Long-Term Improvement of Quality of Life as a Result of Tonsillotomy (With Radiofrequency Technique) and Tonsillectomy in Youths

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.

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.

Intracapsular tonsillectomy in the treatment of recurrent and chronic tonsillitis in adults: a protocol of a prospective, single-blinded, randomised study with a 5-year follow-up (the FINITE trial)

INTRODUCTION

The standard surgical treatment for recurrent or chronic tonsillitis is extracapsular tonsillectomy. Recent studies show that intracapsular tonsillectomy has the potential to reduce the postoperative morbidity of patients undergoing tonsil surgery. The Finnish Intracapsular Tonsillectomy (FINITE) trial aims to provide level I evidence to support the hypothesis that the recovery time from tonsil surgery can be reduced with intracapsular tonsillectomy. Additionally, from this trial, major benefits in quality of life, reduction of postoperative complications, treatment costs and throat symptoms might be gained.

METHODS AND ANALYSIS

The FINITE trial is a prospective, randomised, controlled, patient-blinded, three-arm clinical trial. It is designed to compare three different surgical methods being extracapsular monopolar tonsillectomy versus intracapsular microdebrider tonsillectomy versus intracapsular coblation tonsillectomy in the treatment of adult patients (16-65 years) suffering from recurrent or chronic tonsillitis. The study started in September 2019, and patients will be enrolled until a maximum of 200 patients are randomised. Currently, we are in the middle of the study with 125 patients enrolled as of 28 February 2022 and data collection is scheduled to be completed totally by December 2027. The primary endpoint of the study will be the recovery time from surgery. Secondary endpoints will be the postoperative pain scores and the use of analgesics during the first 3 weeks of recovery, postoperative haemorrhage, quality of life, tonsillar remnants, need for revision surgery, throat symptoms, treatment costs and sick leave. A follow-up by a questionnaire at 1-21 days and at 1, 6, 24 and 60 months will be conducted with a follow-up visit at the 6-month time point.

ETHICS AND DISSEMINATION

Ethical approval was obtained from the Medical Ethics Committee of the Hospital District of Southwest Finland (reference number 29/1801/2019). Results will be made publicly available in peer-reviewed scientific journals.

TRIAL REGISTRATION NUMBER

NCT03654742.

Quality of Life Assessment for Tonsillar Infections and Their Treatment

Background and Objectives: Tonsillar infections are a common reason to see a physician and lead to a reduction in the patients’ health-related quality of life (HRQoL). HRQoL may be an important criterion in decision science and should be taken into account when deciding when to perform tonsillectomy, especially for chronic tonsillitis. The aim of this study was to determine the health utility for different states of tonsillar infections. Materials and Methods: Hospitalized patients with acute tonsillitis or a peritonsillar abscess were asked about their HRQoL with the 15D questionnaire. Patients who had undergone tonsillectomy were reassessed six months postoperatively. Results: In total, 65 patients participated in the study. The health states of acute tonsillitis and peritonsillar abscess had both a utility of 0.72. Six months after tonsillectomy, the mean health utility was 0.95. Conclusions: Our study confirms a substantial reduction in utility due to tonsillar infections. Tonsillectomy significantly improves the utility and therefore HRQoL six months after surgery.

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.

Coblation intra-capsular tonsillectomy: A prospective tertiary center trial

INTRODUCTION

There is a growing interest in intra-capsular coblation tonsillectomy (ICT) for the treatment of obstructive sleep apnea (OSA) in children. Literature remains controversial regarding which intra-capsular tonsillectomy (IT) technique is most effective and with least morbidity. Therefore, the aims of this study are to objectively measure the post-operative morbidity and the effectiveness of the ICT technique.

MATERIALS AND METHODS

107 children undergoing ICT (with or without adenoidectomy) for upper airway obstruction due to tonsillar hypertrophy at a tertiary center university hospital were prospectively enrolled from March 2016 to March 2018. Efficacy of the surgery was assessed by a pre-and post-operative Obstructive Sleep Apnea score (OSA-18). Post-operative morbidity was measured based on the Parent's Post-operative Pain Measure questionnaire (PPPM), type and duration of administered pain medication, time before resuming a full diet and a normal activity, readmission for dehydration and post-operative bleeding incidence.

