Improved quality of life in adults undergoing tonsillectomy for recurrent tonsillitis. Is adult tonsillectomy really a low priority treatment?

Evaluation of Guidelines For Tonsillectomy in Adults With Recurrent Acute Tonsillitis

OBJECTIVES

The criteria for selecting patients with recurrent acute tonsillitis (RT) for tonsillectomy remain unsettled and different guidelines are used internationally. We aimed to evaluate currently used guidelines for tonsillectomy in adults with RT and identify the best predictive parameters for improved throat-related quality of life (TR-QOL) after surgery.

METHODS

About 66 RT patients undergoing tonsillectomy was prospectively included and categorized into 3 groups based on which guideline(s) they met: Group 1: patients not meeting any of the Danish/Paradise/Scottish Intercollegiate Guideline Network (SIGN) guidelines. Group 2: patients meeting the Danish guidelines. Group 3: patients meeting the Paradise and/or the SIGN guidelines. TR-QOL was assessed using the Tonsillectomy Outcome Inventory 14 (TOI-14) before and 6 months after tonsillectomy as well as the Glasgow Benefit Inventory (GBI). Predictive parameters for improved TR-QOL were investigated using multiple linear regression.

RESULTS

About 61 (92%) patients completed the questionnaires. Patients in all groups had significant TR-QOL improvements (Group 1 (n = 20): ΔTOI-14 31.1; GBI 29.4; Group 2 (n = 31): ΔTOI-14 32.0; GBI 36.4; Group 3 (n = 10): ΔTOI-14 45.6; GBI 39.7) and satisfaction rates were high (94%-100%). Preoperative TOI-14 score was the best predictor for improved TR-QOL (P < .001, R2 = .80), followed by the number of tonsillitis episodes with physician verification within the previous 12 months (P = .002, R2 = .25).

CONCLUSIONS

Patients in all groups experienced massive TR-QOL improvements suggesting that currently used guidelines may be too restrictive. Preoperative TOI-14 score was the best parameter for predicting TR-QOL improvement, and this tool may be useful in the selection of adults with RT for tonsillectomy.

Tonsillectomy compared with conservative management in patients over 16 years with recurrent sore throat: the NATTINA RCT and economic evaluation

Background

The place of tonsillectomy in the management of sore throat in adults remains uncertain.

Objectives

To establish the clinical effectiveness and cost-effectiveness of tonsillectomy, compared with conservative management, for tonsillitis in adults, and to evaluate the impact of alternative sore throat patient pathways.

Design

This was a multicentre, randomised controlled trial comparing tonsillectomy with conservative management. The trial included a qualitative process evaluation and an economic evaluation.

Setting

The study took place at 27 NHS secondary care hospitals in Great Britain.

Participants

A total of 453 eligible participants with recurrent sore throats were recruited to the main trial.

Interventions

Patients were randomised on a 1 : 1 basis between tonsil dissection and conservative management (i.e. deferred surgery) using a variable block-stratified design, stratified by (1) centre and (2) severity.

Main outcome measures

The primary outcome measure was the total number of sore throat days over 24 months following randomisation. The secondary outcome measures were the number of sore throat episodes and five characteristics from Sore Throat Alert Return, describing severity of the sore throat, use of medications, time away from usual activities and the Short Form questionnaire-12 items. Additional secondary outcomes were the Tonsil Outcome Inventory-14 total and subscales and Short Form questionnaire-12 items 6 monthly. Evaluation of the impact of alternative sore throat patient pathways by observation and statistical modelling of outcomes against baseline severity, as assessed by Tonsil Outcome Inventory-14 score at recruitment. The incremental cost per sore throat day avoided, the incremental cost per quality-adjusted life-year gained based on responses to the Short Form questionnaire-12 items and the incremental net benefit based on costs and responses to a contingent valuation exercise. A qualitative process evaluation examined acceptability of trial processes and ramdomised arms.

