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研究生:王瀛標
研究生(外文):Ying-Piao Wang
論文名稱:扁桃腺周圍膿瘍, 扁桃腺炎與深頸部感染: 以全國樣本為基礎的世代研究
論文名稱(外文):Peritonsillar abscess, tonsillitis and deep neck infection: A nationwide cohort study in Taiwan
指導教授:周碧瑟周碧瑟引用關係
指導教授(外文):Pesus Chou
學位類別:博士
校院名稱:國立陽明大學
系所名稱:公共衛生研究所
學門:醫藥衛生學門
學類:公共衛生學類
論文種類:學術論文
論文出版年:2014
畢業學年度:103
語文別:英文
論文頁數:81
中文關鍵詞:扁桃腺周圍膿瘍復發扁桃腺炎細針抽吸扁桃腺切除深頸部感染世代研究全國性的
外文關鍵詞:Peritonsillar abscessrecurrencetonsillitisneedle aspirationtonsillectomydeep neck infectioncohort studynationwide
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深頸部感染是頸部嚴重的感染,其原發感染源來自於扁桃腺、牙齒、唾液腺、深頸部淋巴結、或惡性腫瘤,而扁桃腺感染是深頸部感染的重要病因。在數種深頸部感染中,扁桃腺周圍膿瘍是最常見的一種深頸部感染,約占了30%。然而關於扁桃腺周圍膿瘍及其復發的流行病學研究目前仍待研究。在本論文的第一部分,我們研究扁桃腺周圍膿瘍的發生率,復發率及其決定因子;第二部分研究扁桃腺切除後深頸部感染的風險。
研究一 扁桃腺周圍膿瘍的發生率,復發率及其決定因子
過去曾有文獻報導扁桃腺炎會增加扁桃腺周圍膿瘍的機會,然而這些研究並無一致性結果,也沒有控制不同治療方式可能造成的confounding effect,本研究目的即是探討扁桃腺周圍膿瘍的發生率,復發率以及扁桃腺炎和不同治療方式對復發造成的影響。收集全國所有從2001年到2009年因扁桃腺周圍膿瘍而住院的病人為我們研究的回溯性世代,總共有28837人因扁桃腺膿瘍住院而納入本研究,在平均4.74年的追蹤期間扁桃腺周圍膿瘍的復發率為5.15%。使用Cox proportional hazard model來分析發現前一年罹患5次以上扁桃腺炎者其扁桃腺周圍膿瘍復發的危險性是沒有扁桃腺炎者的2.82倍;而罹患1-4次扁桃腺炎者其復發的危險性則為1.59倍。治療上以細針抽吸的危險性為1.08倍,不具統計意義。在年齡分層後發現,在30歲以前的族群,若前一年罹患5次以上扁桃腺炎者,其危險性會更加升高;而細針抽吸使用於小於等於18歲的族群也會使復發的危險性變為1.98倍。扁桃腺周圍膿瘍的復發在所有年齡層都和扁桃腺發炎有關,前一年扁桃腺炎的次數愈多,復發的危險性也愈高。在治療方面使用細針抽吸只有在小於等於18歲的族群會提高復發的風險。
研究二: 扁桃腺切除與深頸部感染的風險
扁桃腺是人類上呼吸消化道對抗外來病原體的第一道防線,目前對於扁桃腺切除和發生深頸部感染的相關性仍不清楚。本研究目的就是要探討扁桃腺切除後的病人深頸部感染的發生率與風險。我們以回溯性世代研究的方式從台灣健保局資料庫收集從2001年到2009年的資料。總共有9915個接受過扁桃腺切除的病人納入本研究,對照組則選取99150人。在扁桃腺切除和對照組中,分別有34個病人(71.6/每100,000人年)和174的病人(36.6/每100,000人年)有深頸部感染。經過校正之後,無論是Cox Proportional hazard model或 propensity score model,扁桃腺切除病人的的深頸部感染發生率皆比一般人高1.71倍。此相關性並未因病人是因慢性/復發性扁桃腺炎或是呼吸中止症來接受手術而改變。根據此全國性的研究,我們發現深頸部感染的機率在扁桃腺切除的病人身上有明顯升高,未來仍需要更進一步的基礎研究來探討背後可能的發生機轉。

