Risk of reoperation after tonsillotomy versus tonsillectomy: a population-based cohort study

Intracapsular versus extracapsular tonsil surgery: Comparison of postoperative haemorrhage outcomes in the Australasian setting

OBJECTIVE

To investigate the incidence and timing of postoperative haemorrhage between intracapsular (ICT) and extracapsular tonsillectomy (ECT) techniques and evaluate factors influencing haemorrhage risk and severity.

METHODS

A retrospective review of patients undergoing tonsillectomy over 5 years across otolaryngology services in Australia and New Zealand. Primary outcomes were rate and timing of post-tonsillectomy haemorrhage.

RESULTS

A total of 12,275 patients were included in this study. The overall post-tonsillectomy bleed rate was 3.3 %, with 0.65 % requiring return to theatre. ICT had a significantly lower bleed rate of 1.7 % compared to 4.1 % for ECT (p < 0.001). The rate of return to theatre was markedly lower for ICT (0.08 %) compared to ECT (0.93 %, p < 0.001). Median day of bleeding was not different between the techniques. Patients undergoing surgery for recurrent tonsillitis had the highest rate of postoperative haemorrhage (15 %), while those with sleep-disordered breathing alone had the lowest (3 %, p < 0.001).

CONCLUSION

ICT results in significantly lower rates of postoperative haemorrhage and need for surgical intervention compared to ECT. This was most pronounced in paediatric patients with sleep-disordered breathing. ICT may be considered a preferable option for certain patient groups, especially younger children with sleep-disordered breathing, though more evidence is needed to confirm its efficacy and safety in patients with recurrent tonsillitis.

Total versus subtotal tonsillectomy for recurrent tonsillitis: 5-year follow up of a prospective randomized noninferiority clinical trial

PURPOSE

In long-term follow-up, it remains uncertain whether tonsillectomy, a procedure associated with significant comorbidity, can be substituted with partial tonsillectomy in patients with recurrent tonsillitis. This paper is to present the 5-year follow-up data of our previous study titled "Total versus subtotal tonsillectomy for recurrent tonsillitis-a prospective randomized noninferiority clinical trial."

MATERIALS AND METHODS

The underlying study was performed as single-blinded prospective noninferiority procedure in patients with recurrent chronic tonsil infection, where one side was removed completely (tonsillectomy) and the other side partially (intracapsular/partial tonsillectomy). Five years after surgery, we collected data on the frequency of tonsillitis in the first, second, third, fourth, and fifth year post-surgery. We obtained assessments from patients, their ENT physicians, and general practitioners separately. To assess the impact of surgical therapy on overall quality of life, we employed the Glasgow Benefit Inventory (GBI).

RESULTS

Out of the 111 patients initially included in the years 2015-2018, 79 were eligible for the 5-year follow-up, representing a 71% follow-up rate. The mean follow-up time was 60 months. Notably, during the first 12 months post-surgery, no cases of bacterial inflammation were observed in the remaining tonsillar tissue following partial tonsillectomy, suggesting noninferiority compared to total tonsillectomy. This effect remained consistent over the 5-year study period. GBI results indicate that both total and partial tonsillectomy positively impact the physical and mental health of patients with recurrent tonsillitis.

CONCLUSION

Considering that partial tonsillectomy is associated with less pain and reduced postoperative bleeding, it may emerge as a potential replacement for total tonsillectomy as the standard method in the future.

Tonsillectomy Versus Tonsillotomy in Pediatric Sleep-Disordered Breathing: A Systematic Review and Multi-subgroup Meta-analysis

OBJECTIVES

To evaluate the potential of tonsillotomy (TT) as an alternative to tonsillectomy (TE) for treating children with obstructive sleep-disordered breathing (oSDB).

DATA SOURCES

Two independent reviewers searched PubMed, the Cochrane Library, Embase, and additional sources to identify controlled studies comparing TT versus TE in pediatric patients with oSDB.

REVIEW METHODS

We evaluated post-surgery symptom relief, and short- and long-term postoperative benefits for children. Fixed-effect meta-analysis, sensitivity analysis, and subgroup analysis were conducted.

RESULTS

In our analysis of 32 studies with 9,430 children, the analysis revealed TT group had a similar therapeutic effect on improvement of OSA-18 as TE group (MD = 5.20, 95% CI: -32.67 to 43.07, p = 0.96). In terms of short-term outcome, the days to return to normal diet for TT group were shorter than that for TE group (MD = -2.49, 95%CI: -3.57 to -1.28; p < 0.001), less analgesics use (MD = -3.19, 95% CI = -3.44 to -2.93, p < 0.001), and lower postoperative secondary bleeding (RR = 0.33; 95%CI: 0.23 to 0.47; p < 0.001). But the risk of reoperation (OR = 8.28; 95%CI: 2.66 to 12.64; p < 0.001), oSDB recurrence (OR = 2.16; 95%CI: 1.20-3.86; p = 0.01), and postoperative infection (OR = 1.82; 95%CI: 1.34 to 2.47; p < 0.001) in TT group was significantly higher than that in TE group.

CONCLUSIONS

Tonsillotomy reduces postoperative pain and bleeding, speeding up recovery for children with oSDB, and improving their quality of life. Yet, the risk of recurrent infections from residual tonsil tissue, which may require reoperation, calls for a careful evaluation of the procedure's short-term gains against its long-term risks.

LEVEL OF EVIDENCE

NA Laryngoscope, 2024.

Postoperative Analgesic Regimens and Their Satisfaction Rates-Data from the Swedish Quality Register for Tonsil Surgery

OBJECTIVE

To describe postoperative analgesic regimens and patient-reported pain-related outcomes after tonsil surgery.

METHODS

Cohort study including perioperative data (n = 9274) and patient-reported outcome measures (n = 5080) registered in the Swedish Quality Register for Tonsil Surgery during 2023.

RESULTS

After tonsil surgery, 92.7% received at least paracetamol and a NSAID/COX inhibitor, while 6.8% received no NSAID/COX inhibitor. Opioids were prescribed after tonsillectomy to 62.9% of adults and less often to adolescents and children (13-17-year-olds: 48.2%, 6-12-year-olds: 8.8%, 0-5-year-olds: 4.0%). Clonidine was frequently prescribed to 0-5-year-olds after tonsillectomy (54.4%). Overall, 11.7% reported dissatisfaction with the pain treatment, with the highest dissatisfaction rate after tonsillectomy in adolescents (20.6%) and adults (20.0%), and the lowest after tonsillotomy in children (4.9-6.8%). The most common complaint among dissatisfied patients was analgesics not being sufficiently helpful. Adult patients who received addition of opioids were less dissatisfied with the pain treatment (15.9% vs. 25.9%, p < 0.001), but also reported more side effects (5.7% vs. 2.7%, p = 0.039), compared with patients who received only paracetamol and NSAID/COX inhibitors.

CONCLUSION

Tonsil surgery patients in Sweden receive various analgesic regimens. Although most are satisfied with pain treatment, there is room for improvement, particularly among adolescents and adults undergoing tonsillectomy. Paracetamol and a NSAID/COX inhibitor seem advisable as basic treatment. However, many patients need more effective treatment. The addition of opioids in adults results in greater satisfaction with pain treatment, but safety issues with opioid prescriptions must be taken into consideration.

LEVELS OF EVIDENCE

Level 4 Laryngoscope, 2024.

Recurrence of sleep apnea in children after intracapsular coblation tonsillectomy: A comprehensive exploration of tonsil regrowth

OBJECTIVES

Sleep apnea is a prevalent issue in children, associated with significant morbidities such as cardiovascular and neurocognitive disorders. There is increasing interest in intra-capsular tonsillectomy by coblation (ICTC) as a method to address obstructive sleep apnea (OSA) in children. However, the literature remains controversial regarding the most effective intra-capsular tonsillectomy (ICT) technique with the least morbidity. Our current research extends a previous study that established the effectiveness and safety of ICTC, demonstrating rapid post-surgical recovery with minimal analgesic needs. This new investigation specifically focuses on long-term follow-up. Our aim is to assess tonsil regrowth and the risk of recurrence of OSA symptoms at a mean follow-up of 6.1 years post-surgery. By presenting the results of this extended study, our goal is to gain a better understanding of the long-term effectiveness of this surgical intervention in treating OSA in children. Thus, considering the initial benefits, we will also explore potential long-term implications.

