Depressive symptoms in children after tonsillectomy

Intracapsular tonsillectomy improves children's postoperative behavior measures

BACKGROUND

Tonsillectomy represents one of the most frequently performed surgical interventions in pediatric otolaryngology (Bohr and Shermetaro, 2023) [1]. The selection of surgical technique plays a crucial role in determining multiple aspects of postoperative recovery, including pain management, healing trajectory, and behavioral adaptation (Karam et al., 2022; Lin et al., 2024). This investigation sought to evaluate the differential impacts of coblation intracapsular tonsillectomy (CIT) versus traditional cold dissection total tonsillectomy (TT) on postoperative behavioral patterns in pediatric patients.

OBJECTIVE

This study aimed to conduct a comprehensive comparison of postoperative behavioral outcomes between pediatric patients undergoing CIT versus TT procedures.

METHODS

The investigation prospectively enrolled 163 pediatric patients, aged 2-15 years, scheduled for tonsillectomy. Subjects underwent either CIT or TT procedures according to standardized protocols. Postoperative assessment utilized two validated instruments: the Parental Postoperative Pain Management (PPPM) questionnaire and the Wong-Baker Faces Pain Scale. Parents completed these assessments daily from postoperative day (POD) 1 through 7.

RESULTS

Analysis revealed consistently superior behavioral outcomes in the CIT group compared to the TT cohort. Initial evaluations on POD 1 demonstrated advantages for the CIT technique across all measured parameters, with two reaching statistical significance. By POD 7, the behavioral differences between groups had become more pronounced, with seven parameters showing statistically significant advantages in the CIT group. Composite behavioral scores similarly demonstrated significant superiority in the CIT cohort.

CONCLUSIONS

The postoperative period following tonsillectomy presents substantial challenges for pediatric patients and their families, characterized by notable behavioral modifications. Our findings demonstrate that CIT procedures are associated with markedly improved behavioral outcomes compared to conventional TT approaches. These results provide compelling evidence supporting the preferential use of CIT when considering the behavioral impact of tonsillectomy in pediatric populations. This data contributes valuable insights to inform surgical decision-making in pediatric tonsillectomy cases.

Stress-Related Disorders Among Young Individuals With Surgical Removal of Tonsils or Adenoids

Importance

Studies have suggested an increased risk of psychiatric disorders and suicidal behavior among individuals who have undergone tonsillectomy. However, little is known about stress-related disorders.

Objective

To investigate whether surgical removal of tonsils or adenoids is associated with a subsequent risk of stress-related disorders.

Design, Setting, and Participants

This cohort study used Swedish nationwide population and health registry data of all individuals born between January 1, 1981, and December 31, 2016. Individuals who had undergone surgical removal of tonsils or adenoids (ie, exposed persons) were compared with unrelated unexposed individuals individually matched by sex, birth year, and calendar date at the start of follow-up (population-matched cohort) and with their unexposed full siblings (sibling-matched cohort). The analysis was performed between December 15, 2023, and October 11, 2024.

Exposure

Surgical removal of tonsils or adenoids.

Main Outcomes and Measures

The Swedish Patient Register was used to identify stress-related disorders, including posttraumatic stress disorder (PTSD), acute stress reaction, and adjustment disorder or other stress reaction. In the population-matched cohort, a Cox proportional hazards regression model was used to assess the association of tonsillectomy with the risk of stress-related disorders, conditioned on sex, birth year, and calendar date at the start of follow-up and adjusted for parental educational attainment and history of stress-related disorders. To address potential familial confounding, analyses were replicated using the sibling-matched cohort.

Results

The population-matched cohort included 83 957 exposed and 839 570 unexposed persons (median [IQR] age at the start of follow-up, 14.4 [6.5-18.6] years; 55.2% female), and the sibling-matched cohort included 51 601 exposed persons (median [IQR] age at start of follow-up, 14.9 [6.9-18.7] years, 55.8% female) and 75 159 unexposed full siblings (median [IQR] age at start of follow-up, 13.3 [6.9-19.5] years; 52.6% male). Compared with the unexposed population reference, exposed persons exhibited a higher subsequent risk of stress-related disorders (hazard ratio [HR], 1.43; 95% CI, 1.38-1.48), especially PTSD (HR, 1.55; 95% CI, 1.43-1.69). These results were replicated in the sibling-matched cohort (any stress-related disorder: HR, 1.34 [95% CI, 1.25-1.44]; PTSD: HR, 1.41 [95% CI, 1.18-1.69]). An increased risk was consistently noted regardless of sex, age at surgery, time since surgery, parental educational attainment, or parental history of stress-related disorders and was mainly noted for a surgery due to adenotonsillar diseases or sleep and respiratory abnormalities.

