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Auris Nasus Larynx xxx (2017) xxxxxx

Contents lists available at ScienceDirect

Auris Nasus Larynx

journal homepage: www.elsevier.com/locate/anl

Is corticosteroid a treatment choice for the management of

peritonsillar abscess?
Hasan Emre Koak *, Harun Acpayam, Mustafa Suphi Elbistanl, Aye Pelin Yi
gider,
Wesam M.E. Alakhras, Mehmet Nurettin Kral, Fatma Tlin Kayhan
Bakrky Dr. Sadi Konuk Training and Research Hospital, Department of OtorhinolaryngologyHead and Neck Surgery, Istanbul, Turkey

A R T I C L E I N F O A B S T R A C T

Article history: Objective: To investigate the effect of the single systemic use of corticosteroid following drainage
Received 23 July 2016 procedure in patients with peritonsillar abscess (PTA).
Accepted 12 April 2017 Methods: This retrospective case-control trial included 32 patients with the diagnosis of PTA
Available online xxx
between December 2013 and January 2016 in our clinic. Patients were divided into two groups
based on the approaches of two authors for the treatment after PTA drainage. The study group
Keywords:
included the patients treated with single dose systemic corticosteroid after PTA drainage. Other
Peritonsillar abscess
Steroid treatment
patients who had no corticosteroid treatment were in the control group. Two groups were compared
Trismus based on time to oral intake, grade of trismus, pain severity and duration of hospitalization.
Results: Statistically significant differences between two groups were observed in terms of time to
oral intake, grade of trismus, pain severity and length of hospitalization. The degree of trismus and
pain severity significantly decreased in study group comparing to control group at the end of the first
day. This difference disappeared at Day 7. Time to oral intake and the duration of hospitalization
were shorter in the study group than in control group.
Conclusion: Corticosteroid treatment following drainage procedure in patients with peritonsillar
abscess improves pain severity and trismus thus it decreases time to oral intake and duration of
hospitalization.
2017 Elsevier B.V. All rights reserved.

1. Introduction complication of acute tonsillitis. PTA develops by local

Peritonsillar abscess (PTA) is a common emergency
condition for ear, nose and throat (ENT). Classical symptoms
of the patients with PTA include throat pain, fever, dysphagia,
odynophagia, weakness, trismus and the hot-potato voice.
Oropharynx examination reveals that the uvula which was
pushed to the opposite side, a peritonsillar asymmetry between
the two regions, redness and swelling [1]. PTA is a suppurative
* Corresponding author at: Bakrky Dr. Sadi Konuk E gitim ve Aratrma
Hastanesi, Zuhuratbaba Mah. Tevfik Saglam Cad. No: 11, Bakrky, Istanbul,
Turkey.
E-mail address: drhekbb@gmail.com (H.E. Koak).
invasion and proliferation of microbiological factors into the
peritonsillar area [2]. PTA is most common deep neck
infections in young adults and children [3]. Although PTA
occurs in all age groups, it is most common in patients between
the ages of 20 and 40 [3,4]. PTA usually is diagnosed by the first
family physician and the most of the patients had been treated
with systemic antibiotics prior to admission. The annual
incidence of PTA was estimated as 3/10,000 [5]. However, PTA
incidence in our country is still unknown. Drainage and
antibiotic treatment are usually sufficient for PTA. However,
oral intake difficulties due to the secondary symptoms such as
trismus and odynophagia caused by local edema and
inflammation may require hospitalization for feeding. It has

http://dx.doi.org/10.1016/j.anl.2017.04.008
0385-8146/ 2017 Elsevier B.V. All rights reserved.

