Trends and changes in paediatric tonsil surgery in Sweden 1987-2013: a population-based cohort study

Comparison of postoperative bleeding in pediatric tonsillectomy versus tonsillotomy

OBJECTIVE

Tonsillar surgery is a common intervention for pediatric obstructive sleep apnea and recurrent tonsillitis. This study compared postoperative bleeding incidence and severity following tonsillotomy and tonsillectomy at a single medical center.

STUDY DESIGN

A retrospective cohort study on 1984 pediatric patients (1-18 years old) who underwent surgery during 2004-2011 and 2019-2022. Tonsillectomy was performed during 2004-2011, while tonsillotomy was preferred for obstructive sleep apnea during 2019-2022. Tonsillectomy was performed using cold steel technique with complete removal of tonsillar tissue, while tonsillotomy was conducted using mono- or bipolar diathermy, preserving minimal tissue on the tonsillar capsule.

SETTING

Shaare-Zedek Medical Center, Faculty of Medicine, Hebrew University.

METHODS

Outcome measures included postoperative bleeding incidence and severity, surgery duration, hospitalization length, and readmission.

RESULTS

Tonsillotomy was conducted on 958 (48.3 %) patients, and tonsillectomy was performed on 1026 (51.7 %) patients. Obstructive sleep apnea was the only indication in 1553 (78.3 %) patients. Overall bleeding rate was lower following tonsillotomy (3.9 %) than tonsillectomy (9.5 %) (p < 0.001). Significantly more patients required surgical bleeding control post-tonsillectomy than post-tonsillotomy: 39 (3.7 %) vs. 5 (0.5 %), respectively (p < 0.001). Tonsillectomy resulted in higher readmission rates (11.8 % vs 6.1 %, p < 0.001), more blood transfusions (3 vs. 0), and higher postoperative hemoglobin diminution (1.57 ± 2 vs. 0.94 ± 1 g/dL, p = 0.035). The duration of the surgery was shorter for tonsillotomy (24.7 vs 26.5 min, p = 0.012). Tonsillectomy sustained higher bleeding rates for obstructive sleep apnea patients (7.0 % vs 3.9 %, p = 0.006). For recurrent tonsillitis patients, bleeding rates did not vary between year groups. Older age and tonsillectomy were the most significant risk factors for postoperative bleeding.

CONCLUSION

Among children undergoing tonsillar surgery for obstructive sleep apnea, tonsillotomy was associated with a safer postoperative bleeding profile, reduced bleeding severity, and fewer readmissions compared to tonsillectomy.

Efficacy of partial tonsillectomy in periodic fever, aphthous stomatitis, pharyngitis and adenitis syndrome: a STROBE retrospective observational study

INTRODUCTION

PFAPA (Periodic Fever, Aphthous stomatitis, Pharyngitis, Adenitis) or Marshall syndrome is the most frequent cause of recurrent auto-inflammatory fever in children. Frequent episodes impair the child's quality of life and family life. Total tonsillectomy demonstrated efficacy in improving symptoms, but few studies assessed partial tonsillectomy in this indication. The aim of the present study was to assess postoperative course after partial tonsillectomy for PFAPA syndrome, with comparison to total tonsillectomy.

MATERIALS AND METHODS

This retrospective cohort study adhered to STROBE guidelines. It included children with PFAPA syndrome on EUROFEVER criteria, treated by partial or total tonsillectomy between January 1, 2011 and December 31, 2022 in our university hospital center. For comparisons, the significance threshold was set at P<0.005.

RESULTS

Thirty-six children were included: 16 with partial and 20 with total tonsillectomy. With partial tonsillectomy, the number of episodes decreased by 10 per year (range, 5-21) (P<0.005) over 6 years' follow-up. The decrease was 50% with partial tonsillectomy and 93% with total tonsillectomy (P=0.056). The decrease in number was statistically suggestive (P=0.028). There were no complications with partial tonsillectomy and 2 patients with complications (10%) with total tonsillectomy. Two of the 16 patients with partial tonsillectomy (12.5%) required totalization, achieving remission in both cases.

CONCLUSION

Partial tonsillectomy significantly reduced the frequency, duration and intensity of postoperative episodes in PFAPA syndrome. It may be less effective than total tonsillectomy, but has a lower risk of complications awaiting remission in adolescence.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

LEVELS OF EVIDENCE

Level 4 Laryngoscope, 2024.

Endoscopic Powered Intracapsular Tonsillectomy and Adenoidectomy in Pediatric Obstructive Sleep Apnea With High-Risk Comorbid Disease Conditions: A Case Series

OBJECTIVE

Pediatric obstructive sleep apnea (OSA) caused by adenoids or an enlarged palatine tonsil has a negative impact on physical and mental growth. Surgical removal of the tissue is effective but entails a life-threatening risk of postoperative bleeding, which is up to 30 times higher in chronic pediatric disease cases. However, endoscopes and resection devices provide safe, reliable surgical methods. Here, we report the efficacy and safety of endoscopic powered intracapsular tonsillectomy and adenoidectomy (PITA) for pediatric OSA in patients with high-risk comorbidities.

