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急性扁桃炎・慢性扁桃炎・扁桃周囲炎・扁桃周囲膿瘍

著者: 鈴木正志 大分大学医学部 耳鼻咽喉科学講座

著者: 渡辺 哲生 大分大学医学部 耳鼻咽喉科学講座

監修: 森山寛 東京慈恵会医科大学附属病院

著者校正/監修レビュー済:2021/02/10
参考ガイドライン:
  1. 厚生労働省健康局結核感染症課抗微生物薬適正使用の手引き 第二版
  1. ドイツ科学医療専門家協議会(AWMF):Clinical practice guideline: tonsillitis I. Diagnostics and nonsurgical management. (2016)
  1. ドイツ科学医療専門家協議会(AWMF):Clinical practice guideline: tonsillitis II. Surgical management. (2016)
  1. 米国耳鼻咽喉科・頭頸部外科学会(AAO-HNSF):Clinical Practice Guideline: Tonsillectomy in Children (Update) February 2019
患者向け説明資料

概要・推奨   

  1. 急性扁桃炎では治療においてウイルス性か細菌性かの鑑別、重症度が重要である。原因の鑑別にはCentorスコア、McIsaacスコア(G)、重症度には急性咽頭・扁桃炎スコアリングシステム(J)が参考となる(推奨度2)。
  1. 反復性扁桃炎では口蓋扁桃摘出術が適応となる。小児においては推奨される(推奨度2)が、成人においては効果について検討を要する(G)。
  1. 扁桃周囲膿瘍では抗菌薬投与に加えて穿刺吸引、切開排膿、即時扁摘が推奨される(G)(推奨度2)。
薬剤監修について:
オーダー内の薬剤用量は日本医科大学付属病院 薬剤部 部長 伊勢雄也 以下、林太祐、渡邉裕次、井ノ口岳洋、梅田将光による疑義照会のプロセスを実施、疑義照会の対象については著者の方による再確認を実施しております。
※薬剤中分類、用法、同効薬、診療報酬は、エルゼビアが独自に作成した薬剤情報であり、
著者により作成された情報ではありません。
尚、用法は添付文書より、同効薬は、薬剤師監修のもとで作成しております。
※薬剤情報の(適外/適内/⽤量内/⽤量外/㊜)等の表記は、エルゼビアジャパン編集部によって記載日時にレセプトチェックソフトなどで確認し作成しております。ただし、これらの記載は、実際の保険適用の査定において保険適用及び保険適用外と判断されることを保証するものではありません。また、検査薬、輸液、血液製剤、全身麻酔薬、抗癌剤等の薬剤は保険適用の記載の一部を割愛させていただいています。
(詳細はこちらを参照)
著者のCOI(Conflicts of Interest)開示:
鈴木正志 : 特に申告事項無し[2021年]
渡辺 哲生 : 特に申告事項無し[2021年]
監修:森山寛 : 特に申告事項無し[2021年]

改訂のポイント:
  1. 定期レビューを行い、「抗微生物薬適正使用の手引き 第二版」の引用と新型コロナウイルス感染症との関連を追加した。

病態・疫学・診察

疾患情報(疫学・病態)  
  1. 急性扁桃炎は、細菌またはウイルスなどの感染によって起こる。
  1. 起炎菌としてはA群ß溶血性連鎖球菌が最も多く、小児では15~30%、成人では10~15%で検出される。ウイルスの関与は、小児では10~40%、成人では20~30%とされる。
  1. 急性炎症が咽頭粘膜に強い場合には急性咽頭炎、口蓋扁桃の炎症が強い場合には急性扁桃炎とされ、多くの場合は急性咽頭・扁桃炎の病態をとる。
  1. 慢性扁桃炎は、ワルダイエル咽頭輪に所属する扁桃・リンパ組織に生じた慢性炎症と定義され、①慢性単純扁桃炎、②反復性扁桃炎、③扁桃病巣感染症――に大きく分類される。
  1. 急性炎症が口蓋扁桃を超えて周囲組織(扁桃周囲間隙)に波及した場合に扁桃周囲炎となり、さらに膿瘍を形成した場合に扁桃周囲膿瘍となる。
 
