Sie sind auf Seite 1von 5

American Journal of OtolaryngologyHead and Neck Medicine and Surgery 38 (2017) 371374

Contents lists available at ScienceDirect

American Journal of OtolaryngologyHead and Neck


Medicine and Surgery
journal homepage: www.elsevier.com/locate/amjoto

Original Contributions

Management of recurrent tonsillitis in children,,


Diaa El Din El Hennawi a, Ahmed Geneid b, Salah Zaher c, Mohamed Rifaat Ahmed a,
a
Department of Otorhinolaryngology, Faculty of Medicine, Suez Canal University, Ismailia, Egypt
b
Department of Ear, Nose and Throat Disorders and Phoniatrics-Head and Neck Surgery, Helsinki, Finland
c
Department of Pediatrics, Faculty of Medicine, Alexandria University, Alexandria, Egypt

a r t i c l e i n f o a b s t r a c t

Article history: Objective: To compare azithromycin (AZT) and benzathine penicillin (BP) in the treatment of recurrent tonsillitis
Received 16 January 2017 in children.
Methods: The study comprised of 350 children with recurrent streptococcal tonsillitis, 284 of whom completed
Keywords: the study and 162 children received conventional surgical treatment. The rest of the children, 122, were divided
Chronic tonsillitis
randomly into two equal main groups. Group A children received a single intramuscular BP (600,000 IU for
Benzathine penicillin
children 27 kg and 1,200,000 IU for 27 kg) every two weeks for six months. Group B children received single
Azithromycin
oral AZT (250 mg for children 25 kg and 500 mg for 25 kg) once weekly for six months.
Results: Both groups showed marked signicant reduction in recurrent tonsillitis that is comparable to results of
tonsillectomy. There were no statistical differences between group A and B regarding the recurrence of infections
and drug safety after six-month follow-up. Group B showed better compliance.
Conclusion: AZT proved to be good alternative to BP in the management of recurrent tonsillitis with results similar
to those obtained after tonsillectomy.
2017 Elsevier Inc. All rights reserved.

1. Introduction frequent tonsillitis are the ones who benet from surgery in comparison
to the less severely affected children [5].
In the present state of medical literature, tonsils are considered as as- Sirimanna et al. reported the usefulness of long-acting penicillin in
sets to the immunological system and they are removed or partially ex- signicant reduction of recurrent tonsillitis [6]. However, long acting
cised only when there is a medical necessity caused by their size, penicillin has multiple drawbacks such as hypersensitivity reactions,
recurrent bacterial infections or tumor [1]. Recurrent tonsillitis has anaphylaxis and severe local pain [7].
been dened as four or more conrmed infection episodes per year Azithromycin (AZT) is an Azalide, a subclass of macrolide antibiotic
with streptococci A-infection diagnosed in one of them [2]. Prevalence which is widely distributed throughout the body, achieving higher con-
is from 11.0 to 12.3% with marked family burden and risk of man serious centrations in tonsillar tissues with adequate therapeutic levels during
complication especially in developing countries [3]. Recurrent tonsillitis medication with minimal side effects [8].
is usually treated by either tonsillectomy or conservative medical treat- Recurrent tonsillitis always present on a continuum rather than a
ment when tonsillectomy criteria are not fullled or there is a contrain- dichotic representation. Children seem to suffer from different
dication for tonsillectomy [4]. A review by Burton et al. in 2014 found grades of recurrent tonsillitis. The possibility of having other treat-
that children with recurrent acute tonsillitis have a small benet from ment measures than tonsillectomy is tempting especially when the
adeno-/tonsillectomy [5]. The procedure will avoid only 0.6 episodes child has recurrent tonsillitis that falls little short of the criteria for
of any type of sore throat in the rst year after surgery compared to tonsillectomy [9].
non-surgical treatment. The children who had surgery had three epi- The aim of the present study was to compare the efcacy of AZT and
sodes of sore throat on average compared to 3.6 episodes experienced benzathine penicillin (BP)both administered for six months in the
by the other children. One of the three episodes is the episode of pain management of recurrent tonsillitisto conventional tonsillectomy.
caused by surgery. It seems that children with the more severe and
2. Materials and methods
Conicts of interests: None.
Financial and material support: None. 2.1. Design, setting and participants
Level of evidence: 3b.
Corresponding author.
E-mail addresses: ahmed.geneid@hus. (A. Geneid), Pedotomanager@entnet.org A randomized controlled clinical trial study created in the otolaryn-
(S. Zaher), m_rifaat@yahoo.com (M.R. Ahmed). gology department - Suez Canal University Hospital Ismailia Egypt

