JOURNAL READING

“Management of Reccurent Tonsilitis in Children”

PEMBIMBING:
dr. Dwi Antono, Sp. THT-KL (K)
Disusun oleh
Toha al mubarok
012106286
 Journal Identity
 Title : Management of Recurrent Tonsillitis in Children
 Author : Diaa El Din El Hennawi , Ahmed Geneid , Salah Zaher,
Mohamed Rifaat Ahmed
 Publisher : American Journal of Otolaryngology–Head and Neck
Medicine and Surgery
 Year : 2017
Tonsilitis ???

Tonsilitis is inflammation of tonsila palatina

which is part of waldayer’s ring

The most cause is Stretococuus

alfa gram positive
Recurrent infection Infiltration of epithel

Mucosa epithel & lymphoid Infiltration of

tissue erosion polymorphonuclear
leukocytes

Scarring DETRITUS

Crypt widened
TO : Previous tonsillectomy
T1 : Tonsils or palatopharyngeal arches narrow
the oropharyngeal inlet less than 25%
T2 : Tonsils or palatopharyngeal arches narrow
the oropharyngeal inlet between 25-50%
T3 : Tonsils or palatopharyngeal arches narrow
the oropharyngeal inlet between 50-75%
T4 : Tonsils or palatopharyngeal arches narrow
the oropharyngeal inlet more than 75%
 INTRODUCTION
Recurrent tonsillitis has been defined as four or more confirmed infection
episodes per year with streptococci A-infection diagnosed in one of them.
Prevalence is from 11.0 to 12.3% with marked family burden and risk of man
serious complication especially in developing countries .

Recurrent tonsillitis is usually treated by either tonsillectomy or

conservative medical treat- ment when tonsillectomy criteria are not
fulfilled or there is a contrain- dication for tonsillectomy .

The usefulness of long-acting penicillin in significant reduction of

recurrent tonsillitis . However, long acting penicillin has multiple
drawbacks such as hypersensitivity reactions, anaphylaxis and severe
local pain

Azithromycin (AZT) is an Azalide, a subclass of macrolide antibiotic

which is widely distributed throughout the body, achieving higher con-
centrations in tonsillar tissues with adequate therapeutic levels during
medication with minimal side effects.
 Purpose
The aim of the present study was to compare the efficacy of AZT
and benzathine penicillin (BP)—both administered for six months in
the management of recurrent tonsillitis—to conventional
tonsillectomy
 METHOD
A randomized controlled clinical trial study created in the otolaryn-
gology department - Suez Canal University Hospital – Ismailia – Egypt and
Alexandria University Children Hospital – Egypt from March 2005 to May
2012

Recurrent tonsillitis was defined as four or more episodes of ton-

sillitis per year (for children of either gender) with two of the
episodes confirmed to be group A streptococcal infection.

The 350 children enrolled fulfilled the inclusion criteria and did not
have any significant co-morbidities. Significant morbidities included
rheumatic heart disease, rheumatic fever, marked anesthetic risk,
sensitivity to AZT or BP, the intake of drugs that might interfere with
AZT or BP, hepatic impairment, or long QT syndrome (a prolonged QT
interval of N 45 ms in ECG).
350 anak 284 anak

randomization

Group 1: Group 2:
Tonsilectomy group : 162 Conservative medical
children treatment group : 122
children

Grup B : 61 children received

Grup A : 61 children received BP IM
AZT single dose PO (250 mg for
single dose (600.000 IU for children ≤
children ≤ 25 kg and 500 mg for
27 kg and 1.200.000 IU for ≥27 kg)
≥25 kg) once per week for 6
every two weeks for 6 months.
months.
 Data collected included complete medical histories with an emphasis on
recurrent tonsillitis. Symptoms' severity was assessed using a visual analog scale
for symptoms' severity (with 0 indicating no symptoms and 10 indicating the
most severe symptoms).