METHODS

This retrospective case series included pediatric patients with OSA who underwent PITA at a single tertiary medical center between April 2017 and May 2023. Ten patients (three males and seven females; mean age 6.4 years, range 2-12 years) were included; all met the Japanese criteria for complex chronic pediatric conditions.

RESULTS

The average operative time was 61 min; a microdebrider was used in eight cases and a coblator in two cases. Although there was no postoperative bleeding, one case experienced regrowth.

CONCLUSIONS

Our data show that an endoscopic PITA approach could reduce the risk of severe bleeding and relieve the sleeping conditions of pediatric patients with complex chronic OSA.

Tonsillotomy for Periodic Fever Syndrome: A Randomized and Controlled Trial

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

LEVEL OF EVIDENCE

2 Laryngoscope, 134:968-972, 2024.

Long-term complications after tonsil surgery: an analysis of 54,462 patients from the Swedish Quality Register for Tonsil Surgery

Objective

This study aims to evaluate long-term complications after tonsil surgery using an exploratory retrospective cohort study design based on data from the Swedish Quality Register for Tonsil Surgery (SQTS).

Methods

All patients registered in the SQTS between 1 January 2009 and 31 May 2021 were eligible for the study. In this study, a long-term complication is defined as any complication persisting for a minimum of 6 months after surgery. The definition of a complication was based on individual patient reports, provided in a free text format, of any remaining issues 6 months after tonsil surgery. Complications were categorized as follows: disturbed taste or sense of smell, dysphagia, miscellaneous and general symptoms and signs, miscellaneous throat problems, pain or discomfort in the mouth or throat, problems with jaws or teeth, problems with the ears or hearing, problems with the nose or sinuses, problems with throat secretions or throat clearing, problems with voice or speech, and sensory symptoms. A multivariable logistic regression analysis was used to identify independent predictors of long-term complications.

Results

In total, 54,462 patients were included in the study. A total of 3,780 patients (6.9%) reported one or more long-term complications. The most frequent long-term complications, with a plausible connection to the surgery, were found in the following categories: pain or discomfort in the mouth or throat (1.9%), problems with throat secretions or throat clearing (0.8%), dysphagia (0.6%), and problems with voice or speech (0.6%). Tonsillotomy was associated with a lower risk of long-term complications than tonsillectomy.

Conclusion

This study suggests that subjective long-term complications after tonsil surgery, in general, are relatively common (6.9%). However, complications with a plausible connection to the surgery were less common (4.0%), and specific complications seemed to be relatively rare, with no single specific problem reaching a prevalence of ≥0.6%.

The efficacy of cryogenic plasma tonsillectomy in the treatment of obstructive sleep apnea-hypopnea syndrome in children: A meta-analysis

BACKGROUND

Obstructive sleep apnea hypopnea syndrome (OSAHS) refers to the apnea and hypopnea caused by partial or complete obstruction of the upper airway collapse during sleep. The cryogenic plasma tonsillectomy is mostly used for the clinical treatment of children with OSAHS.

AIMS

The objective of this meta-analysis is to investigate the clinical efficacy of cryogenic plasma tonsillectomy for OSAHS in children.

MATERIALS & METHODS

The literature search was conducted through China National Knowledge Infrastructure (CNKI), Wanfang Database, Embase, PubMed, and Web of Science databases. The search was from the establishment of each database to June 2022. Randomized controlled trials (RCTs) meeting the criteria for partial/total cryo-plasma tonsillectomy for treating patients with obstructive sleep apnea-hypopnea syndrome in children were included, with data extracted. The meta-analysis was performed using the Stata 16.0 and Review Manager 5.4. Seven RCTs were included in this study.

RESULTS

The results showed that the partial/complete cryo-plasma tonsillectomy in the experimental group had a better therapeutical effective rate than the control group of patients treated with conventional surgery [Odds ratio (OR) = 2.181, 95% CI: 1.306-3.645, P < 0.05]. Also, in terms of postoperative adverse reactions, the number of adverse reactions in the experimental group was significantly lower than in the control group (OR = 0.445, 95% CI: 0.287-0.689, P = 0.001). The analysis of surgical efficacy showed that the operative time, intraoperative blood loss, and postoperative pain score were all significantly lower than those of the control group. Furthermore, further analysis of the apnea-hypopnea index (AHI) and the lowest oxygen saturation (LSaO2) of the two groups showed that the cryo-plasma tonsillectomy treatment had higher LSaO2 levels than conventional treatment [Standardized mean difference (SMD) = 0.380, 95% CI: 0.094-0.667, P = 0.009].

CONCLUSION

The application of cryo-plasma tonsillectomy can significantly improve the treatment effect of OSAHS, reducing adverse reactions.

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

Objectives

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

Methods

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

Results

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

Conclusion

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

•

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

•

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

•

Follow-up after adenotonsillotomy is recommended.

