Braz. j. . vol.82 número6

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www.bjorl.org

Brazilian

Journal

of

OTORHINOLARYNGOLOGY

ORIGINAL

ARTICLE

The

role

of

the

mean

platelet

volume

and

neutrophil-to-lymphocyte

ratio

in

peritonsillar

abscesses

夽

,

夽夽

Mehmet

¸entürk

S

∗

_{, ˙Isa}

_Azgın,

_Gültekin

_Övet,

_Necat

_Alatas

_¸,

_Betül

_A˘

_gırgöl,

_Esra

_Yılmaz

KonyaEducationandResearchHospital,DepartmentofOtolaryngologyHeadandNeckSurgery,Konya,Turkey

Received19June2015;accepted28November2015 Availableonline28March2016

KEYWORDS Meanplatelet volume; Neutrophil-to-lymphcyterate; Peritonsillarabscess; Treatment

Abstract

Introduction:Peritonsillarabscessisaseriousinfectiousdiseaseofthetonsillartissue. Treat-ment generally requires both medical and surgical approaches to relieve the symptoms. Recently, in addition to clinical follow-up, some inflammatory markers, such as the mean platelet volumeandneutrophil-to-lymphocyte ratio,havebeenconsideredtobe additional inflammatorymonitoringmarkersininflammatorydiseases.

Objective:The aim of this study was to describe the role of mean platelet volume and neutrophil-to-lymphocyteratioinpatientswithperitonsillarabscess.

Methods:A retrospectivestudy wasconducted in88patients withperitonsillar abscessand 88healthyindividuals.Weanalyzedthewhitebloodcellcount,neutrophilcount,lymphocyte count,plateletcount,C-reactiveprotein,meanplateletvolumeandneutrophil-to-lymphocyte ratiovaluesandcomparedthemamongthepatientandcontrolgroups.

Results:Themeanplateletvolumelevelsweresignificantlyhigherintheperitonsillarabscess pretreatmentgroupthanintheperitonsillarabscessposttreatmentgroupandthecontrolgroup. Ameanplateletvolumevalueof8.7wastheoptimalcut-offvalueforevaluatingthesensitivity, specificity,positivepredictivevalueandnegativepredictivevalueof75%,65.9%,68%and72%, respectively.Theneutrophil-to-lymphocyteratiolevelsweresignificantlyhigherinthe periton-sillarabscesspretreatmentgroupthanintheperitonsillarabscesspost-treatmentgroupand thecontrolgroup.Aneutrophil-to-lymphocyteratiovalueof3.08wastheoptimalcut-offvalue forevaluatingthesensitivity,specificity,positivepredictivevalueandnegativepredictivevalue of90.9%,90.9%,90.9%and90.9%,respectively.Whilethewhitebloodcellcount,neutrophil count,lymphocytecountandC-reactiveproteinvaluesweresignificantlydifferentamongthe patientandcontrolgroups(p<0.05),theplateletcountwasnotsignificantlydifferentamong thepatientandcontrolgroups(p>0.05).

夽 _Please_cite_this_article_as:_S¸entürk_M,_{Azgın ˙I,}_Övet_G,_Alatas¸_N,_A˘_gırgöl_B,_Yılmaz_E._The_role_of_the_mean_platelet_volume_and neutrophil-to-lymphocyteratioinperitonsillarabscesses.BrazJOtorhinolaryngol.2016;82:662---7.

夽夽_The_protocol_of_this_study_was_approved_by_the_{institutional}_review_board_of_the_Selc_¸uk_University,_Medical_Faculty,_Konya,_Turkey (Decisionn◦_2015/123).

∗_{Corresponding}_author.

E-mail:drmehmetsenturk@gmail.com(M.S¸entürk). http://dx.doi.org/10.1016/j.bjorl.2015.11.018

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Conclusion: Themeanplateletvolumeandneutrophil-to-lymphocyteratiovaluesmadeusthink thattheseparameterswerequick,inexpensiveandreliableinflammatoryfollow-upparameters andcouldbeeasilyintegratedinto dailypracticeforperitonsillarabscess treatmentexcept plateletcount.

creativecommons.org/licenses/by/4.0/).