Results

There was a median of 27 (interquartile range 12-52) sore throats over the 24-month follow-up. A smaller number of sore throats was reported in the tonsillectomy arm [median 23 (interquartile range 11-46)] than in the conservative management arm [median 30 (interquartile range 14-65)]. On an intention-to-treat basis, there were fewer sore throats in the tonsillectomy arm (incident rate ratio 0.53, 95% confidence interval 0.43 to 0.65). Sensitivity analyses confirmed this, as did the secondary outcomes. There were 52 episodes of post-operative haemorrhage reported in 231 participants undergoing tonsillectomy (22.5%). There were 47 re-admissions following tonsillectomy (20.3%), 35 relating to haemorrhage. On average, tonsillectomy was more costly and more effective in terms of both sore throat days avoided and quality-adjusted life-years gained. Tonsillectomy had a 100% probability of being considered cost-effective if the threshold for an additional quality-adjusted life year was £20,000. Tonsillectomy had a 69% probability of having a higher net benefit than conservative management. Trial processes were deemed to be acceptable. Patients who received surgery were unanimous in reporting to be happy to have received it.

Limitations

The decliners who provided data tended to have higher Tonsillectomy Outcome Inventory-14 scores than those willing to be randomised implying that patients with a higher burden of tonsillitis symptoms may have declined entry into the trial.

Conclusions

The tonsillectomy arm had fewer sore throat days over 24 months than the conservative management arm, and had a high probability of being considered cost-effective over the ranges considered. Further work should focus on when tonsillectomy should be offered. National Trial of Tonsillectomy IN Adults has assessed the effectiveness of tonsillectomy when offered for the current UK threshold of disease burden. Further research is required to define the minimum disease burden at which tonsillectomy becomes clinically effective and cost-effective.

Trial registration

This trial is registered as ISRCTN55284102.

Funding

This award was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme (NIHR award ref: 12/146/06) and is published in full in Health Technology Assessment; Vol. 27, No. 31. See the NIHR Funding and Awards website for further award information.

Patient Perspectives on Removing Adult Tonsillectomy and Septoplasty from the Government Health Insurance Plan in a Publicly Funded Health Care System

In several publicly funded health care systems, including Ontario, Canada, adult tonsillectomies and septoplasties have been suggested to be removed or "delisted" from the government health insurance plan. Thus, the objective of this study was to explore patient perspectives regarding out of pocket (OOP) payment for these procedures. An anonymous survey was administered to patients consented to undergo a tonsillectomy or septoplasty at a community otolaryngology-head and neck surgery (OHNS) practice. The survey asked patients if they would pay the projected cost for their surgery OOP and the maximum amount of time they would wait for their surgery. The survey also contained questions on socioeconomic status and disease severity. Seventy-one patients were included. Overall, 21% of patients were willing to pay OOP for their surgery. Forty-nine percent of patients reported that the maximum amount of time they would be willing to wait for their surgery was 2 to 6 months. There was no significant correlation found between any of the demographic variables or disease severity and willingness to pay OOP for these surgeries. In this study, a small percentage of patients who met the clinical indications for a tonsillectomy or a septoplasty would pay for their surgery in the event that it was not covered by the government health insurance plan. These surgeries are common operations and delisting them could potentially decrease the provision of these services and have a significant impact on Canadian OHNS practices.

Normative tonsillectomy outcome inventory 14 values as a decision-making tool for tonsillectomy

Purpose

The study aimed to determine normative values for the Tonsillectomy Outcome Inventory 14 (TOI-14) in a healthy middle-European cohort. We also compared these generated values with TOI-14 scores from a patient population with recurrent tonsillitis (RT) and explored the factorial structure of the TOI-14.

Methods

We systematically studied the responses of healthy individuals (reference cohort) and patients with RT (clinical cohort) to the TOI-14 survey. The reference cohort contained 1000 participants, who were recruited using the Respondi panel for market and social science research. This subsample was quoted to the population distribution of the German Microcensus and selected from a non-probability panel. Tonsillitis patients were assessed before and 6 and 12 months after tonsillectomy.

