Tonsillectomy--clinical consequences twenty years after surgery?

Age-related changes of the innate immune system of the palatine tonsil in a healthy cohort

Although tonsillectomy is performed frequently, the role of palatine tonsils in life long immune protection or tolerance is still debated and the consequences of their removal for the immune system are of general interest. We analysed the tonsillar myeloid compartment in healthy subjects across a wide range of age (64% male; age range: 3 - 85 years) and compared its composition to the peripheral blood. We could observe a strong accumulation of all granulocyte subsets in the aging tonsil, which was most pronounced for basophils and mast cells. On functional level, an increase of CD163 and CD206 expression among monocytes and an increase of neutrophils expressing the inhibitory FcγRIIb correlated with increasing age. While the age-related shift of the leukocyte composition towards monocytes in blood is not reflected in tonsils, the increasing immunoregulatory phenotype of tonsilar monocytes is potentially counteracting the phenomenon of inflammaging at higher age.

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.

Effectiveness of TCM cauterization in recurrent tonsillitis: A protocol for systematic review and meta-analysis

INTRODUCTION

Recurrent tonsillitis (RT) is often treated with antibiotic therapy and surgery. Although these treatments have advantages, they are also controversial. The purpose of this study is to analyze the safety and effectiveness of traditional Chinese medicine (TCM) cauterization in the treatment of RT, so as to provide an alternative for the clinicians and to cover the shortage of therapeutic methods.

METHODS AND ANALYSIS

This protocol is guided by the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols (PRISMA-P) and by the Cochrane Collaboration Handbook. We will formulate strict inclusion and exclusion criteria in English databases (PubMed, EMBASE, and Web of Science), Chinese databases (CNKI, Wanfang databases, CBM, and VIP), and search literatures in different clinical registration platforms (Cochrane Library, Chinese Cochrane Centre's Clinical Trial Registry Platform). The included articles will be evaluated using Cochrane RCT evaluation criteria. Stata 15.0 will be used for data analysis. Subgroup analysis, sensitivity analysis, and meta-regression will detect sources of heterogeneity. Egger's Test or Begg's Test will detect publication bias quantitatively.

CONCLUSION

Cauterization can effectively control the recurrence of tonsillitis through clinical trials, but evidence-based medicine needs to be adopted to provide strong evidence for its effectiveness. The purpose of our research is to provide the evidence.

OSF REGISTRATION NUMBER

DOI 10.17605/OSF.IO/PZ69Q.

Association of adenotonsillectomy with asthma and upper respiratory infection: A nationwide cohort study

Adenotonsillectomy is a common paediatric surgery for treating obstructed breathing or recurrent inflammation; however, the long-term health consequences on the developing immune system are unknown. This study investigated the potential association between adenotonsillectomy and the development of asthma and upper respiratory infections (URI). This propensity score-matched retrospective cohort study utilized data from the National Sample Cohort 2002–2013. In the asthma cohort, we used a Cox-proportional hazards model to analyze the hazard ratio (HR) of adenotonsillectomy for asthma events. In the URI cohort, equivalence testing of postoperative visits for URI was performed. The margin of equivalence of the difference was set at -0.5–0.5. Asthma incidence was 66.97/1000 person-years in children who underwent adenotonsillectomy and 30.43/1000 person-years in those who did not. Adjusted asthma HRs were 2.25 (95% confidence interval, 1.96–2.57) in the adenotonsillectomy vs. non-adenotonsillectomy groups. In a subgroup analysis, children aged 5–9 years living in metropolitan areas showed a higher incidence of subsequent asthma than those of other ages and areas. However, any significant difference between the groups in terms of URI events in the 1–11-year postoperative period was not identified. Adenotonsillectomy in children is associated with an increased incidence of asthma, with no significant impact on postoperative visits for URI.