RESULTS

After a mean follow-up of 21.6 months, OSA-18 mean total score was 78.77 (SD = 15.74) before ICT and 23.7 (SD = 9.25) after surgery, with a significant difference between pre-operative and post-operative scores (p < 0.001). Mean PPPM scores were low at all evaluation points (5.89, 2.42 and 0.83 at days 2, 5 and 10 respectively). Analgesic use was restricted to acetaminophen in nearly all children for a mean duration of 1.93 days. They resumed a normal diet after 2.42 days and a normal activity (including return to school) after 2.7 days. No hospital readmission nor post-operative hemorrhage were reported.

CONCLUSION

Intra-capsular tonsillectomy by coblation is an effective and safe procedure that provides rapid post-operative recovery with minimal analgesic requirements, thus deserving a wider application in treating upper airway obstruction due to tonsillar hypertrophy in children.

Total or partial tonsillar resection (tonsillectomy or tonsillotomy) to change the quality of life for adults with recurrent or chronic tonsillitis: study protocol for a randomised controlled trial

BACKGROUND

Tonsillar surgery has been used for decades to treat recurrent and chronic tonsillitis in adults. Recurrent and chronic tonsillitis result in disturbing symptoms, treatment costs, sick leave, and impaired quality of life (QoL). Theoretically, removing all or part of the altered pathological palatal lymphoid tissue alleviates the symptoms and enhances the QoL. Whether this is true with total or partial tonsillar resection (tonsillectomy (TE) and tonsillotomy (TT), respectively) has not been reported in a randomised trial yet.

METHODS

We conduct a multicentre, partly blinded, randomised, 6-month, parallel-group clinical study including 285 adult participants referred to surgical treatment for chronic or recurrent tonsillitis. The participants will either have TE, TT or watchful waiting (WW). The primary outcome will be the difference between the mean disease-specific Tonsillectomy Outcome Inventory-14 (QoL questionnaire) scores at 6 months. Comparison is made firstly between the combined TE+TT and WW groups (superiority analysis), and secondly between the TE and TT groups (non-inferiority analysis).

DISCUSSION

This study will add significant new information to the effects and harms of TE and TT procedures in the treatment of adults with chronic or recurrent tonsillitis.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT04657549.

[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.

Prospektive Erfassung der postinterventionellen Lebensqualität nach Adenotomie und Adenotonsillotomie bei Kindern

Hintergrund

Die Bewertung der Effektivität der Adenotomie (AT) und Adenotonsillotomie (ATT) bei symptomatischer adenotonsillärer Hyperplasie orientiert sich in Studien oft nur am Ausmaß der postoperativen Symptomreduktion. Daher sollte erstmals im Rahmen dieser Studie erfasst werden, ob die AT und ATT zu einer postoperativen Verbesserung der kindlichen Lebensqualität (LQ) mittels dem Fragebogen „Glasgow Children’s Benefit Inventory“ (GCBI) und einer visuellen Analogskala (VAS) zur LQ führt.

Material und Methoden

Es wurden n = 111 Kinder prospektiv rekrutiert (3 bis 6 Jahre, ♂ 65 % ♀ 35 %, Æ Alter 4,2 Jahre, AT (66 %), ATT (34 %), Follow-up 3,5 Monate). Die kindliche LQ wurde mittels GCBI (24 Items) und einer VAS zur LQ (0 bis 10 Punkte) erfasst.

Ergebnisse

Bei 107 Kindern (96,4 %) ergab sich eine postoperative Verbesserung der LQ anhand der GCBI-Score-Werte. Es ergab sich ein mittlerer Score-Wert von +32,7 ± 22,14, Konfidenzintervall (KI) [+28,5–+36,9] mit maximal +97,9 und minimal −25,0 Punkten. In der Gruppe ATT wurde mit +39,4 ± 25,18 ein signifikant höherer mittlerer Score-Wert als in der Gruppe AT +29,3 ± 19,67 erreicht (p = 0,024). Bei 91 (82,0 %) der Kinder gaben die Eltern postoperativ einen höheren Punktewert in der VAS an, bei 16 (14,4 %) bemerkten die Eltern keine Änderung, nur bei 4 (3,6 %) verschlechterte sich die LQ.

Diskussion

Schon die reine Rachenmandelhyperplasie beeinflusst die allgemeine LQ relevant. Die Verbesserung der LQ in GCBI und VAS durch die Operation belegt den klaren Benefit. Bei zusätzlicher Hyperplasie der Gaumenmandeln verbessert eine zusätzliche Tonsillotomie die LQ noch deutlicher. Adenotomie und Adenotonsillotomie sind daher bei differenzierter Indikationsstellung effektive Operationen, um neben der reinen Symptomreduktion auch eine signifikante Verbesserung der kindlichen LQ zu erzielen.