Lactoferrin versus Long-Acting Penicillin in Reducing Elevated Anti-Streptolysin O Titer in Cases of Tonsillopharyngitis

Background

Beta-Hemolytic streptococci are the most frequent bacteria causing tonsillitis. Lactoferrin may play a role in the treatment of chronic tonsillitis due to its direct antimicrobial activity.

Objective

To assess the possible role of lactoferrin in reduction of raised serum Anti-Streptolysin O Titer (ASOT) in cases of chronic tonsillopharyngitis in comparison to long acting penicillin.

Methods

This study included 117 children with tonsillopharyngitis with high ASOT randomly divided into three groups; group 1 treated with lactoferrin, group 2 treated with long acting penicillin and group 3 treated with both drugs. For all patients ASOT was measured after three and six months of starting treatment.

Results

This study included 60 males and 57 females with the mean age (8.5 ± 2.4). There is statistically significant reduction in ASOT in all groups after three months of treatment. ASOT after 3 months was significantly lower in group1 (370±440) and group 3 (350±450) in comparison to group 2 (420±560) with p value 0.02, 0.004, respectively, with no significant difference in comparing group 1 to group 3 p value 0.4. Also, ASO titre after 6 months was significantly lower in group1 (350±420) and group 3 (340±440) in comparison to group 2 (420±550) with p value 0.02, 0.007, respectively, with no significant difference in comparing group 1 to group 3 p value 0.5. In comparing ASOT at three months and six months of treatment in the three studied groups; it decreased by 2% in group 1, and 1.6% in group 3 and no change in group 2.

Conclusion

Lactoferrin alone or in combination with long acting penicillin is safe and more effective than long acting penicillin alone in reducing ASOT. Treatment for six months with lactoferrin alone or in combination with long acting penicillin could offer a better response.

Adenotonsillectomy and adenoidectomy in children: The impact of timing of surgery and post-operative outcomes

AIM

To investigate the impact of adenotonsillectomy (ADT) and adenoidectomy (AD) on child health and evaluated their post-operative complications.

METHODS

We included all children aged <16 years undergoing ADT (tonsillectomy ± adenoidectomy) or AD in New South Wales, Australia, 2008-2017. Health information was obtained from administrative hospitalisation data. Rates of post-operative complications and reoperation were evaluated using generalised estimating equations and Kaplan-Meier methods, respectively.

RESULTS

Out of 156 500 included children, 112 361 had ADT and 44 139 had AD. Population rates increased during 2008-2017 (ADT: 68-79 per 10 000 children; AD: 25-34 per 10 000), and children were increasingly operated on at a younger age. Overall, 7262 (6.5%) and 1276 (2.9%) children had post-operative complications (mostly haemorrhage), and 4320 (3.8%) and 5394 (12.2%) required reoperation, following ADT and AD, respectively. Complication rates were highest among children aged 0-1 years, lowest for those 2-5 years and increased with age thereafter. Three-year reoperation rates for children aged 0-1 years were 9.0% and 25.9% following ADT and AD, respectively, decreasing thereafter to 0.5% and 2.1% in children aged 12-13 years.

CONCLUSIONS

ADT and AD in Australian children have both increased in frequency and are being done at a younger age. Post-operative complications and reoperation rates highlight surgery is not without risk, especially for children under 2 years old. These findings support a more conservative approach to management of upper respiratory symptoms, with surgery reserved for cases where potential benefits are most likely to outweigh harms.

Reference rate for post-tonsillectomy haemorrhage in Australia—A 2000–2020 national hospital morbidity database analysis

This study aims to provide a national benchmark rate of post-tonsillectomy haemorrhage (PTH) in Australia. Using data from Australia’s National Hospital Morbidity Database (NHMD) from 1 July 2000 to 30 June 2020, we have conducted a nation-wide population-based study to estimate a reference rate of PTH. Outcomes of interest included the overall rate and time-trend of PTH, the relationship between PTH rates with age and gender as well as the epidemiology of tonsillectomy procedures. A total of 941,557 tonsillectomy procedures and 15,391 PTH episodes were recorded for the study period. Whilst the incidence of tonsillectomy procedures and the number of day-stay tonsillectomy procedures have increased substantially over time, the overall rate of PTH for all ages has remained relatively constant (1.6% [95% CI: 1.61 to 1.66]) with no significant association observed between the annual rates of PTH and time (year) (Spearman correlation coefficient, R_s = 0.24 (95% CI: -0.22 to 0.61), P = 0.3). However, the rate of PTH in adults (aged 15 years and over) experienced a statistically significant mild to moderate upward association with time (year) R_s = 0.64 (95% CI: 0.28 to 0.84), P = 0.003. Analysis of the odds of PTH using the risk factors of increasing age and male gender showed a unique age and gender risk pattern for PTH where males aged 20 to 24 years had the highest risk of PTH odds ratio 7.3 (95% CI: 6.7 to 7.8) compared to patients aged 1 to 4 years. Clinicians should be mindful of the greater risk of PTH in male adolescents and young adults. The NHMD datasets can be continually used to evaluate the benchmark PTH rate in Australia and to facilitate tonsillectomy surgical audit activities and quality improvement programs on a national basis.