Data were analysed using principal component and exploratory factor analyses.

Results

The PCA revealed three TOI-14 domains (physiological, psychological and socio-economic), which explained 73% of the total variance. The reference cohort perceived a good quality of life (QOL) with a TOI-14 total score of 11.8 (physiological: 8.0, psychological: 5.8, and socio-economic subscale score: 13.9). TOI-14 scores were higher in the patient cohort, indicating that the TOI-14 discriminates between patients with RT and healthy individuals with no RT. Age and female gender significantly influenced the total TOI-14 score, especially in the psychological (age) and socio-economic (gender) subscales.

Conclusion

We have developed a set of normative values that, together with the TOI-14, can determine the disease burden indicating tonsillectomy.

[State of the art of quality-of-life measurement in patients with chronic otitis media and conductive hearing loss]

The evaluation of results after middle ear reconstruction has been mainly based on functional parameters. In clinical practice as well as in otological research, the pure tone audiogram represents the gold standard in the assessment of the postoperative outcome. In order to assess the patient's subjective outcome, outcome analyzes focus increasingly on the health-related quality of life (HRQOL). However, the evaluation of HRQOL requires reliable and validated measuring instruments. A modest number of validated questionnaires for determination of the disease-specific HRQOL in patients with chronic otitis media and/or conductive hearing loss are currently available. Three of seven available questionnaires were developed and validated in the German-speaking countries, the Zurich Chronic Middle Ear Inventory 21 (ZCMEI-21), the Chronic Otitis Media Outcome Test 15 (COMOT-15) and the Stapesplasty Outcome Test 25 (SPOT-25). In this review, all seven available disease-specific measuring instruments as well as the generic questionnaires, which were used in previous clinical trials, are explained and current findings of quality-of-life research in patients with chronic otitis media and/or conductive hearing loss are presented.

Is Scottish Intercollegiate Guidelines Network guidance for GP management of tonsillitis suitable? A qualitative study

BACKGROUND

The Scottish Intercollegiate Guidelines Network (SIGN) developed guidelines for the management of sore throat and indications for tonsillectomy in 1999 to address concerns of unnecessary surgery. Emergency admissions to hospital for tonsillitis have since increased. Adults experience an average of 27 episodes of tonsillitis before undergoing tonsillectomy. We wished to explore the appropriateness of the guidance and/or its implementation in primary care.

AIM

To explore the attitudes of GPs to the referral criteria they use when managing adults presenting with acute tonsillitis.

DESIGN

Secondary analysis of qualitative data from the NAtional Trial of Tonsillectomy IN Adults (NATTINA) feasibility and process evaluation.

PARTICIPANTS AND SETTING

Twenty-one GPs from practices throughout the UK.

METHOD

In-depth interviews with GPs concerning both the feasibility and process evaluation phases of NATTINA. Analysis was conducted using the framework method.

RESULTS

GPs felt it was rarely necessary to refer patients. They were aware of guidelines and would refer if requested by a patient who fulfilled the guidelines criteria and/or who were missing considerable amounts of work.

CONCLUSION

The introduction of the guidelines appears to coincide with what some may have hoped to be a desired effect of reducing adult sore throat referrals and subsequent tonsillectomies by increasing the number of episodes a patient must suffer before the referral threshold is met. GPs may find equipoise for tonsillectomy referral challenging as many patients express a strong preference for surgery. We believe this paper reinforces GP professionalism and patient-centred consultations, and challenges the role of clinical guidelines.

Variation in tonsillectomy rates by health care system type

OBJECTIVE

To analyze variation in tonsillectomy procedure rates between health care system types around the world.

STUDY DESIGN

International database analysis.