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.

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.

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

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

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.

Tonsillotomy versus tonsillectomy in adults suffering from tonsil-related afflictions: a systematic review

OBJECTIVE

Tonsillotomy has emerged as an alternative for tonsillectomy in treating patients with tonsil-related afflictions. Tonsillotomy provides favourable outcomes in children, but treatment of choice in adults remains unclear. This systematic review sought to evaluate the current literature on the efficacy and adverse events of tonsillotomy compared to tonsillectomy in adults.

METHODS

A Medline and Cochrane search was conducted for randomized clinical trials (RCTs) and cohort studies comparing tonsillotomy to tonsillectomy in adults. Risk of bias was assessed. Outcome measures were efficacy of the procedure in resolving the initial tonsil-related symptoms (tonsillitis, obstructive sleep apnoea, tonsil stones, halitosis, dysphagia), procedure-related complications, recovery time, post-operative use of analgesics, patient satisfaction, and operating time.

RESULTS

In total nine papers were included. These trials had a high risk of bias and the inter-comparability of results was poor. The reported studies found generally a similar efficacy for both interventions. With regard to pain, the use of analgesics, patient satisfaction and operation time, the results were generally in favour of tonsillotomy. Post-operative haemorrhages were more frequent after tonsillectomy.

CONCLUSION

Current evidence suggests an equal efficacy of tonsillotomy and tonsillectomy in adults and a preference for tonsillotomy in terms of pain, analgesics use, patient-satisfaction, operation time and post-operative complications.

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.

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Randomized study comparing inflammatory response after tonsillectomy versus tonsillotomy

To determine if there was a difference in the inflammatory reaction after tonsil surgery with "traditional" techniques (tonsillectomy and adenoidectomy or TA) compared to partial intracapsular tonsillectomy and adenoidectomy (PITA).

DESIGN

Randomized, double-blind study.

SETTING

tertiary care academic hospital. Children under the age of 16 years with a diagnosis of obstructive sleep disordered breathing were randomly allocated into three study groups: TA with electrocautery (n = 34), PITA with CO₂ laser (n = 30) and PITA with debrider (n = 28). All of the children underwent adenoidectomy with a current at the same surgical procedure.

MAIN OUTCOME MEASURE

c-reactive protein level (CRP) was the primary endpoint. In addition, the following were assessed: white blood cells (WBC), neutrophils (NEU), interleukin-6 (IL-6) and tumor necrosis factor-alpha (TNF-α). Pre- and post-procedure measurements were compared between the groups. Parents filled out a questionnaire daily during the first postoperative week assessing pain, swallowing and snoring. CRP levels ascended higher in the PITA groups after surgery (p = 0.023), WBC and NEU showed the same pattern, IL-6 levels were higher in PITA group and there was no difference in TNF-alpha levels between the two types of procedures. Postoperative pain and postoperative hemorrhage were significantly lower in the PITA groups as compared to the TA group (p = 0.01 and 0.048). PITA in comparison to TA is associated with lower morbidity; however, the inflammatory response does not differ significantly in the first 24 h after surgery. Additional long-term studies assessing efficacy of PITA are warranted.

LEVEL OF EVIDENCE

Level 1, prospective randomized controlled trial.

Treatment Options for Pediatric Obstructive Sleep Apnea

There are a variety of therapies available for the treatment of pediatric obstructive sleep apnea syndrome (OSAS). In children with enlarged adenoids or tonsils, adenotonsillectomy (AT) is the preferred treatment, but other surgical options include partial tonsillectomy and lingual tonsillectomy. In specific populations, craniofacial or bariatric surgery may be indicated, and tracheostomy should be reserved for cases where there is no other therapeutic option. Positive airway pressure (PAP) is the most effective non-surgical therapy for OSAS as it can be successfully used in even cases of severe OSAS. Nasal steroids and leukotriene receptor antagonists may be used in the treatment of mild or moderate OSAS. Rapid maxillary expansion and dental appliances may be effective in select populations with dental problems. Other non-surgical therapies, such as positional therapy, supplemental oxygen, and weight loss have not been shown to be effective in most pediatric populations.

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

OBJECTIVES/HYPOTHESIS

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

STUDY DESIGN

Prospective randomized surgical trial.