http://dx.doi.org/10.1016/j.amjoto.2017.03.001
0196-0709/ 2017 Elsevier Inc. All rights reserved.
372 D.E.D. El Hennawi et al. / American Journal of OtolaryngologyHead and Neck Medicine and Surgery 38 (2017) 371374

and Alexandria University Children Hospital Egypt from March 2005 2) ASOT and ESR levels were taken before the start of the study and
to May 2012. The study protocol was approved by the local faculty six months after it. 3) Symptoms' severity was assessed using the vi-
ethics committee and written informed consent was obtained from all sual analog scale for symptoms severity as described above. 4) The
patients relevant. safety of drugs were assessed by the detection of adverse effects,
which were classied as minor and accepted adverse effects (GIT
2.2. Patient eligibility and enrolment upset, dizziness) or major, necessitating the exclusion of the child
from the study (anaphylaxis, jaundice, a prolonged QT interval).
A total of 350 children with recurrent tonsillitis were included in the 5) Satisfaction assessment was made by asking direct questions to
study. Recurrent tonsillitis was dened as four or more episodes of ton- the patients, their parents, and the medical staff. Patients' satisfac-
sillitis per year (for children of either gender) with two of the episodes tion was classied as a) the patient is comfortable and accepts the
conrmed to be group A streptococcal infection. The enrolled children regimen; b) the patient is not comfortable but accepts and continues
were aged from ve to 12. The 350 children enrolled fullled the inclu- the regimen; c) the patient is not comfortable and does not accept
sion criteria and did not have any signicant co-morbidities. Signicant the regimen and discontinues it (whereupon they were excluded
morbidities included rheumatic heart disease, rheumatic fever, marked from the study).
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 2.5. Statistical analysis
prolonged QT interval of N 45 ms in ECG).
Data collected were processed using SPSS version 18 (SPSS Inc.,
2.3. Study plan Chicago, IL, USA). Quantitative data were expressed as means SD
while qualitative data were expressed as numbers and percentages.
Children were divided randomly and equally into two groups. The Student's t-test was used to compare the signicance of difference
Randomization was performed prior to study commencement as fol- for the quantitative variables that followed a normal distribution.
lows: Opaque envelopes were numbered sequentially from 1 to 350.
A computer-generated table of random numbers was used for group 2.6. Ethical considerations
assignment; if the last digit of the random number was from 0 to 4,
assignment was to group 1 (received conventional tonsillectomy), The study protocol was approved by the faculty's ethical committee
and if the last digit was from 5 to 9, assignment was to group 2 (re- and written informed consent was obtained from the parents of the
ceived BP or AZT). Group 2 was randomized again in similar manner children enrolled in the study after an explanation of the study's design,
in group A and group B. The assignments were then placed into the and the benets and risks associated with the treatment regimen.
opaque envelopes and the envelopes sealed. As eligible participants
were entered into the trial, these envelopes were opened in sequen- 3. Results
tial order to give each patient his or her random group assignment.
The envelopes were opened by the ORL specialist after patient con- 3.1. ASOT and ESR levels
sent and just prior to the treatment method; Group A received med-
ical treatment with BP and group B received AZT. Subgroup A The tonsillectomy group had a mean ESR level of 70.3 13.1 ml/h
children received single intramuscular. during the last episode of tonsillitis before tonsillectomy. Six months
BP (600,000 IU for children 27 kg and 1,200,000 IU for children after the operation this level dropped to 8.7 1.9 ml/h (P = 0.005).
27 kg) every two weeks for six months [10)]. Subgroup B children re- The mean ASOT for the tonsillectomy group was 436 IU/ml before sur-
ceived single oral AZT (250 mg for children 25 kg and 500 mg for gery and declined to 115 IU/ml after six months with statistically signif-
children 25 kg) once weekly for six months [11]. Children in the AZT icant improvement (P = 0.006).
subgroup were subjected to ECG, calculation of the QT interval and The mean ASOT before treatment in group A was 476 IU/ml and
liver enzymes before starting the treatment. 491 IU/ml in group B. After six-months follow-up a statistically signi-
Out of the 350 children, only 284 managed to complete the study. cant reduction in the ASOT in both groups occurred as group A became
The children had a mean age of 7.4 1.6 years. 126 IU/ml while group B became 141 IU/ml (Table 1). There was no sta-
350 children randomly divided into tonsillectomy and medical treat- tistically signicant difference between the two groups.
ment group with 175 in each. Drop out of 13 children in the tonsillecto- The mean ESR level also showed a statistically signicant reduction
my group and 53 children in the conservative medical treatment one. in its values from before treatment to the end of the six-months
Tonsillectomy group was 162 children. Conservative medical treatment follow-up (Table 1). However, there was no statistically signicant dif-
group was 122 children. 61 children in group A that received BP while ference between group A and group B in terms of the improvement
61 children in group B received AZT. More patients dropped out of the
conservative medical treatment group. It is postulated that this may Table 1
be due to some of them seeking conventional tonsillectomy in the pri- The mean degree of the ASOT in both groups after treatment.
vate health care sector or due to poor compliance with the conservative Group Before treatment After treatment
medical treatment.
Mean SD Mean SD