METHODS

The 2015 Organization for Economic Co-operation and Development (OECD) Health Statistics surgical procedures database was used to ascertain tonsillectomy procedure volumes for 31 countries. Each country's health system type and structure were classified by overall system type, and by health care regulation, financing, and provision methods. Each system type and structure variable were compared using the rate of tonsillectomy procedures per 100,000 citizens.

RESULTS

10.5 million tonsillectomy procedures completed between 1993 and 2014 were analyzed. Overall, social health insurance system types had higher total tonsillectomy rates versus other health care system types (p < 0.05 for each comparison). Health systems with private care provision had a higher procedure rate versus state provided care (159.1 vs. 131.1 per 100,000 citizens; p = 0.002). Health care systems with societal regulation and financing had a higher procedure count versus state regulated or financed care (regulation 193.3 vs. 139.7 per 100,000 citizens, p < 0.0001; financing 168.2 vs. 135.0 per 100,000 citizens, p = 0.0004).

CONCLUSIONS

The volume of tonsillectomy procedures is associated with a health care system's overall structure, regulation, financing, and provision methods. International health care systems with state mediated provision, regulation, and financing had lower tonsillectomy rates versus systems with private provision, and societal regulation or financing. Further study is needed to determine differences in indications for tonsillectomy between countries, but these results underscore potential variation in health care delivery in different systems.

Long-Term Results From Tonsillectomy in Adults

BACKGROUND

Tonsillectomy is performed more than 400 000 times in the European Union each year, making it one of the most common operations. Nonetheless, there have been only a few long-term studies of quality of life after tonsillectomy.

METHODS

In 2004, data on the quality of life after tonsillectomy were obtained from adult German-speaking tonsillectomy patients by means of the Glasgow Benefit Inventory and a questionnaire specifically designed for that study. The present study concerns the further followup of these patients, sometimes many years later. 114 patients with recurrent tonsillitis were included in this descriptive study.

RESULTS

Of the 114 patients, 97 (85%) provided further data at 14 months, and 71 (62%) at ca. 7 years. The Glasgow Benefit Inventory revealed postoperative improvement of quality of life at 14 months and at 7 years, with median values of 16.67 points (quartile 11.11/25) and 13.89 points (quartile 8.33/25) (p=0.168). The mean number of annual episodes of sore throat fell from 10 preoperatively to 2 postoperatively (p=0.0001). The number of visits to the doctor, the intake of analgesic drugs and antibiotics, and the number of medical absences from work also declined significantly over the period of observation.

CONCLUSION

Tonsillectomy was associated with a longlasting improvement of health and quality of life, and with lower utilization of medical resources. The 62% response rate at 7 years leaves the question open whether patients with a favorable postoperative course may have been more likely than others to participate in the study.

Tonsillectomy is not a procedure of limited value - the unseen costs of tonsillitis and quinsy on hospital bed consumption

OBJECTIVES

To assess the impact of the introduction of the SIGN Clinical guidelines in 1999 and subsequent revision in 2005 on tonsillectomy, hospital admission with tonsillitis and peritonsillar abscess rates in four countries.

METHODS

Retrospective analysis using English, Welsh, Australian and New Zealand National healthcare hospital admission databases between 2000 and 2013. Primary outcomes measures included tonsillectomy rates and hospital admission rates for tonsillitis and peritonsillar abscess. Secondary outcome measures included bed-day usage in England and Wales. Linear forecasting was used to identify the potential impact of any trends.

RESULTS

Following guideline introduction for tonsillectomy, a significant decline in tonsillectomy rates in England (P < 0.01) and Wales (P < 0.05) was seen. Hospital admissions for acute tonsil infections increased in England (P < 0.01) and Wales (P < 0.01). In Australia and New Zealand, tonsillectomy and admission for tonsillitis rates both increased (P < 0.01). During this time, the increased rate of admission for tonsillitis in England and Wales was significantly greater than Australasia (P < 0.01).