METHODS

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

RESULTS

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

CONCLUSION

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

LEVEL OF EVIDENCE

1b.

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

Background

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

Subjects and methods

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

Results

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

Conclusion

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

Sleep related quality of life before and after adenotonsillar surgery in pediatric population

OBJECTIVE

To assess the quality of life in children with adenotonsillar problems before and after adenotonsillectomy in short term follow-up.

METHODS

Quasi-experimental study (before and after study) of children with adenotonsillar problems at Tehran University of Medical Sciences, Amir'Alam hospital. Eighty six pediatric patients aged 3 through 13 years (58 boys and 28 girls) who underwent adenotonsillectomy, for treatment of sleep disordered breathing or recurrent throat infection, were recruited. Parents completed OSA-18 quality of life survey and Brouillette score questionnaire before and one month after surgery.

RESULTS

Reliability of the Brouillette score and OSA-18 survey was established by evaluating the Cronbach α value. Cronbach α for Brouillette score was 0.70 and for OSA-18 survey it was 0.88. Preoperative values for the OSA-18 total and domain scores were high in children: mean±SD; 61.65±20.78. Preoperative values for the Brouillette score were: mean±SD; 0.41±2.34. The total OSA-18 survey score and the scores for all domains showed significant improvement after surgery: mean±SD; 28.01±9.09 (P<0.001). Post-operative Brouillette score had a significant improvement: mean±SD; -3.57±0.91 (P<0.001).

CONCLUSION

Considering the OSA-18 survey and Brouillete score results, surgical therapy with adenotonsillectomy is associated with marked improvement in quality of life in both obstructive and infective adenotonsillar disease.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Does tonsillectomy improve quality of life in adults? A systematic literature review

Aim:

To determine whether tonsillectomy improves quality of life in adults suffering from chronic or recurrent tonsillitis.

Method:

A systematic literature search of the Medline and Pubmed databases was conducted in order to identify all relevant studies measuring quality of life directly.

Results and Conclusion:

Eight studies were identified. The Glasgow Benefit Inventory and the Short Form questionnaire were the main tools used to assess quality of life changes. Tonsillectomy is likely to improve the overall quality of life as it particularly improves patients' physical and general health. The social benefits of tonsillectomy appear to be non-significant. The effects are likely to be long-lasting and have a greater impact on younger patients. The presence of coexisting chronic conditions and the severity of infective symptoms due to tonsillitis are also influencing factors.

[Development and validation of the Tonsillectomy Outcome Inventory 14]

BACKGROUND

Until now, no validated instrument to measure disease-specific, health-related quality of life (HR-QOL) in adults with chronic tonsillitis (CTO) exists.

MATERIAL AND METHODS

After an item reduction of the alpha-version of the Tonsillectomy Outcome Inventory (TOI), the TOI-14 resulted. In addition to the total score, it includes the subscales throat problems, overall health, resources, and social-psychological restrictions. In phase 2, the TOI-14 was prospectively validated on 108 adults with CTO, who had undergone a tonsillectomy.

RESULTS

The TOI-14 had, on average, good reliability. It included all important aspects of the HR-QOL. Patients with CTO can be distinguished with high sensitivity from healthy subjects. All scores showed moderate to good correlation with the subjective limitation in quality of life. The sensitivity of the questionnaire demonstrated major effects postoperatively.

CONCLUSION

The TOI-14 constitutes the first worldwide-validated, disease-specific instrument to measure HR-QOL in adults with CTO. Due to its ease of use, it can be utilized both in the outcome research and in clinical routine.

Intraindividual comparison of 1,470 nm diode laser versus carbon dioxide laser for tonsillotomy: a prospective, randomized, double blind, controlled feasibility trial

INTRODUCTION

The need for reduction of post-tonsillectomy hemorrhage has led to promotion of tonsillotomy techniques for tonsil tissue reduction in obstructive tonsillar hypertrophy. This trial compares ablative tissue effects using 1,470 nm diode laser and carbon dioxide laser for tonsillotomy in an intraindividual design.

METHODS

21 children aged 3-13 years (mean age 6.3 years) underwent laser tonsillotomy for obstructive tonsillar hypertrophy in this double blind, prospective, randomized, clinical feasibility trial. In each of the blinded patients, tonsillotomy was performed using fiber guided 1,470 nm diode laser (contact mode, 15 W power) on the one side and carbon dioxide laser (12 W power) on the other side. An independent, blinded physician documented clinical presentation and patients' symptoms preoperatively and on Days 1, 3, 7, 14, and 21 post-operatively using standardized questionnaire including VAS for each side separately.