Treatment of Obstructive Sleep Apnea in Children: Handling the Unknown with Precision

Treatment approaches to pediatric obstructive sleep apnea (OSA) have remarkably evolved over the last two decades. From an a priori assumption that surgical removal of enlarged upper airway lymphadenoid tissues (T&A) was curative in the vast majority of patients as the recommended first-line treatment for pediatric OSA, residual respiratory abnormalities are frequent. Children likely to manifest persistent OSA after T&A include those with severe OSA, obese or older children, those with concurrent asthma or allergic rhinitis, children with predisposing oropharyngeal or maxillomandibular factors, and patients with underlying medical conditions. Furthermore, selection anti-inflammatory therapy or orthodontic interventions may be preferable in milder cases. The treatment options for residual OSA after T&A encompass a large spectrum of approaches, which may be complementary, and clearly require multidisciplinary cooperation. Among these, continuous positive airway pressure (CPAP), combined anti-inflammatory agents, rapid maxillary expansion, and myofunctional therapy are all part of the armamentarium, albeit with currently low-grade evidence supporting their efficacy. In this context, there is urgent need for prospective evidence that will readily identify the correct candidate for a specific intervention, and thus enable some degree of scientifically based precision in the current one approach fits all model of pediatric OSA medical care.

Association of Long-Term Risk of Respiratory, Allergic, and Infectious Diseases With Removal of Adenoids and Tonsils in Childhood

Importance

Surgical removal of adenoids and tonsils to treat obstructed breathing or recurrent middle-ear infections remain common pediatric procedures; however, little is known about their long-term health consequences despite the fact that these lymphatic organs play important roles in the development and function of the immune system.

Objective

To estimate long-term disease risks associated with adenoidectomy, tonsillectomy, and adenotonsillectomy in childhood.

Design, Setting, and Participants

A population-based cohort study of up to 1 189 061 children born in Denmark between 1979 and 1999 and evaluated in linked national registers up to 2009, covering at least the first 10 and up to 30 years of their life, was carried out. Participants in the case and control groups were selected such that their health did not differ significantly prior to surgery.

Exposures

Participants were classified as exposed if adenoids or tonsils were removed within the first 9 years of life.

Main Outcomes and Measures

The incidence of disease (defined by International Classification of Diseases, Eighth Revision [ICD-8] and Tenth Revision [ICD-10] diagnoses) up to age 30 years was examined using stratified Cox proportional hazard regressions that adjusted for 18 covariates, including parental disease history, pregnancy complications, birth weight, Apgar score, sex, socioeconomic markers, and region of Denmark born.

Results

A total of up to 1 189 061 children were included in this study (48% female); 17 460 underwent adenoidectomy, 11 830 tonsillectomy, and 31 377 adenotonsillectomy; 1 157 684 were in the control group. Adenoidectomy and tonsillectomy were associated with a 2- to 3-fold increase in diseases of the upper respiratory tract (relative risk [RR], 1.99; 95% CI, 1.51-2.63 and RR, 2.72; 95% CI, 1.54-4.80; respectively). Smaller increases in risks for infectious and allergic diseases were also found: adenotonsillectomy was associated with a 17% increased risk of infectious diseases (RR, 1.17; 95% CI, 1.10-1.25) corresponding to an absolute risk increase of 2.14% because these diseases are relatively common (12%) in the population. In contrast, the long-term risks for conditions that these surgeries aim to treat often did not differ significantly and were sometimes lower or higher.

Conclusions and Relevance

In this study of almost 1.2 million children, of whom 17 460 had adenoidectomy, 11 830 tonsillectomy, and 31 377 adenotonsillectomy, surgeries were associated with increased long-term risks of respiratory, infectious, and allergic diseases. Although rigorous controls for confounding were used where such data were available, it is possible these effects could not be fully accounted for. Our results suggest it is important to consider long-term risks when making decisions to perform tonsillectomy or adenoidectomy.