Comparison of clinical practice of tonsil surgery from quality register data from Sweden and Norway and one clinic in Denmark

OBJECTIVES

To compare the application of indications, demographics, surgical and haemostatic techniques in tonsil surgery in three countries.

DESIGN

Non-randomised, prospective, observational cohort.

SETTING

All patients registered in the National Tonsil Surgery Quality Registers in Sweden, Norway and West Jutland, Denmark.

PARTICIPANTS

Data were retrieved from 2017 to 2019; registered surgeries: Sweden: 20 833; Norway: 10 294 and West Jutland, Denmark: 505.

RESULTS

Tonsil surgery for obstruction was twice as common in Sweden (62.2%) compared with Norway (31%) and Denmark (27.7%). Recurrent tonsillitis was registered twice as frequently in Norway (35.7%) and Denmark (39%) compared with Sweden (16.7%). Chronic tonsillitis was registered more frequently in Norway (29.8%) than in Sweden (13.8%) and Denmark (12.7%). Day surgery (>76%) was comparable. The higher frequency of obstruction in Sweden affected age and gender distributions: Sweden (7 years, 50.4% boys), Norway (17 y, 42.1%) and Denmark (19 y, 38.4%). For obstructive disorders, tonsillotomy with adenoidectomy was used in a majority of Swedish children (72%), whereas tonsillectomy with or without adenoidectomy dominated in Norway (53.5%) and Denmark (57.9%). Cold steel was the technique of choice for tonsillectomy in all three countries. For tonsillotomy, hot dissection techniques dominated in all countries. Disparities were observed with regard to haemostatic techniques. Bipolar diathermy was commonly used in all countries. Monopolar diathermy was practically only used in Sweden. Infiltration with epinephrine in the tonsillar bed was registered in Sweden and Norway but not at all in Denmark. Combined cold surgical and cold haemostatic techniques were more commonly used in Sweden (22.7%) than in Norway (10.4%) and Denmark (6.2%).

CONCLUSIONS

This study demonstrates disparities among the Nordic countries in tonsil surgery in terms of indications plus surgical and haemostatic techniques. Increased coverage and further monitoring of outcomes is needed to identify best practices and ideal guidelines for improved care.

Cost and economic determinants of paediatric tonsillectomy

Objective Hospital utilisation research is important in pursuing cost-saving healthcare models. Tonsillectomy is one of the most common paediatric surgeries and the most frequent reason for paediatric hospital readmission. This study aimed to report the government-funded costs of paediatric tonsillectomy in the state of Victoria, Australia, extrapolate costs across Australia, and identify the cost determinants. Methods A population-based longitudinal study was conducted with a bottom-up costing approach using linked datasets containing all paediatric tonsillectomy and tonsillectomy with adenoidectomy surgeries performed in the state of Victoria between 2010 and 2015. Results The total average annual cost of tonsillectomy hospitalisation in Victoria was A$21 937 155 with a median admission cost of A$2224 (interquartile range (IQR) 1826-2560). Inflation-adjusted annual tonsillectomy costs increased during 2010-2015 (P < 0.001), not explained by the rising number of surgeries. Hospital readmissions resulted in a total average annual cost of A$1 427 716, with each readmission costing approximately A$2411 (IQR 1936-2732). The most common reason for readmission was haemorrhage, which was associated with the highest total cost. The estimated total annual expenditure of both tonsillectomy and resulting readmissions across Australia was A$126 705 989. Surgical cost in the upper quartile was associated with younger age, male sex, lower socioeconomic status, surgery for reasons other than infection alone, overnight vs day case surgery, public hospitals and metropolitan hospitals. Surgery for obstructed breathing during sleep had the strongest association to high surgical cost. Conclusions This study highlights the cost of paediatric tonsillectomy and associated hospital readmissions. The study findings will inform healthcare reform and serve as a basis for strategies to optimise patient outcomes while reducing both postoperative complications and costs.

Comparison of short-term recovery in children with obstructive sleep apnea undergoing tonsillotomy vs. tonsillectomy

OBJECTIVES

To compare the pain levels, degrees of pharyngeal swelling, and weight loss after tonsillectomy vs. tonsillotomy in children clinically diagnosed with obstructive sleep apnea (OSA) over the first seven postoperative days, and to determine which procedure was associated with better recovery in the early postoperative period.

METHODS

Between April 2021 and December 2021, 121 children with OSA (80 males and 41 females), ranging from 3 to 12 years of age with an average age of 6.7 years, were prospectively enrolled in this study conducted at Zhengzhou Central Hospital Affiliated to Zhengzhou University. The patients were randomly divided into two groups: a tonsillotomy group with 63 cases (40 males and 23 females) and a tonsillectomy group with 58 cases (40 males and 18 females). The patients' pain levels [as indicated by Parents' Postoperative Pain Measure (PPPM) scores] and degrees of pharyngeal swelling were recorded for seven days postoperatively, and the patients' body weights were recorded on postoperative day seven.