2.4. Objective and outcome measurement assessment ASOT A 476 18 126 14


B 491 16 141 13
ESR A 68.7 9.7 9.4 3.2
Data collected included complete medical histories with an empha- B 71.2 12.3 10.2 2.8
sis on recurrent tonsillitis. Symptoms' severity was assessed using a vi- Dysphagia A 8.1 1.5 5.3 1.8
sual analog scale for symptoms' severity (with 0 indicating no B 8.7 1.1 4.9 1.4
Fever A 9.3 1.1 4.3 0.9
symptoms and 10 indicating the most severe symptoms). In addition,
B 8.9 2.3 4.1 1.2
a complete ENT and general physical examination were carried out be- Arthralgia A 7.2 0.9 3.9 1.8
fore the start of the study. CBC, ASOT, and ESR data were collected from B 7.9 1.4 3.6 0.9
all children at the beginning of the study and after six months. Body ache A 8.7 1.4 3.7 1.1
The outcomes were assessed through the following measures: B 8.1 0.8 3.2 1.7

1) Medical history and clinical evaluation by the end of the trial. P = 0.005, n = 61 for group A and B.
D.E.D. El Hennawi et al. / American Journal of OtolaryngologyHead and Neck Medicine and Surgery 38 (2017) 371374 373

degree of the ESR. Flow chart of the study, pre- and post-treatment as- also continued the treatment. It is evident that the AZT patients were
sessments are shown in Fig. 1. more comfortable with the drug than the BP patients, with a statically
signicant difference between both groups regarding satisfaction.
3.2. Severity of symptoms N90% of both groups were taking the drug regularly. There was no
statically signicant difference between the groups regarding
The means of the score for the intensity of the symptoms of tonsilli- compliance.
tis before treatment among group A and group B are summarized in
Table 1. No statistically signicant differences were found between
the groups. 4. Discussion
Six months after starting the treatment, the means of the scores for
the intensity of the symptoms of tonsillitis in group A group B were cal- Recurrent tonsillitis is considered to be one of the common reasons
culated. There was a marked statistically signicant improvement in for primary care visits to physicians. Recurrent tonsillitis among chil-
both groups from before treatment to the end of the six-months dren has a considerable impact on the quality of life, not only due to
follow-up (P = 0.03). However, there was no statically signicant dif- the effects on children but also the burden on the parents when their
ference between the two groups (Table 1). child is suffering. Tonsillectomy remains a common procedure, especial-
In terms of the adverse effects encountered in the AZT group, three ly in western countries [12]. However, a number of immunological stud-
patients had minor adverse reactions e.g. nausea, vomiting, and abdom- ies on the effects of tonsillectomy point to the importance of a
inal cramps with diarrhea. ECG was carried out for all the patients as a conservative attitude from an immunological point of view towards
baseline and all showed a normal sinus rhythm. In regular ECG follow- adenotonsillectomy [13].
ups, 50 patients (82%) of the AZT group showed QT prolongation and The aim of this study has been to look into alternatives to tonsillec-
11 patients (18%) showed shortening. The mean of QT rose signicantly tomy, especially when the tonsillectomy criteria are not fully fullled,
from 41.6 + 1.7 ms before treatment to 43.8 + 2.9 ms (P = 0.007) after. resources are not available or the parents opt for medical treatment.
There was no statistically signicant difference between genders re- The two alternatives were BP and AZT.
garding changes in QT interval. Also, liver enzymes did not show a sig- Although intramuscular BP is still the drug of choice for the treat-
nicant rise from before treatment to after treatment, nor was there a ment and prevention of recurrent acute rheumatic fever, there are
difference between group A and group B. No serious adverse reactions international data reporting an incidence rate of allergic reactions
were reported in either group. No patients developed rheumatic activity of about 3.2% with 0.2% reporting an anaphylaxic reaction due to
during the study and follow-up period. monthly BP injections. Unfortunately, there were three deaths docu-
Being comfortable with the treatment was assessed in both groups mented in Zimbabwe resulting from BP produced by three different
on a single parameter dichotic scale of comfortable vs. uncomfortable. manufacturers [14].
Group A had a lower level of 36 (59.1%) comfortable patients, versus Previous studies have shown that in comparison to oral penicillin,
25 who reported discomfort (40.9%). However, the uncomfortable intramuscular penicillin has been more effective with rheumatic fever
group continued the treatment till the end of the year. Satisfaction recurrence and streptococcal throat infections [15].
among group B patients was signicantly higher among 58 patients Azithromycin which is Azalide antibiotic, has better compliance and
(95.61%). Only three reported to be uncomfortable (4.9%) but they is much easier to take than intramuscular BP.

Fig. 1. Pre- and post-treatment assessments of the children in different groups.


