Comparison Of Medical Therapy Alone to

Medical Therapy with Surgical Treatment of

Peritonsillar Abcess

Detia Anandari Ilman (13711025)

Husna Nadiyya (13711156)
Introduksi
PTA -> kasus infeksi spasial dalam dari kepala dan leher ->
insidensi 30 per 100.000 dengan 45ribu kasus baru

Biaya yang dibutuhkan untuk pengobatan PTA -> >150

juta US dollar

Kegagalan drainase Tidak ditangani ->

Selulitis peritonsilar
saat tonsilitis -> kegagalan jalan nafas,
-> formasi flegmon
migrasi patogen ekstensi hingga ke
-> formasi abses pada
bakterial melalui spasial leher,
spasial peritonsilar
kanal limfatik bakteremia & sepsis
 Selama puluhan tahun -> PTA Resiko perdarahan tinggi
ditangani dgn pembedahan -> Insisi & Tingkat kegagalan kedua tindakan ->
drainase atau dengan aspirasi jarum 6% - 20%

Penelitian terdahulu : Studi 2008 -> membandingkan terapi

PTA dengan medikamentosa vs bedah
Pemberian steroid setelah NA -> -> hasil klinis tidak memiliki
meningkatkan hasil klinis perbedaan yang signifikan
 Proyek Process Improvement (PI) mengimplementasikan algoritma terapi
Medikamentosa pada pasien dewasa dengan PTA tanpa komplikasi di SCPMG
- Jika tidak membaik secara Selama 5 tahun terakhir (2008-

terapi

SCPMG
pemberian terapi

Pusat pelayanan SCPMG

- Normal saline D5%, 1-L
IGD
di IGD

bolus signifikan -> menjalani 2013) :

tindakan bedah - 12 pusat -> terapi
- Deksametason 10mg
terdiagnosa di

Observasi pemberian
- Di follow up pada hari medikamentosa -> 92% pasien
Saat terdiagnosa

- Ceftriakson 2 g berikutnya oleh dept. tertangani

- Klindamisin 600 mg Bedah kepala dan leher -> - 7 pusat lain -> terapi
jika membaik boleh medikamentosa + terapi bedah
pulang -> jika tidak -> 92% pasien tertangani

Observasi
- Obat rawat jalan: membaik -> drainase

Pusat
HIPOTESA -> tingkat
Saat

Klindamisin 4x300mg bedah atau terapi

medikamentosa ulang komplikasi dan kegagalan sama
selama 10 hari pada kedua metode terapi
 Metode
✢ Menggunakan kalkulasi priori power
-> 84 pasien pada masing-masing
kelompok -> mendeteksi perbedaan
signifikan secara statistik dengan 0,05
level (kekuatan 80%)
✢ Pengukuran hasil luaran :
nyeri, volume opioid yang diresepkan,
rata-rata hari sakit, jumlah hari cuti
kerja, tingkat kegagalan dan tingkat
komplikasi
✢ Variabel dinilai saat 1-2 jam setelah terapi, hari
ke-1, 2, 3, 7 dan 42
✢ Variabel yang dinilai : usia, jenis kelamin,
lokasi RS, tanggal, nyeri, riwayat demam,
temperatur, trismus, deviasi uvula, toleransi
asupan cair atau padat, jumlah hari sakit,
jumlah hari hingga bisa makan per oral, jumlah
pus selama bedah, kesulitan bernafas,
perdarahan, jumlah hari cuti kerja, jumlah
opioid yang diberikan 42 hari setelah
didiagnosis, jumlah kunjungan klinik selama 42
hari setelah diagnosa, kegagalan terapi dan
komplikasi yang muncul
Memastikan cukup waktu sampai dengan muncul kegagalan -> kegagalan pada kedua
kelompok -> adanya prosedur bedah yang dilakukan dalam 42 hari selama kunjungan
awall

Komplikasi yang berkaitan dengan PTA -> aspirasi, bakteremia, perdarahan, mediastinitus,
abses parafaring, abses retrofaring, sepsis, shortness of breath, syncope, palpitasi dan
kelemahan (weakness)

Analisis statistik -> uji Pearson X2, uji wilcoxon rank-sum (WRSTs), uji Fisher exact dan
analisis regresi logistik
Results
Baseline
characteristic

No statistically significant
difference

Patients in both groups did

not have a PTA closer than
the previous 12 months
Volume of Opioid Prescription, Average
Number of Sore Days, and Days Off
Work

volume of narcotic pain medication per

prescription : no significant

volume of narcotic refilled : significant.

MT<ST (p < 0.0001)

MT<ST significant : fewer “sore days” (P =

0.0004) and days off work (P = 0.044)
COMPLICATION
AND FAILURE
RATES

Failure rates : no significant difference (MT 8.1%

Complication vs rate
NoST:comorbidities
no
6.2significant
%, P = .58)difference
 Patients
Patients with
with Trismus
Trismus
PATIENT WITH ST>MT (odds
ST>MT (odds ratio,
ratio, 3.8;
3.8;
TRISMUS 95%
95% confidence
confidence interval,
interval,
2.2-6.5;
2.2-6.5; P
P<< 0.0001).
0.0001).

The
The number
number ofof sore
sore days
days ::
no
no significant
significant difference
difference (P
(P
=
= 0.066
0.066 [WRST];
[WRST]; 4.94.9 days
days
MT,
MT, 5.2
5.2 days
days ST).
ST).

