analog scale for symptoms
severity as described above.
4. The safety of drugs were assessed by the detection of adverse effects, which
were classified as minor and accepted adverse effects (GIT upset, dizziness) or
major, necessitating the exclusion of the child from the study (anaphylaxis,
jaundice, a prolonged QT interval).

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METHODS
5. Satisfaction assessment was made by asking direct questions to the patients,
their parents, and the medical staff. Patients' satisfac- tion was classified as
a) the patient is comfortable and accepts the regimen;
b) the patient is not comfortable but accepts and continues the regimen;
c) the patient is not comfortable and does not accept the regimen and
discontinues it (whereupon they were excluded from the study).

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METHODS
Data collected were processed using SPSS version 18 (SPSS Inc., Chicago, IL,
USA). Quantitative data were expressed as means ± SD while qualitative data
were expressed as numbers and percentages. The Student's t-test was used to
compare the significance of difference for the quantitative variables that
followed a normal distribution.

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 RESULT
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AFTER TREATMENT RESULT

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 ASOT AND ESR LEVELS
• The tonsillectomy group had a mean ESR level of 70.3 ± 13.1 ml/h during
the last episode of tonsillitis before tonsillectomy. Six months after the
operation this level dropped to 8.7 ± 1.9 ml/h (P = 0.005).
• The mean ASOT for the tonsillectomy group was 436 IU/ml before sur- gery
and declined to 115 IU/ml after six months with statistically signif- icant
improvement (P = 0.006).
• The mean ASOT before treatment in group A was 476 IU/ml and 491 IU/ml
in group B. After six-months follow-up a statistically signifi- cant reduction in
the ASOT in both groups occurred as group A became 126 IU/ml while group
B became 141 IU/ml (Table 1). There was no sta- tistically significant
difference between the two groups.

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 SEVERITY OF SYMPTOMS
Before Treatment After Treatment
• symptoms Group
Mean SD Mean SD

Dysphagia A 8,1 1,5 5,3 1,8

B 8,7 1,1 4,9 1,4

Fever A 9,3 1,1 4,3 0,9

B 8,9 2,3 4,1 1,2

arthralgia A 7,2 0,9 3,9 1,8

B 7,9 1,4 3,6 0,9

Body ache A 8,7 1,4 3,7 1,1

B 8,1 0,8 3,2 1,7

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 ADVERSE EFFECT
• adverse effects encountered in the AZT group, three patients had minor
adverse reactions e.g. nausea, vomiting, and abdom- inal cramps with
diarrhea.
• liver enzymes did not show a sig- nificant rise from before treatment to after
treatment, nor was there a difference between group A and group B.
• No serious adverse reactions were reported in either group.
• No patients developed rheumatic activity during the study and follow-up
period.

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 COMFORTABILTY
• Group A had a lower level of 36 (59.1%) comfortable patients, versus 25 who
reported discomfort (40.9%). However, the uncomfortable group continued the
treatment till the end of the year.
• Satisfaction among group B patients was significantly higher among 58
patients (95.61%). Only three reported to be uncomfortable (4.9%) but they
also continued the treatment.
• It is evident that the AZT patients were more comfortable with the drug than
the BP patients, with a statically significant difference between both groups
regarding satisfaction

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 COMPLIANCE
• N 90% of both groups were taking the drug regularly. There was no statically
significant difference between the groups regarding compliance.

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 DISCUSSION
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 DISCUSSION
Recurrent tonsillitis is considered to be one of the common
reasons for primary care visits to physicians. Recurrent tonsillitis
among chil- dren has a considerable impact on the quality of
life, not only due to the effects on children but also the burden
on the parents when their child is suffering.
Tonsillectomy remains a common procedure.
However, a number of immunological stud- ies on the effects of
tonsillectomy point to the importance of a conservative attitude
from an immunological point of view towards
adenotonsillectomy

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 DISCUSSION
The aim of this study has been to look into alternatives to
tonsillectomy, especially when the tonsillectomy criteria are not fully
fulfilled, resources are not available or the parents opt for medical
treatment. The two alternatives were BP and AZT.
The present study showed that there is no significant difference be-
tween the group A (BP) and B (AZT) in regard to recurrent tonsillitis
after six- months follow-up. The ASOT and ESR levels were also
reduced to nor- mal and there was no statistically significant
difference between the groups.

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 DISCUSSION
The main concern for using AZT in long treatment has been its
pos- sible association with increased cardiovascular risk and
may lead to cardiovascular-related death in high-risk patients.
A meta-analysis of randomized controlled trials by Almalki
and Guo, reported AZT safety in patients studied in 12 trials
included in the meta-analysis from 1990 to 2013.
Nevertheless, its safety and effectiveness is comparable to
Penicillin V

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 DISCUSSION
The results of this study show the efficacy of AZT in preventing re-
current tonsillitis and reducing ASOT and ESR levels to a range
compa- rable to those of BP and tonsillectomy. The children were
more comfortable with an AZT regimen rather than a BP regimen.
Minor ad- verse reactions were reported with AZT.
The message of this study is that treatment options other than ton-
sillectomy exist for treating recurrent tonsillitis. AZT, which is one of
the treatments, proved to be safe and effective in our study.
Further studies should look into the possibility of having shorter
regimens of AZT when treating recurrent tonsillitis.

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 CONCLUSION
The treatment of recurrent tonsillitis is equally
effective by treat- ment with AZT or BP in
comparison to tonsillectomy. AZT was as effec-
tive as BP and tonsillectomy against recurrent
tonsillitis after six months of treatment.

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 THANK YOU!
Any question?

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