RESULTS

In the tonsillotomy group, the PPPM scores were the highest on the day of surgery and on the first postoperative day; the patients' pain levels gradually decreased.The PPPM scores in the tonsillectomy group were higher than those in the tonsillotomy group from the day of surgery to the seventh postoperative day (p < 0.05). The degree of pharyngeal swelling was lower in the tonsillotomy group than in the tonsillectomy group. Weight loss was lower in the tonsillotomy group than in tonsillectomy group on the 7th day after surgery (p < 0.05). On the fifth, sixth, and seventh postoperative days, compared with preschool children, school-age children who had undergone tonsillotomy experienced more pain relief than those who had undergone tonsillectomy (p < 0.05).

CONCLUSION

Children with OSA experienced less pain, less pharyngeal swelling, and less weight loss with tonsillotomy than with tonsillectomy. On the fifth, sixth, and seventh postoperative days, compared with preschool children, tonsillotomy in school-age children is more advantageous in school-age children.

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.

Establishment of resilience in a challenging recovery at home after pediatric tonsil surgery-Children's and caregivers' perspectives

The objective of this study was to explore children's and caregivers’ experiences and management of postoperative recovery at home after tonsil surgery. The study had an explorative qualitative design with an inductive approach. Twenty children (5‐12 years of age) undergoing tonsillectomy or tonsillotomy with or without adenoidectomy participated along with their caregivers in semi‐structured interviews at a mean time of 28 days after surgery. The interviews were analyzed with content analysis. One main category emerged from the interviews: children and caregivers struggle to establish resilience in a challenging recovery. The families’ resilience relied on their situational awareness and capacity to act, which in turn formed a basis for the ability to return to normal daily life. Children and caregivers described the recovery as an evident interruption of daily life which had an impact on the children's physical and psychological well‐being. Both children and caregivers described the pain as a central concern. The families used different pharmacological and complementary strategies to manage the pain, which in some cases were complex. Some families said that the analgesics were insufficient in preventing breakthrough pain, and spoke about a lack of support as well as inadequate and contradictory information from healthcare staff. Caregivers also expressed uncertainty, ambivalence, or anxiety about the responsibility associated with their child's recovery. To optimize and support the recovery after tonsil surgery, it is crucial to obtain knowledge of children's and caregivers’ perspectives of postoperative recovery at home. The results indicate that the postoperative period included several troublesome experiences for which neither the children nor the caregivers were informed or prepared. The experience of pain was significant, and often complex to manage. To increase families’ resilience, the information provided by healthcare professionals needs to be broadened. Multidisciplinary teamwork is necessary to achieve this goal.

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSION

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

[Second opinion process for tonsillectomy and tonsillotomy: analysis of the quantitative and qualitative justifying conditions]

BACKGROUND

In 2017, the Federal Joint Committee determined tonsillectomy and hysterectomy in non-oncologic diseases as well as tonsillotomy for second opinion procedure. We discuss the suitability of tonsillectomy and tonsillotomy for the second opinion procedure on its quantitative and qualitative characteristics.

MATERIALS AND METHODS

Data from the Federal Statistical Office concerning numbers of cases were evaluated. Numbers and regional distribution of ENT-specialists providing second opinion were analyzed by websites of Associations of SHI Physicians.

RESULTS

Between 2005 and 2018a significant decrease in tonsillectomy cases from 119 808 to 42 548 is observable that is by far not compensated by increasing tonsillotomy numbers from 4659 (2007) to 18 369. At the same time, surgical procedure rates at regional levels remain volatile. 218 ENT-specialists in 142 towns provide second opinion. On basic of case numbers in 2018a relationship of 1(ENT-specialist): 280 (tonsillectomy/tonsillotomy patients) results (range from 1:90 to 1:800).

CONCLUSIONS

On the background of decreasing surgical rates tonsil surgery does not comply with the requirements of second opinion procedure. Reachability of second opinion providers is difficult in many regions, such compromising a compensation of different levels of surgery. As a result of our investigation we recommend scientific supervision of currently second opinion procedures and a survey of actual demand from the patient's viewpoint.

Changes in healthcare utilisation for paediatric tonsillectomy and adenoidectomy in the Netherlands: a population-based study

Objectives

Tonsillectomy and adenoidectomy in children are controversial subjects with large regional variation in surgical rates, partly explained by cultural differences and lack of high‐quality evidence on indications for surgery. A quality of care cycle was executed on this topic in the Netherlands. The objective of this study was to estimate changes in healthcare utilisation for paediatric tonsil surgery in the Netherlands.

Methods

Population‐based data on tonsillectomies and adenoidectomies in children up to age 10 were retrieved retrospectively from Dutch administrative databases between 2005 and 2018. A change point analysis was performed to detect the most pivotal change point in surgical rates. We performed univariate analyses to compare surgical patients’ characteristics before and after the pivotalpoint . Impact on healthcare budget and societal costs were estimated using current prices and data from cost‐effectiveness analyses.