Deep neck infections (DNIs) are serious infectious diseases in the complex deep cervical fascia. Primary sources of DNIs arise from an infection focus of the tonsils, teeth, salivary glands, deep neck lymph nodes, or malignancy, and then progress to an abscess of the deep neck spaces. Tonsillar infection is the important source of this disease entity. Among several kinds of DNIs, peritonsillar abscess (PTA) is the most common type, comprising 30% of head and neck abscess. However the epidemiological knowledge about PTA and its recurrence is still not very well known .
In the first part of my research, I report the incidence of PTA, PTA recurrence rate and investigate the impact of previous tonsillitis and treatment modalities on the risk of PTA recurrence. In the second part of my research, I evaluate the risk for deep neck infections in patients underwent tonsillectomy.

Study I. The incidence of PTA/PTA recurrence and the impact of prior tonsillitis and treatment modality on the recurrence of peritonsillar abscess
Studies suggest an increased risk of peritonsillar abscess (PTA) recurrence in patients with prior tonsillitis. However, this association is inconsistent and could be confounded by different treatment modalities. The first study aimed to assess the risk of recurrence among PTA patients with different degrees of prior tonsillitis and treatment modalities. All in-patients with peritonsillar abscess between January 2001 and December 2009 were identified in a nationwide, retrospective cohort study. Factors independently associated with recurrence were analyzed using Cox proportional hazard model after adjusting for demographic and clinical data. There were 28,837 PTA patients, with a 14.49 in100000/year overall incidence. The recurrence rate was 5.15% during 4.74 years of follow-up. The recurrence rates were significantly higher among subjects with more than five prior tonsillitis or 1-4 prior tonsillitis compared to those without prior tonsillitis (adjusted hazard ratio, 2.82 [95% confidence interval, 2.39-3.33] and 1.59 [95% CI: 1.38-1.82]). The adjusted HR in patients treated with needle aspiration was 1.08 compared to those treated with incision &; drainage ( 95% CI: 0.85-1.38). After age stratification, the adjusted HRs of more than five prior tonsillitis increased to 2.92 and 3.50 in patients aged ≦18 and 19-29 years respectively. The adjusted HR of needle aspiration only increased in patients ≦18 years old (aHR: 1.98 [95% CI: 0.99-3.97]). The overall tonsillectomy rate was 1.48% during our study period. In brief, the risk of PTA recurrence increases with higher degrees of prior tonsillitis in all age groups and management by needle aspiration only in the pediatric population. Patients younger than 30 years old with PTA and more than five prior tonsillitis have the greatest risk of recurrence.

Study II. Tonsillectomy and the risk for deep neck infection
Although the tonsils contribute to first line immunity against foreign pathogens in the upper aero-digestive tract, the association of tonsillectomy with the risk of deep neck infection remains unclear. A total of 9,915 subjects that had undergone a tonsillectomy were identified in the Taiwan National Health Insurance Research Database from 2001 to 2009. Cox Proportional hazard models and propensity score models were performed to assess the association between tonsillectomy and deep neck infection after adjusting for demographic and clinical data. Patients that had undergone a tonsillectomy had a 1.71-fold greater risk of deep neck infection based both on Cox proportional hazard model (95% confidence interval, 1.13-2.59) and propensity score model (95% confidence interval, 1.10-2.66). This association was not altered in patients that underwent a tonsillectomy for either chronic/recurrent tonsillitis or sleep apnea/hypertrophy of tonsil (p=0.9797). Additional basic research is needed to explore the possible mechanisms behind these findings.

