The Distribution of Peritonsillar Abscess Patients in Sanglah Hospital Denpasar at 2010 until 2017

Peritonsillar abscesses (PTAs) are collections of purulent material that usually develop outside the tonsillar capsule near the superior pole. Peritonsillar abscess (PTA) is the most common complication of tonsil infections in adults. To know the distribution of patients with peritonsillar abscess in Sanglah Hospital Denpasar at period 2010-2017. This is an observational retrospective study using medical records of patients with peritonsillar abscess in Sanglah Hospital Denpasar during January 2010 until March 2017. 38 patients with peritonsillar abscess were male 65.78%, mean of age 38.76 years, 78.95% with sore throat, 100% unilateral, most common aerob culture detected Streptococcus viridans (63.16%) that 100% sensitive to cefuroxime, cefepime, meropenem and linezolid. The most length of hospital stay was 4 days (65.78%) with average 4.5 days, mostly found without difficulting factors and there is no complication in this study. This study revealed male more frequent than female, with sore throat is the frequent symptoms, mostly unilateral and Streptococcus viridans is the most bacteria in microbiological culture and 100% sensitive to cefuroxime, cefepime, meropenem and linezolid. There is no difficulting factors and complication in this study.


INTRODUCTION
Peritonsillar abscesses (PTA) are acute infection followed by collections of purulent material in loose connective tissue between faryngeal constrictor muscle with tonsil at fossa tonsil. 1,2This infection penetrate tonsillar capsule near superior pole.Peritonsillar abscess (PTA) is the most common complication of acute tonsilitis. 3,4ritonsillar abscess (PTA) is one of the head and neck infections often in adults.The onset of peritonsillar abscess starting from superficial infections and progressively developing into tonsillar cellulitis.Peritonsillar abscess complications that may occur include expansion into parapharing infection, mediastinitis, dehydration, pneumonia, intracranial infections such as cavernous sinus thrombosis, meningitis, brain abscess and airway obstruction. 3e clinical symptoms such as sore throat, localized pain, high fever, weakness and nausea.The other symptoms are halitosis, vomiting, ear pain or otalgia and trismus. 5,6ere is no data shown patients with peritonsillar abscesses in Sanglah General Hospital at Denpasar.The authors are interested to research on the distribution of patients with peritonsillar abscesses in Sanglah General Hospital at period January 2010 to March 2017.This results are expected for evidence information of peritonsillar abscess that could be implemented in managemenet of PTA properly and optimally.

METHODS
The study was observational retrospective by using the medical records of patients with peritonsillar abscess who came to ENT Departement and the laboratory results from Microbiology Departement Sanglah General Hospital.We use concecutive sampling for patients with peritonsillar abscess between January 2010 and March 2017.The incomplete medical records will exclude in this study.Further data were tabulated and presented descriptively in tables and narrative.

