Morbidity after pediatric tonsillotomy versus tonsillectomy: A population‐based cohort study

Comparison of postoperative bleeding in pediatric tonsillectomy versus tonsillotomy

OBJECTIVE

Tonsillar surgery is a common intervention for pediatric obstructive sleep apnea and recurrent tonsillitis. This study compared postoperative bleeding incidence and severity following tonsillotomy and tonsillectomy at a single medical center.

STUDY DESIGN

A retrospective cohort study on 1984 pediatric patients (1-18 years old) who underwent surgery during 2004-2011 and 2019-2022. Tonsillectomy was performed during 2004-2011, while tonsillotomy was preferred for obstructive sleep apnea during 2019-2022. Tonsillectomy was performed using cold steel technique with complete removal of tonsillar tissue, while tonsillotomy was conducted using mono- or bipolar diathermy, preserving minimal tissue on the tonsillar capsule.

SETTING

Shaare-Zedek Medical Center, Faculty of Medicine, Hebrew University.

METHODS

Outcome measures included postoperative bleeding incidence and severity, surgery duration, hospitalization length, and readmission.

RESULTS

Tonsillotomy was conducted on 958 (48.3 %) patients, and tonsillectomy was performed on 1026 (51.7 %) patients. Obstructive sleep apnea was the only indication in 1553 (78.3 %) patients. Overall bleeding rate was lower following tonsillotomy (3.9 %) than tonsillectomy (9.5 %) (p < 0.001). Significantly more patients required surgical bleeding control post-tonsillectomy than post-tonsillotomy: 39 (3.7 %) vs. 5 (0.5 %), respectively (p < 0.001). Tonsillectomy resulted in higher readmission rates (11.8 % vs 6.1 %, p < 0.001), more blood transfusions (3 vs. 0), and higher postoperative hemoglobin diminution (1.57 ± 2 vs. 0.94 ± 1 g/dL, p = 0.035). The duration of the surgery was shorter for tonsillotomy (24.7 vs 26.5 min, p = 0.012). Tonsillectomy sustained higher bleeding rates for obstructive sleep apnea patients (7.0 % vs 3.9 %, p = 0.006). For recurrent tonsillitis patients, bleeding rates did not vary between year groups. Older age and tonsillectomy were the most significant risk factors for postoperative bleeding.

CONCLUSION

Among children undergoing tonsillar surgery for obstructive sleep apnea, tonsillotomy was associated with a safer postoperative bleeding profile, reduced bleeding severity, and fewer readmissions compared to tonsillectomy.

Care of the Pediatric Patient for Ambulatory Tonsillectomy With or Without Adenoidectomy: The Society for Ambulatory Anesthesia Position Statement

The landscape of ambulatory surgery is changing, and tonsillectomy with or without adenoidectomy is one of the most common pediatric surgical procedures performed nationally. The number of children undergoing tonsillectomy on an ambulatory basis continues to increase. The 2 most common indications for tonsillectomy are recurrent throat infections and obstructive sleep-disordered breathing. The most frequent early complications after tonsillectomy are hemorrhage and ventilatory compromise. In areas lacking a dedicated children's hospital, these cases are managed by a nonpediatric specialized anesthesiologist and general otolaryngology surgeon. In response to requests from our members without pediatric fellowship training and/or who care for pediatric patients infrequently, the Pediatric Committee of the Society for Ambulatory Anesthesia (SAMBA) developed a position statement with recommendations for the safe perioperative care of pediatric patients undergoing tonsillectomy with and without adenoidectomy in freestanding ambulatory surgical facilities. This statement identifies children that are more likely to experience complications and to require additional dedicated provider time that is not conducive to the rapid pace and staffing ratios of many freestanding ambulatory centers with mixed adult and pediatric practices. The aim is to provide health care professionals with practical criteria and suggestions based on the best available evidence. When high-quality evidence is unavailable, we relied on group consensus from pediatric ambulatory specialists in the SAMBA Pediatric Committee. Consensus recommendations were presented to the Pediatric Committee of SAMBA.