CONCLUSIONS

Following the introduction of these Clinical guidelines, there was a decrease in the rate of tonsillectomy in England and Wales and a presumed associated increase in admissions with tonsillitis. This did not occur in Australasia where tonsillectomy rates rose over time. If these trends continue, it is likely that they will have a significant deleterious impact on healthcare spending in the future.

'Thinking that somebody's going to delay [a tonsillectomy] for one to two years is quite horrifying really': a qualitative feasibility study for the NAtional Trial of Tonsillectomy IN Adults (NATTINA Part 2)

OBJECTIVES

Level one evidence on the value of adult tonsillectomy versus non-surgical management remains scarce. Before embarking on a costly national randomised controlled trial, it is essential to establish its feasibility.

DESIGN

Feasibility study with in-depth qualitative and cognitive interviews.

SETTING

ENT staff and patients were recruited from nine hospital centres across England and Scotland.

PARTICIPANTS

Patients who were referred for tonsillectomy (n = 15), a convenience sample of general practitioners (n = 11) and ear, nose and throat staff (n = 22).

MAIN OUTCOME MEASURES

To ascertain whether ear, nose and throat staff would be willing to randomise patients to the treatment arms. To assess general practitioners' willingness to refer patients to the NAtional Trial of Tonsillectomy IN Adults (NATTINA) centres. To assess patients' willingness to be randomised and the acceptability of the deferred surgery treatment arm. To ascertain whether the study could progress to the pilot trial stage.

RESULTS

Ear, nose and throat staff and general practitioners were willing to randomise patients to the proposed NATTINA. Not all ENT staff were in equipoise concerning the treatment pathways. Patients were reluctant to be randomised into the deferred surgery group if they had already waited a substantial time before being referred.

CONCLUSIONS

Findings suggest that the NATTINA may not be feasible. Proposed methods could not be realistically assessed without a pilot trial. Due to the importance of the question, as evidenced by NATTINA clinicians, and strong support from ENT staff, the pilot trial proceeded, with modifications.

Adult tonsillectomy: postoperative pain depends on indications

Introduction

Intense pain is one of the most important postoperative complaints after tonsillectomy. It is often described by patients as comparable to the pain that accompanies an acute tonsillitis. Although recurrent tonsillitis is the most frequent indication for surgery, many tonsillectomies are performed due to other indications and these patients may be unfamiliar with such pain.

Objective

To verify whether individuals with recurrent tonsillitis experience different post-tonsillectomy pain intensity than those with other indications for surgery, with no history of episodes of acute tonsillitis.

Methods

A total of 61 tonsillectomies were performed under general anesthesia, using a potassium titanyl phosphate (KTP) laser (to eliminate the potential influence on the study results of forceful dissection of fibrotic tonsils in patients with history of recurrent tonsillitis) and multiple ligations of blood vessels within the tonsillar beds. The patients received 37.5 mg Tramadoli hydrochloridum + 325 mg Paracetamol tablets for 10 days. Postoperative variables included the duration of hospital stay, postoperative hemorrhage and readmission rate. The patients reported pain intensity on consecutive days, pain duration, weight loss on postoperative day 10, character, intensity and duration of swallowing difficulties, and the need for additional doses of painkillers. Healing was also assessed. Capsular nerve fibers were histologically examined in the resected tonsils by immunostainings for general and sensory markers.

Results

Indications for the surgery were: recurrent acute tonsillitis (34 patients), no history of recurrent tonsillitis: focus tonsil (20) and intense malodour (7). Pain intensity on postoperative days 3–4 and incidence of readmissions due to dehydration were significantly higher in the group with no history of recurrent tonsillitis. No significant differences in relative densities of protein gene product (PGP) 9.5- and calcitonin gene-related peptide (CGRP)-immunoreactive nerve fibers were observed.

