Skip to main content

Advertisement

SpringerLink
Log in

Clinical evaluation of antibiotic regimens in patients with surgically verified parapharyngeal abscess: a prospective observational study

  • Head and Neck
  • Published:
European Archives of Oto-Rhino-Laryngology Aims and scope Submit manuscript

Abstract

Purpose

We aimed to evaluate the effectiveness of different antibiotic regimens for the treatment of parapharyngeal abscess (PPA) and characterize patients, who suffered potentially preventable complications (defined as death, abscess recurrence, spread of infection, or altered antibiotic treatment because of insufficient progress).

Methods

Sixty adult patients with surgically verified PPA were prospectively enrolled at five Danish Ear–nose–throat departments.

Results

Surgical treatment included internal incision (100%), external incision (13%), and tonsillectomy (88%). Patients were treated with penicillin G ± metronidazole (n = 39), cefuroxime ± metronidazole (n = 16), or other antibiotics (n = 5). Compared to penicillin-treated patients, cefuroxime-treated patients were hospitalized for longer (4.5 vs 3.0 days, p = 0.007), were more frequently admitted to intensive care (56 vs 15%, p = 0.006), underwent external incision more frequently (31 vs 5%, p = 0.018), and suffered more complications (50 vs 18%, p = 0.022), including re-operation because of abscess recurrence (44 vs 3%, p < 0.001). Nine patients suffered potentially preventable complications. These patients displayed significantly higher C-reactive protein levels, received antibiotics prior to admission more frequently, underwent external incision more commonly, and were admitted to intensive care more frequently compared to other patients.

Conclusion

The majority of patients with PPA were effectively managed by abscess incision, tonsillectomy, and penicillin G ± metronidazole. Cefuroxime-treated patients were more severely ill at time of admission and had worse outcome compared to penicillin-treated patients. We recommend penicillin G + metronidazole as standard treatment for patients with PPA, but in cases with more risk factors for potentially preventable complications, we recommend aggressive surgical and broadened antibiotic therapy, e.g. piperacillin–tazobactam.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Similar content being viewed by others

Availability of data and material

Anonymized data can be obtained from the corresponding author upon request.

References

  1. Brito TP, Hazboun IM, Fernandes FL, Bento LR, Zappelini CEM, Chone CT, Crespo AN (2017) Deep neck abscesses: study of 101 cases. Braz J Otorhinolaryngol 83:341–348. https://doi.org/10.1016/j.bjorl.2016.04.004

    Article  PubMed  Google Scholar 

  2. Oh JH, Kim Y, Kim CH (2007) Parapharyngeal abscess: comprehensive management protocol. ORL J Otorhinolaryngol Relat Spec 69:37–42. https://doi.org/10.1159/000096715

    Article  PubMed  Google Scholar 

  3. Klug TE, Fischer AS, Antonsen C, Rusan M, Eskildsen H, Ovesen T (2014) Parapharyngeal abscess is frequently associated with concomitant peritonsillar abscess. Eur Arch Otorhinolaryngol 271:1701–1707. https://doi.org/10.1007/s00405-013-2667-x

    Article  PubMed  Google Scholar 

  4. Alaani A, Griffiths H, Minhas SS, Olliff J, Lee AB (2005) Parapharyngeal abscess: diagnosis, complications and management in adults. Eur Arch Otorhinolaryngol 262:345–350

    Article  CAS  PubMed  Google Scholar 

  5. Daya H, Lo S, Papsin BC, Zachariasova A, Murray H, Pirie J, Laughlin S, Blaser S (2005) Retropharyngeal and parapharyngeal infections in children: the Toronto experience. Int J Pediatr Otorhinolaryngol 69:81–86

    Article  PubMed  Google Scholar 

  6. Sichel JY, Attal P, Hocwald E, Eliashar R (2006) Redefining parapharyngeal space infections. Ann Otol Rhinol Laryngol 115:117–123

    Article  PubMed  Google Scholar 

  7. Gianoli GJ, Espinola TE, Guarisco JL, Miller RH (1991) Retropharyngeal space infection: changing trends. Otolaryngol Head Neck Surg 105:92–100