 A complete ENT and general physical examination were carried out before the start
of the study.
Data were collected from all children at the beginning of the study and after six
months
 CBC: Complete blood count
◦ ASOT: A Streptococcus Test
◦ ESR: Eritrosit Sedimentasion test (non specific test for infections or autoimmune disease)
 Medical history and clinical
evaluation by the end of the trial.
Step Assignment
ASOT and ESR levels were
taken before the start of the
study and six months after it. • Minor (GIT upset, dizziness)
• Major (anaphylaxis, jaundice,
a prolonged QT interval)
Symptom’s severity was assessed using
the visual analog scale for symptoms
severity
a) the patient is comfortable
and accepts the regimen
The safety of drugs were b) the patient is not
assessed by the detection of comfortable but accepts
Data collected were processed using SPSS version 18
adverse effects and continues the regimen
(SPSS Inc., Chicago, IL, USA). Quantitative data were
c) the patient is not
expressed as means ± SD while qualitative data were
comfortable and does not
expressed as numbers and percentages. The Student's
accept the regimen and
t-test was used to compare the significance of
Satisfaction assessment discontinues it
difference for the quantitative variables that followed a
(whereupon they were
normal distribution
excluded from the study)
RESULT
 ESR and
ASOT
level

Adverse Outcome Comfortness

effect
After Treatment Result
 ESR AND ASOT LEVEL

 The tonsillectomy group had a mean ESR level of 70.3 ± 13.1 ml/h during the last
episode of tonsillitis before tonsillectomy. Six months after the operation this level
dropped to 8.7 ± 1.9 ml/h (P = 0.005).
 The mean ASOT for the tonsillectomy group was 436 IU/ml before surgery and
declined to 115 IU/ml after six months with statistically significant improvement (P =
0.006).
The mean ASOT before treatment in group A was 476 IU/ml and 491 IU/ml in group B.
After six-months follow-up a statistically significant reduction in the ASOT in both groups
occurred as group A became 126 IU/ml while group B became 141 IU/ml. There was no
statistically significant difference between the two groups.
 In the AZT group, three
50 patients (82%) of the AZT
patients had minor adverse
group showed QT
reactions e.g. nausea,
prolongation and 11 patients
vomiting, and abdom- inal
(18%) showed shortening.
cramps with diarrhea.

Liver enzymes did not show

a significant rise from before
No serious adverse reactions
Side treatment to after
treatment, nor was there a
were reported in either
group.
effect difference between group A
and group B.

No patients developed
rheumatic activity during the
study and follow-up period.
 Group A had a lower level of 36
(59.1%) comfortable patients, versus
25 who reported discomfort (40.9%).
However, the uncomfortable group
continued the treatment till the end
of the year.

Satisfaction among group B patients

was significantly higher among 58
patients (95.61%). Only three Comfortness
reported to be uncomfortable (4.9%).

the AZT patients were more 90% of both groups were

comfortable with the drug than the taking the drug regularly
BP patients
 DISCUSSION
The present study showed that there is no significant
difference between the group A and B in regard to
recurrent tonsillitis after six- months follow-up.

The ASOT and ESR levels were also reduced to normal

and there was no statistically significant difference
between the groups..

AZT has been proven to be very effective in treating

group A strepto- coccal tonsillopharyngitis when it
presents in the acute form .
The results of this study show the efficacy of AZT in preventing recurrent tonsillitis and
reducing ASOT and ESR levels to a range comparable to those of BP and tonsillectomy.
The children were more comfortable with an AZT regimen rather than a BP regimen.
Minor adverse reactions were reported with AZT.
The message of this study is that treatment options other than tonsillectomy exist for
treating recurrent tonsillitis. AZT, which is one of the treatments, proved to be safe and
effective in our study. Further studies should look into the possibility of having shorter
regimens of AZT when treating recurrent tonsillitis.
 CONCLUSION

The treatment of recurrent tonsillitis is equally

effective by treat- ment with AZT or BP in comparison
to tonsillectomy. AZT was as effec- tive as BP and
tonsillectomy against recurrent tonsillitis after six
months of treatment.
CRITICAL APPRAISAL
PICO
Population
P 350 children were aged from to 12 with recurrent tonsillitis history, and fulfilled
inclusion criteria and did not have eksclusion factor.
Intervention
I Children received single oral AZT (250 mg for children ≤ 25 kg and 500 mg for ≥25 kg)
once weekly for six months.
Comparation
C Children received a single intramuscular BP (600,000 IU for children ≤ 27 kg and
1,200,000 IU for ≥27 kg) every two weeks for six months.
Outcome
The treatment of recurrent tonsillitis is equally effective by treatment with AZT or BP
O in comparison to tonsillectomy. AZT was as effective as BP and tonsillectomy against
recurrent tonsillitis after six months of treatment.

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 Title and Author

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 Abstract

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2 Includes component Objective, Method, +

Result, Conclusion

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4 Without abbreviation other than the +

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