Conclusion

Patients with recurrent tonsillitis qualified for tonsillectomy reported lower pain intensity than those without recurrent tonsillitis and the pain scores were unrelated to nerve fibers density.

Predictive factors for quality of life after tonsillectomy among adults with recurrent pharyngitis: a prospective cohort study

OBJECTIVES

To assess health-related quality of life (QoL) and clinical factors predicting it after tonsillectomy among adult patients with recurrent pharyngitis.

DESIGN

Prospective cohort design.

SETTING

Tertiary referral centre.

PARTICIPANTS

Adults (n = 153) who underwent tonsillectomy for recurrent pharyngitis.

MAIN OUTCOME MEASURES

QoL 6 months after tonsillectomy measured by the Glasgow Benefit Inventory (GBI). Factors predicting high postoperative QoL were sought using multiple linear regression analysis.

RESULTS

Of the 142 patients (93% of all eligible) responding to the GBI questionnaire, 94 (66%) were female; median age was 26 years (range 14-65). GBI Total Scores varied markedly (range -19 to +69), but on average showed improvement (median +27, interquartile range 18-36), most evidently in the GBI Physical Health Score (median +83), after tonsillectomy. Among routinely recorded clinical characteristics, the number of prior pharyngitis episodes, frequent throat pain, untreated dental caries and chronically infected tonsils made up the optimal subset of factors for predicting the GBI Total Score. However, in a random sample of patients (n = 56) for whom preoperative diary-based data were also available, somewhat better predictive ability was achieved based on just two diary items: number of days with throat pain and with fever during the preceding few months (correlation coefficient, r, between observed and fitted scores improved from 0.39 to 0.55). Yet, the precision of even these predictions was still quite low.

CONCLUSIONS

Adult patients with recurrent pharyngitis were on average satisfied after tonsillectomy, regardless of the aetiology of the episodes. Clinical factors rather modestly predicted which patients benefited most from the operation.

Microdebrider-assisted intracapsular tonsillectomy in adults with chronic or recurrent tonsillitis

OBJECTIVES/HYPOTHESIS

We compared the effectiveness and morbidity of microdebrider-assisted total intracapsular tonsillectomy (ICTE) with conventional extracapsular tonsillectomy (ECTE) in adults with chronic or recurrent tonsillitis.

STUDY DESIGN

Prospective randomized surgical trial.

METHODS

Adult patients with recurrent or chronic tonsillitis who underwent tonsillectomy between July 2010 and July 2012 in the Department of Otorhinolaryngology-Head and Neck Surgery, Medical University Innsbruck, Innsbruck, Austria, were consecutively included. Patients were randomized to receive either ICTE or ECTE. Patients and examiners were blinded to the surgical procedure. Effectiveness was assessed with the Tonsil and Adenoid Health Status Instrument (TAHSI). Various parameters of perioperative morbidity and the occurrence of tonsillar remnants were recorded.

RESULTS

In the 104 randomized patients, the average TAHSI score was 34.6 ± 11.7 before and 2.2 ± 5.7 after 6 months following tonsillectomy (P < 0.001). TAHSI scores improved equally in patients receiving conventional ECTE (33.6 points; 95% confidence interval (CI), 29.5 to 37.6) and in patients with ICTE (31.8 points; 95% CI, 27.7 to 35.9; between groups P = 0.6). Posttonsillectomy hemorrhage was more frequent following conventional ECTE (P = 0.03). Following ECTE, patients required more pain medication then following ICTE (P < 0.05). Tonsillar remnants were significantly more frequent after ICTE (P < 0,001). However, presence of tonsillar remnants had no influence on postoperative THASI scores (P > 0.5).

CONCLUSION

Tonsillectomy reduced symptoms of chronic or recurrent tonsillitis in adults with remarkable effectiveness. Microdebrider-assisted ICTE reduced symptoms as effectively as conventional ECTE. ICTE was associated with lower morbidity, but residual tonsils occurred in almost half of patients, costs were higher, and the intracapsular approach was more intricate and time-consuming.