Conclusions and Relevance

In this cohort study, the findings suggest that early-life surgical removal of tonsils or adenoids is associated with a higher future risk of stress-related disorders and highlight a need to understand the role of adenotonsillar diseases or associated health conditions in the development of stress-related psychiatric disorders.

Reddit Perspectives on Tonsillectomy Procedure: Sentiment and Thematic Analysis

INTRODUCTION

Every year, 530,000 tonsillectomies are performed in the United States. Many patients use social media for medical advice and support. This study investigates Reddit perspectives to identify the current needs of tonsillectomy patients.

METHODS

The "Top" 500 posts of the r/tonsillectomy subreddit community (3600 members) were qualitatively classified by theme, author, and post content. A Python sentiment analysis package, Valence Aware Dictionary sEntiment Reasoner (VADER), assigned summary Compound scores (-1=most negative, +1=most positive). A Lexicon-based syuzhet package analyzed the emotions of each post. Word frequency analysis elucidated top descriptors. Kruskal-Wallis and Mann-Whitney tests were used to determine statistical significance.

RESULTS

Posts were themed as Attitudes/Experiences (n=440, 88%), Medical/Procedural (n=9, 1.8%), or Both (n=51, 10.2%). Most were patient-authored (n=474, 94.8%), with many sharing personal anecdotes (n=476, 95.2%) and seeking validation (n=109, 21.8%). Few involved preoperative (n=15, 3%) or postoperative (n=45, 9%) concerns, with no operative or medication-related questions. VADER analysis revealed an average Compound score of 0.26, with 320 Positive, 179 Negative, and one Neutral post. Fear and trust had the most associated words from the National Research Council (NRC) Emotion dictionary. Common descriptors were "pain" (n=2063), "throat" (n=718), "water" (n=675), "feel" (n=576), and "ice" (n=328).

CONCLUSION

Most Reddit users viewed their tonsillectomy experience as positive. Many shared experiences and a few of them involved clinical questions. The descriptor "pain" was particularly prevalent. Providers should supply detailed pain-related expectations. Reddit may allow surgeons to better grasp how real patients manage pain, combining home remedies with prescribed medications. Care can be enhanced through personalized support that aims to minimize fear and improve patient-physician trust.

Depression in the Pediatric Otolaryngology Clinic Setting

OBJECTIVES/HYPOTHESIS

For most pediatric specialty clinics, mental health is not the primary presenting complaint, yet can portend unrecognized morbidity. We describe rates and risk factors of depression and suicidal ideation in adolescents seen at a pediatric specialty clinic and examine changes during COVID-19.

STUDY DESIGN

Retrospective database review.

METHODS

Outpatient pediatric otolaryngology clinic encounters of patients aged 12-19 years at a tertiary academic medical center were identified from October 2018 to July 2020. Demographic characteristics, ICD-10 primary diagnosis, Patient Health Questionnaire (PHQ)-2 score, and PHQ-9 score (if administered) were obtained. Multivariable regression examined risk factors for PHQ-9 administration, PHQ-9 scores ≥10, and suicidal ideation. Patient characteristics and PHQ scores were compared before and after March 23, 2020 (California COVID-19 Stay-at-Home order).

RESULTS

Three thousand six hundred nine encounters with PHQ-2 data were identified. Of these, 223 (6.2%) scored ≥3 and underwent PHQ-9 assessment, of which 121 (3.4% of 3,609) scored ≥10 on the PHQ-9 and 53 (1.5%) endorsed suicidal ideation. Factors associated with PHQ-9 administration were female gender (odds ratio [OR] 1.58, P = .001), obesity (OR 1.48, P = .043), and neck mass/neoplasm/cancer diagnosis (OR 1.99, P = .013). Female gender was also associated with suicidality (OR 2.47, P = .008). Comparison of pre-COVID-19 versus during COVID-19 showed no differences in depression or suicidality. However, subgroup analysis revealed some significant findings.

CONCLUSIONS

We demonstrate substantial prevalence of positive depression screening and suicidal ideation among adolescent pediatric otolaryngology clinic encounters. Depression rates were similar to pre-COVID-19 and during COVID-19, yet barriers to screening during this time were substantial. Pediatric specialty providers must remain vigilant for mental health issues in their patients.

