Vitamin D Levels in Children with Recurrent Acute Tonsillitis in Jordan: A Case-Control Study.

Background: Vitamin D is essential for many functions of the body. In addition to its primary function of regulating the absorption of calcium in the small intestine, its role in the immune system has recently been studied. The current study aimed to test the impact of vitamin D deficiency on the rate of recurrent acute tonsillitis in children. Methods: According to Paradise criteria, two hundred forty-two children with recurrent acute tonsillitis were recruited. A group of healthy children (n = 262) was also recruited as controls. Poisson regression was run to predict the number of tonsillitis episodes per year based on vitamin D levels. The mean vitamin D level in the study group was lower than in the control group (p < 0.0001). Poisson regression of the rate of recurrent tonsillitis and vitamin D level (OR = 0.969 (95% CI, 0.962−0.975)) showed that for every single unit increase in vitamin D level, there was a 3.1% decrease in the number of tonsillitis episodes per year (p < 0.0001). Conclusions: Vitamin D deficiency is associated with higher rates of recurrent acute tonsillitis. Future controlled trials should investigate the role of vitamin D supplementation in reducing the rate of recurrent tonsillitis.

Author's reply to letter-to-the-editor.

We welcome the opportunity to continue the discussion and to clarify issues you raised in your letter. You will find enclosed a point-by-point response to your comments. Please note that all of these points are already discussed in the "discussion" section of our article "Comparison of needle aspiration versus incision and drainage under local anaesthesia for the initial treatment of peritonsillar abscess". Regarding the retrospective design of our study, we think that the length of hospital stay was the best criterion to be used as primary outcome because it is a clinical endpoint and a composite criterion, reflecting the global improvement of the patient. Our study included PTA patients aged under 15 because the management of peritonsillar abscess in children follows specific guidelines and requires specific care, and due to evident issues of understanding, compliance and pain handling, incision and drainage under local anaesthesia is not routinely used in younger children. We fully agree that this subject remains an area of debate and we are perfectly aware that due to methodological limitations and especially the retrospective design, the level of evidence of our study is not sufficient to draw firm conclusions on the superiority of one technique on the other. At this day, only low-quality evidence studies have been published on this subject and the debate remains opened to determine whether needle aspiration or incision and drainage is the most safe and effective technique in treating peritonsillar abscess.

Comparison of needle aspiration versus incision and drainage under local anaesthesia for the initial treatment of peritonsillar abscess.

PURPOSE: The treatment of peritonsillar abscess (PTA) is still controversial regarding the best method of drainage to perform. This study aims to compare effectiveness and safety of needle aspiration versus incision and drainage under local anaesthesia for the initial treatment of PTA. METHODS: A retrospective review of patients (age > 15 years) admitted in two tertiary medical centres for a PTA between November 2010 and October 2016 was performed. Patients were divided into two groups according to the type of drainage: needle aspiration or incision and drainage, under local anaesthesia. The primary outcome was the length of hospital stay; the need to repeat the procedure or to go to the operating room was also assessed. Complications or adverse events were listed in each group to assess safety. RESULTS: Over a 6-year period, 182 patients were admitted for a PTA and included in the analysis, with 82 patients in the aspiration group and 100 patients in the incision group. Mean age was 36.3 years, with a sex ratio of 1.33. The length of hospital stay ranged from 1 to 7 days (mean 2.7 days, median 2 days) with a median length of stay of 3.0 days (interquartile range 2-4) in the aspiration group versus 2.0 days (IQR 2-3) in patients who underwent incision and drainage (p = 0.009). A repetition of the needle aspiration was made for 46.3% of patients versus 10% of repetition of the procedure in the incision group (p = 0.0001). 12 patients (14%) of the aspiration group and 4 patients (4%) of the incision group required an additional drainage under general anaesthesia (p < 0.001). We found no differences regarding safety in both groups. CONCLUSION: Our study showed a significant decrease in the length of hospital stay in patients admitted for a PTA who underwent an initial incision and drainage under local anaesthesia, compared to needle aspiration, as well as a lower risk of repeating the procedure. A well-designed prospective and randomized study on a larger sample of patients is required to support these findings.

Necrotizing fasciitis. Possible profiles of professional liability with reference to two cases.

Necrotizing fasciitis is one of the most dangerous complication of an abscess and it is still a disease with a high mortality. In this work, we decided to consider two cases: the first one concerns a male subject, aged 66, deceased because of a fatal necrotizing fasciitis associated to a cervical descending mediastinitis, which evolved from a primary peritonsillar abscess; the second is about a 50-year-old woman with a perineal abscess, then evolved into necrotizing fasciitis associated to a fatal septis shock. After a systematic consideration of necrotizing fasciitis as pathology and an analysis of the possible related risks to a diagnostic or therapeutic delay, we analyzed the particular history of both cases to underline the possible critical issues in professional behavior of the medical staff intervened. KEY WORDS: Abscess, Medical malpractice, Mortality, Necrotizing fasciitis, Professional liability.

