Changing trends in pediatric tonsil surgery

Tonsillotomy for Periodic Fever Syndrome: A Randomized and Controlled Trial

OBJECTIVE

Tonsillectomy is an effective treatment for periodic fever, aphthous stomatitis, pharyngitis, and cervical adenitis (PFAPA) syndrome. Tonsillotomy has a milder operative risk profile and postoperative morbidity in children than tonsillectomy. We aimed to compare the efficacy of tonsillotomy to observation-only in children with PFAPA syndrome at a 3-month follow-up.

METHODS

This was a randomized multicenter trial with sequential design. Participants were randomized into a tonsillotomy group and a control group that was only observed. The trial started in 1/2017 and was accomplished in 12/2021 with 16 patients (10 boys, six girls, the mean age 4.2 years). The symptoms were monitored with daily symptom diaries.

RESULTS

After the 3-month follow-up, 7/8 patients (87.5%) in the tonsillotomy group and 2/8 (25%) patients in the control group were free from PFAPA symptoms (95% CI 13% to 87%; p = 0.0021). The mean number of days with fever was 2.6 (SD 3.7) in the tonsillotomy group and 8.0 (SD 6.5) days in the control group (n = 8) (p = 0.06). Mean number of fever days compatible with PFAPA syndrome was 0.8 (SD 1.4) in the tonsillotomy group and 6.5 (SD 6.0) in the control group (95%CI -10% to -1%; p = 0.007). Rescue tonsillectomy was needed for all patients in the control group and none of the patients in the tonsillotomy group.

CONCLUSIONS

Tonsillotomy might be an effective treatment option for children with PFAPA syndrome. Further studies are needed to clarify the long-term efficacy of tonsillotomy for treating PFAPA.

LEVEL OF EVIDENCE

2 Laryngoscope, 134:968-972, 2024.

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Hemorrhage after adenotonsillectomy in children: tertiary center experiences

BACKGROUND

Adenotonsillectomy is the most commonly performed surgery in the pediatric population. Hemorrhage after adenotonsillectomy, which can occur at any time postoperatively, is one of the most serious complications.

OBJECTIVE

To determine the frequency of hemorrhage in children after adenotonsillectomy and to compare postoperative hemorrhage with regard to age and sex.

METHODS

A cross-sectional longitudinal study was conducted at the Ear, Nose, and Throat Clinic, University Clinical Center Tuzla, and included all children of both sexes, aged 3 to 15 years, who underwent adenotonsillectomy during a 1.5-year period.

RESULTS

A total of 201 children aged 3-15 years underwent adenotonsillectomy, 113 males and 88 females, which corresponds to a ratio of 1.28: 1. Adenotonsillectomy was performed in 147 (73.1%) patients and adenoidectomy in 54 (27%). In the overall sample, there were 19 (9.5%) subjects with postoperative hemorrhage. Primary hemorrhage occurred in 9 subjects (47%) and secondary hemorrhage in 10 subjects (53%). Significantly more female subjects had postoperative hemorrhage. In the group of subjects with hemorrhage, the mean age (standard deviation) was 8.45 (3.3) years. Tonsillar lodges are common sites of hemorrhage.

CONCLUSION

The frequency and causes of hemorrhage after adenotonsillectomy in our study are partially comparable to the world data.

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.

The Tonsil Lymphocyte Landscape in Pediatric Tonsil Hyperplasia and Obstructive Sleep Apnea

Tonsil hyperplasia is the most common cause of pediatric obstructive sleep apnea (OSA). Despite the growing knowledge in tissue immunology of tonsils, the immunopathology driving tonsil hyperplasia and OSA remains unknown. Here we used multi-parametric flow cytometry to analyze the composition and phenotype of tonsillar innate lymphoid cells (ILCs), T cells, and B cells from pediatric patients with OSA, who had previous polysomnography. Unbiased clustering analysis was used to delineate and compare lymphocyte heterogeneity between two patient groups: children with small tonsils and moderate OSA (n = 6) or large tonsils and very severe OSA (n = 13). We detected disturbed ILC and B cell proportions in patients with large tonsils, characterized by an increase in the frequency of naïve CD27^-CD21^hi B cells and a relative reduction of ILCs. The enrichment of naïve B cells was not commensurate with elevated Ki67 expression, suggesting defective differentiation and/or migration rather than cellular proliferation to be the causative mechanism. Finally, yet importantly, we provide the flow cytometry data to be used as a resource for additional translational studies aimed at investigating the immunological mechanisms of pediatric tonsil hyperplasia and OSA.