LEVEL OF EVIDENCE

1b.

Evaluation of a German version of the tonsil and adenoid health status instrument

Background

To create and validate a German version of the Tonsil and Adenoid Health Status Instrument (TAHSI) for evaluation of tonsillectomy outcome in adult patients with chronic or recurrent tonsillitis.

Subjects and methods

46 healthy volunteers were assessed twice in a 6 week interval with the TAHSI questionnaire. Their results were compared with 45 patients suffering from chronic tonsillitis before tonsillectomy and 6 months following surgery. For internal consistency, Cronbach’s alpha was calculated; to identify normal score values, the optimum cutoff between healthy and diseased individuals was identified with receiver operating characteristic analysis; and responsiveness was assessed using Guyatt’s Responsiveness Index (GRI).

Results

Cronbach’s alpha for all questions was 0.92. Test- retest intraclass correlation coefficient was 0.89 (95% confidence interval 0.80-0.94 p < 0.001). Mean score for the healthy individuals was 7.0 (95% confidence interval 4.2-9.7). The optimum cut off score between healthy and diseased was 20 with a sensitivity of 80% and a specificity of 90% to differentiate controls from tonsillectomy patients.

Conclusion

The TAHSI performed well in this validation tests and is considered a favorable instrument to evaluate the effectiveness of tonsillectomy in adults with chronic or recurrent tonsillitis.

Routine tonsillar bed oversew after diathermy tonsillectomy: does it reduce secondary tonsillar haemorrhage?

Tonsillectomy is a common otolaryngological procedure and is associated with a small risk of postoperative pharyngeal haemorrhage. This study compares secondary post tonsillectomy haemorrhage rates between two operative techniques: diathermy tonsillectomy and diathermy tonsillectomy with tonsillar bed oversew. A total of 424 patients underwent tonsillectomies with or without other procedures such as adenoidectomy and grommet insertion by two ears, nose and throat surgeons at three hospitals from May 2012 to July 2013. A diathermy tonsillectomy was performed in 266 patients, while a diathermy tonsillectomy with tonsillar bed oversew was performed in 158 patients. All patients were followed up within 2-4 weeks of surgery. Primary haemorrhage did not occur in either surgical technique groups. Secondary haemorrhage occurred in 20 patients (7.52 %) in the diathermy tonsillectomy group and in 9 patients (5.70 %) in the diathermy with tonsillar bed oversew group. This result was not significantly different (OR = 0.74, 95 % CI 0.33-1.67, p = 0.47). Sex, age, indication for surgery and whether or not a tonsillectomy was performed alone or with other procedures were not significant factors for secondary haemorrhage. In summary, routine tonsillar bed oversew after diathermy tonsillectomy does not reduce the risk of secondary tonsillar haemorrhage.

Malpractice claims and unintentional outcome of tonsil surgery and other standard procedures in otorhinolaryngology

BACKGROUND

Septoplasty, tonsillectomy (with and without adenoidectomy) and cervical lymph node excision are amongst the most common 50 inpatient operations in Germany. Intracapsular tonsillectomies (i.e. tonsillotomies) are increasingly performed. The aim of this study was to evaluate technical traps and pitfalls as well as alleged medical malpractice associated with tonsillectomy (TE), adenoidectomy (AE), tonsillotomy (TT), septoplasty (SP) and cervical lymph node excision (LN).

METHODS

A questionnaire was sent to the Regional Medical Conciliation Boards, Medical Services of the Health Insurance Companies (MDK) and Regional Institutes of Forensic Medicine in Germany to collect anonymized cases of complications following TE, TT, AE, LN and SP. The results were discussed in the light of the contemporary medical literature and published trials and verdicts in Germany.