Outcome of tonsillotomy in children with obstructive sleep-disordered breathing

OBJECTIVE/BACKGROUND

Most children treated for obstructive sleep disordered breathing (oSDB) are not systematically assessed by polysomnography (PSG) nor by structuredsymptom quantification before surgical treatment. The main objective of this study wasto investigate the effect of adeno-tonsillotomy (ATO) on symptom burden and PSGparameters.

METHODS

Children aged 2-10 years with oSDB were selected for ATO based uponclinical findings according to current standards of care in Denmark. Each childunderwent standardized assessment before and 3 months after surgery, including aPSG, tonsil size assessment, and the Pediatric Sleep Questionnaire -Sleep RelatedBreathing Disorder (PSQ) to quantify symptom burden. Obstructive sleep apnea (OSA)was defined as an obstructive apnea-hypopnea index (oAHI) ≥2/h. Successfultreatment was defined as post-surgery oAHI ≤5/h, and complete cure as oAHI ≤2/h.

RESULTS

Fifty-two children were included. Mean age was 5.0 years (SD ± 1.76). Thirteen children were identified with baseline oAHI <2/h. Significant improvement inOSA severity was observed in children with moderate-to-severe OSA, in whom oAHI decreased from 15.7/h to 2.6/h (p < 0.001). Treatment success was obtained in 85% and cure was obtained in 42% of children. PSQ-score significantly improved from 0.52 (CI 0.47-0.56) to 0.26 (CI 0.21-0.32) (p < 0.001). Baseline OSA severity was notcorrelated to baseline symptom burden nor to symptom relief after ATO. There were noserious adverse events.

CONCLUSIONS

Adeno-tonsillotomy significantly reduced symptom burden in otherwise healthy children with oSDB symptoms. Significant improvement in oAHI was observedonly in children with moderate-to-severe OSA. We recommend combining clinicalevaluation with PSQ and oAHI.

Adenotonsillectomy for Obstructive Sleep Apnea in Children

Obstructed breathing is the most common indication for tonsillectomy in children. Although tonsillectomy is performed frequently worldwide, the surgery is associated with a number of significant complications such as bleeding and respiratory failure. Complication risk depends on a number of complex factors, including indications for surgery, demographics, patient comorbidities, and variations in perioperative techniques. While polysomnography is currently accepted as the gold standard diagnostic tool for obstructive sleep apnea, studies evaluating outcomes following surgery suggest that more research is needed on the identification of more readily available and accurate tools for the diagnosis and follow-up of children with obstructed breathing.

Procedural outcomes in children with mild type 1 von Willebrand disease

Background

In patients with mild type 1 von Willebrand disease (VWD), treatment guidelines suggest individualization of surgical management. However, these conditional recommendations are based on very low-certainty evidence due to limited data on surgical outcomes in this population.

Objectives

To characterize procedural bleeding prophylaxis strategies and outcomes in children with mild type 1 VWD.

Methods

This is a retrospective cohort study that included patients aged between 0 and 21 years with mild type 1 VWD (defined as von Willebrand factor antigen and/or an activity of 30-50 IU/dL) who underwent a procedure from July 1, 2017, to July 1, 2022. Demographic, surgical, medication, and bleeding data were collected by manual chart review.

Results

A total of 161 procedures were performed in 108 patients. The population was primarily female (75%), White (77.8%), and non-Hispanic (79.6%). Median age was 15.8 years (IQR, 8.2-17.6). Fifty-nine surgeries were classified as major, 66 as minor, and 36 as dental. For most procedures, patients received only antifibrinolytics for bleeding prophylaxis (n = 128, 79.5%); desmopressin was used in 17 (10.6%) procedures, and von Willebrand factor concentrate was used in 12 (7.5%) procedures. Bleeding complications occurred in 8 (5.0%) procedures: these included 1 major, 4 clinically relevant nonmajor, and 3 minor bleeding events. No patient required blood transfusion or an additional procedure to achieve hemostasis. Most bleeding complications were seen following intrauterine device (IUD) placement (5/8). Nearly 30% of patients who underwent IUD placement reported bleeding.