Chronic tonsillitis and biofilms: a brief overview of treatment modalities

Recurrent tonsillitis is described as when an individual suffers from several attacks of tonsillitis per year. Chronic and recurrent tonsillitis both cause repeated occurrences of inflamed tonsils which have a significant impact on a patient's quality of life. Numerous children suffer from recurrent tonsillitis and sore throats, and these illnesses become part of their life. Antimicrobials can provide temporary relief, but in many cases, tonsillitis recurs. The cause of such recurrent infections have been identified as microorganisms which often create biofilms and a repository of infection in the wet and warm folds of the tonsils. This review discusses different treatment modalities, their advantages and disadvantages, and new treatment options focusing on biofilms. All treatment options should be selected based on evidence and individual need.

A tonsillectomy increased the risk of chronic rhinosinusitis among children: A three-year follow-up study

OBJECTIVES

The study aimed to estimate the risk of developing chronic rhinosinusitis (CRS) among children who had undergone a tonsillectomy by utilizing a cohort study based on a population-based database.

METHODS

Data for this retrospective cohort study were sourced from the Taiwan "Longitudinal Health Insurance Database 2000". We included 202 children who had undergone a tonsillectomy as the study group and 2020 sex- and age-matched children as the comparison group. We used stratified Cox proportional hazard regressions to calculate the hazard ratio (HR) and its corresponding 95% confidence interval (CI) for CRS during the 3-year follow-up period.

RESULTS

Of 2222 sampled children, the incidence rate of CRS during the 3-year follow-up period was 3.2 (95% CI = 2.0-4.8) 1000 person-years; 18.2 (95% CI = 9.1-32.5) per 1000 person-years and 1.7 (95% CI = 0.8-3.0) per 1000 person-years for the study and comparison group, respectively. The stratified Cox proportional analysis showed that the adjusted hazard ratio for CRS during the 3-year follow-up period was 8.28 (95% CI = 3.24-21.16) for children who had undergone a tonsillectomy than comparison patients.

CONCLUSIONS

We demonstrated that the risk of developing CRS is significantly increased among children who have undergone a tonsillectomy.

Quality of life after tonsillectomy versus azithromycin

BACKGROUND

Recurrent tonsillitis is a common disease with marked evidence of affecting children quality of life (QOL) such as their progression in school and increased burden to extended families. The aim of this study was to compare the QOL outcomes after conventional dissection tonsillectomy versus azithromycin treatment in controlling recurrent tonsillitis.

METHODS

A double-blind, randomized clinical trial was carried out in 184 children with recurrent tonsillitis randomly divided into two groups: Group A was subjected to conventional dissection tonsillectomy, whereas Group B received single 250 mg (children ≤25 kg) and 500 mg (children ≥25 kg) of oral azithromycin once weekly.

RESULTS

There were no significant differences between the groups with regard to ear, nose, and throat infections during the 5-year follow-up. Better QOL was observed in both groups when compared with the pretreatment, but similar QOL in both groups QOL after treatment.

CONCLUSION

Azithromycin is an effective method as a prophylaxis against recurrent tonsillitis with a great benefit for better QOL outcomes.

Cost-Effectiveness of Tonsillectomy for Recurrent Acute Tonsillitis

Objectives:

We used a retrospective case series to perform a preliminary study to determine the clinical effectiveness and cost-effectiveness of tonsillectomy for recurrent acute tonsillitis.

Methods:

We studied 25 children and 16 adults who had tonsillectomy for recurrent acute tonsillitis. The adult patients and the children's caregivers were asked to respond to a questionnaire regarding the efficacy of their tonsillectomy. The cost of medical care and the work disability cost for tonsillitis and for tonsillectomy were calculated. We then applied the technique of break-even time analysis to assess when the total health care cost savings from surgery overtook the total cost of tonsillectomy.

Results:

In children, the overall economic costs (medical costs and work-related costs) were recovered at 1.6 years after tonsillectomy (break-even point). In adults, the overall economic costs (medical costs and work-related costs) were recovered at 2.5 years after tonsillectomy (break-even point).

Conclusions:

Tonsillectomy for recurrent acute tonsillitis is both clinically effective and cost-effective for children and adults in Japan.