PALAVRAS-CHAVE Volumeplaquetário médio;

Relac¸ão

neutrófilos/linfócitos; Abscesso

periamigdaliano; Tratamento

Opapeldovolumeplaquetáriomédioearelac¸ãoneutrófilos/linfócitosemabscesso periamigdaliano

Resumo

Introdução: Oabscessoperiamigdaliano (APA)éumadoençainfecciosagravedotecido ton-silar.Oseutratamentogeralmenterequerumaabordagemmedicamentosaecirúrgicaparao alíviodossintomas.Recentemente,alémdoacompanhamentoclínico,algunsmarcadores infla-matórios,como ovolumeplaquetáriomédio(VPM)earelaçãoneutrófilos/linfócitos(RN/L), foramconsideradosmarcadoresdemonitoramentoadicionaisemdoençasinflamatórias.

Objetivo: Oobjetivodesteestudofoidescreveropapel osVPMeaRN/Lempacientescom APA.

Método: Estudoretrospectivorealizadocom88pacientescomATPe88indivíduossaudáveis. Analisamos a contagemde leucócitos, neutrófilos, linfócitos, plaquetas, proteína C-reativa (PCR),VPMeRN/Leacomparamososvaloresentreogrupodepacientesegrupocontrole.

Resultados: OsníveisdeVPMeramsignificativamentemaioresnogrupoAPApré-tratamento quenogrupoAPApós-tratamentoenogrupocontrole.Umvalordecortede8,7paraoVPM foiconsideradoidealparaavaliarsensibilidade,especificidade,valorpreditivopositivoevalor preditivonegativode75,65,9,68e72%,respectivamente.OsníveisdaRN/Leram significan-tementemaioresnogrupoAPApré-tratamentoquenogrupoAPApós-tratamentoenogrupo controle.Umvalorde3,08paraaRN/Lfoiovalordecorteidealparaavaliarsensibilidade, especificidade,valorpreditivopositivoevalorpreditivonegativode90,9,90,9,90,9e90,9%, respectivamente.Enquantoacontagemdosvaloresdeleucócitos,neutrófilos,linfócitosePCR foisignificantementediferenteentreosgruposdepacientesecontrole(p<0,05),acontagem deplaquetasnãofoi(p>0,05).

Conclusão:OsvaloresdeVPMeRN/Lsugeremqueestessãoparâmetrosinflamatóriosde acom-panhamentorápido,baratoeconfiável,equepodemserfacilmenteintegradosàpráticadiária paraotratamentodeAPA,excetopelacontagemdeplaquetas.

creativecommons.org/licenses/by/4.0/).

Introduction

Peritonsillarabscessisoneofthemostcommondeepneck infectionsandischaracterizedbytheaccumulationofpus between the palatine tonsils andthe superior pharyngeal constrictormuscle.1,2_Airway_obstruction,_abscess_rupture, pus aspiration,asphyxiaandsepticemia maydevelop asa resultofinadequatetreatmentoraprogressedinfection.3

This severeinfectionneedstobefollowed-upclinically aswellasbyperformingahematologicalparameter follow-up.2 _Although _{procalcitonin,} _{pro-adrenomedullin,}4 _serum amyloidA,fibrinogenandCD-14bindingprotein5_are_among the sensitive follow-up parameters that are used for fol-lowing up oninflammation, theymay not be available in everyinpatientservice’slaboratories andpresent an addi-tionalcost.However,simplehemogramvalues,suchasthe white blood cell (WBC) count, neutrophil count and lym-phocytecount,whichareamongthemostcommonlyused

parameters,areoftenavailableineveryclinicallaboratory andbear noadditional cost. Aroutine pus culture rarely changesthecourseoftreatment; however,itis expensive andshouldnotbesenttothelaboratory unlessthereisa findingthatrequiresare-assessmentoftheclinicalresults.2 Moreover,atleast48harenecessarytoreceiveresultsfrom abscesscultures.Delaysintreatmentselectionmaysuppress theimprovementinsymptomsandcanleadtoanincrease inthespreadofinfectionandlossofpatients’time.6