Conclusion

Pediatric patients with mild type 1 VWD can safely undergo procedures using a tailored approach. Bleeding complications were uncommon, with the majority following IUD placement.

Long-term complications after tonsil surgery: an analysis of 54,462 patients from the Swedish Quality Register for Tonsil Surgery

Objective

This study aims to evaluate long-term complications after tonsil surgery using an exploratory retrospective cohort study design based on data from the Swedish Quality Register for Tonsil Surgery (SQTS).

Methods

All patients registered in the SQTS between 1 January 2009 and 31 May 2021 were eligible for the study. In this study, a long-term complication is defined as any complication persisting for a minimum of 6 months after surgery. The definition of a complication was based on individual patient reports, provided in a free text format, of any remaining issues 6 months after tonsil surgery. Complications were categorized as follows: disturbed taste or sense of smell, dysphagia, miscellaneous and general symptoms and signs, miscellaneous throat problems, pain or discomfort in the mouth or throat, problems with jaws or teeth, problems with the ears or hearing, problems with the nose or sinuses, problems with throat secretions or throat clearing, problems with voice or speech, and sensory symptoms. A multivariable logistic regression analysis was used to identify independent predictors of long-term complications.

Results

In total, 54,462 patients were included in the study. A total of 3,780 patients (6.9%) reported one or more long-term complications. The most frequent long-term complications, with a plausible connection to the surgery, were found in the following categories: pain or discomfort in the mouth or throat (1.9%), problems with throat secretions or throat clearing (0.8%), dysphagia (0.6%), and problems with voice or speech (0.6%). Tonsillotomy was associated with a lower risk of long-term complications than tonsillectomy.

Conclusion

This study suggests that subjective long-term complications after tonsil surgery, in general, are relatively common (6.9%). However, complications with a plausible connection to the surgery were less common (4.0%), and specific complications seemed to be relatively rare, with no single specific problem reaching a prevalence of ≥0.6%.

Comparison of three common tonsil surgery techniques: cold steel with hot hemostasis, monopolar and bipolar diathermy

PURPOSE

To analyze the risk of postoperative hemorrhage in tonsil surgery with different surgical methods, instruments, indications, and age groups. Monopolar diathermy compared to bipolar diathermy was of particular interest.

METHODS

The data from tonsil surgery patients were retrospectively collected between 2012 and 2018 in the Hospital District of Southwest Finland. The surgical method, instruments, indication, sex and age and their association with a postoperative hemorrhage were analyzed.

RESULTS

A total of 4434 patients were included. The postoperative hemorrhage rate for tonsillectomy was 6.3% and for tonsillotomy 2.2%. The most frequently used surgical instruments were monopolar diathermy (58.4%) cold steel with hot hemostasis (25.1%) and bipolar diathermy (6.4%) with the overall postoperative hemorrhage rates 6.1%, 5.9% and 8.1%, respectively. In tonsillectomy patients, the risk for a secondary hemorrhage was higher with bipolar diathermy compared to both monopolar diathermy (p = 0.039) and the cold steel with hot hemostasis technique (p = 0.029). However, between the monopolar and the cold steel with hot hemostasis groups, the difference was statistically non-significant (p = 0.646). Patients aged > 15 years had 2.6 times higher risk for postoperative hemorrhage. The risk of a secondary hemorrhage increased with tonsillitis as the indication, primary hemorrhage, tonsillectomy or tonsillotomy without adenoidectomy, and male sex in patients aged ≤ 15 years.

CONCLUSION

Bipolar diathermy increased the risk for secondary bleedings compared to both monopolar diathermy and the cold steel with hot hemostasis technique in tonsillectomy patients. Monopolar diathermy did not significantly differ from the cold steel with hot hemostasis group regarding the bleeding rates.

Readmission after OSA surgery in pediatric patients

OBJECTIVES

This study aimed to determine the readmission rate after adenotonsillectomy with the diagnosis of obstructive sleep apnea (OSA) and analyze the factors associated with readmission.