中文摘要 ………………………………………………………………………… i
英文摘要 ………………………………………………………………………… iii
目錄 ………………………………………………………………………… vi
表目錄 ………………………………………………………………………… vii
圖目錄 ………………………………………………………………………… viii
1.Introduction
1.1 Background ……………………………………………………………… 1
1.2 Objectives ……………………………………………………………… 5
1.3 Significance ………………………………………………………… 5

2.Literature Review
2.1 Incidence and PTA ……………………………………………………… 8
2.2 The relation between PTA and tonsillitis…… 12
2.3 PTA recurrence rate……………………………………………………… 14
2.4 Tonsillectomy and deep neck infection…………… 19

3.Materials and Methods
Research Part 1: The incidence of PTA, PTA recurrence and the impact of prior tonsillitis and treatment modality on the recurrence of PTA
3.1.1 Study designs ………………………………………………………… 25
3.1.2 Hypothesis ………………………………………………………………… 25
3.1.3 Subjects …………………………………………………………………… 26
3.1.4 Study variables ……………………………………………………… 27
3.1.5 Statistics …………………………………………………………………… 30

Research Part 2: Tonsillectomy and the risk for deep neck infection
3.2.1 Study designs ………………………………………………………… 32
3.2.2 Hypothesis ………………………………………………………………… 32
3.2.3 Subjects …………………………………………………………………… 33
3.2.4 Study variables ………………………………………………………… 34
3.2.5 Statistics …………………………………………………………………… 40

4.Results
4.1.1 The incidence of PTA, PTA recurrence and patient characteristics……………………………………………………………………………………… 41
4.1.2 Prior tonsillitis, treatment modalities and recurrent PTA ………………………………………………………………………………………………… 42
4.1.3 Age stratification………………………………………………………………………… 42
4.1.4 Tonsillectomy performed in PTA patients in Taiwan
…………………………………43
4.2.1 Patient characteristics and risk for DNI……………… 43
4.2.2 Analysis with Cox proportional hazard model……… 44
4.2.3 Analysis with Propensity score method…………………… 44

5.Discussion
5.1 Incidence of PTA, PTA recurrence and the impact of prior tonsillitis and treatment modality on PTA recurrence …………………………………………………………………………………………………………………………… 46
5.2 Tonsillectomy and the risk for deep neck infection. …………………………………………………………………………………… 50

6.Strength and limitations……………………………………………………… 55

7.Conclusions……………………………………………………………………………………………… 60

Reference……………………………………………………………………………………………………………… 72

Table List
Table 1. Previous epidemiological studies regarding the incidence Of PTA …………………………………………………………………………………… 11
Table 2. Literature reviews on the issue of PTA recurrence……………………………………………………………………………………………………… 18
Table 3. Variables used in “PTA recurrence”…………………………… 31
Table 4. Variables used in “ Tonsilletomy and the risk for deep neck infection in Taiwan”…………………………………………………………… 38
Table 5. Characteristics of patients with peritonsillar abscess……………………………………………………………………………………………………………… 64
Table 6. Adjusted hazard ratios for the risk of PTA recurrence……………………………………………………………………………………………………………… 65
Table 7. Risk of PTA recurrence stratified by age……………… 66
Table 8. Demographic characteristics of patients receiving tonsillectomy and subjects in the comparison group…………… 67
Table 9. Risk of deep neck infection for tonsillectomized patients and controls……………………………………………………………………………… 69
Table 10. Stratified by the indications for tonsillectomy…………………………………………………………………………………………… 70
Table 11. Hazard ratios of deep neck infection among patients with and without tonsillectomy, stratified by quintile of propensity score……………………………………………………… 71

Figure List
Figure 1. Assembly of PTA cohort……………………………………………… 61
Figure 2. Age distribution in the PTA cohort (2001-2009 )
………………………………………………………………………………………………………… 62
Figure 3. Incidence of PTA (per 100000 person-year) in the
study cohort………………………………………………………………………………… 62
Figure 4. PTA incidence by age group……………………………………… 63
Figure 5. Deep neck infection-free probability in two
cohorts……………………………………………………………………………………… 63

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