Please cite this article in press as: Koak HE, et al. Is corticosteroid a treatment choice for the management of peritonsillar abscess? Auris Nasus
Larynx (2017), http://dx.doi.org/10.1016/j.anl.2017.04.008
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2 H.E. Koak et al. / Auris Nasus Larynx xxx (2017) xxxxxx
been proved that corticosteroids in the treatment of infectious,
inflammatory disease improve symptoms of the patients
[6]. There are few studies investigating the efficacy of systemic
corticosteroid usage in the treartment of PTA and further trials
are needed in this outcome [7]. The purpose of our study is to
investigate the effect of the single systemic use of corticosteroid
following drainage procedure in patients with peritonsillar
abscess (PTA) in our clinical practice.
2. Materials and methods
2.1. Participants
In our study, electronic file records of 50 patients who were
diagnosed by two authors Hasan Emre Koak and Mustafa
Suphi Elbistanl as PTA in our clinic between December
2013 and January 2016 were examined. Age, sex, symptoms,
examination findings, prior use of antibiotics and PTA history
of the patients were recorded. Patients who were treated by local
or systemic corticosteroid and antibiotic treatment in last seven
days, patients who have not signed the informed consent form
and the patients without purulent discharge following the
incision were not included in the study. Patients without
sufficient information in their medical file were excluded from
the study. Totally 18 patients were excluded.
2.2. Ethics committee
Our study was performed as a retrospective, case-control
study after approval of the local ethical committee.
2.3. Study design
Firstly, incision (with a guarded scalpel make a small
incision above the tonsil, in the soft palate) and drainage
procedures under local anesthesia with lidocaine (10%
Vemcaine1 Pump spray and Vem Pharmaceuticals, Istanbul,
Turkey) were performed in all patients with PTA. All drainage
procedures were performed by same resident surgeon Harun
Acpayam under the supervision of a senior surgeon. We did
not performed any radiological imaging before or after the
drainage procedure. Hemogram and C-reaktif protein (CRP)
blood tests were obtained. Author H.E. Koak routinely
administered single intravenous methylprednisolone at the
dose of 1 mg/kg (Prednol-L40 mg amp1, MN, Istanbul,
Turkey) following the procedure depending on personal
experience and preference while the author M.S. Elbistanl did
not use steroid treatment. Patients treated with corticosteroid
were included in the study group, and the others were assumed
as the control group. After the procedure, all patients received
7-day systemic clindamycin intravenously or intramuscularly
(IV/IM) (during hospitalization, three times daily IV/IM
Klindan1 600 mg vials, after discharge three times daily
Klindan1 300 mg tablets, Bilim Pharmaceuticals, Istanbul,
Turkey), 7-day systemic paracetamol (during hospitalization,
three times daily IV/IM Parol1 10 mg/ml, 100 ml vials, after
discharge three times daily Parol1 500 mg tablets, Atabay
Pharmaceuticals, Istanbul, Turkey) and 1000 cc isotonic Na/Cl
Please cite this article in press as: Koak HE, et al. Is corticosteroid a treatment choice for the management of peritonsillar abscess? Auris Nasus
Larynx (2017), http://dx.doi.org/10.1016/j.anl.2017.04.008
Fig. 1. Visual pain scale (VPS). Images in the figure were used for the illiterate
patients.
solution (during hospitalization, two times daily). All patients
were hospitalized after the drainage procedure and released
after symptom improvements such as fever control and well-
being following oral intake. Oral systemic clindamycin
treatment was completed within seven days after discharge.
Totally, 18 patients were treated with IV methylprednisolone
(1 mg/kg). Pain and trismus severity at Days 1 and 7 were
evaluated in patient medical records. Also, time to oral intake,
duration of hospitalization and side effect profile of single
dose of the steroid were reviewed. Patients had been followed-
up at Month 1 for recurrence or complications. Visual pain
scale (VPS) was used for pain assessment (Fig. 1). Time to oral
intake (h) was estimated as the time until the patient could
swallow easily. The degree of trismus was rated by measuring
the distance between the upper and lower incisors during
difficult mouth opening. Trismus degree at Days 1 and 7 was
compared between two groups. Trismus was rated as follows:
No trismus: mouth can be opened more than 40 mm with
effort; mild trismus: mouth can be opened between 35 and
40 mm with effort; moderate trismus: mouth can be opened
between 25 and 35 mm; severe trismus: mouth can be opened
between 15 and 25 mm; very severe trismus: mouth can be
opened less than 15 mm with effort [8]. In statistical rating
mild, moderate, severe and very severe trismus were assessed
as grade 14 respectively.
2.4. Statistical analysis
Mean, standard deviation, median minimum, maximum,
frequency and ratio values were used in descriptive statistics.
KolmogorovSmirnov test assessed the distribution of vari-
ables. MannWhitney U test and independent samples t-test
were used for quantitative data analysis. Wilcoxon test was used
to analyze the repeated measures. Qualitative data were
analyzed by chi-square test. SPSS 22.0 software was used
for the data analysis.
3. Results
A total of 32 patients were included in the study. In addition
to the standard treatment protocol, 18 patients were adminis-
tered IV methylprednisolone. The mean age of the patients was
26.8  6.9 (range 1141). 19 patients were male. 18 patients
had left side PTA, and PTA was located on the right side in the
rest of the patients. Although the symptoms were variable
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H.E. Koak et al. / Auris Nasus Larynx xxx (2017) xxxxxx 3