Clinical practice guideline: tonsillitis II. Surgical management.

In 2013, a total of 84,332 patients had undergone extracapsular tonsillectomies (TE) and 11,493 a tonsillotomy (TT) procedure in Germany. While the latter is increasingly performed, the number of the former is continually decreasing. However, a constant number of approximately 12,000 surgical procedures in terms of abscess-tonsillectomies or incision and drainage are annually performed in Germany to treat patients with a peritonsillar abscess. The purpose of this part of the clinical guideline is to provide clinicians in any setting with a clinically focused multi-disciplinary guidance through the surgical treatment options to reduce inappropriate variation in clinical care, improve clinical outcome and reduce harm. Surgical treatment options encompass intracapsular as well as extracapsular tonsil surgery and are related to three distinct entities: recurrent episodes of (1) acute tonsillitis, (2) peritonsillar abscess and (3) infectious mononucleosis. Conservative management of these entities is subject of part I of this guideline. (1) The quality of evidence for TE to resolve recurrent episodes of tonsillitis is moderate for children and low for adults. Conclusions concerning the efficacy of TE on the number of sore throat episodes per year are limited to 12 postoperative months in children and 5-6 months in adults. The impact of TE on the number of sore throat episodes per year in children is modest. Due to the heterogeneity of data, no firm conclusions on the effectiveness of TE in adults can be drawn. There is still an urgent need for further research to reliably estimate the value of TE compared to non-surgical therapy of tonsillitis/tonsillo-pharyngitis. The impact of TE on quality of life is considered as being positive, but further research is mandatory to establish appropriate inventories and standardized evaluation procedures, especially in children. In contrast to TE, TT or comparable procedures are characterized by a substantially lower postoperative morbidity in terms of pain and bleeding. Although tonsillar tissue remains along the capsule, the outcome appears not to differ from TE, at least in the pediatric population and young adults. Age and a history of tonsillitis are not a contraindication, abscess formation in the tonsillar remnants is an extremely rare finding. The volume of the tonsils should be graded according to Brodsky and a grade >1 is considered to be eligible for TT. The number of episodes during 12 months prior to presentation is crucial to indicate either TE or TT. While surgery is not indicated in patients with less than three episodes, a wait-and-see policy for 6 months is justified to include the potential of a spontaneous healing before surgery is considered. Six or more episodes appear to justify tonsil surgery. (2) Needle aspiration, incision and drainage, and abscess tonsillectomy are effective methods to treat patients with peritonsillar abscess. Compliance and ability of the patient to cooperate must be taken into account when choosing the surgical method. Simultaneous antibiotic therapy is recommended but still subject of scientific research. Abscess tonsillectomy should be preferred, if complications have occurred or if alternative therapeutic procedures had failed. Simultaneous TE of the contralateral side should only be performed when criteria for elective TE are matched or in cases of bilateral peritonsillar abscess. Needle aspiration or incision and drainage should be preferred if co-morbidities exist or an increased surgical risk or coagulation disorders are present. Recurrences of peritonsillar abscesses after needle aspiration or incision and drainage are rare. Interval TE should not be performed, the approach is not supported by contemporary clinical studies. (3) In patients with infectious mononucleosis TE should not be performed as a routine procedure for symptom control. TE is indicated in cases with clinically significant upper airway obstruction resulting from inflammatory tonsillar hyperplasia. If signs of a concomitant bacterial infection are not present, antibiotics should not be applied. Steroids may be administered for symptom relief.

Peritonsillar abscess: clinical presentation and efficacy of incision and drainage under local anaesthesia.

BACKGROUND: Peritonsillar abscess (PTA) is one of the most commonly encountered abscess in the head and neck region. The aims of this study were to list the frequency of the disease by age, sex and laterality, and to list the presentation of the disease by symptoms, signs and complications, and to determine the efficacy of incision and drainage (I&D) procedure under local anaesthesia (LA) in terms of hospital stay and recurrence. METHODS: This descriptive study was conducted at the Department of Otorhinolaryngology and Head & Neck Surgery, District Headquarters Hospital, Lakki Marwat, from 1st June 2007 to 30th May 2010. Adult patients (> 15 years) of both sexes with unilateral peritonsillar abscess were included sequentially. Children (15 years or less), patients with acute follicular tonsillitis or peritonsillitis and those who refused incision and drainage under LA were excluded. All patients received the same antibiotic Amoxicillin/Clavunate and underwent I&D procedure under LA. RESULTS: Sixty patients were included in the study, 42 male and 18 female. Mean age of the patients was 30.02 +/- or = 9.42 (range 16-50 years). It was more on the left side (35, 58.35%). Forty-four (73.35%) patients gave an antecedent history of tonsillitis. Three (5%) patients presented with complications. Mean hospital stay was 1.55 +/- 1.00 (range 1-5 days). All patients underwent I&D with no recurrence. Interval tonsillectomy was performed in 38 selected cases after 6 weeks. CONCLUSION: Incision and drainage under LA still remains the gold standard procedure for peritonsillar abscess in our setup.