    Article  CAS  PubMed  Google Scholar 

  8. Page C, Chassery G, Boute P, Obongo R, Strunski V (2010) Immediate tonsillectomy: indications for use as first-line surgical management of peritonsillar abscess (quinsy) and parapharyngeal abscess. J Laryngol Otol 124:1085–1090

    Article  CAS  PubMed  Google Scholar 

  9. Woods CR, Cash ED, Smith AM, Smith MJ, Myers JA, Espinosa CM, Chandran SK (2016) Retropharyngeal and parapharyngeal abscesses among children and adolescents in the United States: epidemiology and management trends, 2003–2012. J Pediatric Infect Dis Soc 5:259–268. https://doi.org/10.1093/jpids/piv010

    Article  PubMed  Google Scholar 

  10. Ohori J, Iuchi H, Nagano H, Umakoshi M, Matsuzaki H, Kurono Y (2020) The usefulness of abscess tonsillectomy followed by intraoral drainage for parapharyngeal abscess concomitant with peritonsillar abscess in the elderly. Auris Nasus Larynx 47:697–701. https://doi.org/10.1016/j.anl.2019.06.003

    Article  PubMed  Google Scholar 

  11. Sethi DS, Stanley RE (1991) Parapharyngeal abscesses. J Laryngol Otol 105:1025–1030

    Article  CAS  PubMed  Google Scholar 

  12. Thapar A, Tassone P, Bhat N, Pfleiderer A (2008) Parapharyngeal abscess: a life-threatening complication of quinsy. Clin Anat 21:23–26

    Article  PubMed  Google Scholar 

  13. Klug TE, Greve T, Andersen C, Hahn P, Danstrup C, Petersen NK, Ninn-Pedersen MN, Mikkelsen S, Pauli S, Fuglsang S, Døssing H, Christensen AL, Rusan M, Kjeldsen A (2021) Microbiology of parapharyngeal abscess in adults: in search of the significant pathogens. Eur J Clin Microbiol Infect Dis. https://doi.org/10.1007/s10096-021-04180-y

    Article  PubMed  PubMed Central  Google Scholar 

  14. Versalovic J, Carroll KC, Funke G, Jorgensen JH, Landry ML, Warnock DW. Manual of Clinical Microbiology, 10 Edn. https://doi.org/10.1128/9781555816728

  15. Franzese CB, Isaacson JE (2003) Peritonsillar and parapharyngeal space abscess in the older adult. Am J Otolaryngol 24:169–173

    Article  PubMed  Google Scholar 

  16. Klug TE (2014) Incidence and microbiology of peritonsillar abscess: the influence of season, age, and gender. Eur J Clin Microbiol Infect Dis 33:1163–1167. https://doi.org/10.1007/s10096-014-2052-8

    Article  CAS  PubMed  Google Scholar 

  17. Sichel JY, Dano I, Hocwald E, Biron A, Eliashar R (2002) Nonsurgical management of parapharyngeal space infections: a prospective study. Laryngoscope 112:906–910

    Article  PubMed  Google Scholar 

  18. Grisaru-Soen G, Komisar O, Aizenstein O, Soudack M, Schwartz D, Paret G (2010) Retropharyngeal and parapharyngeal abscess in children–epidemiology, clinical features and treatment. Int J Pediatr Otorhinolaryngol 74:1016–1020

    Article  PubMed  Google Scholar 

  19. Johnston D, Schmidt R, Barth P (2009) Parapharyngeal and retropharyngeal infections in children: argument for a trial of medical therapy and intraoral drainage for medical treatment failures. Int J Pediatr Otorhinolaryngol 73:761–765

    Article  PubMed  Google Scholar 

  20. Kieff DA, Bhattacharyya N, Siegel NS, Salman SD (1999) Selection of antibiotics after incision and drainage of peritonsillar abscesses. Otolaryngol Head Neck Surg 120:57–61

    Article  CAS  PubMed  Google Scholar 

  21. Wikstén JE, Pitkäranta A, Blomgren K (2016) Metronidazole in conjunction with penicillin neither prevents recurrence nor enhances recovery from peritonsillar abscess when compared with penicillin alone: a prospective, double-blind, randomized, placebo-controlled trial. J Antimicrob Chemother 71:1681–1687. https://doi.org/10.1093/jac/dkw038