RESULTS AND DISCUSSION
A total of 28 patients with peritonsillar absces at period January 2010 to March 2017 were included in this study with a ratio of 25 males (65.78%) and 13 females (34.22%) (Table .1).
In United States the incidence is 1/6500 of the population or 30.1/40000 people per year. 7alihoglu et all., reports a total of 26 patients with peritonsillar abscess are 92.4% males with an average age was 22.2 years old. 4 Ozbek et all., reports from total 62 patients with peritonsillar abscess the ratio is 25 (40.33%)females and 37 (59.67%)males with average age was 27.9 years old. 9Naik and Naik reports from total 27 patients with peritonsillar abscess the ratio is 18 (66.67%)males and 9 (33.33%)females in average age was 30.4 years old. 10In this study, the male in patients with abscesses peritonsil is higher than female same as Salihoglu et all., Ozbek et all., Naik and Naik studies.
The distribution of patients with PTA is highest in group of age 41-50 year which 15 patients (39.48%).The lowest distribution by group of age is above 60 years which 1 patients (2.63%) (Table 2).The average age in this study was 38.76 years which is higher than Salihoglu et all., Ozbek et all., Naik and Naik studies.Peritonsillar abscess often seems in adults at the age of 20 to 40 years.It is rare in children, except on immunocompromise condition.In Northern Ireland, author reports 1 per 10.000 patients per year, with an average age of 26.4 years old. 8Salihoglu et all., reports the average age was 22.2 years old. 4 Ozbek et al., reports the average age was 27.9 years old. 9Naik and Naik reports the average age was 30.4 years old. 10re throat is the most major complaint in about 30 patients (78.95%) in this study.While the lowest is dysphagia in about 8 patients (21.05%) (Table 3).In anamnese mostly obtained progressive sore throat despite untreated, localized pain, high fever, weakness and nausea.Odinophagia can be a prominent complaint and the patient may difficult when eat and even swallowing. 11,12Frequently hypersalivation as a result can not cope salivary secretions and the saliva often dripping out.Other complaints are halitosis, vomiting until refered pain over to the ear (otalgia).Trismus occurs when the infection extends the pterigoidius muscles. 12ara and Spinou reports sore throat are common complaints in patients with peritonsillar abscess that is equal to 92%. 13 Sore throat in our study is the most major complaint peritonsillar abscess similar with Kara and Spinou study.
Most patients with peritonsillar abscess occur unilateral 100% in this study.This results shown a higher quantity than Papacharalampous et all., and Edinger et all., case studies.Physical examination of the tonsil found unilateral swelling, because rarely both tonsils are infected at the same time.If both are infected when the oposite tonsil become swelling after the infected tonsil getting better.When swelling occurs simultaneously, the symptoms of sleep apnea and airway obstruction will be worsed. 12Papacharalampous et all., reports a case of bilateral peritonsillar abscess in 19 years female. 2Naik and Naik 10 and Wang et all., reports there were no differences site of location in peritonsillar abscess. 14Edinger et all., reports a case of bilateral peritonsillar abscess in 24 years female. 15sed on microbiological culture, Streptococcus viridans is highest about 24 patients (63.16%), while Enterococcus sp is the lowest about 1 patient (2.63%).Eighteen point fourty three percent shows no growth of in microbiology culture (Table 4).This results is supported by Sakae et all., and Repanos et all., studies which are Streptococcus viridans is highest in patients with peritonsillar abscess.Microbiological culture was done to    growing population of aerobic bacteria as much as the mix of flora that involves microorganisms Gramnegative and Gram-positive.Some studies reports Streptococcus viridans is the most common cause of peritonsillar abscess, followed by Streptococcus pyogenes.Streptococcus sp and anaerobic bacteria have been identified as causative agents. 6,16akae et all., found 32% Streptococcus viridans in peritonsillar abscess culture in Brazil. 17Repanos et all., reports 43.7% Streptococcus sp in peritonsillar abscess culture. 18reptococcus viridans was obtained the most sensitive to the antibiotic cefuroxime, cefepime, meropemen, and linezolid respectively by 100% in this study.Streptococcus viridans mostly resistance to the antibiotic ampicillin established at 62.5% (Table 5).Repanos et all., reports 0.84% Streptococcus sp resistance to the antibiotic group penicillin . 18The resistancy of Streptococcus viridans to ampicillin is higher in our study than Repanos et all., studies.Takenaka et all., in their study reports all Grampositive bacteria sensitive to the antibiotic penicillin group and cephalosporin. 19Sowerby et all., reports 32% Streptococcus sp resistance to clindamycin and 41% resistant to erythromycin. 20However, in our study the resistancy of Streptococcus viridans to clindamycin and erythromycin was low.Some authors suggested second or third generation cephalosporins administration compared with group penicillin . 6e distribution of patients with peritonsillar abscess is highest obtain for 4 days about 25 patients (65.78%) in this study.Only 1 patient (2.63%) was treated for 6 days (Table 6).In our study, the length of hospital stay inpatient with peritonsillar abscess is longer than Repanos et all., Wang et all., Kara and Spinou, Naik and Naik studies.The average length of treatment peritonsillar abscess obtained in this study is 4.5 days.Repanos et all., reports an average to treat patient with peritonsillar abscess requires for 2.4 days inpatient. 18Naik and Naik reports the average for hospital stay is 3.5 days. 10Kara and Spinou reports the average for hospital stay is 2.2 days. 13Wang et all., reports the average for hospital stay is 4.2 days. 14 7), which is higher in Wang et all., studies.Several difficulting factors that affect peritonsillar abscess including trismus and systemic diseases, especially diabetes melitus. 21Wang et all., reports 3.5% of patients with peritonsillar abscess found with diabetes mellitus. 14lihoglu et all., reports 88.46% of patients with peritonsillar abscess accompanied by trismus. 4total 38 patients in this study found wihout any complications.In our study, we found without any complications same as in Ozbek et all., studies.Immediate complications can occur in the form of dehydration due to less food intake.Spontaneous rupture of the abscess with blood or pus aspiration pneumonitis or abscess can cause infection to the pulmonary area. 1,8,22Expansion to parapharing, may result in an abscess parapharing, spreading into the mediastinum may result in mediastinitis. 22zbek et all., in their studies did not obtained any complications of peritonsillar abscess such as abscess in the deep neck spaces or mediastinis. 23

CONCLUSION
A total 38 patients with peritonsillar abscess who came into Sanglah General Hospital between January 2010 and March 2017 were predominant male.The mean of age was 38.76 years old.Sore throat is the most symptoms when came into the hospital.Mostly cases occur are unilateral.The most common microbiological culture was Streptococcus viridans.The most length of hospital stay was 4 days with average 4.5 days.In this study, mostly found without difficulting factors and there is no any complication occurs.