MATERIALS AND METHODS

This research follows up on children from our previous study who underwent ICTC, with or without adenoidectomy, for OSA resulting from tonsillar hypertrophy at a tertiary-level university hospital between March 2016 and March 2018. They were followed up for an average of 6.1 years postoperatively. Symptom recurrence is assessed by comparing preoperative OSA-18 questionnaire results with those obtained at the 6.1-year mark. Tonsil regrowth is evaluated by comparing preoperative Brodsky scores with those obtained at 6.1 years.

RESULTS

The mean total score of OSA-18 significantly decreased from 79.41 (SD = 14.95) before ICTC to 25.47 (SD = 8.92) at 6.1 years postoperatively (p < 0.001, mean difference = 53.94, 95 % CI [50.32, 57.56]). Similarly, the mean Brodsky score dropped from 2.95 (SD = 0.51) before ICTC to 1.04 (SD = 0.24) 6.1 years postoperatively (p < 0.001, mean difference = 1.92, 95 % CI [1.80, 2.04]). The overall regrowth rate was 2.35 % (n = 2), with a revision surgery rate of 1.18 % (n = 1).

CONCLUSION

ICTC exhibits minimal risk of tonsil regrowth and maintains long-term efficacy in preventing the recurrence of OSA symptoms. Therefore, it justifies broader utilization in addressing OSA symptoms arising from tonsillar hypertrophy in children.

Intracapsular Versus Total Tonsillectomy in Patients with Trisomy 21

OBJECTIVES

Intracapsular tonsillectomy and adenoidectomy (iTA) has become a popular alternative to extracapsular tonsillectomy and adenoidectomy (TT) for the treatment of pediatric obstructive sleep apnea (OSA) due to improved recovery and fewer complications. The objective of this study was to compare surgical recovery and impact on OSA of iTA versus TT in patients with Trisomy 21 (T21).

METHODS

This is a case series with chart review of all T21 patients who underwent iTA or TT at our institution between July 1, 2015 and August 15, 2022. Data collected included demographics, comorbidities, preoperative sleep studies, intraoperative data, complications and recovery, postoperative sleep studies, and follow-up data.

RESULTS

There were 62 (21.7%) patients who underwent iTA and 224 (78.3%) patients who underwent TT. The iTA group had significantly lower pain scores (p < 0.001), decreased use of narcotics (p < 0.001), shorter length of stay (p = 0.003), and faster return to oral intake (p = 0.01) during their postoperative hospital admission, and fewer 30-day complications (p = 0.009) compared to the TA group. Both groups showed significant improvements in their sleep studies. For 41 (66.1%) of iTA patients who had follow-up, median follow-up was 1.8 years and for 169 (75.4%) TT patients, median follow-up was 2.6 years. At follow-up, 21 of 41 (51.2%) iTA patients and 83 of 169 (49.1%) TT patients exhibited OSA symptoms (p = 0.084) and tonsillar regrowth was not significantly different between the two groups (p = 0.12).

CONCLUSION

Patients with T21 experience less pain and fewer postoperative respiratory complications from iTA than from TT. The short-term impact of iTA versus TT on OSA, as measured by poysomnography, does not differ between the two techniques.

LEVEL OF EVIDENCE

3 Laryngoscope, 134:2430-2437, 2024.

Management of Periodic Fever, Aphthous Stomatitis, Pharyngitis, Adenitis with Intracapsular Tonsillectomy

OBJECTIVE

This study aimed to present 2 children clinically diagnosed with periodic fever, aphthous stomatitis, pharyngitis, and adenitis (PFAPA) syndrome and treated with intracapsular tonsillectomy with adenoidectomy (ITA).

METHODS

We conducted a retrospective analysis of 2 children who were referred for an otolaryngology consultation between 2019 and 2022 for surgical treatment of PFAPA syndrome. Both patients had symptoms strongly suggestive of PFAPA and were at risk for total tonsillectomy (TT) complications. ITA was performed using a microdebrider. Both patients were followed up postoperatively to assess for symptomatic resolution and complications.

RESULTS

Two children exhibited recurrent febrile episodes prior to ITA. The procedure was efficacious in both patients, with neither experiencing postoperative complications or recurring PFAPA symptoms for over 1 year after surgery.

CONCLUSION

Our study reported on the use of ITA as a surgical treatment option for PFAPA. We showed that ITA eliminated febrile attacks and was safely performed without postoperative complications in 2 pediatric patients after 1-year follow-up. Future studies involving larger cohorts of PFAPA patients and lengthier follow-ups will need to be conducted to further evaluate ITA as a surgical option. Laryngoscope, 134:1967-1969, 2024.

Postoperative Outcomes of Intracapsular Tonsillectomy With Coblation: A Systematic Review and Meta-Analysis

OBJECTIVE

Following tonsillectomy, postoperative pain and hemorrhage from the tonsillar bed are causes of significant morbidity. Intracapsular tonsillectomy with Coblation is suggested to minimize such morbidity while remaining efficacious in long-term outcomes. This systematic review and meta-analysis assessed short-term morbidity and long-term outcomes from intracapsular tonsillectomy with Coblation, focusing primarily on posttonsillectomy hemorrhage.

DATA SOURCES

Medline, Embase, and the Cochrane Library.

REVIEW METHODS

Guided by PRISMA guidelines, studies on intracapsular tonsillectomy with Coblation published between December 2002 and July 2022 evaluating frequency of posttonsillectomy hemorrhage were screened. Studies without primary data were excluded. Meta-analysis was conducted using the random-effect model. The primary outcome was the proportion of patients who experienced posttonsillectomy hemorrhage. The secondary outcomes were posttonsillectomy pain, the proportion requiring revision tonsillectomy, and severity of sleep-disordered breathing measured by polysomnography outcomes.

RESULTS

From 14 studies there were 9821 patients. The proportion of total posttonsillectomy hemorrhage was 1.0% (95% confidence interval [CI] 0.5%-1.6%, n = 9821). The proportion experiencing primary hemorrhage, secondary hemorrhage, and those requiring further tonsil surgery were 0.1% (95% CI 0.0%-0.1%; study n = 7), 0.8% (95% CI 0.2%-1.4%; study n = 7), and 1.4% (95% CI 0.6%-2.2%; study n = 6), respectively. Mean reduction in apnea-hypopnea index was -16.0 events per hour (95% CI -8.8 to -23.3, study n = 3) and mean increase in oxygen nadir was 5.9% (95% CI 2.6%-9.1%, study n = 3).

CONCLUSION

Intracapsular tonsillectomy with Coblation has been demonstrated to have a low rate of posttonsillectomy hemorrhage. Data regarding long-term tonsil regrowth and need for reoperation were encouraging of the efficacy of this technique.

An update on diagnosis and management of obstructive sleep apnoea in the first 2 years of life

The aim of this review is to summarise evidence that became available after publication of the 2017 European Respiratory Society statement on the diagnosis and management of obstructive sleep apnoea syndrome (OSAS) in 1- to 23-month-old children. The definition of OSAS in the first 2 years of life should probably differ from that applied in children older than 2 years. An obstructive apnoea-hypopnoea index >5 events·h-1 may be normal in neonates, as obstructive and central sleep apnoeas decline in frequency during infancy in otherwise healthy children and those with symptoms of upper airway obstruction. A combination of dynamic and fixed upper airway obstruction is commonly observed in this age group, and drug-induced sleep endoscopy may be useful in selecting the most appropriate surgical intervention. Adenotonsillectomy can improve nocturnal breathing in infants and young toddlers with OSAS, and isolated adenoidectomy can be efficacious particularly in children under 12 months of age. Laryngomalacia is a common cause of OSAS in young children and supraglottoplasty can provide improvement in children with moderate-to-severe upper airway obstruction. Children who are not candidates for surgery or have persistent OSAS post-operatively can be treated with positive airway pressure (PAP). High-flow nasal cannula may be offered to young children with persistent OSAS following surgery, as a bridge until definitive therapy or if they are PAP intolerant. In conclusion, management of OSAS in the first 2 years of life is unique and requires consideration of comorbidities and clinical presentation along with PSG results for treatment decisions, and a multidisciplinary approach to treatment with medical and otolaryngology teams.