Table 1
Epidemiological characteristics of study.

Study group Control group Total

Mean  .s.s./n Mean  .s.s./n Mean  .s.s./n-%
n 18 14 32
Age 26,9  6,7 26,5  7,4 26.8  6.9
Gender Female 8 5 13- %40.6
Male 10 9 19- %59.4
Side Left 10 8 18- %56
Right 8 6 14- %44
Fever + 15 11 26- %81.2
3 3 6- %18.8
Hot-potato voice + 10 8 18- %56
8 6 14- %44
Common symptoms (sore throat, oral intake difficulty, fatigue) + 18 18 32- %100
0 0 0- %100

between patients, the most common symptoms were a sore
throat, oral intake difficulty, and fatigue which were present in
all patients. 26 patients (81.2%) had fever (>37,5  C) and
18 patients (56%) had hot-potato voice (Table 1). Approxi-
mately half of the patients (15 patients) had also ipsilateral
lymphadenopathy (LAP).
The average time between the onset of symptoms and
admission was 2.6  1.5 days, and no statistically significant
difference was observed between two groups (2.4  1.0 day for
the study group and 2.9  1.9 days for control group;
p = 0.739).
The average hospitalization time was 1.2  0.5 days and
2.6  1.1 days for the study group and control group,
respectively with statistically significant difference
(p = 0.001) (Fig. 2).
Time to oral intake after incision and drainage procedure was
evaluated hourly basis. Time to oral intake was 6.3  6.2 h and
17.2  8.4 h in study group and control group, respectively
with statistically significant difference (p = 0.001) (Fig. 2).
All patients had trismus with varying degrees during the
examination. Four patients had mild trismus while 11 patients
had moderate trismus. Severe and very severe trismus were
observed in 13 and four patients, respectively. No statistically
significant difference was detected between the study group
(2.6  0.8) and control group (2.5  1.0) for the baseline
trismus severity (p = 0.732). However, at the end of Day
1 statistically, a significant difference was observed for trismus
severity between study group (0.4  0.7) and control group
(1.9  0.8) (p = 0.001). At the end of Day 7, this difference was
disappeared, and all patients could open their mouth more than
40 mm (Fig. 3).
No significant difference was found for the mean pain scores
measured by VPS during the admission between study group
(8.8  0.9) and control group (8.7  1.1). (p = 0.874). At the
end of Day, VPS scores were 4.2  1.8 and 6.8  2.1 in study
and control groups, respectively with statistically significant
difference (p = 0.002). At the end of Day 7 no significant
difference was detected between the groups (Fig. 3).
4. Discussion
PTA is an infectious disease characterized by the collection
of pus between the fibrous capsule of tonsils and superior
pharyngeal constrictor muscle. Usually, PTA develops in the
upper pole of the tonsils [8,9]. Although it can occur at any age,
PTA is common in young adults aged 2040 years [9]. While

Fig. 2. Duration of hospitalization and time to oral intake in study and control Fig. 3. VPS scores and trismus severity at Days 1 and 7.
groups.