ST
ST received
received more
more
opioid prescriptions
opioid prescriptions
than
than those
those treated
treated with
with
MT
MT alone
alone (P
(P =
= 0.01)
0.01)
Discussion
Justification behind treating PTAs Basis for Antibiotic choice and use
with MT of steroids

Tindakan bedah -> resiko Ceftriakson & klindamisin

kegagalan, komplikasi -> board-spectrum, covering
bedah, biaya mahal, & gram negatif, positif dan
ketidak-nyamanan pasien anaerob

Pasien yang datang ke IGD -> Penelitian sebelumnya :

belum ada abses -> tidak ada deksametason -> mengurangi
pus yang didapat saat tindakan nyeri, memperbaiki trismus,
-> terpapar resiko dari prosedur disfagia, temperatur tubuh dan
yang tidak perlu mengurangi waktu rawat inap
 Discussions
Jenis studi -> limitasi
Dokter IGD ->
menetapkan diagnosis
-> bias pemilihan,
-> riwayat dan
coding dan kelalaian
pemeriksaan fisik

Pusat medis individu

-> tidak ada indikasi
pasien untuk ST

Menangani bias ->

Tingkat komplikasi
membandingkan
dan kegagalan sama
subgrup trismus pada
pada kedua grup
MT dan ST
Conclusion
• Complication or failure rates, nor could any
NO SIGNIFICANT
difference be identified in the time until
DIFFERENCES
tolerating liquids or solids.

• MT superiority in the amount of liquid opioid

POTENTIAL prescribed, the average number of sore days, and days
off from work.
ADVANTAGES & • Surgical intervention is not necessarily required
FUTURE STUDY • Future study should be conducted in which objective
criteria
Critical Appraisal
CASE SERIES STUDY
Questions Yes No Unclear Not
applicable
1. Were there clear criteria for inclusion in the case ✔
series?
We narrowed the search down to 1747 patients with
PTA who, according to the coding and documentation in
their chart, had uncomplicated PTAs and received
therapy exactly according to the PI protocol (MT)

2. Was the condition measured in a standard, ✔

reliable way for all participants included in the case
series?
A total of 6782 patients were diagnosed clinically with a
PTA by ED physicians during this period (International
Classification of Diseases, Ninth Revision [ICD-9] code
475). Of these, 6132 (90%) were treated without a
surgical intervention Current Procedural Terminology
(CPT) code, while 650 (10%) were treated in the ED
with a surgical intervention code (CPT 42700, 42999 or
ICD-9 28.0).
3. Were valid methods used for identification of the ✔
condition for all participants included in the case
series?
Using a priori power calculations, we had
determined that at least 84 patients would be
required in each ST and MT group to detect a
statistically significant difference at the .05 level
(with 80% power) between the 2 groups in each
of the following outcome measures: pain, the
volume of opioid prescribed, average number of
sore days, days off of work, failure rates, and
complication rates.

4. Did the case series have consecutive inclusion of ✔

participants?
Upon Kaiser institutional review board approval
(10246), a chart review of PTA treatment
outcomes throughout the SCPMG system from
January 2008 to January 2013 was performed
(Figure 1).
5. Did the case series have complete inclusion of ✔
participants?
We reviewed these 1747 patients’ charts to see who
received the same MT regimen but who also
received standard surgical drainage at one of the 7
service centers where surgery was routinely per-
formed, and 96 patients were identified (surgical
treatment [ST]). Outcomes for these 96 ST patients
were then compared to 211 randomly selected out of
the 1747 MT patients treated without drainage at the
other 12 service centers where medical therapy was
primarily implemented.

6. Was there clear reporting of the demographics of the ✔

participants in the study?
Baseline Characteristics
No statistically significant difference in the following
baselineparameters could be identified at any time
point: age,age range, sex, level of pain on a scale of
1 to 10, temperature,or the ability to eat liquids or
drink solids (Table 1).Patients in both groups did not
have a PTA closer than theprevious 12 months.
7. Was there cleas reporting of clinical information of the ✔
participants?
Complication and Failure Rates
The number of PTA-associated complications and diagnoses was
recorded (Table 2), along with the day on which the occurrence
was noted. If the complication is not listed in Table 2, then it
was not associated with PTA treatment in either group.

8. Were the outcomes or follow up results of case clearly reported? ✔

Seventeen patients (8.1%) in the medical group had a procedure
reported within 42 days of diagnosis, and 6 surgical patients
(6.2%) required a second procedure within 42 days, and these
were considered treatment failures. There was no statistically
significant difference in failure rates between the ST and MT
groups (8.1% vs 6.2 %, P = .58) out to 42 days.
There were 39 (18.4%) cases of trismus in the MT group and 44
(45.8%) in the ST group (Table 3). Patients with trismus at
presentation were more likely to have ST than MT (odds ratio,
3.8; 95% confidence interval, 2.2-6.5; P < 0.0001). In the MT
group, 36 (92%) patients with trismus did not have a procedure,
and 3 of the 39 subsequently received a procedure after the
initial presentation (7.7% failure rate). Three of the 44 (6.7%) in
the ST group had trismus at 24 hours, requiring a second
procedure.
9. Was there clear reporting of presenting site(s) ✔
clinic(s) demographic information?
( Baseline Characteristics, Page 3)

10. Was statistical analysis appropriate? ✔

Statistical analyses, including Pearson x2 tests,
Wilcoxon rank-sum tests (WRSTs), Fisher exact
tests, and logistic regression analysis, were
performed on the data. Univariate comparisons
between groups involved Pearson x2 tests and
Fisher exact tests for categorical variables and
WRSTs for ordered (including continuous)
variables. Noninferiority of MT vs ST was defined
as no significant difference in outcomes.
Multivariate analyses were performed to account
for potential confounding variables.
Terima Kasih