Extracapsular Tonsillectomy versus Intracapsular Tonsillotomy in Paediatric Patients with OSAS

OBJECTIVE

The objective of our study was to compare our experience of intracapsular tonsillotomy performed with the help of a microdebrider usually used for adenoidectomy with results obtained from extracapsular surgery through dissection and from adenoidectomy in cases of people affected with OSAS, linked to adeno-tonsil hypertrophy, observed and treated in the last 5 years.

METHODS

3127 children with adenotonsillar hyperplasia and OSAS-related clinical symptoms (aged between 3 and 12 years) underwent tonsillectomy and/or adenoidectomy. A total of 1069 patients (Group A) underwent intracapsular tonsillotomy, while 2058 patients (Group B) underwent extracapsular tonsillectomy, from January 2014 to June 2018. The parameters considered in order to evaluate the effectiveness of the two different surgery techniques taken into consideration were as follows: the presence of possible postoperative complications, represented mainly by pain and perioperative bleeding; the level of postoperative respiratory obstruction compared with the original obstruction through night pulse oximetry, performed 6 months before and after the surgery; tonsillar hypertrophy relapse in Group A and/or the presence of residues in Group B with clinical evaluation performed 1 month, 6 months, and 1 year after the surgery; and postoperative life quality, evaluated through submitting to parents the same survey proposed before the surgery 1 month, 6 months, and 1 year after the surgery.

RESULTS

Regardless of the technique used (extracapsular tonsillectomy or intracapsular tonsillotomy), there was a clear improvement in both the obstructive respiratory symptomatology and quality of life in both patient groups, as highlighted by the pulse oximetry and the OSA-18 survey submitted later.

CONCLUSIONS

Intracapsular tonsillotomy surgery has improved in terms of a reduction in postoperative bleeding cases and pain reduction, with an earlier return to patients' usual lifestyle. Lastly, using a microdebrider with the intracapsular technique seems to be particularly effective in removing most of the tonsillar lymphatic tissue, leaving only a thin border of pericapsular lymphoid tissue and preventing lymphoid tissue regrowth during one year of follow-up.

A retrospective observational cohort study evaluating the postoperative outcomes of intracapsular coblation tonsillectomy in children

Coblation intracapsular tonsillectomy (ICT) is becoming popular due to its decreased postoperative complications. However, a concern exists about the need for revision surgery. We conducted a retrospective observational cohort study, with a null hypothesis that Coblation ICT is not associated with recurrence of the preoperative symptoms, obstructive tonsillar regrowth, or the need for revision tonsillar surgery. We reviewed 345 patients (median age of 4.5 years; IQR 3.2-6.3), operated by the senior author between Feb 2017 and Sep 2020, for a median follow-up of 395.0 days (IQR 221.5-654.5). Most patients had snoring (94.2%), mouth breathing (92.8%), restless sleep (62.6%), and sleep disorder breathing (52.8%); 12.5% had recurrent tonsillitis. The mean initial total symptoms score (TSS) was 5.2 (SD 1.4, range 1-8); 87.5% had three or more symptoms; 86.7% underwent ICT; TSS decreased postoperatively to a mean of 0.2, SD 0.8, range 0-7. The mean hospital stay was 0.96 day (SD 0.36, range 0-3). Secondary bleeding occurred in 0.7% of ICT patients. No patient required admission or intervention. There was no documented tonsillar regrowth resulting in upper airway obstruction. No one needed tonsillar revision surgery. Intracapsular tonsillectomy was shown to be an effective procedure with long-lasting results.

Adenotonsillotomy versus adenotonsillectomy in pediatric obstructive sleep apnea: A 5-year RCT

Objectives

Adenotonsillectomy (ATE) is a common treatment for pediatric obstructive sleep apnea (OSA). Intracapsular adenotonsillotomy (ATT) is associated with less postoperative morbidity. Our previous randomized controlled trial (RCT) compared ATE and ATT in otherwise healthy children with moderate to severe OSA. No differences in polysomnographic (PSG) and OSA-18 were found between the groups at one-year follow-up. This study presents the long-term results of the RCT.

Methods

Non-obese children (n = 79, 2–6 years) who had undergone either ATE (n = 40) or ATT (n = 39) were offered PSG and OSA-18 questionnaire five-years after surgery. Primary outcome was the group difference in postoperative Obstructive Apnea/Hypopnea Index (OAHI). ATE was recommended to the ATT group if they had a relapse of OSA.

Results

The follow-up was completed by 45 of 79 (57%) children; 28 (35%) drop-outs, and six of 39(15%) in the ATT group were excluded after ATE. After ATE(n = 17), OAHI decreased from mean 12.3(SD 8.0) to 0.6(0.7), and after ATT(n = 28) from 12.6(7.4) to 0.5(0.6), a mean difference in postoperative OAHI of 0.1(95% CI -0.3 – 0.5). Sensitivity analyses did not change the results. The median OSA-18 decreased in the ATE group from 57(interquartile range 47–79) to 27(22–36), and in the ATT group from 67(53–79) to 32(25–44), without group differences for postoperative values.

Conclusion

The results of this five-year follow-up of otherwise healthy OSA-children showed a high drop-out rate, but indicates that ATT could be an effective treatment for pediatric OSA. However, ATT warrants follow-up due to the risk of recurrence, and further studies are needed.

•

Adenotonsillotomy is an effective treatment for Obstructive sleep apnea in otherwise healthy children.

•

Six children out of 39 were reoperated with adenotonsillectomy within three years.

•

Follow-up after adenotonsillotomy is recommended.

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.

Do tonsils regrow after partial tonsillectomy? - Histology of regrown tonsils and predisposing factors for tonsillar regrowth

OBJECTIVES

It has been suggested that after partial tonsillectomy, referred here as tonsillotomy (TT), the remaining tonsillar tissue might be altered, leading to scarring or chronic tonsillitis. The objectives were to compare the histology of regrown tonsillar tissues with native tonsils and to assess the incidence of reoperations and predictive factors for tonsillar regrowth after TT.

METHODS

Tonsillar tissues of 1) children that underwent TT and later requiring resurgery and 2) children operated on for the first time with TT were prospectively analysed. To assess the incidence of resurgery because of tonsillar regrowth and predictive factors for tonsillar regrowth, the data covering TTs and tonsillectomies performed in 2009-2020 were retrospectively retrieved.

RESULTS

Altogether 11 children formed the regrowth group, with the control group consisting of 19 children. In the histological analysis of tonsillar tissues, neutrophil infiltration in the epithelium and crypts and severe lymphoplasmacytic infiltration in the epithelium were significantly more frequent in samples of the regrowth group relative to the control group. The number of germinal centres was greater in the regrowth group. In the retrospective analysis of 3141 children, the incidence of resurgery after primary TT was 1.9%. Logistic regression analysis showed that age was the only significant predisposing factor for resurgery.

CONCLUSION

Inflammatory cells were present more often in regrown tonsillar tissues but there was no evidence of severe chronic inflammation or scarring in the regrown tonsils. The risk of resurgery after TT was low. Young age predisposed to tonsillar regrowth, no other risk factors were found.

Coblation intracapsular tonsillectomy: a cohort study of NHS practice in England using Hospital Episode Statistics

OBJECTIVES

To identify paediatric intracapsular Coblation tonsillectomy procedures from routine administrative data in England, and determine their safety.

DESIGN

Retrospective observational cohort study of four ENT centres using routine data from Hospital Episode Statistics (HES).

SETTING

Acute NHS trusts in England conducting exclusively intracapsular Coblation tonsillectomy PARTICIPANTS: Children (≤16 years old) undergoing bilateral intracapsular Coblation tonsillectomy MAIN OUTCOME MEASURES: Number of procedures, readmissions for pain, readmissions for bleeding and requirement for additional surgery for regrowth.

RESULTS

5525 procedures were identified. The median patient age was 4 (IQR 2-5). In-hospital complications occurred in 1%, with 0.1% returning to theatre for arrest of primary tonsil bleeding. Almost half of the procedures were conducted as a day-case (44%), with only a small proportion staying in hospital more than one night (7%). Within 28 days, 1.2% of patients were readmitted with bleeding, 0.7% with infection and 0.3% with pain. 0.2% of patients required return to theatre for control of secondary haemorrhage. Longitudinal follow-up has found that revision tonsil surgery is 0.3% at 1 year (n=4498), 1.1% at 2 years (n=2938), 1.7% at 3 years (n=1781), 1.9% at 4 years (n=905), 2.2% at 5 years (n=305) CONCLUSIONS: Intracapsular coblation tonsillectomy safety outcomes in this study show primary and secondary bleed rates and emergency return to theatre rates are lower than all tonsillectomy techniques reported in the National Prospective Tonsillectomy Audit and also lower than previously published Hospital Episode Statistics analysis of tonsillectomy procedures.