Primary and secondary postoperative hemorrhage in pediatric tonsillectomy

BACKGROUND

Tonsillectomy is the most common procedure for treatment of pediatric recurrent acute tonsillitis and tonsillar enlargement that contributes to obstructive sleep apnea hypopnea syndrome. Postoperative hemorrhage of tonsillectomy is a life-threatening complication.

AIM

To identify the risk factors that may contribute to primary and secondary post-operative hemorrhage in pediatric tonsillectomy.

METHODS

The clinical data from 5015 children, 3443 males and 1572 females, aged 1.92-17.08 years, with recurrent tonsillitis and/or tonsil hypertrophy who underwent tonsillectomy in our hospital from January 2009 to December 2018 were retrospectively collected. The variables including sex, age, time of onset, diagnosis, method of tonsillectomy, experience of surgeon, time when the surgery started and monthly average air temperature were abstracted. The patients with postoperative hemorrhage were classified into two groups, the primary bleeding group and the secondary bleeding group, and their characteristics were compared with those of the nonbleeding group separately. Statistical analysis was performed by chi-square test with SPSS 20.

RESULTS

Ninety-two patients had post-tonsillectomy hemorrhage, and the incidence rate of post-tonsillectomy hemorrhage was 1.83%. The mean age was 5.75 years. Cases of primary hemorrhage accounted for approximately 33.70% (31/92), and cases of secondary hemorrhage occurred in 66.30% (61/92). The rate of reoperation for bleeding was 0.92%, and the rate of rehospitalization for bleeding was 0.88% in all patients. Multiple hemostasis surgery was performed in 6.52% (3/46) of patients. The method of tonsillectomy (coblation tonsillectomy) and experience of the surgeon (junior surgeon with less than 5 years of experience) were significantly associated with primary hemorrhage (χ² = 5.830, P = 0.016, χ²= 6.621, P = 0.010, respectively). Age (over 6 years old) and time of onset (more than a 1-year history) were significantly associated with secondary hemorrhage (χ²= 15.242, P = 0.000, χ²=4.293, P = 0.038, respectively). There was no significant difference in sex, diagnosis, time when the surgery started or monthly average air temperature. There was a significant difference in the intervention measures between the primary bleeding group and the secondary bleeding group (χ²= 10.947, P = 0.001). The lower pole and middle portion were the common bleeding sites, followed by the upper pole and palatoglossal arch.

CONCLUSION

The incidence rate of post-tonsillectomy hemorrhage is low. Coblation tonsillectomy and less than 5 years’ experience of surgeon contribute to the tendency for primary hemorrhage. Age and time of onset are responsible for secondary hemorrhage.

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSION

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

Post-Tonsillectomy Bleeding: A National Perspective

OBJECTIVES

Tonsillectomy is one of the most common otolaryngologic procedures. Hemorrhage after tonsillectomy is one of the most feared complications by surgeons and patients alike. The objective of this study was to analyze the risk factors associated with an increase in post-tonsillectomy hemorrhage in the pediatric population using a large national database.

METHODS

The Kids' Inpatient Database (KID) from 2000 to 2012 was queried for patients between the ages of 1 to 17 years with post-tonsillectomy hemorrhage. Univariate and multivariate analyses were performed to obtain trends in patient demographics, comorbidities, and hospital information.