374 D.E.D. El Hennawi et al. / American Journal of OtolaryngologyHead and Neck Medicine and Surgery 38 (2017) 371374

The present study showed that there is no signicant difference be- [2] Alho OP, Koivunen P, Penna T, et al. Tonsillectomy versus watchful waiting in recur-
rent streptococcal pharyngitis in adults: randomised controlled trial. BMJ 2007 May
tween the group A and B in regard to recurrent tonsillitis after six- 5;334(7600):939 [Epub 2007 Mar 8].
months follow-up. The ASOT and ESR levels were also reduced to nor- [3] Kvestad E, Kvaerner K, Roysamb E, et al. Heritability of recurrent tonsillitis. Arch
mal and there was no statistically signicant difference between the Otolaryngol Head Neck Surg 2005;131:3837.
[4] Georgalas CC, Tolley NS, Narula PA. Tonsillitis. Clin Evid (Online) 2014 Jul;22:2014.
groups. [5] Burton MJ, Glasziou PP, Chong LY, et al. Tonsillectomy or adenotonsillectomy versus
AZT has been proven to be very effective in treating group A strepto- non-surgical treatment for chronic/recurrent acute tonsillitis. Cochrane Database
coccal tonsillopharyngitis when it presents in the acute form [16]. Syst Rev 2014 Nov 19;11.
[6] Sirimanna KS, Madden GJ, Miles SM. The use of long-acting penicillin in the prophy-
The main concern for using AZT in long treatment has been its pos- laxis of recurrent tonsillitis. J Otolaryngol 1990 Oct;19(5):3434.
sible association with increased cardiovascular risk and may lead to [7] Brunton LL, Parker KL. Penicillin, cephalosporin and other beta lactam inhibitor an-
cardiovascular-related death in high-risk patients. A meta-analysis of tibiotics. Goodman and Goldman Pharmacol Therap 2008:73052.
[8] Lister PJ, Balechandran T, Ridgway GL, et al. Comparison of azithromycin and doxy-
randomized controlled trials by Almalki and Guo, reported AZT safety
cycline in the treatment of non-gonococcal urethritis in men. J Antimicrob
in patients studied in 12 trials included in the meta-analysis from Chemother 1993;31(suppl E):18592.
1990 to 2013 [17]. Nevertheless, its safety and effectiveness is compara- [9] Zielnik-Jurkiewicz B, Jurkiewicz D. Implication of immunological abnormalities after
ble to Penicillin V [18]. adenotonsillotomy. J Pediatr Otorhinolaryngol]>Int J Pediatr Otorhinolaryngol
2002 Jun 17;64(2):12732.
Long-term prophylaxis against streptococcal infections using AZT [10] Broderick MP, Hansen CJ, Russell KL, et al. Serum penicillin G levels are lower than
was attempted by Snider et al. in the prophylaxis of children with expected in adults within two weeks of administration of 1.2 million units. PLoS
PANDAS (pediatric autoimmune neuropsychiatric disorders associated One 2011;6(10):e25308.
[11] Gopal R, Harikrishnan S, Sivasankaran S, et al. Once weekly azithromycin in second-
with streptococcal infections). A 12-month trial administration of AZT ary prevention of rheumatic fever. Indian Heart J 2012 Jan-Feb;64(1):125.