Extracapsular versus intracapsular tonsillectomy: Outcomes in children with a focus on developmental delay

INTRODUCTION

Outcomes following intracapsular tonsillectomy (IT) have not been well established in children with developmental delays. The objective of this study was to compare outcomes and complications between intracapsular and extracapsular tonsillectomy (TT) in pediatric patients with developmental delay (DD) in comparison to non-developmentally delayed children.

METHODS

This is a retrospective study of pediatric patients with DD undergoing tonsillectomy between 2016 and 2019 at a tertiary care hospital. This group included patients with Down Syndrome, Autism Spectrum Disorder, other genetic syndromes, and patients with a diagnosis of global developmental delay. Outcomes and complications were analyzed for IT and TT.

RESULTS

2267 charts were reviewed, and 320 patients were identified with DD. Of those, 72 patients underwent IT and 248 underwent TT. In the DD cohort, the IT group had a shorter length of stay (0.97 vs 1.7 days, p < .0001) and was less likely to receive post-operative narcotic medication (2.8% vs 35%, p < .0001) and corticosteroids (9.7% vs 64%, p < .0001) during their hospital stay. Reductions in emergency room (ER) visits (5.6% vs 10%, p = .21) and post-op bleeding (PTH) (1.4% vs 4.8%, p = .31) for IT vs TT were not statistically significant in the DD group. In the NDD group, fewer patients undergoing IT returned to the ER (11% vs 2.3%, p < .0001) or had PTH (4.8% vs 0.25%, p, 0.0001) as compared to those children undergoing TT. There was no difference between parental report of symptom improvement between the groups (39% vs 33%, p = .39). Analysis of 180 patients with preoperative and postoperative sleep study data revealed post-op Apnea Hypopnea Index (AHI) improved with both techniques (74% TT vs 79% IT, p = .7). There were no differences noted for persistent obstructive sleep apnea (OSA) among the two techniques for both study groups (p = .63).

CONCLUSION

Children with DD undergoing IT have reduced length of stay and reduced inpatient administration of post-operative opioids and steroids. IT has comparable efficacy to TT in treating symptoms of pediatric sleep apnea with a better safety profile. Overall, children undergoing IT return to the operating room less frequently than those undergoing TT. Longer follow-up studies will be needed to evaluate rate of tonsil regrowth, risk of revision surgery and persistence of OSA in these patients.

Impact of tonsillotomy versus tonsillectomy on health-related quality of life and healthcare costs in children with sleep-disordered breathing

Objective

This study aimed to explore health-related quality of life and use of healthcare services and ensuing costs before and after tonsillotomy in children with sleep-disordered breathing and to compare the results to an earlier cohort of children who had undergone tonsillectomy.

Method

Children undergoing tonsillotomy answered the 17-dimensional, standardised health-related quality of life instrument questionnaire and a questionnaire on use of healthcare services and sick leave before and after surgery. Costs of specialist care were obtained pre- and post-operatively. The data were compared with similar data collected previously from children with tonsillectomy.

Results

Tonsillotomy improved mean total health-related quality of life score significantly at 6 and 12 months. Healthcare costs and number of sick-leave days diminished significantly from 3 months pre-operatively to 12 months after surgery. Tonsillotomy had similar positive effects compared with tonsillectomy regarding health-related quality of life and healthcare costs.

Conclusion

Tonsillotomy improves health-related quality of life in children with sleep-disordered breathing and reduces healthcare service needs and sick leave similarly to tonsillectomy.

Predictive Pediatric Characteristics for Revision Tonsillectomy After Intracapsular Tonsillectomy

OBJECTIVES

There is little research on the rate and risk factors for revision tonsillectomy after primary intracapsular tonsillectomy. Our study aimed to determine the revision rate following intracapsular tonsillectomy, identify patient characteristics that may increase the probability of revision surgery, and report the tonsillar hemorrhage rate after revision.

STUDY DESIGN

Level III, retrospective case-control study.

SETTING

A tertiary care pediatric center (Alfred I. duPont Hospital for Children, Wilmington, Delaware).

METHODS

A case-control study of pediatric patients who underwent intracapsular tonsillectomy between January 1, 2004, and December 31, 2018, was performed. Patients aged 2 to 20 years were analyzed and compared with matched controls who underwent intracapsular tonsillectomy within 7 days of the same surgeon's case. In total, 169 revision procedures were included with 169 matched controls.

RESULTS

A 1.39% revision rate was observed among a total of 12,145 intracapsular tonsillectomies. Among the 169 patients who underwent a revision procedure, the mean time between cases was 3.5 years. Tonsillitis was the most common diagnosis prompting revision tonsillectomy. Four (2.4%) patients underwent operative control of a postoperative tonsillar hemorrhage after revision surgery. Younger patients (P < .001) and patients with a history of gastroesophageal reflux disease (P = .006) were more likely to undergo revision tonsillectomy.

CONCLUSION

Patients below age 4 years and patients with gastroesophageal reflux disease may be at increased risk of undergoing revision tonsillectomy after primary intracapsular tonsillectomy. These factors should be considered when selecting an intracapsular technique for primary tonsillectomy in pediatric patients.

Subtotal intracapsular tonsillectomy may be the first choice for tonsillectomy in children

Objective

To investigate the effect and prognosis of subtotal intracapsular tonsillectomy.

Methods

All children (n=162) with tonsillar hypertrophy and chronic tonsillitis were randomly divided into two groups: tonsillectomy (n=75) and subtotal intracapsular tonsillectomy (n=87). Tonsillectomy: the tonsillar tissue was completely removed along with the tonsillar capsule. Subtotal intracapsular tonsillectomy: 80% to 90% of the tonsils and the complete epithelium of the tonsillar crypts were removed without damaging the tonsillar capsule. The Face, Legs, Activity, Cry, and Consolability (FLACC) and parents’ postoperative pain measure (PPPM) scales were used to evaluate postoperative pain, and the obstructive sleep apnea (OSA)-18 questionnaire was used to assess the children’s postoperative quality of life. The patients were followed-up for 2 years.

Results

1. The FLACC and PPPM scales indicated that the children’s postoperative pain after subtotal intracapsular tonsillectomy was significantly less than that of children undergoing tonsillectomy. 2. The OSA-18 scale scores indicated that subtotal intracapsular tonsillectomy significantly improved the children’s quality of life. 3. Two years after subtotal intracapsular tonsillectomy, no patients required reoperation.

Conclusion

Subtotal intracapsular tonsillectomy may be the first choice for tonsillar hypertrophy and chronic tonsillitis patients.

[Frequency of secondary tonsillectomy in Germany]

BACKGROUND

Tonsillar remnants are occasionally the subject of clinical negligence claims in tonsillectomy patients, but obligatory in every tonsillotomy procedure. In both cases, clinically relevant symptoms can require a secondary tonsillectomy (STE).

OBJECTIVE

The purpose of this retrospective longitudinal study was to identify the prevalence of STE in Germany between 2005 and 2018, using a report commissioned by the Federal Office for Statistics.

MATERIALS AND METHODS

STE was identified using the operation and procedure key (Operationen- und Prozedurenschlüssel, OPS) code 5‑281.4, and the prevalence stratified by year, age, and gender. Linear regression analysis was performed. In addition, the prevalence of tonsillectomy and tonsillotomy was determined by the OPS codes 5‑281.5, 5‑281.0, and 5.282.0.

RESULTS

Between 2005 and 2018, 11,018 patients underwent STE in Germany. The total number of STE per year decreased significantly from 1080 in 2005 to 483 in 2018 (p < 0.001). The number of inpatient tonsillotomy cases increased between 2007 and 2018 from 4658 to 18,369.

CONCLUSION

The annual number of STE in Germany decreased continually during the observation period. The population-based data used in the study were insufficient to determine whether STE had been performed after tonsillectomy or tonsillotomy. Further patient-level research is thus required.

International Pediatric Otolaryngology group (IPOG) consensus on the diagnosis and management of pediatric obstructive sleep apnea (OSA)

OBJECTIVE

To develop an expert-based consensus of recommendations for the diagnosis and management of pediatric obstructive sleep apnea.