The role of tonsillectomy in IgA nephropathy

The IgA nephropathy (IgAN) is a very common glomerulonephritis and can result in end-stage renal disease. From a clinical point of view, IgAN is characterised by repeated events of macrohaematuria associated with infections of the upper airways. In IgAN, the IgA released by the tonsillar lymphatic tissue into blood circulation are defective in glycosylation. These aberrant IgA can reach the glomeruli and deposit into mesangium causing an inflammation with cellular proliferation. The treatment is not yet well defined: steroids and immunosuppressive drugs are suggested in cases with a progressive disease. Tonsillectomy was proposed to reduce the infective events of upper airways and the lymphatic tissue producing undergalactosylated IgA. The experiences in literature coming from Asia report positive effects of tonsillectomy on IgAN. In patients with tonsillectomy, the renal signs improved (less haematuria and proteinuria) and the renal outcome was better (slower progression of renal damage). These were uncontrolled studies and tonsillectomy was associated with steroid and immunosuppressive treatment, so it is not possible to tell the real effect of tonsillectomy. In contrast, the European studies reported that the tonsillectomy was not associated with a better outcome of IgAN. A critical review of the subject reveals that most of the papers with positive results were uncontrolled retrospective experiences, while in a randomised controlled trial paper the advantages of tonsillectomy disappeared. In conclusion, this review, in agreement with the international guidelines, concludes that tonsillectomy does not play any role in the progression of IgAN.

Tonsillectomies and adenoidectomies do not prevent the onset of pediatric autoimmune neuropsychiatric disorder associated with group A streptococcus

BACKGROUND

In children presenting with obsessive compulsive disorder (OCD) and/or tics, especially those with a temporal association with streptococcal pharyngitis (eg, Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcus), there is speculation about whether tonsillectomy/adenoidectomy might improve the child's neuropsychiatric course. Our objective was to examine whether removal of the tonsils and/or adenoids impacted streptococcal antibody titers, the timing of onset of OCD and/or tics and the clinical severity of these symptoms.

METHODS

Study participants (N = 112; average age = 9.2 ± 2.4; 44 women) were recruited as part of a prospective investigation of neuropsychiatric phenomena with temporal association to streptococcal pharyngitis and examined by family history, diagnostic interview, physical examination, medical record review, psychological testing and streptococcal antibodies and divided into surgical or nonsurgical groups. The surgical group consisted of children having previously had a tonsillectomy and/or adenoidectomy (n = 32). The remaining children were categorized as nonsurgical group (n = 76). Measures of OCD and tic severity, streptococcal antibody titers and Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcus classification were compared between both groups.

RESULTS

There were no significant differences as determined by streptococcal antibody titers, Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcus classification and OCD or tic severity between the surgical and nonsurgical groups. Most participants had surgery before the onset of neuropsychiatric symptoms and surgery did not affect symptomology.

CONCLUSIONS

Streptococcal antibodies and neuropsychiatric symptom severity did not differ on the basis of surgical status. From these data, we cannot infer that tonsillectomy and adenoidectomy are likely to impact positively the course of OCD/tics or streptococcal antibody concentrations.

Poor lung function and tonsillectomy in childhood are associated with mortality from age 18 to 44

BACKGROUND

The aim of this analysis was to examine associations between lung health in childhood and mortality between ages 18 and 44 years in the Tasmanian Longitudinal Health Study (TAHS).

METHODS

The 1961 Tasmanian birth cohort who attended school in 1968 (n=8583) were linked to the Australian National Death Index (NDI) to identify deaths. Additional deaths were notified by families through a 37 year follow-up postal questionnaire. Information on lung health at age 7 years and on potential confounders was obtained from the original 1968 TAHS survey and school medical records. Cox proportional hazards modelling was used to assess determinants of mortality.

RESULTS

A total of 264 (3%) deaths were identified. The principal causes of death were external injury (56.1%, n=97) and cancer (17.9%, n=31). Males were more likely than females to have died (p=<0.1). Only two (1.1%) participants had died from respiratory conditions. Having an FEV(1)<80% predicted at 7 years of age was associated with a 2-fold increased incidence of death. Tonsillectomy before age 7 years was associated with a 1.5-fold increase in mortality (p=0.05); being male with a 3.6-fold increase in mortality (p=0.0001); and repeated chest illnesses at age 7 years causing >30 days confinement in the last year, was associated with a 2.2-fold increase in mortality (p=0.03).