Please cite this article in press as: Koak HE, et al. Is corticosteroid a treatment choice for the management of peritonsillar abscess? Auris Nasus
Larynx (2017), http://dx.doi.org/10.1016/j.anl.2017.04.008
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4 H.E. Koak et al. / Auris Nasus Larynx xxx (2017) xxxxxx
acute episodes of tonsillitis are more common in children but
PTA is most common in young adults suggesting the complex
pathophysiology and etiology [9,10]. Although male patient
predominance was observed (19/13 in our study) there is no
gender difference for PTA in the literature [10,11].
Tonsils are a pair of organs located in the oropharynx and
PTA can develop from any neighboring tissue. In our study left
sided PTA were common (18/14), and bilateral PTA was not
observed. Bilateral PTA is also rare in the literature [10]. In
accordance with the literature, the most common symptoms
were a sore throat and weakness in our study and the majority of
patients had a high fever at admission. In addition, ten patients
(32%) had ipsilateral otalgia. Because otoscopic examination
was normal otalgia was assessed as reflected pain (referred
otalgia).
Pain severity was assessed by visual pain scale (VPS) at
baseline, Days 1 and 7 (Fig. 3). No significant difference
between the groups was observed in terms of VPS score at
baseline. At the end of Day 1, marked improvement was
detected in the study group compared to the control group
(Fig. 3). This difference was attributed to the anti-inflammatory
effect of steroids by decreasing edema in the peritonsillar areas
and masticatory muscles. However, at the end of Day 7, this
difference was disappeared because the recovery in all patients.
In their randomized, double-blind study Chau et al. [12] IV
reported that pain scores in first 24 h in patients treated with IV
dexamethasone were significantly lower than in placebo group,
but this difference disappeared at Day 2.
Trismus caused by affected mastication muscles from local
inflammation and edema was observed in all patients, but it was
generally mild or moderate in severity. Salivation caused by
swallowing difficulty of saliva was one of the common
symptoms. There was no significant difference between the two
groups in terms of trismus severity in the baseline (p = 0.732).
At the end of Day 1, a significant difference was determined
between the two groups (p < 0.001). Although significant
improvement was observed in two groups for trismus compared
to the baseline, the improvement was significantly higher in the
study group. At the Day 7 trismus was improved in all patients
without difference between the groups (Fig. 3). Similarly,
Ozbek et al. [13] showed faster improvement of trismus in
patients received single dose of steroids than in placebo patients
in their study
Mean time to oral intake in the study was 11.1  9.0 h.
Statistically, a significant difference was observed for mean
time to oral intake between study group (6.3  6.2 h) and
control group (17.2  8.4 h). Trismus and pain have a direct
effect on oral intake and patients feel better after improving oral
intake. Thus, duration of hospitalization may decrease.
In our study, the mean duration of hospitalization following
the procedure was 1.8  1.1 days. Statistically, a significant
difference was observed for mean duration of hospitalization
between study group (1.2  0.5 days) and control group
(2.6  1.1 days) (p < 0.001). This may be a positive outcome of
corticosteroid treatment reducing the treatment costs. This field
needs new trials focusing on costs of treatment of PTA.
Please cite this article in press as: Koak HE, et al. Is corticosteroid a treatment choice for the management of peritonsillar abscess? Auris Nasus
Larynx (2017), http://dx.doi.org/10.1016/j.anl.2017.04.008
Duration of hospitalization for both groups was significantly
lower than in the similar studies in the literature [10,13,14]. We
believe that this difference occurred due to the different criteria
for discharge across the clinics. We decide to discharge after
improvement of oral intake, fever relief, and well-being.
Although observation of earlier and better improvement in
clinical findings such as local redness, swelling and edema in
cases treated with corticosteroids is expected we did not
compare these findings between two groups as they are not
recorded after discharge of the patient from the hospital. This
could be a limitation to our study.
No recurrence within 1-month follow-up was observed, but
long-term follow-up records are not available. None of the
patients was developed secondary side effect after steroid use.
5. Conclusion
Corticosteroid treatment following drainage procedure in
patients with peritonsillar abscess improves pain severity and
trismus thus it decreases time to oral intake and duration of
hospitalization.
Funding
None.
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