METHODS

A two-iterative Delphi method questionnaire was used to formulate expert recommendations by the members of the International Pediatric Otolaryngology Group (IPOG).

RESULTS

Twenty-six members completed the survey. Consensus recommendations (>90% agreement) are formulated for 15 different items related to the clinical evaluation, diagnosis, treatment, postoperative management and follow-up of children with OSA.

CONCLUSION

The recommendations formulated in this IPOG consensus statement may be used along with existing clinical practice guidelines to improve the quality of care and to reduce variation in care for children with OSA.

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.

Current Status and Future Trends: Pediatric Intracapsular Tonsillectomy in the United States

OBJECTIVES

1) To assess the current status of pediatric intracapsular tonsillectomy in the United States, and 2) To apply lessons from the scientific literature and adoption of surgical innovation to predict future trends in pediatric intracapsular tonsillectomy.

METHODS

This was a cross-sectional survey study and literature review. An anonymous survey was sent to all members of the American Society of Pediatric Otolaryngology (ASPO) to determine current practices in pediatric tonsillectomy. Statistical analysis was performed to compare differences in individuals who perform intracapsular tonsillectomy as opposed to extracapsular tonsillectomy. A literature analysis of the adoption of new technological advancements and innovative surgical techniques was then performed.

RESULTS

The survey was sent to 540 pediatric otolaryngologists with a response rate of 42%. Of all respondents, 20% currently perform intracapsular tonsillectomy. The primary reason cited for not performing the procedure was concern for tonsillar regrowth. Time in practice, practice setting, and fellowship status was not associated with an increased incidence of intracapsular tonsillectomy.

CONCLUSIONS

Only 20% of pediatric otolaryngologist respondents in the United States perform intracapsular tonsillectomy. Based on the documented advantages of intracapsular tonsillectomy over extracapsular tonsillectomy and an analysis of adoption of novel surgical techniques, we predict a paradigm shift in the specialty toward intracapsular tonsillectomy.

LEVEL OF EVIDENCE

3 Laryngoscope, 131:S1-S9, 2021.

Caregivers' absence from work before and after tonsil surgery in children with sleep-disordered breathing

Purpose

Sleep-disordered breathing, SDB, in children is associated with morbidity that can result in caregivers having to stay at home from work. The aim of this study was to investigate whether the number of days when caregivers are reimbursed, temporary parental benefit (TPB) to stay at home from work to care for their sick child is increased among children with SDB before and after tonsil surgery.

Methods

This is a retrospective, cross-sectional study of children (n = 440), aged 2–11 years, that underwent tonsil surgery for SDB in day surgery at Sahlgrenska University Hospital in 2014 and 2015. TPB, was provided by the Swedish Social Insurance Agency. The expected days of TPB in the general population of the region were calculated. The number of days with TPB was compared 2 years before and 2 years after surgery and compared with the expected days of TPB.

Results

Two years before surgery, the children had no more days of TPB than expected. Two years after surgery, the children with SDB had 4.8 more days with TPB (p < 0.001) than expected, but, when the 1st month after surgery was excluded from the analysis, there was no difference in days of TPB compared with the general population.

Conclusion

Children with SDB who had tonsil surgery had no more days of parental benefits 2 years before and 2 years after surgery than expected. SDB is associated with increased morbidity, but it does not appear to cause caregivers to stay at home in the majority of children.

[Tonsillectomy and tonsillotomy]

The number of operations for tonsillectomy have been significantly decreasing for many years in Germany. In children the number of adenotonsillectomies has decreased by two thirds within a decade. This phenomenon is mirrored by a significant increase in the number of annually performed tonsillotomies, a surgical procedure which is preferably performed for volume reduction in cases of tonsillar hypertrophy. The aim of this article is to elucidate the different interventional procedures, their typical indications and risks.

Pediatric tonsillectomy: A short-term and long-term comparison of intracapsular versus extracapsular techniques

OBJECTIVE

To review a cohort of over 2500 patients and investigate the short and long-term outcomes of intracapsular as compared to extracapsular tonsillectomy, and show if the complication rates are comparable between methods.

STUDY DESIGN

A multicenter, retrospective chart review was conducted, evaluating pediatric tonsillectomies performed from 2004 to 2014. The electronic medical record was reviewed through December 2018, providing up to 14 years of follow-up data.

SETTING

Two tertiary care, academic medical centers.

SUBJECTS AND METHODS

A retrospective chart review was conducted to identify children undergoing tonsillectomy and adenotonsillectomy. A chart review was first performed of patients by a single surgeon (MEG) and then the analysis was repeated using enterprise data warehouse (EDW) to search for complications and interventions using International Classification of Diseases, ninth revision, (ICD-9) and Current Procedural Terminology (CPT) codes. The second surgeon's patients (JLC) patients were added to increase the cohort. Patients were excluded from the review of long-term outcomes if there was less than two-year follow-up. Short-term outcomes examined included rate of post-tonsillectomy hemorrhage and re-presentation for dehydration, while long-term outcomes included rates of peritonsillar abscess and tonsillar regrowth requiring revision tonsillectomy.

RESULTS

A total of 2508 pediatric patients were identified who had undergone tonsillectomy or adenotonsillectomy. In 1456 (58.1%) of these patients, the intracapsular technique was used and in 1052 (41.9%) patients, the extracapsular technique was used. The mean documented follow-up time was 8.2 years. Thirty-five patients (1.4%) were identified with post-tonsillectomy hemorrhage, 2 of these patients (5.7%) with primary hemorrhage and 33 patients (94.3%) with secondary hemorrhage. 11 underwent intracapsular tonsillectomy and 24 underwent extracapsular tonsillectomy (p = 0.0042). The rate of post-tonsillectomy hemorrhage with intracapsular tonsillectomy was 0.76%, compared to 2.3% in the extracapsular group. Three patients (0.12%) undergoing intracapsular tonsillectomy required revision tonsillectomy; no patients in the extracapsular group required revision surgery. Three patients (0.12%) developed peritonsillar abscess post-operatively, two following intracapsular tonsillectomy and one following extracapsular tonsillectomy.

CONCLUSION

This retrospective review comparing the intracapsular and extracapsular techniques for tonsillectomy provides further evidence of the benefits of this technique. It is worthwhile to continue offering intracapsular tonsillectomy to patients and their families during pre-operative discussions.

Tonsillectomy versus tonsillotomy for obstructive sleep-disordered breathing in children

BACKGROUND

Obstructive sleep-disordered breathing (oSDB) is a condition encompassing breathing problems when asleep due to upper airway obstruction. In children, hypertrophy of the tonsils and/or adenoids is thought to be the commonest cause. As such, (adeno)tonsillectomy has long been the treatment of choice. A rise in partial removal of the tonsils over the last decade is due to the hypothesis that tonsillotomy is associated with lower postoperative morbidity and fewer complications.

OBJECTIVES

To assess whether partial removal of the tonsils (intracapsular tonsillotomy) is as effective as total removal of the tonsils (extracapsular tonsillectomy) in relieving signs and symptoms of oSDB in children, and has lower postoperative morbidity and fewer complications.

SEARCH METHODS

We searched the Cochrane ENT Trials Register; Central Register of Controlled Trials (CENTRAL); MEDLINE; EMBASE; CINAHL; Web of Science; ClinicalTrials.gov; ICTRP and additional sources for published and unpublished trials. The search date was 22 July 2019.

SELECTION CRITERIA

Randomised controlled trials (RCTs) comparing the effectiveness of (adeno)tonsillectomy with (adeno)tonsillotomy in children aged 2 to 16 years with oSDB.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methods and assessed the certainty of the evidence for our pre-defined outcomes using GRADE. Our primary outcomes were disease-specific quality of life, peri-operative blood loss and the proportion of children requiring postoperative medical intervention (with or without hospitalisation). Secondary outcomes included postoperative pain, return to normal activity, recurrence of oSDB symptoms as a result of tonsil regrowth and reoperation rates.