CONCLUSIONS

Childhood lung health appears to be associated with increased mortality in adulthood, perhaps by affecting the ability to survive trauma, major illnesses and other physical stresses.

The development of sleep disordered breathing from 4 to 12 years and dental arch morphology

OBJECTIVE

To track the development of sleep disordered breathing (SDB) as well as dento-facial morphology in cohort of children by having them complete a questionnaire at ages 4, 6 and 12. Clinical examination, sleep studies (at ages 4 and 12) and orthodontic evaluation were carried out on all who were reported to snore regularly and children who did not snore at all.

RESULTS

Out of the original group of 615 children, 64% (393) answered the inquiry on all three occasions. Of those, 27 snored regularly and 231 did not snore at all at the age of 12. There were differences between those groups on all answers, especially prevalence of oral breathing: 78% versus 5% (p<0.001). The prevalence of OSA decreased from 3.1% at the age of 4 to 0.8% at age 12 and the severity decreased from a mean AHI 14.8 at 4 to a mean AHI of 1.95 at age 12. The minimum prevalence of snoring regularly was estimated to 4.2% at 12 years compared to 5.3% at 4, calculated for the original cohort of 644 children. The odds for a child who snored regularly at 4 or 6 years to be snoring regularly also at age 12 was 3.7 times greater than for a not snoring child in spite of surgery (OR 3.7, 95% CI 2.4-5.7). 63 children had undergone surgery due to snoring by age 12. 14 of them never snored and 17 snored regularly at the age 12. The dental arch was narrower in the children snoring regularly at 4, 6 and 12 years compared to not snoring children. Cross-bites were more common among snoring children than among non-snoring children, at 4 and 6 as well as at 12.

CONCLUSION

The prevalence of regular snoring is about the same from 4 to 12 years independent of surgery, but the prevalence of OSA decreased considerably. The children snoring regularly generally have a narrower maxilla compared to children not snoring. Surgery in young children is necessary but "cures" the snoring only temporary.

Long-term effects of intracapsular partial tonsillectomy (tonsillotomy) compared with full tonsillectomy

OBJECTIVE

To compare the long-term effects (six years after surgery) of two techniques for pediatric tonsil surgery with respect to snoring, apneas, eating difficulties, infections and general health. The two methods were intracapsular partial tonsillectomy (tonsillotomy, "TT") using CO(2)-laser technique and traditional (total) blunt dissection tonsillectomy (TE).

STUDY DESIGN

A questionnaire distributed by mail to the parents of children, who, in 1998, were included in a prospective clinical randomized study in one tertiary care ENT clinic.

METHOD

A 10 question survey follow-up of 41 children, between 9 and 15 years of age, who originally, six years earlier had been randomized to either TT with CO(2)-laser (n=21) or TE (n=20). The main indication for the surgery was a history of sleep related breathing distress (SRBD). Before the present study, all of the children had participated in earlier follow-ups at six months and one year after surgery.

RESULTS

All the children in both groups answered the questionnaire. There were no significant differences between the answers from the two groups in any respects: the effect on snoring and apneas was equally stable for both groups. The number of children who remained free from snoring decreased from 40 after the first year to 25 after six years (11 TT, 14 TE). Snoring in the recurrent cases was not rated to be as frequent or as loud as before the surgery. Infections of the upper respiratory tract (URI) that had been treated with antibiotics occurred to the same extent in both groups. None had eating difficulties. The patients' satisfaction with the results of the surgery was high or very high in 18/21 TT and 20 TE cases, and the vast majority of the parents rated their children's present health status as improved compared with the preoperative condition.

CONCLUSION

Tonsillotomy with CO(2)-laser seems to be a reliable method for tonsil surgery with substantially less primary morbidity than conventional tonsillectomy and with the same positive long-term effects after six years.