Role of microbiological studies in management of peritonsillar abscess.

INTRODUCTION: Peritonsillar abscess (quinsy) is one of the most common ENT emergencies. A 2002 UK audit of quinsy management revealed that an average ENT department treated 29 cases annually; the most common treatment was needle aspiration with intravenous antibiotics, and culture of the aspirate was often performed routinely. The aims of our study were to evaluate the value of routine culture of quinsy aspirates, and to establish whether the information thus gained was clinically useful. METHODS: We examined the notes of patients admitted with quinsy to two hospitals in south-west England, from January 1998 to January 2004 in one hospital and from January 1995 to January 2005 in the other. A total of 577 cases was found. Aspirated pus had been sent for culture in 119 (21 per cent). These cases were examined in more detail. RESULTS: Of the 119 patients, 78.2 per cent (93/119) were treated with either a cephalosporin or penicillin, plus metronidazole. Streptococcal species were cultured in 43.7 per cent (52/119) and anaerobes in 23.5 per cent (28/119; of these cultures, 5.9 per cent (7/119) were pure anaerobes only). All the anaerobes were sensitive to metronidazole. One of the 119 cultures, growing aerobic bacteria, was resistant to penicillin; however, this patient improved clinically on a combination of penicillin and metronidazole. No patients had their treatment changed because of culture results. CONCLUSIONS: There appears to be no need to routinely culture quinsy aspirates, based upon our findings (of 16 hospital years) and previous studies (which found no recorded episodes of treatment change as a result of culture sensitivities). The combination of penicillin or a cephalosporin, plus metronidazole appeared to be theoretically effective in 99.2 per cent (118/119) of our specimens; this finding is supported by other studies. However, the rare but potentially life-threatening complications of quinsy must be recognised.

Deep neck infections: clinical considerations in aggressive disease.

Deep neck infections are common and occur as a consequence of several etiologies. Antibiotic therapy, interventional radiology, and patient support modalities have become increasingly sophisticated, although surgery continues to be the mainstay of treatment for most patients. Today, neck infections are rarely life threatening when sound and timely management is applied.

[The microbiology of peritonsillar abscesses]. / Flora bakteryjna ropni okolomigdalkowych.

BACKGROUND: Peritonsillar abscess (quinsy) is a complication of acute bacterial tonsillitis. Its treatment remains controversial. One element of controversy is the choice of antibiotics after surgical drainage of the abscess. Results of many studies support the resistance of grown bacteria to many antibiotics and the potential importance of anaerobic species in development of peritonsillar abscesses. AIM: The purpose of the study was to investigate bacteriology of peritonsillar abscesses in the group of own patients in an attempt to establish optimal method of antibiotic treatment after drainage of the abscess. MATERIAL AND METHODS: Abscess material from 12 patients aged 20-43 years (mean: 31.5, s.d.: 6.8), 4 women and 8 men, with peritonsillar abscesses was obtained by aspiration and sent for aerobic and anaerobic cultures. All patients were subsequently treated with oral phenoxymethylpenicillin (4.5 million units per day) and metronidazole (1500 mg per day). RESULTS: A total 18 bacterial isolates (9 anaerobic and 9 aerobic and facultative) were recovered, accounting for 1.5 isolate per specimen. Anaerobic bacteria only were present in 3 patients, aerobic and facultatives in 3, and mixed aerobic and anaerobic flora in 6. Single bacterial isolates were recovered in 6 infections. The predominant bacterial isolates were Streptococcus and Bacteroides. Recovery in all examined subjects was complete. CONCLUSIONS: In the routine management of peritonsillar abscess, bacteriologic studies are unnecessary on initial presentation. It is, however, necessary to consider infection with anaerobes, hence we recommend penicillin and metronidazole as the antibiotic regimen of choice in the treatment of peritonsillar abscesses.

Head and neck infections caused by Streptococcus milleri group: an analysis of 17 cases.