MAIN RESULTS

We included 22 studies (1984 children), with predominantly unclear or high risk of bias. Three studies used polysomnography as part of their inclusion criteria. Follow-up duration ranged from six days to six years. Although 19 studies reported on some of our outcomes, we could only pool the results from a few due both to the variety of outcomes and the measurement instruments used, and an absence of combinable data. Disease-specific quality of life Four studies (540 children; 484 (90%) analysed) reported this outcome; data could not be pooled due to the different outcome measurement instruments used. It is very uncertain whether there is any difference in disease-specific quality of life between the two surgical procedures in the short (0 to 6 months; 3 studies, 410 children), medium (7 to 13 months; 2 studies, 117 children) and long term (13 to 24 months; 1 study, 67 children) (very low-certainty evidence). Peri-operative blood loss We are uncertain whether tonsillotomy reduces peri-operative blood loss by a clinically meaningful amount (mean difference (MD) 14.06 mL, 95% CI 1.91 to 26.21 mL; 8 studies, 610 children; very low-certainty evidence). In sensitivity analysis (restricted to three studies with low risk of bias) there was no evidence of a difference between the groups. Postoperative complications requiring medical intervention (with or without hospitalisation) The risk of postoperative complications in the first week after surgery was probably lower in children who underwent tonsillotomy (4.9% versus 2.6%, risk ratio (RR) 1.75, 95% CI 1.06 to 2.91; 16 studies, 1416 children; moderate-certainty evidence). Postoperative pain Eleven studies (1017 children) reported this outcome. Pain was measured using various scales and scored by either children, parents, clinicians or study personnel. When considering postoperative pain there was little or no difference between tonsillectomy and tonsillotomy at 24 hours (10-point scale) (MD 1.09, 95% CI 0.88 to 1.29; 4 studies, 368 children); at two to three days (MD 0.93, 95% CI -0.14 to 2.00; 3 studies, 301 children); or at four to seven days (MD 1.07, 95% CI -0.40 to 2.53; 4 studies, 370 children) (all very low-certainty evidence). In sensitivity analysis (restricted to studies with low risk of bias), we found no evidence of a difference in mean pain scores between groups. Return to normal activity Tonsillotomy probably results in a faster return to normal activity. Children who underwent tonsillotomy were able to return to normal activity four days earlier (MD 3.84 days, 95% CI 0.23 to 7.44; 3 studies, 248 children; moderate-certainty evidence). Recurrence of oSDB and reoperation rates We are uncertain whether there is a difference between the groups in the short (RR 0.26, 95% CI 0.03 to 2.22; 3 studies, 186 children), medium (RR 0.35, 95% CI 0.04 to 3.23; 4 studies, 206 children) or long term (RR 0.21 95% CI 0.01 to 4.13; 1 study, 65 children) (all very low-certainty evidence).

AUTHORS' CONCLUSIONS

For children with oSDB selected for tonsil surgery, tonsillotomy probably results in a faster return to normal activity (four days) and in a slight reduction in postoperative complications requiring medical intervention in the first week after surgery. This should be balanced against the clinical effectiveness of one operation over the other. However, this is not possible to determine in this review as data on the long-term effects of the two operations on oSDB symptoms, quality of life, oSDB recurrence and need for reoperation are limited and the evidence is of very low quality leading to a high degree of uncertainty about the results. More robust data from high-quality cohort studies, which may be more appropriate for detecting differences in less common events in the long term, are required to inform guidance on which tonsil surgery technique is best for children with oSDB requiring surgery.

Tonsillotomy versus Tonsillectomy for Chronic Recurrent Tonsillitis in Children

Objective

This study was conducted to compare two different surgical methods; partial tonsil resection using the bipolar technique, tonsillotomy (TT), and total tonsillectomy (TE) (blunt dissection) for recurrent tonsillitis in children. The frequency of recurrent throat infections was determined during postoperative follow-up.

Methods

A total of 393 patients were included in this study. TT was performed on 174 patients (100 males, 74 females) and TE on 219 patients (112 males, 107 females). Following surgery, an analysis was made of treatment outcomes of patients with upper respiratory tract infections. The patients were followed up for 12-48 months. Their parents were also contacted by telephone to determine the frequency of reinfection and their satisfaction with the surgery. Also, parents of the patients completed a questionnaire pertaining to postoperative satisfaction (scale of 1-10).

Results

In the TT group, 14 (8.1%) patients had recurrent tonsillitis postoperatively. In the TE group, 12 (5.4%) patients required antibiotherapy due to recurrent pharyngitis after the surgery. There was no significant difference between the two groups in terms of the one-year infection recurrence rate after surgery (p=0.281). Three patients (1.6%) in the TT group and 12 (5.4%) in the TE group complained of bleeding within the first 24 hours. The rate of bleeding was significantly lower in the TT group than the TE group (p=0.001). There were no fatalities in either group.

Conclusion

In both groups, the rate of reinfection accorded with the requirement for postoperative antibiotics. For recurrent tonsillitis, TT was as effective as TE. However, TT was superior in terms of the risk of bleeding.

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.

Intracapsular versus extracapsular dissection tonsillectomy for adults: A systematic review

OBJECTIVES

Tonsillectomy is an extremely common ENT surgical procedure. There is a growing interest in the role of intracapsular dissection tonsillectomy (ICDT) due to reported reduced perioperative complications. We aim to compare the outcomes associated with ICDT versus traditional extracapsular dissection tonsillectomy (ECDT) in the adult population.

METHODS

Systematic review of all randomized controlled trials (RCTs) comparing ICDT and ECDT for all indications in the adult population. Electronic searches performed through CENTRAL, PubMed, Ovid EMBASE, Web of Science, ClinicalTrials.gov, and WHO ICTRP. Review Manager 5.3 (RevMan 2014) was used to carry out the meta-analysis.

RESULTS

Nine RCTs were included with a total of 11 reports with mean age of 23.9 years including 181 patients who received ICDT compared to 176 patients receiving ECDT. We found statistically significant reduced postoperative pain and analgesia requirement as well as a reduced rate of secondary postoperative bleeding in patients undergoing ICDT versus ECDT. There appears to be no significant difference in controlling recurrent tonsillitis between the ICDT and ECDT groups.

CONCLUSION

Across the recorded outcomes we noted no clear benefit to performing ECDT over ICDT and evidence suggests high patient satisfaction with ICDT. Laryngoscope, 130:2325-2335, 2020.

Postoperative pain and bleeding after adenotonsillectomy versus adenotonsillotomy in pediatric obstructive sleep apnea: an RCT

Purpose

Our previous randomized controlled trial (RCT) of children with obstructive sleep apnea (OSA) showed no significant differences between adenotonsillectomy (ATE) and adenotonsillomy (ATE) in improving nocturnal respiration and symptoms after one year. This is the continuous report with the evaluation of postoperative morbidity concerning bleeding and pain.

Methods

A double-blinded RCT including 79 children, aged 2–6 years, with moderate to severe OSA, randomized to either ATE (n = 40) or ATT (n = 39). From one to ten days postoperatively, parents filled in a logbook with six pain-related outcomes (parent and child grading pain at different levels, days of analgesic use and return to normal diet). Peri- and postoperative bleeding were also registered.

Results

63 patients (80%) returned the logbook. There were significant differences between groups in only two of the six pain-related outcomes in favor of the ATT group; first day when the children graded themselves as pain free (p = 0.021, Log Rank Test), and first day the caregiver estimated pain VAS ≤ 5 (p = 0.007, Log Rank Test). Two (5%) cases of postoperative bleeding occurred in the ATE group, one of which needed a return to theatre. No case of postoperative bleeding was seen in the ATT group.

Conclusions

The results from this RCT are in line with previous comparative studies between ATT and ATE. Children operated with ATT had significantly less postoperative pain in one-third of the outcomes, and less bleeding than ATE. However, as the differences in morbidity between the surgical methods were minor the clinical significance is uncertain.

Trial registration

This study was approved by the Swedish Regional Ethics Board in Stockholm, Sweden (Dnr 2011/925-32 and 2013/2274-32) and registered at ClinicalTrials.gov (Trial registration number NCT01676181).

Changing trends in pediatric tonsil surgery

OBJECTIVES

We analyzed trends in tonsil surgery over a 10-year period in a single tertiary care hospital and evaluated the effects of these changes on use of hospital services and healthcare costs.

METHODS

This was a retrospective cohort study based on data from databases at the Department of Otorhinolaryngology, Helsinki University Hospital, Helsinki, Finland. Children under 16 years of age with tonsillectomy (TE) or tonsillotomy (TT) performed during 2007-2016 were included in the study.