RESULTS

Overall 45 940 pediatric cases of tonsillectomy were identified of which 5470 (11.9%) resulted in postoperative hemorrhage. Patients with postoperative hemorrhage were significantly older with mean age of 8.62 (±4.75) compared to all patients. Females were found to have higher rates of hemorrhage when compared to males 14.6% versus 11.5% (P < .001). The rate of white patients who had hemorrhage was 16.3% (P < .001). The most common comorbidities significantly associated with hemorrhage were fluid and electrolyte disorders (6.6% P < .001), deficiency anemia (3.8%; P < .001), and coagulopathy (2.7%; P < .001). Urban nonteaching hospitals had higher rates of hemorrhage (19.6%; P < .001) and the Northeast was the most common region (15.2%; P < .001). On multivariate analysis, older patients and white ethnicity showed a significantly increased risk of hemorrhage. Patients with pre-existing comorbidities such as coagulopathy, deficiency anemia, and fluid and electrolyte disorders circulation were also found to have higher odds ratios of bleeding.

CONCLUSION

Postoperative hemorrhage is a common complication following tonsillectomy with a rate of 11.9% in this study. A higher rate of hemorrhage was seen with increasing age, white race, and males overall, as well as patients with fluid and electrolyte disorders. Urban non-teaching hospitals and the Northeast region also saw increased rates of hemorrhage.

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.

Paediatric patient bleeding and pain outcomes following subtotal (tonsillotomy) and total tonsillectomy: a 10-year consecutive, single surgeon series

BACKGROUND

Subtotal tonsil surgery (tonsillotomy) remains a controversial procedure. We aimed to document bleeding rates and return to normal activity for total versus subtotal tonsil surgery in the paediatric population.

METHODS

A 10-year cohort of 608 children from a single-surgeon series was analysed. Bleeding events were classified using the Flinders modification of the Stammberger criteria. Return to normal activity was defined as normal diet and return to childcare/school.

RESULTS

A total of 8.3% of tonsil procedures and a subtotal of 1.8% of procedures had some kind of bleeding episode (P < 0.01; odds ratio 3.2; 95% confidence interval (CI) 1.3-7.6). When blood-stained sputum (type A bleed) was excluded, this dropped to 2.5% versus 0.3%, respectively (P < 0.05; odds ratio 8.5; 95% CI 1.2-96.0). Return to normal activities occurred at a mean of 11.1 (95% CI 9.7-12.5) versus 4.6 (95% CI 4.0-5.3) days, respectively (P < 0.0001).

CONCLUSION

In this 10-year single surgeon series, subtotal tonsillectomy or 'tonsillotomy' was associated with a significant reduction in both prevalence and severity of bleeding, in addition to a more rapid return to normal activities when compared to total tonsillectomy.

[Is the number of tonsillectomies and tonsillotomies a relevant issue? German version]

BACKGROUND

A second-opinion procedure was introduced for (adeno)tonsillectomy and tonsillotomy in 2018 by the Federal Joint Committee, due to the assumed high prevalence of both procedures. This study was conducted to quantify and analyze both types of tonsil surgery in Germany.

METHODS

Data from the Federal Office of Statistics on the number of procedures and population size were used to calculate annual intervention rates between 2005 and 2017. Percentual changes in intervention rates compared to the previous year were calculated for Germany, for the total number of ENT specialists, for the ENT specialists of the federal states, and for four age groups (≤10; ≤20; ≤40; >40 years).

RESULTS

Regression analysis revealed a significant decrease in (adeno)tonsillectomy and a significant increase in tonsillotomy in each investigated year (p < 0.001; exception: 2006 for adenotonsillectomy). Surgical rates of tonsillectomy and tonsillotomy decreased significantly with age (p < 0.001). There was no clear relationship between the density of ENT specialists in the different federal states and the number of surgical procedures.

CONCLUSION

There was no clear association between the surgical prevalence and the density of ENT specialists. The significant decrease in rates of (adeno)tonsillectomy began in 2005 and the tonsillotomy rates have been increasing since 2007, albeit without a compensatory effect. Both procedures are on the list of the 50 most frequently performed operations. The decreasing total number of both surgical procedures questions the value of a second-opinion procedure as suggested by the Federal Joint Committee. Tonsil surgery is significantly associated with young age (<10 years) and discussions on surgery rates must consider the age structure of the investigated population, since this is the most important influencing factor in tonsil surgery.