LEVEL OF EVIDENCE

3 Laryngoscope, 2021.

Paediatric surgery for childhood cancer: Lasting experiences and needs of children and parents

OBJECTIVE

Surgery for paediatric cancer presents many stresses on patients and families. The authors aimed to understand the long-term impact of childhood cancer surgery on survivors and parents.

METHODS

The study recruited participants from 11 Australia/New Zealand hospitals for telephone interviews. The authors used descriptive statistics to analyse participants' quantitative distress ratings and conducted thematic analysis of shared surgical experiences and needs.

RESULTS

Of 32 participants (n = 17 survivors, n = 15 parents), survivors' mean age at surgery was 6.9 (SD = 5.17) and parents' children were 2.1 years old (SD = 1.41) at time of surgery. Survivors had surgery on average 15.2 years ago (SD = 6.72) and parents' children 11.5 years ago (SD = 3.94). Parents and survivors rated surgery as highly distressing. Pre-operatively, survivors recalled experiencing fear and pain mainly associated with pre-operative procedures. Post-operatively, survivors reported immobility and some lasting behavioural disturbances. Parents described pre- and intra-operative anxiety and stress and some lasting post-operative psychological disturbances. Experiences appeared to improve with clear/consistent communication from hospital staff, proximity to hospital, and with support for parents and children post-operatively.

CONCLUSIONS

Surgical treatment for childhood cancer can have a lasting impact for survivors and parents. Better information provision may improve families' surgical experience whilst reducing anxiety, distress and physical discomfort.

The Psychosocial Experiences and Needs of Children Undergoing Surgery and Their Parents: A Systematic Review

INTRODUCTION

Surgery in children can be difficult for patients and parents. We aimed to summarize pediatric patients' and parents' psychosocial experiences and needs in surgery.

METHOD

We used the Ovid search engine and screened 877 abstracts across three databases to extract data on pediatric patients' and parents' surgical experiences.

RESULTS

Our search yielded 11 eligible studies representing 1,307 children undergoing surgery and their parents. Children's adverse experiences included psychological and behavioral changes before, during, and after surgery (e.g., anxiety, eating disturbances). Parents commonly experienced psychological distress. Children's needs related to medical and health care services, whereas parents had high information needs.

DISCUSSION

Children's adverse experiences can negatively affect medical outcomes. Children's experiences are inextricably linked to their parents' and can become negatively affected by their parents' adverse experiences. Patients and parents with previous hospitalizations and surgeries had worse surgical experiences, highlighting further research in the context of chronic illness.

Indications for tonsillectomy stratified by the level of evidence

Background: One of the most significant clinical trials, demonstrating the efficacy of tonsillectomy (TE) for recurrent throat infection in severely affected children, was published in 1984. This systematic review was undertaken to compile various indications for TE as suggested in the literature after 1984 and to stratify the papers according to the current concept of evidence-based medicine. Material and methods: A systematic Medline research was performed using the key word of "tonsillectomy" in combination with different filters such as "systematic reviews", "meta-analysis", "English", "German", and "from 1984/01/01 to 2015/05/31". Further research was performed in the Cochrane Database of Systematic Reviews, National Guideline Clearinghouse, Guidelines International Network and BMJ Clinical Evidence using the same key word. Finally, data from the "Trip Database" were researched for "tonsillectomy" and "indication" and "from: 1984 to: 2015" in combination with either "systematic review" or "meta-analysis" or "metaanalysis". Results: A total of 237 papers were retrieved but only 57 matched our inclusion criteria covering the following topics: peritonsillar abscess (3), guidelines (5), otitis media with effusion (5), psoriasis (3), PFAPA syndrome (6), evidence-based indications (5), renal diseases (7), sleep-related breathing disorders (11), and tonsillitis/pharyngitis (12), respectively. Conclusions: 1) The literature suggests, that TE is not indicated to treat otitis media with effusion. 2) It has been shown, that the PFAPA syndrome is self-limiting and responds well to steroid administration, at least in a considerable amount of children. The indication for TE therefore appears to be imbalanced but further research is required to clarify the value of surgery. 3) Abscesstonsillectomy as a routine is not justified and indicated only for cases not responding to other measures of treatment, evident complications, or with a significant history of tonsillitis. In particular, interval-tonsillectomy is not justified as a routine. 4) TE, with or without adenoidectomy, is efficacious to resolve sleep-related breathing disorders resulting from (adeno)tonsillar hypertrophy in children. However, the benefit is reduced by co-morbidities, such as obesity, and further research is required to identify prognostic factors for this subgroup of patients. Further research is indicated to clarify selection criteria not only for this subpopulation that may benefit from less invasive procedures such as tonsillotomy in the long-term. 5) Further trials are also indicated to evaluate the efficacy of TE on the clinical course in children with psoriasis guttata as well as on psoriasis vulgaris in adults, not responding to first-line therapy. 6) Conflicting results were reported concerning the role of TE in the concert to treat Ig-A nephropathy, mandating further clinical research. 7) Most importantly, randomized-controlled clinical trials with an adequate long-term follow-up are desirable to clarify the benefit of TE in patients with recurrent episodes of tonsillitis, with or without pharyngitis. Factors like age, spontaneous healing rate and postoperative quality of life have to be included when comparing TE with antibiotic therapy.