MPV is one of the platelet function indicators that reflects the platelet production rate and stimulation.7 _It wasfoundthattheMPV,whichisavailabletobemeasured inroutinehematologicalexaminations,directly correlates with the course of the disease, such as sepsis in neonates with a very low birth weight,8 _pediatric _acute pyelonephritis9_and_gastric_cancer.10

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numberoflymphocytes,wassuggestedbyZahorec,5_and_it wasconcludedthatitisasignificantprognosticparameter forpatientsundergoingtreatmentintheintensivecareunit. NLRwasalsoreportedasoneofthemostreliableindicators in distinguishingbetween patients withor without blood-streaminfectionsforthoseadmittedtoemergencyservices withasuspectedbloodstreaminfection11_;_as_a_better follow-upparameterthantheCRPlevels,WBCcountandneutrophil countforthefollow-upofbacteriemia4_;_and_as_a_prognostic factor in phaseI---III patients with colorectalcancer after curativesurgery.12

Althoughtheywerereportedtobeuseful,inexpensive, effective,reliableandeasily accessibleroutinehemogram parametersforfollow-upinmanyinflammatorydiseases,we couldnotfindanystudyintheliteratureregardingtheuse ofMPVandNLRinPTAtreatment.Theaimofthisstudyisto evaluatetheeffectivenessandusefulnessofMPVandNLR levelsinadditiontotheroutinehematologicalinflammatory follow-upparameters.

Methods

Retrospectively, 88 patients who had been hospitalized becauseof PTAbetween January 2008 andFebruary 2015 and 88 healthy individuals with normal hematological parameterswereincluded in the study.PatientswithPTA wereselectedfrompatientswhowerediagnosedwithPTA byan18gaugeneedleaspirationthatwasperformedonthe junctionoftheupperpoleofthemedialswelledtonsilsand uvulabaseand/orfrompatientswhohadpusdrainingfrom theincision.Theprotocolofthisstudywasapprovedbythe InstitutionalEthicalCommittee(Decisionn◦ _2015/123).

The clinical records of patients in the experimental and control groups were screened, and patient informa-tion regarding age, gender, clinical history and course of thediseasewereexamined.Patientswithhypertension, dia-betesmellitus,metabolicsyndrome,coronaryheartdisease, thyroiddysfunction,renalandhepaticdysfunction, malig-nancy, surgical history in the last 3 months, deviation of thenasalseptum,systemicinflammatorydisease,anemia, andchronicobstructivepulmonary disease(COPD)aswell asanypatientswhosmokedorusedmedicationforchronic inflammationwereexcludedfromthestudy.

The patients were divided into (i) pre-treatment, (ii) post-treatment, and (iii) control groups. In the patient group,theleukocytecount(WBC), neutrophilcount, lym-phocyte count, platelet count, C-reactive protein (CRP) levels, MPV levels and NLR levels were examined both at thetime of hospitalization(pre-treatment) and before discharge (post-treatment). Although the MPV values are automaticallycalculated by devices in routine hemogram parameters,theNLRvalueswereobtainedbydividingthe neutrophilcountbythelymphocytecount.Forhealthy indi-vidualsinthecontrolgroup,theotherparametersthatwere mentionedabovewereexamined,exceptforCRP(because CRPisanacutephasereactantthatindicatesacute inflam-mation).

Bloodsampleswerecollectedintubescontaining ethyl-enediaminetetraaceticacid(EDTA)andwereanalyzedinour laboratory.Thehematologicalparametersofpatientswere analyzed witha SysmexXE-2100T Automated Hematology

System(Japan),andnephelometricanalysiswasperformed with a Siemens BNTM-II, Automated Analyser (Germany). The reference range in our laboratory was 6.5---12fL for MPV,4.4---11.3(103␮L)forleukocytes,150---450(103␮L)for

platelets, 0.9---3.2 (103␮L) for lymphocytes and 0---5mg/L

forCRP.