Results

The annual number of adenotonsillectomies reduced by 10 952 procedures (−39%; from 129 per 10 000 children to 87 per 10 000 children) between 2005 and 2018, and the number of adenoidectomies by 14 757 procedures (−49%; from 138 per 10 000 children to 78 per 10 000 children). The most pivotal change point was observed around 2012, accompanied by small changes in patient selection for surgery before and after 2012. An estimated €5.3 million per year was saved on the healthcare budget and €10.4 million per year on societal costs.

Conclusion

The quality of care cycle resulted in fewer operations, with a concomitant reduction of costs. We suggest that part of these savings be invested in new research to maintain the quality of care cycle.

[Sore throat as indication for tonsillectomy before and after implementation of the German guideline for tonsillitis : Longitudinal study covering 115.839 procedures]

BACKGROUND

Tonsillectomy is a reasonable indication in the management of sore throat not responding to antibiotic treatment. This longitudinal patient-level study was conducted to estimate the impact of the German guideline for the management of tonsillitis which was published in 2015.

METHODS

Data of inpatient and outpatient healthcare were retrieved from a database provided by one of the largest German health insurance companies (i.e., Allgemeine Ortskrankenkassen). Procedures for the management of chronic tonsillitis (code: J35.0) between 2012 and 2018 were identified by operation codes (5-281.0; 5‑282.0). Primary care data concerning sore throat were identified by ICD-10 codes (J02; J03; J35.0) including antibiotic prescribing by associated data of the anatomic-therapeutic-chemical classification.

RESULTS

A total of 109,895 cases were eligible for analysis. The annual number of procedures had decreased by 50.3% within the study period. The continuous decrease was emphasized after 2015. The strongest decrease was registered in children (<10 years; -65.7%). Every second patients had received conservative treatment at the most in only one preoperative quarter.

CONCLUSIONS

The impact of the German guideline on the management of sore throat on the annual number of tonsillectomies and common medical practice was limited. Antibiotic treatment appears not to play a major role when tonsillectomy is indicated.

Comparison of two specific quality of life questionnaires in a paediatric population with adenotonsillar disease

INTRODUCTION AND OBJECTIVE

T-14 and TAHSI are validated and reliable specific questionnaires which measure the quality of life in paediatric patients with adenotonsillar disease. The present study aims to compare the adapted and validated versions in Spanish of these two questionnaires (T-14-s and s-TAHSI) in order to assess the preferential use of either of them in our environment.

MATERIAL AND METHODS

A multicentre prospective cross-sectional study was carried out between November 2015 and April 2016, to determine the possible correlation between these two instruments. Subjects aged from 2 to 16 years with indication for adenotonsillar surgery and healthy controls, were consecutively included. Parents or caregivers of these children completed T-14-s and s-TAHSI questionnaires initially, after 2-6 weeks and at 6 months after surgery. T-14-s and s-TAHSI scores of the entire sample were compared globally, patient and control subgroups were compared separately and finally, compared in the group of patients at 6 months from surgery, using Pearson correlation coefficient. The proportion of variability shared between both tests was calculated.

RESULTS

A hundred subjects (50 cases and 50 controls) were studied. The overall correlation presented by both questionnaires was very high (0.97) with a significance level of p < .01. The proportion of shared variability was 94%, very high. The results were maintained when comparing the questionnaires in the subpopulations of cases and controls, as well as the postoperative questionnaires.

CONCLUSION

Quality of life questionnaires for paediatric patients with adenotonsillar pathology, T-14-s and s-TAHSI, showed high correlation and allows the equivalent use of both in our environment.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Trends in tonsillectomy surgery in children in Scotland 2000-2018

BACKGROUND

Tonsillectomy is one of the most common surgical procedures in children but indications and surgical practice change over time.

OBJECTIVES

We aimed to identify trends in tonsillectomy procedures in children, in particular the number of procedures performed, the age of child undergoing tonsillectomy and the type of hospital in which the surgery was performed.

DESIGN

Review of Scottish Morbidity Records data (SMR01) which are routinely collected after everyday case procedure or overnight stay in all Scottish NHS hospitals.

SETTING

All NHS hospitals in all 14 Scottish health boards.

PARTICIPANTS

All children (0-16 years) undergoing tonsillectomy, 2000-2018.

MAIN OUTCOME MEASURES

Number of tonsillectomy procedures; rate of tonsillectomy per 1000 children in the population; number of children aged 0-2 years and 3-4 years undergoing tonsillectomy; health board in which the surgery occurred; diagnostic coding for these episodes; length of stay and readmission within 30 days of surgery.

RESULTS

During 2000-2018, there were 50,208 tonsillectomies performed in children in Scotland (mean 2642/year). The number of tonsillectomies per year remained constant (R = 0.322, P = .178) but tonsillectomies performed in children 0-2 years rose from 0.41 to 1.56 per 1000 (R = 0.912, P < .001), and 3-4 years from 3.06 to 6.93 per 1000 (R = 0.864, P < .001). The proportion of all children's tonsillectomies performed up to age 4 rose from 20.6% to 35.9% and up to age 2 from 2.4% to 8.1%. All specialist children's hospitals showed a significant increase in surgery in very young children.