Tonsillectomy for recurrent sore throats in children: indications, outcomes, and efficacy

OBJECTIVE

To perform a comprehensive narrative review of the literature to provide a better understanding of the indications, outcomes, and efficacy of tonsillectomy for recurrent sore throats in children. This article explores the reasons why there is a lack of robust clinical evidence for its efficacy despite good evidence of positive reported outcomes from parents of children who undergo the procedure.

DATA SOURCES

Articles published between 1960 and July 2013 were searched in PubMed and Cochrane databases.

REVIEW METHODS

A narrative review method was adopted to provide a comprehensive overview of articles. Only individual, interventional studies on children (0-16 years old) undergoing tonsillectomy or adenotonsillectomy for recurrent sore throats with greater than 1 month of follow-up were included.

CONCLUSIONS

The inclusion criteria and outcome measures in the studies were varied, but most investigated changes in symptoms related to sore throats or illness episodes. Quality-of-life tools validated for measuring pediatric outcomes were used in a number of more recent studies. None of the outcome measures were specific for recurrent sore throats in children. No qualitative method designed studies were identified.

IMPLICATIONS FOR PRACTICE

The disparity between parental satisfaction rates and published clinical efficacy can be explained by a lack of parent/child outcome measures specific to tonsillectomy for recurrent sore throats. A more parent/child-centered approach may establish what tonsillectomy could offer this group of children.

Psychopharmacology for medically ill adolescents

Medically ill adolescents are at increased risk for psychological distress and/or functional impairment. However, there are few research studies examining the optimal psychiatric treatments for this population. Psychiatric medication recommendations are largely based on studies of youth with a primary psychiatric disorder, adult studies, hypothesized mechanisms of action, and/or clinical experience. This paper provides evidence-informed recommendations for the psychopharmacological treatment of acutely medically ill adolescents suffering from significant psychological distress and/or functional impairment. Representing the most common problems among medically ill adolescents that are treated with psychiatric medications, recommendations are provided for anxiety and depression; iatrogenic medical trauma, inadequate sleep and insomnia; and, delirium.

The perceived effectiveness of a pre-admission visit for children (and their parents) undergoing day surgery procedures

The purpose of this paper is to present the findings of an evaluation study which examines the perceived effectiveness of a pre-admission visit for children (and their parents) undergoing day surgery procedures in the Republic of Ireland. This follow on paper provides the findings of an evaluation study subsequent to the pre-admission, practice development initiative published in the Journal of Perioperative Practice, June 2010, 20 (6) 203-206.

The psychological impact of an adenoidectomy and adenotonsillectomy on young children

OBJECTIVE

Children react differently to surgeries. The purpose of this study is to examine the stress response in young children after an adenoidectomy and adenotonsillectomy, and whether child characteristics of behavioural and neurophysiological nature can predict this stress response.

METHODS

In this prospective cohort study 43 children, aged 2-7 years, scheduled for adenoidectomy or adenoitonsillectomy (response rate 43%) were recruited from the Ear, Nose and Throat Department of the Academic Medical Centre in Amsterdam, the Netherlands. Parents completed questionnaires about temperament 4 weeks before surgery, about behaviour and sleeping problems 4 weeks before and 6 weeks after surgery, and about posttraumatic stress symptoms 6 weeks after surgery. Neurophysiological measurements (cortisol and Respiratory Sinus Arrhythmia) were performed 4 weeks before, directly after and 6 weeks after surgery. Results were compared with a control group of healthy children. The data was analysed with paired t-tests and one-way repeated ANOVA.

RESULTS

Most children with an indication for an adenoidectomy and adenotonsillectomy had more behavioural and emotional problems before surgery then the control group. After surgery there was an improvement in behaviour and sleep, in respectively 75% and 68% of the children, especially in boys. Posttraumatic stress symptoms were rare. Emotional temperament was associated with more behavioural problems before surgery (r=0.53, P=0.02), after surgery (r=0.38, P<0.000), lower cortisol directly after surgery (r=-0.49, P=0.05) and lower Respiratory Sinus Arrhythmia at follow-up (r=-0.33, P=0.06). Other temperament styles and pre-surgery levels of Respiratory Sinus Arrhythmia and cortisol did not show associations with any behavioural or neurophysiological measures.