Statisticalanalysis

All of the statistical calculations were performed using the SPSS statistical software package (SPSS, version 16.0 for Windows, SPSS, Inc., Chicago, IL). The suitability of the variables for a normal distribution was tested by the Kolmogorov---Smirnov test. The mean±standard deviation (SD) of the data was given as descriptive statistics. The variables in the normal distribution were comparedusing at-test.TheMann---WhitneyUtestwasusedforthe varia-blesthatdidnotfitanormaldistribution.ROCanalysiswas performed for the MPV and NLR toassess the sensitivity, specificity, positive predictive value and negative predic-tive value. A probability value of p<0.05 wasconsidered statisticallysignificant.

Results

There were 88 patients in the PTA group; 46 were male (52.3%)and42werefemale(47.7%).The meanageofthe patientgroupwas35.90±11.62years.Inthecontrolgroup, therewere88healthysubjects;47weremale(53.4%)and41 werefemale(46.6%).Themeanageofthecontrolgroupwas 34.59±12.84. There wasno significant differenceamong patient and control groups in terms of age (p=0.480) or gender(p=1.000).

Considering the MPV values of the groups, the pre-treatment MPV values of the PTA group had higher MPV levelsthanthePTApost-treatmentgroup(10.03±1.56vs. 8.76±2.12fL;p=0.001)andthecontrolgroup(10.03±1.56 vs.8.45±1.35fL;p=0.001);thedifferenceswere statisti-callysignificant.ROCcurveanalysisrevealedthattheMPV levelcut-offpointforadiagnosisofPTAwas8.7fL,witha sensitivity,specificity, positivepredictivevalue(PPV),and negativepredictivevalue(NPV)of75%,65.9%,68%and72%, respectively(areaundercurve:0.782).The MPVvaluesof thegroupsaredepictedinFig.1.

The pre-treatment NLR values of the PTA group had higher levels of NLR than the PTA post-treatment group (7.12±4.29 vs. 2.60±1.44; p=0.001) and the control groups (7.12±4.29 vs. 2.02±0.80; p=0.001); the differ-ences were statistically significant. ROC curve analysis revealedthattheNLRlevelcut-offpointforadiagnosisof PTA was 3.08, with a sensitivity, specificity, positive pre-dictivevalue(PPV),andnegativepredictivevalue(NPV)of 90.9%, 90.9%, 90.9% and 90.9%, respectively (area under curve: 0.976).The NLR valuesof the groups aredepicted inFig.2.

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Table1 HemogramtestresultsandtheMPV,NLRandPLRvaluesofthepre-treatmentandpost-treatmentpatientsandthe controls.

Parameter Group1

(Pre-treatmentgroup ofPTA)

Group2 (Post-treatment groupofPTA)

Group3 (Controlgroup)

p-Value

WBC(103_/

␮L) 15.13±4.19 7.65±1.72 7.18±1.43 0.001a,b;0.51c

NEU(103_/

␮L) 11.82±3.98 4.61±1.20 4.19±1.13 0.001a,b;0.18c

LYM(103_/

␮L) 1.96±0.76 2.08±0.83 2.22±0.56 0.291a;0.012b;0.191c

PLT(103_/

␮L) 273.65±87.39 273.58±59.24 258.03±62.90 0.993a;0.176b;0.93c

CRP(mg/L) 116.34±73.22 3.09±1.03 NS 0.001a_;_NSb,c

MPV(fL) 10.03±1.56 8.76±2.12 8.45±1.35 0,001a,b_,_0.247c

NLR 7.12±4.29 2.60±1.44 2.02±0.80 0.001a,b_;_0.006c NS,nonstudied.

a _Group₁_vs._Group_2. b _Group₁_vs._Group_3. c _Group₂_vs._Group_3.

14

12

10

MPV (fl)

8

Pretreatment MPV Posttreatment MPV Control MPV 6

4

Figure 1 MPV values in the PTA pretreatment and post-treatmentgroupsandthecontrolgroup.

25 13

11 36

57

50

29

68 42 20

15

10

NLR

5

0

Pretreatment NLR Posttreatment NLR Control NLR

Figure 2 NLR values in the PTA pretreatment and post-treatmentgroupsandthecontrolgroup.