扁桃周囲組織

扁桃周囲膿瘍は扁桃周囲間隙(扁桃被膜と上咽頭収縮筋との間)に膿瘍を形成する。

出典

問診・診察のポイント  
問診:
  1. 発熱の有無、その程度

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文献 

著者: Mohammad Waheed El-Anwar, Saad Elzayat, Yasser Ahmed Fouad
雑誌名: Auris Nasus Larynx. 2020 Aug;47(4):559-564. doi: 10.1016/j.anl.2020.06.003. Epub 2020 Jun 15.
Abstract/Text OBJECTIVE: to detect, analyze and discuss the different ear nose throat (ENT) manifestations those were reported in COVID19 positive patients in the reviewed and published literatures.
METHODS: We performed a search in the PubMed databases, Web of Science, LILACS, MEDLINE, SciELO, and Cochrane Library using the keywords; COVID-19, Novel coronavirus, corona, 2019-nCoV, SARS-CoV-2, ENT, ear, nose, throat, otorhinolaryngology, ORL, pharynx, ORL, smell, larynx, different ENT related symptoms. We reviewed published and peer reviewed studies that reported the ENT manifestations in COVID-19 laboratory-confirmed positive patients.
RESULTS: within the included 1773 COVID-19 laboratory-confirmed positive patients, the most common ENT manifestations of COVID-19 were sore throat (11.3%) and headache (10.7%). While the other reported ENT manifestations were pharyngeal erythema (5.3%), nasal congestion (4.1%), runny nose or rhinorrhea (2.1%), upper respiratory tract infection (URTI) (1.9%), and tonsil enlargement (1.3%).
CONCLUSION: ENT manifestations for COVID-19 are not common as fever and cough. But, a universal questionnaire using well-defined COVID-19 manifestations is needed to make the COVID-19 data precisely defined, complete and homogenous.

Copyright © 2020. Published by Elsevier B.V.
PMID 32586739  Auris Nasus Larynx. 2020 Aug;47(4):559-564. doi: 10.101・・・
著者: Robert M Centor, T Prescott Atkinson, Amy E Ratliff, Li Xiao, Donna M Crabb, Carlos A Estrada, Michael B Faircloth, Lisa Oestreich, Jeremy Hatchett, Walid Khalife, Ken B Waites
雑誌名: Ann Intern Med. 2015 Feb 17;162(4):241-7. doi: 10.7326/M14-1305.
Abstract/Text BACKGROUND: Pharyngitis guidelines focus solely on group A β-hemolytic streptococcal infection. European data suggest that in patients aged 15 to 30 years, Fusobacterium necrophorum causes at least 10% of cases of pharyngitis; however, few U.S. data exist.
OBJECTIVE: To estimate the prevalence of F. necrophorum; Mycoplasma pneumoniae; and group A and C/G β-hemolytic streptococcal pharyngitis and to determine whether F. necrophorum pharyngitis clinically resembles group A β-hemolytic streptococcal pharyngitis.
DESIGN: Cross-sectional.
SETTING: University student health clinic.
PATIENTS: 312 students aged 15 to 30 years presenting to a student health clinic with an acute sore throat and 180 asymptomatic students.
MEASUREMENTS: Polymerase chain reaction testing from throat swabs to detect 4 species of bacteria and signs and symptoms used to calculate the Centor score.
RESULTS: Fusobacterium necrophorum was detected in 20.5% of patients and 9.4% of asymptomatic students. Group A β-hemolytic streptococcus was detected in 10.3% of patients and 1.1% of asymptomatic students. Group C/G β-hemolytic streptococcus was detected in 9.0% of patients and 3.9% of asymptomatic students. Mycoplasma pneumoniae was detected in 1.9% of patients and 0 asymptomatic students. Infection rates with F. necrophorum, group A streptococcus, and group C/G streptococcus increased with higher Centor scores (P < 0.001).
LIMITATIONS: The study focused on a limited age group and took place at a single institution. Asymptomatic students-rather than seasonal control participants-and a convenience sample were used.
CONCLUSION: Fusobacterium necrophorum-positive pharyngitis occurs more frequently than group A β-hemolytic streptococcal-positive pharyngitis in a student population, and F. necrophorum-positive pharyngitis clinically resembles streptococcal pharyngitis.
PRIMARY FUNDING SOURCE: University of Alabama at Birmingham and the Justin E. Rodgers Foundation.