RESULTS

The mean duration of operative treatment was 2.7 min using 1,470 nm laser and 4.9 min using carbon dioxide laser respectively. Intraoperative bleeding and the frequency of bipolar forceps use for intraoperative bleeding control was significantly less using 1,470 nm diode laser system. There was no difference in post-operative pain scores between the carbon dioxide laser treated and the 1,470 nm fiber guided diode laser treated side. No infections, hemorrhages or other complications occurred in the course of the 3 weeks post-operative period.

CONCLUSIONS

A fiber-guided 1,470 nm diode laser system offers an efficient and safe method for tonsillotomy as treatment of obstructive tonsillar hypertrophy. Compared to our standard practice (carbon dioxide laser), 1,470 nm laser application provides comparable tissue ablation effects with less intraoperative bleeding and shorter operation time.

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

There is a paucity of studies on patient-reported outcome measures in adult tonsillectomy. Our aim was to add to the body of health-related quality of life (HRQOL) evidence on adult tonsillectomy at a time when this intervention is being branded a low priority treatment in the United Kingdom (UK). We designed a prospective questionnaire study that was carried out in two UK district general hospitals. 41 patients were recruited into the study and completed a pre-operative short form 36 questionnaire. All 41 were contacted at least 1 year after tonsillectomy and were asked to complete the same SF-36 questionnaire and three additional HRQOL questions. There was a significant improvement in quality of life shown by both the mean SF-36 scores and the HRQOL questions. The SF-36 summary measures and the total SF-36 scores improved significantly (p < 0.01). The study emphasises the importance of tonsillectomy being available on the National Health Service to adults with recurrent tonsillitis. This proven quality of life improvement is also highly likely to confer a secondary health economic benefit from less GP attendances and fewer missed work days.

Tonsil surgery efficiently relieves symptoms: analysis of 54 696 patients in the National Tonsil Surgery Register in Sweden

CONCLUSION

Patients operated with tonsillar surgery report a high degree of symptom relief 6 months after surgery.

OBJECTIVE

The purpose of this study was to analyze symptom relief 6 months after tonsil surgery in relation to age, indication, surgical procedure, primary bleeding and unplanned postoperative visits. The National Tonsil Surgery Register in Sweden offers data from 54,696 patients registered during 1997-2008.

METHODS

This was a prospective assessment by questionnaire. Data were collected using three questionnaires, two completed by professionals and one 6 months postoperatively by the parents/patients.

RESULTS

Among 54,696 patients, the most common surgical indications were obstruction (49.7%), followed by recurrent tonsillitis (35.2%). Symptom relief 6 months after surgery was high in all indication groups (>92%), and highest for patients operated on the indication peritonsillitis (>98%). The indications obstruction, recurrent tonsillitis or chronic tonsillitis reported a high degree (>96%) of symptom relief. Of the patients who underwent tonsillectomy with adenoidectomy, 97.5% were symptom-free compared to 96% of patients who had tonsillectomy alone and 96.1% who underwent tonsillotomy (p < 0.0001). In all, 13.9% of patients required an unplanned visit to the clinic postoperatively. Only 148 of 54,696 patients reported worsening of symptoms after surgery.

1-year follow-up after radiofrequency tonsillotomy and laser tonsillotomy in children: a prospective, double-blind, clinical study

In the last decade, tonsillotomy has come into vogue again, whereas the number of tonsillectomies is decreasing rapidly. In a previous study, the tonsillotomy with laser or radiofrequency therapy proved as a safe and effective procedure with minimal pain and hemorrhage. This follow-up study determines which method is more effective with respect to long-term outcome, recurrence of tonsillar hyperplasia and recurrence of tonsillitis. A prospective, randomised, double-blinded controlled clinical study was conducted at the Department of Otorhinolaryngology of the Ludwig-Maximilians-University, Munich, Germany. Twenty-six children with tonsillar hypertrophy were included. Tonsillotomy was performed on one side with monopolar radiofrequency and on the other side with a carbon dioxide laser. Exactly 1 year after the procedure, all 26 patients were documented by digital photography to define a possible recurrence of tonsillar hyperplasia. All parents were asked for occurring tonsillitis and fulfilled the Glasgow Children's Benefit Inventory (GCBI) for health-related quality of life after surgical procedures. In seven children, a slightly visible recurrence of the tonsillar hyperplasia occurred, without any symptoms or correlation to the different methods and sides. One child with recurrent tonsillitis and hyperplasia had to be tonsillectomized 8 months after the initial tonsillotomy procedure. The specimen showed open crypts with bacterial infection in the deep. The GCBI resulted in highly significant benefits of the surgery in all categories and subcategories. In conclusion, both methods, the laser tonsillotomy and the radiofrequency method, were equal concerning the effectiveness and safety after 1 year. Further investigations have to aim at the long-term outcome after tonsillotomy in patients with recurrent infections.