METHODS

It was planned as a retrospective study conducted in a single institution that included pediatric patients who underwent adenotonsillectomy with OSA diagnosis between December 2018 and March 2021. Patients who were readmitted for bleeding or pain/dehydration were compared with those who did not require readmission.

RESULTS

The mean postoperative admission time was 7.27 ± 3.49 days in patients with bleeding and 3.5 ± 2.27 days in patients with pain or dehydration. The mean length of stay in the hospital was 2.6 ± 1.6 days in patients with bleeding and 3.13 ± 2.03 days in patients with pain or dehydration. The postoperative admission time was 5.96 ± 3.57 days, and the hospital stay after readmission was 2.78 ± 1.73 days. No statistically significant correlation was found in terms of age, gender, surgeon's experience, use of electrocautery and seasonality factors, and readmission rates.

CONCLUSIONS

In children who underwent adenotonsillectomy for OSA, the hospitalization period of patients hospitalized due to pain/dehydration is much longer than patients admitted with bleeding. Therefore, measures to reduce pain or dehydration have the most significant potential to reduce the readmission rate and length of stay.

Postoperative morbidity and mortality after adenoidectomy: A national population-based study of 51 746 surgeries

OBJECTIVES

To investigate postoperative morbidity and mortality after paediatric adenoidectomy.

METHODS

This was a retrospective national population-based cohort study of data from the Swedish National Patient Register (NPR) and The Swedish Cause of Death Register (CDR). All patients aged 0-18 years who underwent adenoidectomy from 2007 to 2017 (without concomitant tonsil surgery) were included in this study. To evaluate postoperative morbidity and mortality, all diagnostic and surgical codes registered in the NPR for health care contacts within 30 days of surgery were analysed. The patients retrieved from the NPR were matched with the CDR to identify any deaths occurring within 30 days of the surgery.

RESULTS

A total of 51 746 adenoidectomies were included in this study. No deaths related to adenoidectomy were identified. All types of haemorrhagic complications were rare. Only 0.1% of the surgeries resulted in an outpatient contact due to postoperative haemorrhage and only 0.1% of the adenoidectomies resulted in a readmission due to haemorrhage. The rarest haemorrhagic complication was RTT (return to theatre), with only 4 events (0.01%). Postoperative haemorrhage was most frequent on the first day after surgery. Other complications were rare as well, requiring a total of 922 (2.6%) outpatient visits and 75 (0.2%) readmissions in the adenoidectomy group, with postoperative infection being the most commonly reported.

CONCLUSIONS

Overall, adenoidectomy should be considered a safe surgical procedure associated with few postoperative complications. No deaths related to adenoidectomy were found. Severe complications, such as late postoperative haemorrhage after adenoidectomy, were rare, and haemorrhage resulting in RTT was even rarer. The highest rate of postoperative haemorrhage was observed the first day after surgery, and most haemorrhagic complications occurred within a week. Comparisons with studies on tonsil surgery show that adenoidectomy is associated with substantially lower postoperative morbidity.

Patient injuries from tonsil and adenoid surgery in Finland

Objectives

The aims of this national register-based study were to examine patient injury claims related to tonsil and adenoid surgery injuries and to compare the frequency of claims between tonsillectomies and tonsillotomies in Finland.

Methods

We analyzed the complaints related to tonsil and adenoid surgery received by the Finnish Patient Insurance Center (PIC) between the years 2000 and 2019. One hundred seventy-two cases were included in the analysis. The annual surgery rates between the years 2000 and 2018 were acquired from the Finnish Institute for Health and Welfare.

Results

During the years 2000 to 2018, a total of 292,679 patients had tonsil and/or adenoid surgery nationwide. For tonsil or adenoid surgeries, the national average was 5.3 cases and 1.8 cases per 10,000, respectively, resulting in patient injury claims and compensations. A total of 33.1% of the claims regarding tonsil or adenoid surgery processed by the PIC were compensated. Most of the claims were made after a tonsillectomy (87.8%), and few were made after a tonsillotomy (1.7%). Seven deaths were recorded.