and penicillin was done and showed effectiveness in decreasing strepto- [12] Van Staaji BK, van den Akker EH, Rovers MM, et al. Effectiveness of
coccal infections [19]. adenotonsillectomy in children with mild symptoms of throat infections or
adenotonsillar hypertrophy: open, randomised controlled trial. Clin Otolaryngol
The results of this study show the efcacy of AZT in preventing re- 2005;30:603.
current tonsillitis and reducing ASOT and ESR levels to a range compa- [13] Brandtzaeg P. Immunology of tonsils and adenoids: everything the ENT surgeon
rable to those of BP and tonsillectomy. The children were more needs to know. J Pediatr Otorhinolaryngol]>Int J Pediatr Otorhinolaryngol Dec
2003;67(Suppl. 1):S6976.
comfortable with an AZT regimen rather than a BP regimen. Minor ad-
[14] Wyber R, Zhlke L, Carapetis J. The case for global investment in rheumatic heart-
verse reactions were reported with AZT. disease control. Bull World Health Organ 2014 Oct 1;92(10):76870.
The message of this study is that treatment options other than ton- [15] Manyemba J, Mayosi BM. Intramuscular penicillin is more effective than oral penicil-
lin in secondary prevention of rheumatic fevera systematic review. S Afr Med J
sillectomy exist for treating recurrent tonsillitis. AZT, which is one of
2003 Mar;93(3):2128.
the treatments, proved to be safe and effective in our study. Further [16] Casey JR, Pichichero ME. Higher dosages of azithromycin are more effective in treat-
studies should look into the possibility of having shorter regimens of ment of group A streptococcal tonsillopharyngitis. Clin Infect Dis 2005 Jun 15;
AZT when treating recurrent tonsillitis. 40(12):174855 [Epub 2005 May 13].
[17] Almalki ZS, Guo JJ. Cardiovascular events and safety outcomes associated with
azithromycin therapy: a meta-analysis of randomized controlled trials. Am Health
5. Conclusion Drug Benets 2014 Sep;7(6):31828.
[18] O'Doherty B. Azithromycin versus penicillin V in the treatment of paediatric patients
with acute streptococcal pharyngitis/tonsillitis. Paediatric Azithromycin Study
The treatment of recurrent tonsillitis is equally effective by treat- Group. J Clin Microbiol Infect Dis]>Eur J Clin Microbiol Infect Dis 1996;15(9):
ment with AZT or BP in comparison to tonsillectomy. AZT was as effec- 71824.
tive as BP and tonsillectomy against recurrent tonsillitis after six months [19] Snider LA, Lougee L, Slattery M, et al. Antibiotic prophylaxis with azithromycin or
penicillin for childhood-onset neuropsychiatric disorders. Biol Psychiatry 2005 Apr
of treatment. 1;57(7):78892.

References

[1] Sharma K, Kumar D. Ligation versus bipolar diathermy for hemostasis in tonsillecto-
my: a comparative study. Indian J Otolaryngol Head Neck Surg 2011 Jan;63(1):159.
Reproduced with permission of copyright owner.
Further reproduction prohibited without permission.

Das könnte Ihnen auch gefallen