Paratonsillar abscess (paratonsillitis) - Treatment

The goals of treating peritonsillar abscess (paratonsillitis) are to stop inflammation at the stage of edema and infiltration, drain the purulent process, and remove the source of infection.

Indications for hospitalization

Patients with signs of abscess formation are subject to inpatient treatment. If in the initial stages of paratonsillitis, when there is edema and tissue infiltration, conservative treatment is justified, then in the presence of signs of abscess formation, surgical intervention is certainly indicated (opening of the abscess or, if indicated, performing abscess tonsillectomy).

Non-drug treatment of peritonsillar abscess

It is possible to use various thermal procedures, UHF therapy at the onset of the disease (at the stage of edema and infiltration), as well as after achieving adequate drainage of the purulent process (at the stage of stopping inflammatory phenomena). However, at the stage of abscess formation, thermal procedures are not indicated. Gargling with solutions of disinfectants, chamomile solutions, sage, salt solution, etc. is used.

Drug treatment of paratonsillitis

The isolated pathogens show the greatest sensitivity to such drugs as amoxicillin in combination with clavulanic acid, ampicillin in combination with sulbactam, cephalosporins of the II-III generations (cefazolin, cefuroxime), lincosamides (clindamycin); their combination with metronidazole is effective, especially in cases where the participation of anaerobic flora is assumed.

At the same time, detoxification and anti-inflammatory therapy are carried out; antipyretics and analgesics are prescribed.

Taking into account the deficiency of all links of the immune status identified in patients with paratonsillitis, the use of drugs with an immunomodulatory effect (azoximer, sodium deoxyribonucleate) is indicated.

Surgical treatment

When an abscess matures, usually on the 4th-6th day, one should not wait for it to open and empty on its own. In such cases, it is advisable to open the abscess, especially since a spontaneously formed opening is often not quite sufficient for a quick and stable emptying of the abscess.

The opening is performed after local anesthesia by lubricating or spraying the pharynx with a 10% lidocaine solution, sometimes supplemented by tissue infiltration with a 1% procaine solution or a 1-2% lidocaine solution. The incision is made at the site of the greatest bulge. If there is no such landmark, then at the site where spontaneous opening usually occurs - at the intersection of two lines: a horizontal line running along the lower edge of the soft palate of the healthy side through the base of the uvula, and a vertical line running upward from the lower end of the anterior arch of the diseased side.

Opening in this area is less dangerous in terms of injury to large blood vessels. The incision with a scalpel is made in the sagittal direction to a depth of 1.5-2 cm and a length of 2-3 cm. Then Hartmann forceps are inserted through the incision into the wound cavity and the opening is widened to 4 cm, simultaneously tearing possible bridges in the abscess cavity.

Sometimes, the peritonsillar abscess is opened only with Hartmann forceps or a Schneider instrument, specially designed for this purpose. The Schneider instrument is used to open an anterior-superior peritonsillar abscess through the supratindalar fossa. In case of posterior peritonsillar abscess, an incision is made behind the palatine tonsil at the site of the greatest protrusion (incision depth 0.5-1 cm), in case of a lower localization of the abscess - an incision in the lower part of the anterior arch to a depth of 0.5-1 cm. An abscess of external localization (lateral) is difficult to open, and spontaneous rupture does not often occur here, therefore, abscess tonsillectomy is indicated. Sometimes the passage formed for the outflow of pus closes, therefore, it is necessary to repeatedly reopen the wound and empty the abscess.

In recent decades, active surgical tactics in the treatment of paratonsillitis - performing abscess tonsillectomy - have become increasingly recognized and widespread in clinics. When a patient with a paratonsillar abscess or paratonsillitis in the infiltration stage seeks medical attention, the operation is performed in the first day or even hours ("hot" period), or in the next 1-3 days ("warm" period). It should be noted that the postoperative period is less severe and less painful than after opening the abscess or performing the operation at a later date.

Indications for performing abscess tonsillectomy in a patient with abscessing or infiltrative forms of paratonsillitis are as follows:

• recurring sore throats over a number of years, which indicates that the patient has chronic tonsillitis: an indication by a patient with paratonsillitis of previously diagnosed chronic tonsillitis;
• recurrent pyrathiones and history;
• unfavorable localization of the abscess, for example, lateral, when it cannot be effectively opened and drained;
• no changes in the patient's condition (severe or increasing severity) even after opening the abscess and obtaining pus;
• the appearance of signs of complications of paratonsillitis - sepsis, parapharyngitis, phlegmon of the neck, mediastinitis.

The question of whether it is justified to remove the second tonsil on the opposite side to the abscess during abscess tonsillectomy is decided individually. However, studies conducted in recent years indicate significant pathological changes in the tissue of the intact tonsil, similar to changes in severe (toxic-allergic form of stage II) chronic inflammatory process. This indicates the advisability of simultaneous removal of both tonsils. The operation should begin with the diseased tonsil, as this facilitates the intervention on the other side.

Further management

If patients have chronic tonsillitis of the I or II toxic-allergic stage, they are subject to dispensary observation and treatment courses. Patients with chronic tonsillitis of the II toxic-allergic stage are recommended to undergo bilateral tonsillectomy on a planned basis, no earlier than a month after suffering paratonsillitis,

Forecast

The prognosis for paratonillitis is generally favorable. The approximate period of temporary disability is 10-14 days.