CONCLUSIONS

Tonsillectomy rates remained static between 2000 and 2018, despite a falling population. More tonsillectomies are now performed for obstructive sleep apnoea, at a young age and in regional children's hospitals. This has important implications for the workload of these specialist hospitals.

Practice, complications and outcome in Swedish tonsil surgery 2009-2018. An observational longitudinal national cohort study

Background: To assure a high quality in tonsil surgery, it is necessary to monitor trends in clinical practice, complications and outcome.Aims/objectives: To describe rates and trends regarding indications, methods, techniques, complications, and outcome of tonsil surgery.Material and method: 98 979 surgeries from the National Tonsil Surgery Register 2009-2018. Groups were categorised by indication and method.Results: The proportion of patients undergoing tonsillotomy with adenoidectomy due to obstruction-snoring (mean age 5.3 y.) increased from 2009-2018. Hot tonsillectomy, but not tonsillotomy, techniques were related to a higher risk for postoperative bleeding. The use of cold techniques increased for all types of surgeries. The rates of patients reporting contact due to postoperative pain were associated with indication and method, with the lowest rate reported for tonsillotomy (4.5% in 2018) and the highest for tonsillectomy (34.5% in 2009). The rate of patients reporting that their symptoms were gone 6 months after surgery decreased.Conclusions and significance: All hot tonsillectomy techniques should be avoided as they are related to a higher risk for postoperative bleeding. The high rate of postoperative contacts due to pain after tonsillectomy indicates a need for improvement in pain management. The declining rates of symptom relief must be investigated further.

Is the number of tonsillectomies and tonsillotomies a relevant issue?

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Tonsil surgery in the federal states of Germany: similarities and differences

BACKGROUND

Tonsillectomy remains a common procedure in Germany. However, demographic changes, the advent of tonsillotomy, and current guidelines may have an impact on the overall incidence.

OBJECTIVE

To longitudinally evaluate the number of tonsillectomies, with (ATE) or without adenoidectomy (TE), and tonsillotomies (TT) performed annually in Germany.

MATERIALS AND METHODS

Based on comprehensive data from the Federal Office for Statistics, the number of patients undergoing the above-stated surgical procedures on an inpatient basis was retrospectively assessed in terms of year and federal state, without restriction by age or gender. Annual rates of ATE, TE, and TT were calculated based on population statistics. Regression analysis was performed to compare different federal states, years, and age groups. The variables were compared using the Pearson correlation coefficient.

RESULTS

Between 2005 and 2017, 1,313,449 tonsil surgeries were registered. There was a considerable decrease in the overall incidence rate (per 100,000) of TE (92 to 43), which was even more pronounced for ATE (51 to 15). In contrast, an increased TT rate (6 to 22) was observed. Correlation analysis revealed a strong positive correlation (r = 0.986).

CONCLUSION

The change of trends in tonsil surgery started long before relevant national guidelines were published. The national trend was associated with considerably less surgical activity overall, a significant decrease in ATE/TE, and a significant increase in TT. Regional differences to the national trend were identified and found to be significant in at least in 7 of 16 federal states.

[Tonsil surgery in the federal states of Germany: similarities and differences. German version]

BACKGROUND

Tonsillectomy remains a common procedure in Germany. However, demographic changes, the advent of tonsillotomy, and current guidelines may have an impact on the overall incidence.

OBJECTIVE

To longitudinally evaluate the number of tonsillectomies, with (ATE) or without adenoidectomy (TE), and tonsillotomies (TT) performed annually in Germany.

MATERIALS AND METHODS

Based on comprehensive data from the Federal Office for Statistics, the number of patients undergoing the above-stated surgical procedures on an inpatient basis was retrospectively assessed in terms of year and federal state, without restriction by age or gender. Annual rates of ATE, TE, and TT were calculated based on population statistics. Regression analysis was performed to compare different federal states, years, and age groups. The variables were compared using the Pearson correlation coefficient.

RESULTS

Between 2005 and 2017, 1,313,449 tonsil surgeries were registered. There was a considerable decrease in the overall incidence rate (per 100,000) of TE (92 to 43), which was even more pronounced for ATE (51 to 15). In contrast, an increased TT rate (6 to 22) was observed. Correlation analysis revealed a strong positive correlation (r = 0.986).

CONCLUSION

The change of trends in tonsil surgery started long before relevant national guidelines were published. The national trend was associated with considerably less surgical activity overall, a significant decrease in ATE/TE, and a significant increase in TT. Regional differences to the national trend were identified and found to be significant in at least in 7 of 16 federal states.