Bipolar radiofrequency tonsillotomy compared with traditional cold dissection tonsillectomy in adults with recurrent tonsillitis

Objective: To compare short- and long-term results of radiofrequency tonsillotomy and traditional cold dissection tonsillectomy in adult patients with recurrent tonsillitis.

Study Design: A randomized clinical trial.

Setting: A tertiary referral university hospital.

Subjects and Methods: Of 62 adults with recurrent tonsillitis, 24 patients were treated with cold dissection tonsillectomy, while radiofrequency tonsillotomy (RF) by use of radiofrequency induced thermotherapy probes was performed in the remaining 38 patients. Duration of surgery, amount of intraoperative bleeding, recovery time, postsurgical pain (measured by use of visual analogue scale on days 1, 3, 5, and 10 after surgery), dysphagia, weight loss, and time of return to normal diet and activity were measured. All the patients were followed for 12 to 24 months for recurrence of tonsillitis episodes.

Results: Comparing the radiofrequency tonsillotomy group to the cold dissection tonsillectomy group, mean duration of surgery was 16.89 versus 45.04 minutes, recovery time was 14.32 minutes versus 17.08 minutes, and amount of intraoperative bleeding was 15 to 20 cc versus 250 to 300 cc, respectively ( P < 0.005). There was no difference between the two groups in the recurrence of tonsillitis episodes after 24 months.

Conclusion: Tonsillotomy with radiofrequency is a simple, rapid, and effective method in adult patients with recurrent tonsillitis.

Double-blind, randomised, controlled study of post-operative pain in children undergoing radiofrequency tonsillotomy versus laser tonsillotomy

INTRODUCTION

In the last decade tonsillotomy has come into vogue again, whereas the number of tonsillectomies is decreasing rapidly. Currently, most tonsils are reduced by utilise electrosurgery, radiofrequency or carbon dioxide laser. However, it is not clear whether radiofrequency tonsillotomy is as effective as laser or other surgical techniques in respect of post-operative pain and haemorrhage.

MATERIAL AND METHODS

A prospective, randomised, double-blinded, controlled, clinical study was conducted in the otorhinolaryngology department of Ludwig Maximilians University, Munich, Germany. Twenty-six children with tonsillar hypertrophy were included. Exclusion criteria were: history of peritonsillar abscess, previous tonsil surgery, tonsillitis within two weeks, pain before surgery, psychiatric illness, asymmetrical tonsils, chronic analgesic usage, bleeding disorders and other surgical procedures during the same operation. Tonsillotomy was performed on one side with radiofrequency and on the other side with a carbon dioxide laser. All procedures were performed by a single surgeon, under general anaesthesia. A visual analogue scale was used to measure patients' pain on each side, administered by a 'blinded' nurse on the three post-operative mornings and evenings, within the hospital.

RESULTS

There was no difference in post-operative pain scores or haemorrhage, comparing laser versus radiofrequency tonsillotomy. Patient's overall reported pain was very modest compared with post-tonsillectomy pain. No haemorrhage or other adverse effects were observed.

Child behavior and quality of life before and after tonsillotomy versus tonsillectomy

OBJECTIVES

Compare two techniques for pediatric tonsil surgery with respect to postoperative pain and morbidity and changes in sleep behavior, health related quality of life (HRQL) and benefits due to surgery.

METHODS

67 children (4.5-5.5 years) with tonsillar hypertrophy and obstructive sleep-disordered breathing with or without recurrent tonsillitis were randomized to either regular tonsillectomy (TE) (n=32) or intracapsular tonsillectomy/tonsillotomy (TT) (n=35) with Radiofrequency surgical technique (ellman Int.). Before TT/TE, the parents completed a validated Quality of Life survey of pediatric obstructive sleep apnea, the OSA-18 (Obstructive Sleep Apnea-18) and a standardized assessment of their children's behavior with the Child Behavior Checklist (CBCL). Six months after surgery, the parents repeated these measurements, and assessed the health related benefits of the surgery using the Glasgow Children's Benefit Inventory (GCBI).