RESULTS

In 10 years, 4979 tonsil surgeries were performed on 4951 children: TE in 3170 (64%) and TT in 1781 (36%) children. The total number of tonsil surgeries stayed nearly constant. TT operations commenced in the study hospital in 2009 and from 2012 onwards have been more common than TE procedures. Altogether 279 patients visited the emergency department because of complications; TE patients had 9.0 visits/100 surgeries and TT patients 1.8 visits/100 surgeries. The most common complication was postoperative hemorrhage: 200 cases (6.3%) in the TE group and 11 cases (0.6%) in the TT group. During the two-year follow-up after tonsil surgery the total costs of healthcare services were significantly lower in the TT group than in the TE group.

CONCLUSION

Considerable changes have occurred in tonsil surgery in children during the 10-year study period; TT is today performed more often than TE. As a consequence, complications, readmissions to hospital, and number of patients treated in the operating room because of postoperative hemorrhage have decreased, lowering the costs of healthcare.

French Society of Otorhinolaryngology and Head and Neck Surgery (SFORL) guidelines concerning the role of otorhinolaryngologists in the management of paediatric obstructive sleep apnoea syndrome: Follow-up protocol for treated children

OBJECTIVES

The authors present the French Society of Oto-Rhino-Laryngology and Head and Neck Surgery (SFORL) clinical practice guidelines concerning the role of otorhinolaryngologists in the management of paediatric obstructive sleep apnoea syndrome (OSAS). This chapter is devoted to the follow-up protocol for children treated for OSAS.

METHODS

A multidisciplinary task force was commissioned to carry out a review of the scientific literature on this topic. On the basis of the articles selected and the personal experience of each member of the task force, guidelines were drafted and graded as A, B or C or expert opinion according to a decreasing level of scientific evidence, and were then reviewed by a reading committee, independently of the task force. The final guidelines were established at a consensus meeting.

RESULTS

Short-term, medium-term and long-term clinical follow-up and complementary investigations are necessary in view of the risk of residual OSAS, and the risk of recurrence of OSAS related to adenoid and tonsillar regrowth following adenotonsillectomy, the treatment most commonly performed. The modalities of follow-up after surgery, continuous positive airway pressure (CPAP) ventilation, orthodontic treatment, myofascial rehabilitation, and drug therapy are described. The indications for nasal endoscopy and sleep studies as part of follow-up are specified.

Comparison of Pediatric Intracapsular Tonsillectomy and Extracapsular Tonsillectomy: A Cost and Utility Decision Analysis

Objectives To use decision analysis modeling to compare utility and cost outcomes of intracapsular tonsillectomy (ICT) and extracapsular tonsillectomy (ECT). To use sensitivity analysis to determine the most important factors influencing outcomes favoring one surgical method versus another. Study Design Decision analysis model. Setting Hypothetical cohort. Subjects and Methods A decision analysis model was created with computer software comparing the results of ICT and ECT. The model featured complications with completion tonsillectomy, such as postsurgical bleed, dehydration, and tonsillar regrowth. Outcomes were quantified with a utility scale ranging from 0.95 (1 surgical procedure without complications) to 0.55 (ICT, regrowth requiring completion ECT, post-ECT bleeding). Costs measured out-of-pocket costs for an insured patient and factored in different recovery times for ECT versus ICT. Results Based on baseline parameters, ECT had higher cumulative utility than ICT. Utility model results were highly dependent on the value of having a single uncomplicated surgery, as well as on the tonsillar regrowth rate. Utility was equal at a regrowth rate of 1.64%; rates above this value favored ECT. The base cost model showed that ICT ($4177.92) was less expensive than ECT ($4546.91), although ICT with regrowth had the highest outcome cost ($8393.91). ECT and ICT costs were equal at a tonsil regrowth rate of 17.8% and at a recovery period of 7.4 days. Conclusion Utility decision modeling based on best estimates for baseline parameters suggests that ECT may be slightly superior to ICT, but cost analysis suggests the opposite. However, the comparative results are highly dependent on subtle changes in the tonsil regrowth rate and the potential difference in recovery time.

Tonsil surgery in Sweden 2013-2015. Indications, surgical methods and patient-reported outcomes from the National Tonsil Surgery Register

AIM

To describes how tonsil surgery was performed in Sweden from 2013 to 2015 with data from the National Tonsil Surgery Registry in Sweden (NTSRS).

METHOD

The registry collects data from both professionals and patients through questionnaires. A total of 33,870 tonsil surgeries were analysed, comprising approximately 80% of all tonsil surgeries in Sweden from 2013 to 2015.

RESULTS

The two most common procedures were tonsillectomy (41%) and tonsillotomy with adenoidectomy (38%). Tonsillectomy was most commonly performed to treat frequent tonsillitis, while the main indication for tonsil surgery with combined adenoidectomy and for tonsillotomy alone was upper airway obstruction. The most commonly used techniques were cold steel (70%) for tonsillectomy/adenotonsillectomy and radiofrequency (79%) for tonsillotomy/adenotonsillotomy. Ninety-five percent of patients reported symptom relief after 180 d. Day surgery was utilised in 70% of the surgeries. The rate of readmission due to post-tonsillectomy haemorrhage was 5.1%. Male patients more often underwent tonsil surgery at preschool ages due to upper airway obstruction; in comparison, female patients to a larger extent underwent surgery in their early teens because of previous infections.

CONCLUSIONS

The NTSRS provides an opportunity to survey tonsil surgery in Sweden and to launch and follow up improvement programmes as desired.

The effect of tonsillotomy on chronic recurrent tonsillitis in children

OBJECTIVES

The objective of this study is to determine whether partial tonsillectomy (tonsillotomy) impacts the occurrence of acute or recurrent tonsillitis in children.

METHODS

One hundred and eighty patients (1-14 years) were retrospectively surveyed by a questionnaire or by data analysis of a regional database. Subjects who suffered from severe systemic diseases or immunodeficiency syndromes were excluded. Episodes of acute tonsillitis before and after surgery, rate of antibiotic treatment, postoperative hemorrhage, and re-operation were obtained.

RESULTS

Fifty-one patients suffered from preoperative tonsillitis. The rate of reinfection was 9.8%. The frequency of tonsillitis was significantly reduced in children after tonsillotomy (p < .001). Further, tonsillotomy led to a significant reduction of antibiotic treatment (p < .001). The rate of definitive tonsillectomy was 1.1% and thus effectiveness was very high. About 1.7% of all children suffered from postoperative bleeding, of which one (0.6%) required surgical revision. None of the bleedings was life threatening.

CONCLUSIONS

Tonsillotomy is beneficial for patients with recurrent tonsillitis and carries less risk of postoperative complications than tonsillectomy.

Patient reported pain-related outcome measures after tonsil surgery: an analysis of 32,225 children from the National Tonsil Surgery Register in Sweden 2009-2016

The objective of this study was to describe factors affecting pain after pediatric tonsil surgery, using patient reported pain-related outcome measures (pain-PROMs) from the National Tonsil Surgery Register in Sweden. In total, 32,225 tonsil surgeries on children (1 to <18 years) during 2009-2016 were included; 13,904 tonsillectomies with or without adenoidectomy (TE ± A), and 18,321 tonsillotomies with or without adenoidectomy (TT ± A). Adjustments were made for variables included in the register to compensate for contributable factors in the analysis. When compared to TE ± A for surgical indication obstruction, TT ± A resulted in lower pain-PROMs, shorter use of postoperative analgesics, earlier return to regular food intake, and lower risk for contact with health care services due to pain. Children who underwent TE ± A because of obstruction problems stopped taking painkillers and returned to normal eating habits sooner, compared to children who underwent TE ± A for infectious indications. In both indication groups, TE ± A performed with hot rather than cold technique (dissection and haemostasis) generally resulted in higher pain-PROMs. Older children reported more days on analgesics and a later return to regular food intake after TE ± A than younger ones. No clinically relevant difference between sexes was found. Between 2012 and 2016 (pre-and post-implementation of Swedish national guidelines for pain treatment), the mean duration of postoperative analgesic use had increased. In conclusion, TE ± A caused considerably higher ratings of pain-related outcome measures, compared to TT ± A. For TE ± A, cold surgical techniques (dissection and haemostasis) were superior to hot techniques in terms of pain-PROMs. Older children reported higher pain-PROMs after TE ± A than younger ones.