Is the number of tonsillectomies and tonsillotomies a relevant issue?

BACKGROUND

A second-opinion procedure was introduced for (adeno)tonsillectomy and tonsillotomy in 2018 by the Federal Joint Committee, due to the assumed high prevalence of both procedures. This study was conducted to quantify and analyze both types of tonsil surgery in Germany.

METHODS

Data from the Federal Office of Statistics on the number of procedures and population size were used to calculate annual intervention rates between 2005 and 2017. Percentual changes in intervention rates compared to the previous year were calculated for Germany, for the total number of ENT specialists, for the ENT specialists of the federal states, and for four age groups (≤10; ≤20; ≤40; >40 years).

RESULTS

Regression analysis revealed a significant decrease in (adeno)tonsillectomy and a significant increase in tonsillotomy in each investigated year (p < 0.001; exception: 2006 for adenotonsillectomy). Surgical rates of tonsillectomy and tonsillotomy decreased significantly with age (p < 0.001). There was no clear relationship between the density of ENT specialists in the different federal states and the number of surgical procedures.

CONCLUSION

There was no clear association between the surgical prevalence and the density of ENT specialists. The significant decrease in rates of (adeno)tonsillectomy began in 2005 and the tonsillotomy rates have been increasing since 2007, albeit without a compensatory effect. Both procedures are on the list of the 50 most frequently performed operations. The decreasing total number of both surgical procedures questions the value of a second-opinion procedure as suggested by the Federal Joint Committee. Tonsil surgery is significantly associated with young age (<10 years) and discussions on surgery rates must consider the age structure of the investigated population, since this is the most important influencing factor in tonsil surgery.

Impact of adenotonsillectomy on the evolution of inflammatory markers

BACKGROUND

Tonsils are first-line host defence organs against pathogenic agents and participate in local and systemic immunity. Persistent increases in systemic inflammatory responses may contribute to associated morbidity. The aim of this study was to verify the short- and long-term impact of adenotonsillectomy on the evolution of inflammatory markers in 3- to 9-year-old children.

METHODS

A prospective and longitudinal study was conducted over 1 year in 29 children who underwent tonsillectomy due to either chronic tonsillitis or adenotonsillar hypertrophy. Measurements of high-sensitivity C-reactive protein (hs-CRP) levels were taken. Levels of Th1-type cytokines [interleukin-1, interferon-γ, and tumor necrosis factor-α (TNF-α)] and anti-inflammatory Th2-type cytokines [interleukin-4, -5, -6, -10 and -13] were measured. Levels of transforming growth factor-beta (TGF-β) and intercellular adhesion molecule-1 (ICAM-1) were also determined. The results were compared to those of 29 control children.

RESULTS

At baseline, children with surgery indications presented with higher levels of hs-CRP, interleukin-1 and -10, interferon-γ, TNF-α and ICAM-1, whereas values of interleukin-4 were significantly lower than in control children. Children with severe tonsillar obstruction had higher values of interleukin-1, -4, and -5 and lower values of interleukin-10 compared with children with recurrent tonsillitis. One year after surgery, the levels except IL-4 did not show a significant difference from those obtained in the control group. The levels of hs-CRP and TNF-α decreased significantly in the first month.

CONCLUSION

Children with chronic tonsillitis and/or adenotonsillar hypertrophy have significantly elevated levels of proinflammatory cytokines. Adenotonsillectomy restores the normal values of these parameters 1 year after surgery.

What's New with Tubes, Tonsils, and Adenoids?

Evidence-based recommendations are constantly being updated for various pediatric surgical procedures, including the role for tympanostomy tubes, as well as indications for adenoidectomy and tonsillectomy. With a growing body of research available on some of the most prevalent pediatric conditions, an update on the current concepts surrounding management is warranted.