RESULTS

In the TT group, the children recorded less pain from the first day after surgery onwards, used fewer doses of painkillers and were pain-free 3 days earlier than the children in the TE group. Six months after surgery, there were no significant difference between TT and TE with regard to snoring and ENT-infections. The differences in the total scores and in all the individual domains between the initial OSA-18 and post-surgery scores were all significant (P<0.0001). The improvement in the total problem score measured with CBCL was also significant (P<0.01) and there was no difference between the TT and TE children. The improvements in all subscores of the GCBI indicated a significant health benefit of both TT and TE.

CONCLUSIONS

TT with RF-surgery causes less pain and postoperative morbidity than regular TE and has an equal effect on snoring and recurrent infections. Pre-school children with tonsillar hypertrophy and obstructive sleep-disordered breathing all show an impact on HRQL and behavior before surgery and improve dramatically just as much after TT as after TE. Therefore TT would be considered for treatment of small children.

Tonsillotomy in the treatment of obstructive sleep apnea syndrome in children: polysomnographic results

INTRODUCTION

The therapy of choice in the treatment of pediatric obstructive sleep apnea syndrome (OSAS) consists of tonsillectomy or tonsillotomy combined with adenoidectomy. While tonsillectomy unfortunately has a notable risk of secondary hemorrhage and postoperative pain, tonsillotomy is safer and less painful for children. The effect of both surgical methods on symptoms of OSAS seems to be equal, but up to now postoperative polysomnographic data for children treated by tonsillotomy are missing.

MATERIALS AND METHODS

Twenty children aged 2-9 years (mean age: 4.1+/-2.0 years) with OSAS diagnosed by full-night polysomnography were included in the study. OSAS was defined as an apnea-hypopnea index (AHI) of 5 or more with minimum oxygen saturation (SaO(2) min) of less than 90%. Exclusion criteria were obesity, craniofacial abnormalities or other pulmonary, cardiac or metabolic diseases as well as a history of recurrent tonsillitis. All children were treated by CO(2) laser tonsillotomy and adenoidectomy. Three to 12 months (mean: 7.7 months) after the procedure a control-polysomnography was performed in all children.

RESULTS

No statistically significant changes were seen in the pre- and postoperative distribution of sleep stages, sleep efficacy and total sleep time. The AHI decreased from 14.9+/-8.7 to 1.1+/-1.6 (p<0.001), SaO(2) min increased from 71.1+/-11.1% to 91.2+/-3.5% (p<0.001). Thus, all children were cured by the operation.

DISCUSSION

These polysomnographic data show that CO(2) laser tonsillotomy in combination with adenoidectomy is highly effective in the treatment of pediatric OSAS and should be preferred over tonsillectomy because of less postoperative pain and a lower risk of postoperative bleeding.

Randomized controlled studies and the treatment of middle-ear effusions and tonsillar pharyngitis: How random are the studies and what are their limitations?

Objective

To determine the applicability and external validity of randomized control studies (RCTs) in the light of patient susceptibilities and vulnerabilities to the sequelae of otitis media with effusion (OME) and tonsillar pharyngitis (T&A) and the composition of their cohorts.

Study Design

RCTs for OME and T&A were analyzed to determine which intrinsic and extrinsic susceptibilities to the otolaryngic disease and its sequelae were included or excluded and the composition of the cohort.

Methods

A Medline and a Science Direct search were performed for all RCTs concerning OME and T&A through 2007. The articles selected to be included in this study are the OME RCTs that reported language and/or hearing outcomes and the T&A RCT studies in which the outcome measure was infection, alleviation of airway obstruction, and/or quality of life. These were analyzed for their inclusion or exclusion of intrinsic and extrinsic susceptibilities to the otolaryngic disease and their sequelae and the composition of the cohort. The pertinent otolaryngologic literature was assessed to determine applicable risk factors.

Results

The analysis of the inclusion or exclusion of risk factors showed that for OME 0 percent were included and 16 percent were excluded, and there were no data for 84 percent. The T&A findings were similar in that 1 percent of risk factors were included, 8 percent excluded, and there were no data for 92 percent. Both the OME and the T&A cohorts data were similar in that approximately half of the suitable candidates completed the study; 25 percent of the OME and 13 percent of the T&A enrolled subjects were either withdrawn or placed into a different experimental group. On the average, with data available, it took 4.6 years to recruit the OME sample and 5.5 years to recruit the T&A sample.