Conclusion

Patient injuries from tonsil and adenoid surgeries were mostly related to traditional extracapsular tonsillectomies. Most surgeries, along with most complications, involved specialists, who performed routine operations in high-volume centers. Surgeries for acute or recurrent infections resulted in more claims. Severe complications arising from tonsil and adenoid surgeries were rare.

Level of Evidence

4.

Reducing post-tonsillectomy haemorrhage: a multicentre quality improvement programme incorporating video-based cold technique instruction

OBJECTIVE

Data from the Norwegian Tonsil Surgery Register (NTSR) showed large differences between the hospitals in Norway in the readmission rate due to post-tonsillectomy haemorrhage (rrPTH; range, 0%-25%; national average, 8%). Because of these large variations in the rrPTH, we conducted a quality improvement project involving hospitals with good and bad readmission rates.

METHODS

Seven hospitals with readmission rates greater than 10% and four with rates lower than 5% participated in this project. We recorded videos of ear, nose and throat surgeons from the hospitals with low readmission rates when they performed extracapsular tonsillectomy, and these videos of cold dissection tonsillectomy were used as teaching material for examples of good surgical skills for the other hospitals. After a 2-day workshop, all participants from the hospitals went back to their institutions and prepared local plans to improve their results. We used the Plan-Do-Study-Act model. The primary outcome variable was the patient-reported rrPTH in the NTSR. As secondary goal, we aimed to identify aspects of the tonsillectomy procedure that could help achieve a lower rrPTH.

RESULTS

The participating hospitals reduced their rrPTH from 18% at baseline (2017/2018) to 7% in 2020. Six of seven hospitals changed their dissection technique significantly to more use of cold dissection.

CONCLUSION

By learning cold dissection tonsillectomy from surgeons with low rrPTH, it seems possible to decrease the rates of bleeding complications after tonsillectomy. A combination of videos as a teaching tool, new treatment plans, and focus on quality and improvement may effectively improve surgical results. The videos can show details that are difficult to convey in the literature. Quality registers can be used to identify areas requiring improvement and evaluate the effects of changes in practice.

Comparison of perioperative indicators, treatment efficacy, and postoperative complications between tonsillotomy and tonsillectomy for children with obstructive sleep apnea hypopnea syndrome

OBJECTIVE

This study aimed to compare the perioperative indicators, treatment efficacy, and postoperative complications between tonsillotomy and tonsillectomy for children with obstructive sleep apnea hypopnea syndrome.

METHODS

A total of 134 children with obstructive sleep apnea hypopnea syndrome were divided into tonsillotomy group (n=66) and tonsillectomy group (n=68). The tonsillotomy group received tonsillotomy treatment with a power cutter, while the tonsillectomy group received tonsillectomy treatment. The perioperative indicators, treatment efficacy, and postoperative complications were compared between the two groups.

RESULTS

There was no significant difference in operative time between the two groups (p>0.05), with significant difference in amount of blood loss, postoperative Visual Analogue Scale score, food intake amount, and general diet-taking starting time between the two groups (p<0.05). The total effective rate of treatment had no significant difference between the two groups (p>0.05). There was significant difference in postoperative bleeding, upper respiratory tract infection, and pharyngeal scar grade between the two groups (p<0.05).

CONCLUSIONS

Compared with tonsillectomy treatment for children with obstructive sleep apnea hypopnea syndrome, tonsillotomy treatment is more beneficial to optimize the perioperative indicators, relieve the postoperative pain, facilitate the postoperative recovery, and reduce the postoperative complications, which is worthy of clinical promotion.

Safety and long-term efficacy of tonsillectomy versus subtotal tonsillectomy in children with sleep disordered breathing

OBJECTIVES

to compare safety and long-term symptoms after TE compared to Subtotal Tonsillectomy (STT).

METHODS

A retrospective review data of 412 patients, one to twelve years old that underwent either TE or STT, as treatment for sleep disorder breathing, at two different medical centers. Symptoms were assessed by a questionnaire 3-5 years post-surgery. Additionally, data regarding immediate post-operative symptoms and complications were also collected.