Self-reported postoperative recovery in children after tonsillectomy compared to tonsillotomy

OBJECTIVES

Tonsil surgery is associated with significant morbidity during recovery. Patient-reported outcome measures (PROM) are the golden standard for the planning and follow-up of delivered care, which should also be an axiom for children. The current aims were to describe self-reported postoperative recovery in children after tonsil surgery, and to compare tonsillotomy and tonsillectomy in this respect.

METHODS

In total, 238 children (4-12 years old) with a history of obstructive problems and/or recurrent tonsillitis, and undergoing tonsil surgery were included. Forty-eight per cent were operated with partial tonsil resection/tonsillotomy (TT) and 52% with total tonsillectomy (TE), all in day surgery. Postoperative recovery was assessed on days 1, 4 and 10 using the validated self-rating instrument PRiC, Postoperative Recovery in Children. This includes 23 items covering different aspects of recovery after tonsil surgery. A higher score indicates worse status in the respective items.

RESULTS

Daily life activities (sleeping, eating and playing), physical symptoms (e.g., headache, stomach ache, sore throat, otalgia, dizziness, nausea, defecation, urination), and emotional aspects (sadness, frightening dreams) were affected during the recovery period. The TE-girls showed higher scores than the boys regarding stomach ache, defecation and dizziness. Children above 6 years of age reported higher values for the physical comfort variables, while the younger group showed worse emotional states. Postoperative recovery improved from day 1-10 in all surgical groups. The TE-group showed lower recovery compared to the TT-group (p < 0.01-0.001) in most items.

CONCLUSION

The goal of postoperative management is to minimize or eliminate discomfort, facilitating the recovery process and avoiding complications. Children are able to describe their recovery, and thus, PRiC seems to be able to serve as a PROM to obtain patient-centered data after tonsil surgery. The recovery process after TT causes less postoperative morbidity and a quicker return to normal activity compared to TE.

Adenotonsillotomy Versus Adenotonsillectomy in Pediatric Obstructive Sleep Apnea: An RCT

BACKGROUND

Adenotonsillectomy (ATE) is a well-established and effective treatment of pediatric obstructive sleep apnea (OSA). In recent years, a more conservative method, adenotonsillotomy (ATT), has gained popularity because it is associated with less postoperative morbidity. Yet no previous randomized study has compared these 2 methods regarding their effectiveness in treating pediatric OSA in terms of polysomnographic data, which was the primary aim of this study. The hypothesis was that ATT is noninferior to ATE after 1 year.

METHODS

Seventy-nine children, aged 2 to 6 years, with OSA (Apnea-Hypopnea Index [AHI] 5-30) were randomized to ATT (n = 40) or ATE (n = 39). Polysomnography (PSG) and questionnaire OSA-18 were assessed at baseline and 1 year postsurgery.

RESULTS

Mean difference between groups in the primary outcome, change in AHI, was 0.83, 95% confidence interval -3.2 to 4.9, not exceeding the noninferiority margin of 5. After ATE, AHI decreased from median 12.7 (interquartile range 8.3-19.1) to 2.0 (1.2-3.1) and after ATT from 15.8 (8.5-21.2) to 4.0 (1.2-5.1). For both groups, significant improvements of PSG and OSA-18 questionnaire outcomes were observed, with no significant differences between groups. Five children (13%) in the ATT group needed repeated surgery for tonsil regrowth and recurrence of OSA.

CONCLUSIONS

The results suggest that ATT is noninferior to ATE in treating pediatric OSA regarding PSG outcomes after 1 year. ATT could be considered an alternative to ATE for treatment of pediatric OSA. However, after ATT, there is a nonnegligible risk of recurrence of OSA, and this should be taken into account when selecting surgical method.

Indirect costs related to caregivers' absence from work after paediatric tonsil surgery

Tonsillotomy has gradually replaced tonsillectomy as the surgical method of choice in children with upper airway obstruction during sleep, because of less postoperative pain and a shorter recovery time. The aim of this study was to examine the costs related to caregivers' absenteeism from work after tonsillectomy (TE) and tonsillotomy (TT). All tonsillectomies and tonsillotomies in Sweden due to upper airway obstruction during 1 year, reported to the National Tonsil Surgery Register in children aged 1-11 were included, n = 4534. The number of days the child needed analgesics after surgery was used as a proxy to estimate the number of work days lost for the caregiver. Data from the Social Insurance Agency (Försäkringskassan) regarding the days the parents received temporary parental benefits in the month following surgery were also analysed. The indirect costs due to the caregivers' absenteeism after tonsillectomy vs tonsillotomy were calculated, using the human capital method. The patient-reported use of postoperative analgesic use was 77% (n = 3510). Data from the Social Insurance Agency were gathered for all 4534 children. The mean duration of analgesic treatment was 4.6 days (indirect cost of EUR 747). The mean number of days with parental benefits was 2.9 (EUR 667). The indirect cost of tonsillectomy was 61% higher than that of tonsillotomy (EUR 1010 vs EUR 629). The results show that the choice of surgical method affects the indirect costs, favouring the use of tonsillotomy over tonsillectomy for the treatment of children with SDB, due to less postoperative pain.

Postoperative Bleeding and Associated Utilization following Tonsillectomy in Children

Objective To assess posttonsillectomy hemorrhage (PTH), associated nonoperative readmissions/revisits, and reoperations in children. Data Sources MEDLINE, EMBASE, and the Cochrane Library. Review Methods Two investigators independently screened studies against predetermined criteria and extracted key data. Investigators independently assessed study risk of bias and the strength of the evidence of the body of literature. We calculated unadjusted pooled estimates of PTH frequency and conducted a Bayesian meta-analysis to estimate frequency of primary and secondary PTH and PTH-associated reoperation and revisits/readmissions by partial and total tonsillectomy and surgical approach. Results In meta-analysis, the frequency of primary and secondary PTH associated with total and partial tonsillectomy was <4% for any technique and with overlapping confidence bounds. Pooled frequencies of PTH were also <5% overall (4.2% for total tonsillectomy, 1.5% for partial tonsillectomy) in comparative studies. Fewer PTH episodes occurred with tonsillectomy for obstructive sleep-disordered breathing than for throat infection. In meta-analysis, frequency of PTH-associated nonoperative revisits/readmission or reoperation ranged from 0.2% to 5.7% for total tonsillectomy and from 0.1% to 3.7% for partial tonsillectomy. At least 4 deaths were reported in case series including 1,778,342 children. Conclusions PTH occurred in roughly 4% of tonsillectomies in studies included in this review. Although studies typically did not report bleeding severity or amount, relatively few episodes of PTH necessitated reoperation for hemostasis. Nonetheless, tonsillectomy is not without risk of harm. Frequency of PTH across techniques was similar; thus, we cannot conclude that a given technique is superior.

Comparative Effectiveness of Partial versus Total Tonsillectomy in Children

Objective To assess the effectiveness of partial versus total tonsillectomy in children. Data Sources MEDLINE, EMBASE, and Cochrane Library from January 1980 to June 2016. Review Methods Two investigators independently screened studies and extracted data. Investigators independently assessed risk of bias and strength of evidence of the literature. Heterogeneity precluded quantitative analysis. Results In 16 eligible randomized controlled trials (RCTs), definitions of "partial" tonsillectomy varied. In addition to comparing partial with total tonsil removal, 11 studies compared surgical techniques (eg, coblation). In studies comparing the same technique, return to normal diet or activity was faster with partial removal (more favorable outcomes in 4 of 4 RCTs). In studies with differing surgical techniques, return to normal diet and activity was faster with partial versus total tonsillectomy (more favorable outcomes in 5 of 6 studies). In 3 of 4 RCTs, partial tonsillectomy was associated with more throat infections than total tonsillectomy. Differences between groups were generally not statistically significant for obstructive symptom persistence, quality of life, or behavioral outcomes. Across all studies, 10 (6%) of roughly 166 children had tonsillar regrowth after partial tonsillectomy. Conclusions Data do not allow firm conclusions regarding the comparative benefit of partial versus total removal; however, neither surgical technique nor extent of surgery appears to affect outcomes markedly. Partial tonsillectomy conferred moderate advantages in return to normal diet/activity but was also associated with tonsillar regrowth and symptom recurrence. Effects may be due to confounding given differences in populations and surgical approaches/techniques. Heterogeneity and differences in the operationalization of "partial" tonsillectomy limited comparative analyses.