PMID 25686164  Ann Intern Med. 2015 Feb 17;162(4):241-7. doi: 10.7326/・・・
著者: Masaki Suzumoto, Muneki Hotomi, Dewan S Billal, Keiji Fujihara, Yasuaki Harabuchi, Noboru Yamanaka
雑誌名: Auris Nasus Larynx. 2009 Jun;36(3):314-20. doi: 10.1016/j.anl.2008.07.001. Epub 2008 Sep 5.
Abstract/Text OBJECTIVES: The aim of this study was to develop and evaluate a scoring system for the management of acute pharyngo-tonsillitis.
METHODS: We conducted a prospective study between May 2004 and June 2005. Patients with acute pharyngo-tonsillitis were evaluated for causative pathogens and were assessed clinical symptoms and pharyngo-tonsillar finding by a clinical scoring system.
RESULTS: A total 214 adult patients were enrolled in this study. Streptococcus pyogenes were identified at 13.6%. Thirty-one viruses were also identified by PCR. They were adenovirus (4.8%), influenza virus (1.0%), RS virus (6.3%), and human metapneumovirus (2.9%). Numbers of total white blood cells and levels of C-reactive protein showed a significant positive correlation with clinical scores (p<0.001) and were also higher in cases with S. pyogenes. The clinical scores rapidly improved after the antimicrobial treatments in moderate cases and severe cases.
CONCLUSION: The current study strongly suggested that the clinical scoring system reflected disease severity well and would be very useful for evaluating clinical course and decision making for the antimicrobial treatment of acute pharyngo-tonisllitis.

PMID 18774249  Auris Nasus Larynx. 2009 Jun;36(3):314-20. doi: 10.1016・・・
著者: Michael L Barnett, Jeffrey A Linder
雑誌名: JAMA Intern Med. 2014 Jan;174(1):138-40. doi: 10.1001/jamainternmed.2013.11673.
Abstract/Text
PMID 24091806  JAMA Intern Med. 2014 Jan;174(1):138-40. doi: 10.1001/j・・・
著者: Keiji Fujihara, Hironobu Goto, Masanobu Hiraoka, Masaki Hayashi, Muneki Hotomi, Shinji Tamura, Kiyonori Kuki, Noboru Yamanaka, Peter J Koltai
雑誌名: Int J Pediatr Otorhinolaryngol. 2005 Nov;69(11):1515-20. doi: 10.1016/j.ijporl.2005.04.007. Epub 2005 Jun 24.
Abstract/Text This report is a preliminary exploration of the concept of a "Tonsillectomy Index" (TI) as an objective tool for quantifying the indications for tonsillectomy for recurrent acute tonsillitis (AT). The TI is derived by multiplying the number of episodes of AT by the number of years during which the episodes of AT occurred. Our objective in this study was to investigate whether there is a relationship between the natural history of AT, the immunological functions of tonsils and our proposed TI. For the natural history of AT, we medically followed 11 children with a history of AT for 5 years. When TI was equal to or greater than 8 (TI> or =8), the children suffered a significantly greater number of episodes of AT. For the immunological portion of our study, we enrolled 36 children and 46 adults undergoing tonsillectomy for either AT (study group) or tonsillar hypertrophy (control group, CG). We analyzed the co-stimulatory signals, CD80 and CD86 on tonsillar B-lymphocytes. The expression rates of CD80 and CD86 in the AT group with TI> or =8 were significantly decreased compared to those with TI was less than 8 (TI<8), as well as with those in control (tonsillar hypertrophy) group. Our preliminary findings suggest that when the TI> or =8, the tonsils have deteriorated immunologically and spontaneous resolution of recurrent AT is less likely to occur, hence tonsillectomy is appropriate. TI may be a useful tool for surgical decision making.