RESULTS

Long-term symptoms score was significantly lower in the TE group: 1.585 (±1.719) compared to 1.967 (±1.815) in the STT group (p = 0.033); 51.3% of patients in the ST group presented long-term SDB symptoms, compared to 40.6% in the TE group (p = 0.035); The main difference between the groups was snoring as 49% of the STT group suffered from snoring, versus 28.9% in the TE group (p < 0.001).

CONCLUSIONS

TE showed an advantage over STT in resolving snoring in the long term.

Coblation intracapsular tonsillectomy in children: A prospective study of 1257 consecutive cases with long-term follow-up

OBJECTIVES

Intracapsular tonsillectomy (ICT) is increasingly adopted by paediatric centres worldwide due to its association with reduced pain, fast recovery and low risks of post-operative complications. Questions still surround its role in patients with recurrent tonsillitis, as well as tonsillar regrowth requiring revision surgery.

DESIGN

Prospective consecutive case series from March 2013 to April 2020.

SETTING

Tertiary paediatric ENT referral centre.

PARTICIPANTS

Paediatric patients undergoing Coblation ICT, with or without adenoidectomy, for obstructive and/or infective indications.

MAIN OUTCOME MEASURES

Health-Related Quality of Life (HRQL), analgesia requirement, post-operative haemorrhage rates, time to return to normal diet and activity or school/nursery, and parental satisfaction. We report revision surgery rates and identify predictive factors for revision surgery.

RESULTS

A total of 1257 patients (median age 4.2 years) underwent Coblation ICT, with a median direct and implied follow-up of 101.5 and 1419 days, respectively. We noted significantly improved HRQL scores across all domains. Median analgesia requirement was six days, and no patients required a return to theatre for post-operative haemorrhage. The majority of patients were eating a normal diet within 24 hours and returned to normal activity/school within a week post-operatively. Revision surgery was required in 2.6% of cases, mainly due to recurrent obstructive symptoms from tonsillar regrowth. Being under two years old at initial surgery (OR 5.10), having severe OSA (OR 4.43) or severe comorbidities (OR 2.98) increased the risk of needing revision surgery.

CONCLUSIONS

Long-term data demonstrate the efficacy and safety of Coblation ICT in paediatric patients across a range of indications.

Monopolar tonsillotomy versus cold dissection tonsillectomy in children: Prospective study on postoperative recovery

OBJECTIVES

To compare postoperative self-reported recovery results with monopolar tonsillotomy and cold dissection tonsillectomy in children. To evaluate the feasibility of the monopolar technique in tonsillotomy.

METHODS

Children <12 years undergoing tonsillotomy or tonsillectomy between April 2018 and March 2020 who (with a caregiver) were willing to participate in a two-week follow-up formed the study group. They filled in a questionnaire about pain-related outcomes, return to normal activities, weight changes, complications, and length of home care.

RESULTS

Altogether 166 patients were recruited; 103 (62%) returned the questionnaire. The first pain-free day with tonsillotomy was day 5 and with tonsillectomy day 11. After tonsillotomy, patients returned to normal activities faster, e.g. they were able to eat normally 6.5 days earlier than tonsillectomy patients. During the first postoperative week weight dropped after tonsillectomy, but not after tonsillotomy. The length of home care was 6 days with tonsillotomy and 10 days with tonsillectomy. The incidence of postoperative hemorrhage (including minor bleedings at home) was 14% after tonsillotomy and 32% after tonsillectomy. Hemorrhages needing interventions were 0% with tonsillotomy and 2% with tonsillectomy.

CONCLUSION

Children operated on with monopolar tonsillotomy recovered faster and had less postoperative hemorrhage than those undergoing tonsillectomy. They were able to return earlier to daycare/school and their caregivers back to work. Recovery results with monopolar tonsillotomy were equal to other tonsillotomy techniques reported in the literature, hence the monopolar technique can be considered an alternative method to perform tonsillotomy.