Conclusion

The results of RCTs for these conditions are only applicable to narrowly defined and highly circumscribed populations. They cannot be generalized to the entire patient population because of their limited external validity. Future RCT protocols should be designed to control for the intrinsic and extrinsic susceptibilities that result in a propensity to acquire the disease and/or an exacerbation of the disease's sequelae. These studies would determine the most effective strategies for preventing disorders and/or their deleterious sequelae.

Tonsillectomy versus tonsillotomy performed with scissors in children with tonsillar hypertrophy

OBJECTIVE

We sought to determine the morbidity and the short and long-term effectiveness of tonsillotomy (partial tonsillectomy) performed with scissors compared with conventional cold knife (total) tonsillectomy.

METHODS

We conducted a 2-year prospective non-randomized study at a tertiary children's hospital. One thousand and twenty-three children were recruited (243 in the tonsillotomy and 780 in the tonsillectomy group). Age, sex, weight, and time of operation, immediately post-operative complications and pain were recorded. Eighteen months after the operation data on weight, parents' satisfaction and recurrence of obstructed symptoms was obtained in 60 randomly selected children of each group.

RESULTS

Post-operative complications rates were very low in both groups and their differences did not reach statistical significance. However, tonsillotomies were significantly better than tonsillectomies in relation to post-operative pain the 1st (P<0.001) and the 7th (P<0.001) post-operative day, and lasted an average of 2.5 min less. Concerning long-term effects, both methods resulted in an increase of patients' weight without the difference in weight increase be statistically significant. In addition, parents' satisfaction as well as oral malodour do not seem to differ significantly. Finally, although twice as many children in the tonsillotomy group had a recurrence of snoring compared to tonsillectomy group, only in about half of them was the problem regarded significant enough by their parents to require medical consultation or reoperation. At the end, an estimated 3.5% of the tonsillotomy group was offered a tonsillectomy in the long term.

CONCLUSION

This trial shows that scissors tonsillotomy in combination with an adenoidectomy is a viable therapeutic option with less immediate post-operative morbidity than tonsillectomy in young children whose sleep disorder breathing is due to a combination of tonsilar and adenoid hypertrophy. However, parents should be informed of the possibility of regrowth and reoperation.

Tonsillar regrowth following partial tonsillectomy with radiofrequency

OBJECTIVES

To assess regrowth potential of the tonsils following partial tonsillectomy performed by using radiofrequency.

METHODS

Follow-up results of 42 children (aged from 1 to 10 years) who consecutively had partial tonsillectomy with radiofrequency due to obstructive sleep apnea or snoring were evaluated for regrowth of the tonsils.

RESULTS

Regrowth of the remaining tonsillar tissue was observed in 7 of 42 patients (16.6%). The upper respiratory tract obstruction symptoms recurred in 5 of these 7 patients while the remaining 2 patients were asymptomatic. The tonsils of symptomatic patients were removed completely.

CONCLUSION

Partial tonsillectomy may have a significant potential for regrowth and thereby recurrence of the obstructive symptoms. Although the cause of this regrowth remains unknown, this problem should be remembered by the surgeons, and an informed consent should be obtained from the families prior to radiofrequency tonsillotomy.

[Prevention and relief of pain induced by otolaryngology procedures]

There are many types of pain induced in otolaryngology, stemming from medical acts, sinus drainage, packing of the nasal fossae, or complex bandaging after cancer surgery. In patients with impaired communication abilities resulting from impaired speech, greater attention must be paid to induced pain, sometimes requiring the use of behavioral evaluation scales. Preventing this pain means organizing medical acts and painful treatments by attempting to group them and informing the patient that the caregiver is listening to him and relieving his pain. Non-drug treatments should always be attempted, are based on a trusting relationship with the patient, a comfortable position, diverting his attention, and using bandaging that is less painful when removed. However, use of drug treatments often remains indispensable. The strong morphinics are used most often despite a pharmacokinetic profile that is poorly adapted and the undesirable side effects in case of repeated administration. Local anesthetics should be used whenever possible. Dissemination of nursing protocols for the use of MEOPA provides good pain relief providing that there are trained personnel in sufficient numbers. The intensity of pain induced by certain medical acts requires use of brief general anesthesia, which can often be done in the ambulatory situation and is preferable to deep sedation outside of the safety of the operating room.