PMID 15979731  Int J Pediatr Otorhinolaryngol. 2005 Nov;69(11):1515-20・・・
著者: J L Paradise, C D Bluestone, R Z Bachman, D K Colborn, B S Bernard, F H Taylor, K D Rogers, R H Schwarzbach, S E Stool, G A Friday
雑誌名: N Engl J Med. 1984 Mar 15;310(11):674-83. doi: 10.1056/NEJM198403153101102.
Abstract/Text We studied the efficacy of tonsillectomy, or tonsillectomy with adenoidectomy, in 187 children severely affected with recurrent throat infection. Ninety-one of the children were assigned randomly to either surgical or nonsurgical treatment groups, and 96 were assigned according to parental preference. In both the randomized and nonrandomized trials, the effects of tonsillectomy and of tonsillectomy with adenoidectomy were similar. By various measures, the incidence of throat infection during the first two years of follow-up was significantly lower (P less than or equal to 0.05) in the surgical groups than in the corresponding nonsurgical groups. Third-year differences, although in most cases not significant, also consistently favored the surgical groups. On the other hand, in each follow-up year many subjects in the nonsurgical groups had fewer than three episodes of infection, and most episodes among subjects in the nonsurgical groups were mild. Of the 95 subjects treated with surgery, 13 (14 per cent) had surgery-related complications, all of which were readily managed or self-limited. These results warrant the election of tonsillectomy for children meeting the trials' stringent eligibility criteria, but also provide support for nonsurgical management. Treatment for such children must therefore be individualized.

PMID 6700642  N Engl J Med. 1984 Mar 15;310(11):674-83. doi: 10.1056/・・・
著者: Jochen P Windfuhr, Nicole Toepfner, Gregor Steffen, Frank Waldfahrer, Reinhard Berner
雑誌名: Eur Arch Otorhinolaryngol. 2016 Apr;273(4):989-1009. doi: 10.1007/s00405-016-3904-x. Epub 2016 Feb 16.
Abstract/Text In 2013, a total of 84,332 patients had undergone extracapsular tonsillectomies (TE) and 11,493 a tonsillotomy (TT) procedure in Germany. While the latter is increasingly performed, the number of the former is continually decreasing. However, a constant number of approximately 12,000 surgical procedures in terms of abscess-tonsillectomies or incision and drainage are annually performed in Germany to treat patients with a peritonsillar abscess. The purpose of this part of the clinical guideline is to provide clinicians in any setting with a clinically focused multi-disciplinary guidance through the surgical treatment options to reduce inappropriate variation in clinical care, improve clinical outcome and reduce harm. Surgical treatment options encompass intracapsular as well as extracapsular tonsil surgery and are related to three distinct entities: recurrent episodes of (1) acute tonsillitis, (2) peritonsillar abscess and (3) infectious mononucleosis. Conservative management of these entities is subject of part I of this guideline. (1) The quality of evidence for TE to resolve recurrent episodes of tonsillitis is moderate for children and low for adults. Conclusions concerning the efficacy of TE on the number of sore throat episodes per year are limited to 12 postoperative months in children and 5-6 months in adults. The impact of TE on the number of sore throat episodes per year in children is modest. Due to the heterogeneity of data, no firm conclusions on the effectiveness of TE in adults can be drawn. There is still an urgent need for further research to reliably estimate the value of TE compared to non-surgical therapy of tonsillitis/tonsillo-pharyngitis. The impact of TE on quality of life is considered as being positive, but further research is mandatory to establish appropriate inventories and standardized evaluation procedures, especially in children. In contrast to TE, TT or comparable procedures are characterized by a substantially lower postoperative morbidity in terms of pain and bleeding. Although tonsillar tissue remains along the capsule, the outcome appears not to differ from TE, at least in the pediatric population and young adults. Age and a history of tonsillitis are not a contraindication, abscess formation in the tonsillar remnants is an extremely rare finding. The volume of the tonsils should be graded according to Brodsky and a grade >1 is considered to be eligible for TT. The number of episodes during 12 months prior to presentation is crucial to indicate either TE or TT. While surgery is not indicated in patients with less than three episodes, a wait-and-see policy for 6 months is justified to include the potential of a spontaneous healing before surgery is considered. Six or more episodes appear to justify tonsil surgery. (2) Needle aspiration, incision and drainage, and abscess tonsillectomy are effective methods to treat patients with peritonsillar abscess. Compliance and ability of the patient to cooperate must be taken into account when choosing the surgical method. Simultaneous antibiotic therapy is recommended but still subject of scientific research. Abscess tonsillectomy should be preferred, if complications have occurred or if alternative therapeutic procedures had failed. Simultaneous TE of the contralateral side should only be performed when criteria for elective TE are matched or in cases of bilateral peritonsillar abscess. Needle aspiration or incision and drainage should be preferred if co-morbidities exist or an increased surgical risk or coagulation disorders are present. Recurrences of peritonsillar abscesses after needle aspiration or incision and drainage are rare. Interval TE should not be performed, the approach is not supported by contemporary clinical studies. (3) In patients with infectious mononucleosis TE should not be performed as a routine procedure for symptom control. TE is indicated in cases with clinically significant upper airway obstruction resulting from inflammatory tonsillar hyperplasia. If signs of a concomitant bacterial infection are not present, antibiotics should not be applied. Steroids may be administered for symptom relief.