Efficacy of bupivacaine infiltration for controlling post-tonsillectomy pain, duration of surgery and post-operative morbidities: A systematic review and meta-analysis

The objective of the present review and meta-analysis was to evaluate the efficacy of bupivacaine during tonsillectomy in terms of reducing the mean operative procedure duration, post-operative pain and the onset of post-operative morbidities. The Preferred Reporting Items for Systematic reviews and Meta-Analyses guidelines were followed to perform a systematic literature search using the MEDLINE, Scopus, EMBASE and CENTRAL databases. The present meta-analysis sought to evaluate the efficacy of bupivacaine administered during tonsillectomy as compared to the administration of normal saline. The efficacy of the intervention was evaluated based on pain scores using the visual analogue scale, the duration of the operation and the occurrence of post-operative morbidities. Out of 1,427 records, 15 articles with 729 participants (mean age, 10.2±6.7 years) were included in the study. The present systematic review supported the use of bupivacaine during tonsillectomy at a level of evidence of 1b and confirmed beneficial effects of bupivacaine intervention by demonstrating small to large effect reductions in the visual analog scale score (Hedge's g, -1.48), the mean duration of the operative procedure (Hedge's g, -1.35) and the incidence of post-operative morbidity (Hedge's g, -0.23) in comparison to the placebo groups treated with normal saline. Based on these results, the administration of bupivacaine is recommended during tonsillectomies to reduce the perceived level of pain, the duration of the operation and the post-operative morbidity.

MRI evaluation of distance between tonsillary fossa and internal carotid artery in children

OBJECTIVES

The presence of the internal carotid artery (ICA) near tonsils can also cause severe bleeding during a tonsillectomy. We investigated the relationship between tonsil width and volume; and superior, middle and inferior tonsil-ICA distances in 5-9 and 10-15 years of age children.

METHODS

Cranial MRI images of 200 children between 5 and 15 years of age were evaluated retrospectively. There were 100 children in group 1 (5-9 years of age) and 100 children in group 2 (10-15 years of age). Palatine tonsil width and volume; and superior, middle and inferior tonsil-internal carotid artery (ICA) measurements were performed bilaterally.

RESULTS

Our results showed that bilateral tonsil width and volume; and left superior, middle and inferior tonsil-ICA distance of 5-9 years of age group were lower than those of the 10-15 year-of age group (p < 0.05). The nearest distance between ICA and palatine tonsil is at the inferior tonsil-ICA distance side in both age groups. Especially mean inferior and middle tonsil-ICA distances were lower than 8 mm in 5-9 years of age group and lower than 9 mm in 10-15 years of age group. Minimum middle tonsil-ICA distances were 2.0-2.50 mm in smaller children and 2.0-3.50 mm in older children. Similarly, the minimum inferior tonsil-ICA distances were 2.00 mm in smaller children and 2.20-3.00 mm in older children. There were positive correlations between tonsil width, volume, and superior tonsil-ICA distance; and middle and inferior tonsil-ICA distances (p < 0.05).

CONCLUSION

In younger children, lower tonsil width; and in all children, lower tonsil volume can be a warning sign in terms of lower tonsil superior-ICA distance. During tonsillectomies, working at the middle and inferior tonsillary fossa, maximum attention must be performed for the possibility of the ICA being very closer to the tonsil to avoid unwanted bleedings.

Identifying cohort differences in children undergoing partial intracapsular tonsillectomy vs traditional tonsillectomy for sleep disordered breathing

OBJECTIVE

Partial intracapsular tonsillectomy (PIT) is a well-established technique for reducing post-operative morbidity in pediatric patients with sleep disordered breathing (SDB). Although tonsillar re-growth rates are reported as low, risks of symptom recurrence or need for completion tonsillectomy are clear disadvantages when compared to traditional tonsillectomy (TT). We aim to identify cohort differences to better guide clinical decision making and identify patient-specific factors that may influence this decision. A secondary aim was to evaluate potential risk factors for tonsillar regrowth.

METHODS

Retrospective chart review of pediatric patients who underwent TT or PIT for SDB between 2015 and 2019 at a tertiary care academic medical center. Records were reviewed for age, gender, race, body mass index, comorbidities, diagnosis, apnea-hypopnea index, pre-operative Brodsky tonsil size, length of stay, post-operative hemorrhage, tonsillar regrowth, symptom recurrence, and need for completion tonsillectomy.