BACKGROUND: Streptococcus milleri group (SMG) is a common inhabitant of the mouth and gastrointestinal tract, and can be an aggressive pathogen causing abscess formation at various sites in the body. However, it has rarely been listed as a cause of head and neck infections. OBJECTIVES: The present study was performed to evaluate the clinical significance of SMG by reviewing the microbiology and clinical records of patients with SMG in head and neck infections retrospectively. STUDY DESIGN: A retrospective review of all patients diagnosed as having SMG bacterial infections at Onomichi General Hospital, Hiroshima, between the years 2001 and 2002 was performed; 17 patients developed head and neck infections with SMG. Here, we describe the clinical features and management of SMG in head and neck infection. RESULTS: The patient population consisted of 12 males and 5 females with a median age of 62 years (age range, 8-78 years). The sites of infection were as follows: maxillary sinus (n=6), peritonsillar region (n=4), subcutaneous (n=3), submandibular space-retropharyngeal space (n=1), deep neck-mediastinum (n=1), parapharyngeal space (n=1), submandibular space (n=1), tonsil (n=1), parotid gland (n=1), and masseter muscle (n=1). Ten cases (59%) were of suppurative diseases. Six cases (35%) had mixed SMG with anaerobe infection. Three cases showed deteriorating clinical courses, and all three of these cases were culture-positive for SMG with anaerobes. In addition, one deteriorating case showed gas gangrene regardless of repeated surgical debridement and intravenous antibiotic therapy; hyperbaric oxygen therapy improved this patient's condition. CONCLUSION: It is important to recognize SMG as a pathogen in head and neck infection. In addition, the care should be taken with infectious diseases caused by SMG with anaerobes as the patient's clinical course can deteriorate rapidly.

[Clinical, bactericidal and pharmacological evaluation of the effects of netromycin]. / Klinicheskaia, bakteritsidnaia i farmakologicheskaia otsenka deistviia netromitsina.

AIM: To analyze clinical, bactericidal effectiveness and pharmacokinetics of wide-spectrum antibiotic netromycin (NM). MATERIALS AND METHODS: The trial entered 29 patients: 21 with bronchopulmonary diseases (pneumonia and chronic bronchitis), 5 with exacerbation of chronic pyelonephritis, 2 with infectious endocarditis and 1 with peritonsillar abscess. RESULTS: Microbiologically, most of the agents (80.36%) showed sensitivity to NM. Pharmacologically, NM persisted long in blood serum and sputum irrespective of the administration mode. Positive clinical dynamics after NM treatment was achieved in all the patients but one who had a peritonsillar abscess. CONCLUSION: NM is highly active against both gram-positive and gram-negative flora. Side effects are minimal.

[Experience in the use of eucalymine in acute inflammatory ENT diseases in children]. / Opyt primeneniia évkalimina pri ostrykh vospalitel'nykh zabolevaniiakh LOR-organov u detei.

Eucalyptus-based drug eucalymine made in Russia has been tried in children with acute maxillary sinusitis, exacerbation of chronic purulent maxillary sinusitis and peritonsillar abscess. The findings indicate a good antiinflammatory effect of eucalymine which can be used as a treatment of choice in children with ENT diseases.

[Necrotizing cervico-mediastinal cellulitis. Apropos of 3 cases]. / Les cellulites cervico-médiastinales nécrosantes. A propos de 3 cas.

OBJECTIVE: To outline the most appropriate treatment of descending necrotizing mediastinitis. MATERIALS AND METHODS: Three adult patients had mediastinitis occurring from a descending odontogenic infection in one case and oropharynx infection in two cases. All patients underwent extensive surgical debridement and a cervicomediastinal drainage through a cervical incision. All patients survived. DISCUSSION: Soft-tissue infections of the neck with mediastinitis demand early diagnosis aided by CT scan in order to decrease their threat to life. Extensive surgical debridement and a cervico mediastinal drainage through a cervical incision is adequate when mediastinitis is limited to the upper mediastinum. Thoracotomy has to be performed when the process spread below the carina. Patients must be treated initially aggressively with the aid of multidisciplinary support team (intensive care physicians, thoracic and head and neck surgeons). Early surgery must treat both neck and mediastin. While usually associated with greater than 40% mortality, all the patients in this series survived.

Therapeutic alternatives and clinical outcomes in peritonsillitis.

A retrospective study was conducted on 32 patients with the discharge diagnosis of peritonsillar abscess or peritonsillar cellulitis. Three had pre-existing chronic conditions that may have contributed to the peritonsillitis. The average duration of symptoms prior to diagnosis was 7.4 days. Most patients responded to penicillin given parenterally until the patient were able to take medication orally. Pus was obtained in 88 percent of the patients who underwent drainage procedures. Eight patients were treated with parenteral antibiotics without drainage, including three from whom pus was aspirated. All eight recovered without complication. The most common organism cultured was beta-hemolytic streptococcus, group A (seen in 31 percent). There was no association between the dose or type of oral antibiotic used prior to diagnosis of peritonsillar cellulitis. The clinical outcome suggests that some patients with peritonsillitis may respond to parenteral antibiotics without drainage procedures or tonsillectomy.