CONCLUSIONS

An adenoidectomy and adenotonsillectomy appear not to be stressful, but rather seems helpful for reducing pre-existing behavioural and emotional problems, possibly associated with the indication for surgery. For those children with an increase of behavioural and sleeping problems after surgery, this can only be partly explained by emotional temperament. There are indications that boys and girls react differently; boys tend to show a better behavioural and emotional improvement after an adenoidectomy and adenotonsillectomy. Other behavioural or neurophysiological child characteristics do not have a predictive value on the outcome.

Post-tonsillectomy dysgeusia with weight loss: possible involvement of soft palate

Objective:

To demonstrate the importance of detailed, multidisciplinary examination of patients with post-tonsillectomy taste distortions, and to show that post-tonsillectomy dysgeusia may originate in the caudal part of the soft palate.

Case report:

We describe a 29-year-old man who suffered from severe post-tonsillectomy dysgeusia and phantogeusia with secondary weight loss and depression-like symptomatology. The patient had normal electrogustometric thresholds and sensitivity to touch on the posterior tongue. In contrast, elevated taste threshold and reduced sensitivity to touch was found on the caudal part of the soft palate (the palatoglossal arches). More marked elevation of electrogustometric threshold and insensitivity to touch on the right palatoglossal arch correlated with post-operative haemorrhage from the right tonsillar fossa. Psychiatric examination excluded major depression, eating disorders and drug abuse.

Conclusions:

Dysgeusia constitutes a rare but significant complication of tonsillectomy. Damage to the lingual branch of the glossopharyngeal nerve innervating the posterior tongue is thought to be a major cause of this complication. However, damage to the tonsillar branches of the glossopharyngeal nerve and the soft palate should also be considered as a cause of post-tonsillectomy dysgeusia. Further studies are needed to assess whether post-operative haemorrhage could indicate heightened risk of dysgeusia.

Is elective surgery traumatic for children and their parents?

AIM

The emotional consequences of elective surgery to children and to their parents have not been sufficiently studied. The aim of the present study was to prospectively assess the prevalence and severity of post-traumatic, anxiety and depressive symptoms in this population.

METHODS

Forty children and adolescents consecutively admitted for elective surgery in a general hospital participated in the study. Their parents were also assessed. The assessments were made on the day of admission and surgery, and 1 and 6 months after the surgery.

RESULTS

Minor post-traumatic symptoms of the children were noted at the first and second assessments, decreasing significantly at the 6-month assessment. Further, the prevalence of children with elevated post-traumatic symptoms decreased significantly between the first and second assessments. Parents scored highest for anxiety and depression at the first assessment. Their symptoms, however, decreased significantly within 1 month. A significant decrease between the first and second assessments was also noted in the prevalence of parents with elevated anxiety symptoms. At the 1- and 6-month follow-up assessments, there was a significant correlation between the children's symptoms and their parents'.

CONCLUSION

Mild post-traumatic symptoms may accompany paediatric elective surgery and persist for at least 1 month. Parents may also manifest anxiety and depressive symptoms, which may diminish earlier, that is, immediately after the surgery or within 1 month.

Use of a children questionnaire of health-related quality of life (KIDSCREEN) as a measure of needs for health care services

PURPOSE

To check if the expected association is observed between children and adolescents' self-perceived health-related quality of life (HRQL) and the use of health care services.

METHODS

The data come from the pilot test of a European measure of HRQL for children and adolescents (KIDSCREEN). Children answered the KIDSCREEN 52-item pilot version. Visits to a health professional in the past four weeks and hospitalisation in the past 12 months were collected from parents. A logistic regression model was adjusted to analyse the relationship between the use of health services and HRQL.

RESULTS

A total of 2526 children and their parents were included in the analysis. Factors associated to visits in the past four weeks were poor physical well-being (odds ratio [OR] 1.83; 95% confidence interval [CI] 1.42-2.35), and poor school environment (OR 1.32; 95% CI 1.02-1.71). Low scores on moods and emotions was the associated factor to hospitalization in the past 12 months (OR 2.13; 95% CI 1.29-3.81).

CONCLUSIONS

Children and adolescents are a feasible source for their self-assessment of HRQL. They should be taken into account in health care needs studies.