RESULTS

315 patients were included: 174 underwent TT and 141 underwent PIT. Patients undergoing TT were more likely to have a sleep study showing OSA (OR 3.01, p < 0.0001), asthma (OR 4.28, p = 0.000124), and other comorbidities (OR 4.06, p = 0.0258). The overall complication rate was 4.44% (14/315). Tonsillar regrowth was exclusive to the PIT group, occurring in 7/141 patients (4.96%). Age ≤4 years was significantly associated with increased risk of tonsillar regrowth (≤4 years: 7.69%, >4 years: 0%; p = 0.049). Race and pre-operative tonsil size were not associated with regrowth.

CONCLUSIONS

Our study supports the low incidence of tonsillar regrowth in PIT and suggests an association with younger age. Moreover, we found that patients undergoing TT are more likely to be older, have OSA, asthma, and other comorbidities.

Application of Coblation Tonsillectomy with Inferior Pole Capsule Preservation in Pediatric Patients

OBJECTIVES/HYPOTHESIS

To evaluate the application and advantages of coblation tonsillectomy with inferior pole capsule preservation in pediatric patients with tonsillar hypertrophy and recurrent tonsillitis.

STUDY DESIGN

Retrospective chart review.

METHODS

A total of 726 children who were diagnosed with either tonsillar hypertrophy or recurrent tonsillitis were included. Children were divided into two groups according to the surgical technique: conventional coblation tonsillectomy and coblation tonsillectomy with inferior pole capsule preservation. The duration of surgery, intraoperative hemorrhage volume, and postoperative pain, as well as postoperative hemorrhage data in the format of time, location, and degree were compared between the two groups.

RESULTS

Of the 726 children included, conventional coblation tonsillectomy was performed in 320 children, coblation tonsillectomy with inferior pole capsule preservation was performed in 406 children. There were no significant differences in duration of surgery or intraoperative hemorrhage volume between the two groups. Children who underwent coblation tonsillectomy with inferior pole capsule preservation showed a remarkable improvement in postoperative pain on days 3 and 5 postoperatively. Additionally, the coblation tonsillectomy with inferior pole capsule preservation group exhibited a significantly lower total postoperative hemorrhage rate, secondary hemorrhage rate, and hemorrhage rate in the inferior pole compared with that in the conventional coblation tonsillectomy group. During the 1-year follow-up period, no cases of tonsillar re-hypertrophy or recurrent tonsillitis were observed in either group.

CONCLUSION

For pediatric tonsillar hypertrophy and recurrent tonsillitis, coblation tonsillectomy with inferior pole capsule preservation is a safe and effective technique, capable of reducing postoperative pain and hemorrhage, especially secondary hemorrhage at the inferior pole.

LEVEL OF EVIDENCE

3b Laryngoscope, 131:1157-1162, 2021.

Longterm results after tonsillotomy: outcome, residual symptoms and need for revision surgery

Background: Tonsillotomy (TT) has gradually replaced tonsillectomy for children with upper airway obstruction during sleep in Denmark. The disadvantage is potential tonsil regrowth.Objectives: To present results on outcome of TT in a Danish hospital setting.Material and methods: Observational cohort study with follow up. All patients were invited for a postoperative examination/telephone interview and to fill in a questionnaire.Results: Medical records from 141 consecutive children up to 12 years of age who underwent TT with or without adenoidectomy in 2015 and 2016 were analyzed. Median follow up time was 33 months (18-41 months), 132 (94%) completed the questionnaire, of which 84 underwent clinical examination. 97% would recommend the procedure. At follow up, a significant reduction of all symptoms was found as well as a significant increase in BMI. Tonsil size ≤ 2 was observed in 81% of patients at follow up. One patient had been referred due to postoperative bleeding. Six patients needed revision tonsil surgery.Conclusion and significance: TT is a safe and effective procedure. However, due to the risk of regrowth of tonsils or recurrent tonsillitis, revision surgery may be necessary, and physicians should pay attention to the risk of recurrence of obstructive symptoms.