RESULTS

The response rate of our survey was 55.9%. The Institutes of Forensic Medicine contributed nine cases, 49 cases were submitted by the Regional Conciliation Boards and none by MDK. All forensic cases were associated with exsanguinations following tonsillectomy including two children (5 and 8 years of age) and seven adults (aged 20 to 69 years). The fatal post-tonsillectomy hemorrhage (PTH) had occurred 8.7 days on average; four patients experienced the bleeding episode at home (day 5, 8, 9 and 17, respectively). Repeated episodes of bleeding requiring surgical intervention had occurred in 6 patients. Three Conciliation Boards submitted decicions associated with TT (1), AE (4), LN (3), SP (16) and TE (25). Cases with lethal outcome were not registered. Only three of the 49 cases were assessed as surgical malpractice (6.1%) including lesion of the spinal accessory nerve, wrong indication for TE and dental lesion after insertion of the mouth gag. The review of the medico legal literature yielded 71 published verdicts after AE and TE (29), LN (28) and SP (14) of which 37 resulted in compensation of malpractice after LN (16; 57%), TE (10; 37%), SP (8; 57%) and AE (2; 100%). There were 16 cases of PTH amongst 27 trials after TE resulting either in death (5) or apallic syndrome (5). Bleeding complications had occurred on the day of surgery in only 2 patients. 16 trials were based on malpractice claims following SP encompassing lack of informed consent (6), anosmia (4), septal perforation (2), frontobasal injury (2) and dry nose (2). Trials after LN procedures were associated exclusively with a lesion of the spinal accessory nerve (28), including lack of informed consent in 19 cases. 49 cases (69%) were decided for the defendant, 22 (31%) were decided for the plaintiff with monetary compensation in 7 of 29 AE/TE-trials, 9 of 28 LN-trials and 6 of 14 SP-trials. Lack of informed consent was not registered for AE/TE but LN (11) and SP (2).

CONCLUSION

Complicated cases following TE, TT, ATE, SP and LN are not systematically collected in Germany. It can be assumed, that not every complicated case is published in the medical literature or law journals and therefore not obtainable for scientific research. Alleged medical malpracice is proven for less than 6% before trial stage. Approximately half of all cases result in a plaintiff verdict or settlement at court. Proper documentation of a thourough counselling, examination, indication, informed consent and follow-up assists the surgeon in litigation. An adequate complication management of PTH is essential, including instructions for the patients/parents, instructions for the medical staff and readily available surgical instruments. Successful outcome of life-threatening PTH is widely based on a proper airway management in an interdisciplinary approach. Electrosurgical tonsillectomy techniques were repeatedly labeled as a risk factor for bleeding complications following TE. Institutions should analyse the individual PTH rate on a yearly basis. Contradictory expert opinions and verdicts of the courts concerning spinal accesory nerve lesions following LN are due to a lack of a surgical standard.

Throat-related quality of life in peritonsillar abscess sufferers: application of the adult tonsil outcome inventory

OBJECTIVE

To investigate throat-related quality of life in peritonsillar abscess sufferers.

METHOD

The adult tonsil outcome inventory questionnaire, which is a validated throat-related quality of life tool, was administered to individuals who had recently suffered a peritonsillar abscess and to control subjects.

RESULTS

The mean inventory score was significantly higher (reflecting poorer throat-related quality of life) in peritonsillar abscess sufferers (n = 55, mean score 25.8 out of 100) than in age- and gender-matched controls (n = 55, mean score 8.7) (p < 0.001). Neither gender nor interval between episode of peritonsillar abscess and inventory completion date were significantly correlated with the overall questionnaire scores. However, younger abscess sufferers reported greater symptom severity and throat-related quality of life impact than older abscess sufferers.

CONCLUSION

Peritonsillar abscess had a significant impact on throat-related quality of life. In many, peritonsillar abscess represented an acute episode on a background of chronic throat problems. For optimal management, notably the place and timing of tonsillectomy, this impact should be taken into account. The adult tonsil outcome inventory is an ideal tool for use in clinical practice.