Discussion

Peritonsillarabscesseshavebeenwelldescribed;thedisease wasdiscussed intworecentreviewsfromvariousaspects, such as differentiation from infective mononucleosis,

pusculturefeatures,imagingmodalities,surgicaltreatment approaches,medicaltreatmentfeatures,admissionor out-patient management and interval tonsillectomy issues.2,3 However,follow-up with additional inflammatory markers was not discussed in these reviews. To the best of our knowledge,thereisnopublicationregardingthe investiga-tionof the WBC count,lymphocyte count, plateletcount and CRP levels together with the MPV and NLR levels. Thus,ourstudywasintendedtocomparetheseparameters betweenpatientswithperitonsillarabscessesandacontrol group.

Inthe medicalandsurgical treatment of patients with aperitonsillarabscess,thehematologicalinfection follow-upparametersarerequiredaswellasaroutinefollow-up for the improvement in symptoms. The white blood cell count (WBC), neutrophil count, lymphocyte count and C-reactiveprotein(CRP)levelsareamongthemostcommonly usedhematologicalparametersformonitoringthe effective-nessofinfectiousdiseasetreatment.13_In_the_{pre-treatment} and post-treatment comparison of the white blood cell count(WBC),neutrophilcount,lymphocytecount,platelet countandCRP levelsof patientswithPTA,the difference betweenthepre-andpost-treatmentWBCcount,neutrophil countandCRPlevelsofpatientswithPTAwerestatistically significant,whereastherewasnostatisticallysignificant dif-ferencebetweenthelymphocytecountandplateletcount inourstudy.

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NLRwasshown tobea biomarkerthatdifferentiates bac-teremiain patientsfromasuspectedcommunity-acquired infection.11 _It_was_shown_that_the_NLR_values_{differentiate} bacteremiasignificantlybetterinpatientsadmittedtothe emergencydepartmentthantheroutineparametersofthe CRP level, WBCcount and neutrophil count.4 _In _addition, NLRwasreportedtobesuperiortootherroutinehemogram valuesindistinguishingcommunity-acquiredpneumoniaand pulmonary tuberculosis.14 _NLR _was _also _reported _to _be _a veryeffective parameter that providesinformation about theprognosisandfollow-upofmyocardialinfarction,15 gan-grenousappendicitis16_and_colorectal_cancer.12_According_to ourstudy,therewasa statistically significant decreasein post-treatmentNLRvaluescomparedtothepre-treatment ones.

Plateletsareinvolved inthepathogenesis ofinfectious diseasesinadditiontotheirprimaryhemostaticfunctions.17 Therecanbechangesintheplateletdiameterinresponse toinfectionduringthecourseofinfectiousdiseases;there may be an increase in MPV during a serious infection, and this increase in MPV may be a result of the rapid releaseof platelets in the spleen.18 _In _other _words, _MPV increasesintheinitialphaseofinfectionsasaninflammatory marker. Additionally, it was found to be increased com-paredtothecontrolsinacutepyelonephritis,9_in_acidic_fluid infections,19_in_severe_{community-acquired}_pneumonia_that requires hospitalization20 _and _in _infective _{endocarditis.}21 In our study, it was observed that the MPV parameter in patients withperitonsillar abscesseswas increasedin the pre-treatmentphaseandsignificantlydecreasedafter treat-ment.

Conclusion

Inourstudy,it wasbelieved thattheMPVandNLR values couldbeusedasaquick,inexpensiveandreliable inflamma-toryfollow-up parameter duringPTAtreatment and could easilybe integratedinto thedaily practicefor PTA treat-ment.Itwasalsoobservedthatplateletcountisnotaffected by the course of PTA. In addition, this study is the first investigation of the effectiveness and significance of the MPVand NLR valuesin PTA’sclinical follow-up. Regarding this issue, further studies are needed to assess changes ininflammatory markers in largergroups of patients with PTA.

Conflicts

of

interest

Theauthorsdeclarenoconflictsofinterest.

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