    Article  CAS  PubMed  Google Scholar 

  22. Hallgren F, Lindell E, Nilsson-Helger B, Lundqvist A (2021) Antibiotics in treatment of peritonsillar infection: clindamycin versus penicillin. J Laryngol Otol 22:1–6. https://doi.org/10.1017/S002221512100013X

    Article  Google Scholar 

  23. Klug TE, Henriksen JJ, Fuursted K, Ovesen T (2011) Significant pathogens in peritonsillar abscesses. Eur J Clin Microbiol Infect Dis 30:619–627

    Article  CAS  PubMed  Google Scholar 

  24. Øhrstrøm MT, Danstrup CS, Klug TE (2019) Adherence to antibiotic guidelines in the treatment of acute pharyngeal infections. Dan Med J 66:A5530

    PubMed  Google Scholar 

Download references

Acknowledgments

None.

Funding

This work was supported by the Lundbeck Foundation (Grant number: R185-2014–2482), Fonden for lægevidenskabens fremme, and Ørelæge Hans Skovby´s og Hustru Emma Skouby´s Fond.

Author information

Authors and Affiliations

  1. Department of Otorhinolaryngology, Head and Neck Surgery, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200, Aarhus, Denmark

    Tejs Ehlers Klug & Niels Krintel Petersen

  2. Department of Clinical Microbiology, Aarhus University Hospital, Aarhus, Denmark

    Camilla Andersen & Thomas Greve

  3. Department of Otorhinolaryngology, Head and Neck Surgery, Hospital Lillebaelt, Vejle, Denmark

    Pernille Hahn

  4. Department of Otorhinolaryngology, Head and Neck Surgery, Aalborg University Hospital, Aalborg, Denmark

    Christian Sander Danstrup & Sophie Mikkelsen

  5. Department of Otorhinolaryngology, Head and Neck Surgery, Odense University Hospital, Odense, Denmark

    Helle Døssing & Anette Kjeldsen

  6. Department of Otorhinolaryngology, Head and Neck Surgery, Regional Hospital, Holstebro, Denmark

    Anne-Louise Christensen

  7. Department of Infectious Diseases, Aarhus University Hospital, Aarhus, Denmark

    Maria Rusan

Authors
  1. Tejs Ehlers Klug
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Camilla Andersen
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Pernille Hahn
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Christian Sander Danstrup
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Niels Krintel Petersen
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Sophie Mikkelsen
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. Helle Døssing
    View author publications

    You can also search for this author in PubMed Google Scholar

  8. Anne-Louise Christensen
    View author publications

    You can also search for this author in PubMed Google Scholar

  9. Maria Rusan
    View author publications

    You can also search for this author in PubMed Google Scholar

  10. Anette Kjeldsen
    View author publications

    You can also search for this author in PubMed Google Scholar

  11. Thomas Greve
    View author publications

    You can also search for this author in PubMed Google Scholar

Contributions

TEK: Initiation and design of the study, inclusion of patients, analysis and interpretation of the results, drafting and approval of the manuscript, accountable for all aspects of the work. TG and CA: Design and conduction of microbiological analyses, analysis and interpretation of the results, critical revision, approval of the manuscript, accountable for all aspects of the work. PH, ALC, and AK: Design of the study, inclusion of patients, critical revision, approval of the manuscript; accountable for all aspects of the work. CD, NKP, SM, and HD: Inclusion of patients, critical revision, approval of the manuscript, accountable for all aspects of the work. MR: Analysis and interpretation of the results, critical revision, approval of the manuscript, accountable for all aspects of the work.

Corresponding author

Correspondence to Tejs Ehlers Klug.

Ethics declarations

Conflict of interest

The authors declared that they have no conflicts of interest.

Ethical approval

The study was approved by the Ethical Committee of Aarhus County (# 1–10-72–4-16).

Consent to participate

Informed consent was obtained from all patients.

Consent for publication

Informed consent was obtained from all patients.

Additional information

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Klug, T.E., Andersen, C., Hahn, P. et al. Clinical evaluation of antibiotic regimens in patients with surgically verified parapharyngeal abscess: a prospective observational study. Eur Arch Otorhinolaryngol 279, 2057–2067 (2022). https://doi.org/10.1007/s00405-021-06962-8

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00405-021-06962-8

Keywords

Search

Navigation