PMID 26882912  Eur Arch Otorhinolaryngol. 2016 Apr;273(4):989-1009. do・・・
著者: F S Herzon
雑誌名: Laryngoscope. 1995 Aug;105(8 Pt 3 Suppl 74):1-17. doi: 10.1288/00005537-199508002-00001.
Abstract/Text Currently there is no agreement on the treatment of patients who develop a peritonsillar abscess (PTA). This lack of consensus results in highly variable and possibly expensive therapeutic regimens that may not provide optimum quality patient care at reasonable cost. The present study evaluates surgical, medical, diagnostic, and cost factors that affect the management of PTA based on the following: 1. a cohort study of 123 patients with PTA treated using needle aspiration as the initial surgical drainage; 2. a national survey of the PTA management practices of otolaryngologists; and 3. meta-analyses of various components of the treatment regimen for PTA. In the cohort study, patients diagnosed with PTA were treated by both otolaryngologists and emergency medicine specialists with needle aspiration as the primary surgical modality resulting in a 96% acute resolution rate for PTA. In the national survey, questionnaires were sent to 2000 randomly selected members of the American Academy of Otolaryngology-Head and Neck Surgery regarding their management of PTA. The return rate was 73%. Ninety-six percent of the physicians who returned survey forms treated an average of seven PTAs per year using either needle aspiration, incision and drainage, or abscess tonsillectomy to drain the abscess initially. The incidence of PTA in the United States and Puerto Rico among patients 5 to 59 years of age treated by survey practitioners is 30.1 per 100,000 person years, accounting for approximately 45,000 cases per year. Four meta-analyses were completed to quantify the success rate of needle aspiration in the treatment of PTA (94%), the recurrence rate of PTA (10% to 15%), the rate at which penicillin-resistant microorganisms are found in patients with PTA (0% to 56%), and the rate of prior oropharyngeal infections associated with PTA (11% to 56%). The recurrence rate for PTA in the United States is 10%, which is significantly different from the recurrence rate of 15% reported from the rest of the world (P < .002). A clinical intervention for PTA is proposed based on the clinical series, the national survey data, and the meta-analyses. These clinical guidelines recommend that needle aspiration be used as the initial surgical drainage procedure for all patients with a PTA other than those who have indications for abscess tonsillectomy. Patients should be treated in an outpatient setting, should receive penicillin if they are not allergic to it, and should receive adequate pain medication. The evidence does not suggest that there is any benefit in examining the abscess contents for microorganisms. Approximately 30% of patients with PTA can be expected to exhibit relative indications for a tonsillectomy.(ABSTRACT TRUNCATED AT 400 WORDS)

PMID 7630308  Laryngoscope. 1995 Aug;105(8 Pt 3 Suppl 74):1-17. doi: ・・・

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