Impact of adenotonsillectomy on the evolution of inflammatory markers

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

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

Purpose

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

Methods

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

Results

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

Conclusions

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

Trial registration

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

Changing trends in pediatric tonsil surgery

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSION

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

Clinical characteristics of obstructive sleep apnea versus infectious adenotonsillar hyperplasia in children

INTRODUCTION

Children who undergo adenotonsillectomy have a range of symptoms. Some present with infective symptoms, others with obstructive symptoms, and many with a combination of both. The most common surgical indication has changed over the past several decades from infective symptoms to obstructive symptoms. However, there are few data available to differentiate these groups of children in terms of their clinical characteristics. This study aimed to determine the clinical characteristics of children with obstructive sleep apnea versus infectious adenotonsillar hyperplasia.

METHODS

Data were obtained from the medical records of two district health boards in Auckland, New Zealand. Extraction of clinical information was performed following the identification of all patients under the age of 16 years undergoing adenotonsillectomy between December 2015 and December 2017.

RESULTS

A total of 1538 children were included in this study. There were 112 (7.3%) with recurrent tonsillitis (RT) symptoms only, 624 (40.6%) with RT and sleep-disordered breathing symptoms (SDB), and 802 (52.1%) with symptoms suggestive of obstructive sleep apnea (OSA). Children with OSA were more likely to be male (p < 0.001), younger (p < 0.001), and have lower body mass indexes at time of surgery (p < 0.001). There was no difference between groups in the number of antibiotic courses prescribed in the year before surgery (p = 0.7). There was no significant difference in tonsil or adenoid grade between groups (p = 0.2). Children with OSA were more likely to have a diagnosis of asthma (p < 0.001) and allergic rhinitis (p < 0.001), but less likely than those with RT to have a diagnosis of eczema (p < 0.001). Children with OSA were more likely to have otitis media with effusion requiring ventilation tube insertion (p < 0.001) and a documented history of speech delay (p < 0.001). Thirty-day readmission rates were higher in the OSA (8.5%) and SDB/RT (9.3%) groups when compared to those with RT (1.8%) (p = 0.03).

CONCLUSION

Children with OSA have different perioperative characteristics than those with recurrent tonsillitis, including increased risk of postoperative bleeding and need for post op readmission. Therefore, management strategy may vary according to the indications for tonsillectomy and adenoidectomy.

Patterns of adenoid and tonsil growth in Japanese children and adolescents: A longitudinal study

Lymphoid tissues, such as adenoids (Ad) and tonsils (Tn), are suggested to undergo hypertrophy during childhood and involution in adulthood. Enlargement of Ad and Tn can cause transient obstruction of the respiratory airways, thus inducing obstructive sleep apnoea. To date, the standard Ad and Tn sizes have not been reported, and there are no explicit objective criteria for evaluating their sizes or deducing whether they have enlarged, reduced, or remained constant over time. Our previous cross-sectional study revealed the age-dependent airway occupation ratio of Ad and Tn in Japanese individuals. We conducted a longitudinal observational study of the Ad and Tn sizes in Japanese individuals aged 6–20 years. Ninety individuals were retrospectively enrolled. The average and standard deviation of the sizes was calculated in 5 age-based groups.

Postoperative hemorrhage following tonsillectomy in adults: Analysis of population-based inpatient cohort in Taiwan

OBJECTIVE

Because of the lack of population-based analyses, this study elucidated the epidemiology and 30-day postoperative complications of inpatient adult tonsillectomies in Taiwan.

METHODS

Using the Taiwan National Health Insurance Research Database, we identified all inpatient adult tonsillectomies (age>20years) in Taiwan during 1997-2012 through International Codes of Diseases, 9th Revision. Trend of the inpatient tonsillectomy in adult during the study period was explored. Major complications of readmission, reoperation, and mortality within 30days after tonsillectomies were identified. Factors associated with major complications were analyzed using multivariate logistic model.

RESULTS

In total, 27,365 adults received inpatient tonsillectomies (mean age, 38.4±13.0years; 57.2% male). The overall incidence was 10.2 per 100,000 population per year among adults. Incidence rates increased from 1997 (8.2/100,000 adults) to 2012 (11.2/100,000 adults) (P trend<0.001). The rate of readmission for any reason, readmission for bleeding, reoperation for bleeding, and mortality were 4.9%, 2.2%, 1%, and 0.1%, respectively. Young age increased the risk of bleeding-related readmission and reoperation, whereas old age increased the risk of readmission for any reason and mortality. Male gender increased the risk of all major complications. Hypertension was associated with an increased risk of bleeding-related readmission (odds ratio [OR]=2.21; 95% confidence interval [CI] 1.68-2.92) and reoperation (OR=2.17; 95% CI 1.44-3.27). Existing catastrophic illness increased the risk of readmission (OR=4.28; 95% CI 3.60-5.08) for any reason and mortality (OR=3.24; 95% CI 1.37-7.65). Nonsteroidal anti-inflammatory drugs and steroids were associated with an increased risk of readmission or reoperation for bleeding.

CONCLUSION

Incidence rates of inpatient adult tonsillectomy increased during 1997-2012 in Taiwan. Age, gender, comorbidity, and drug administration characteristics were associated with major complications of adult tonsillectomies in this cohort.

The bacterial community and local lymphocyte response are markedly different in patients with recurrent tonsillitis compared to obstructive sleep apnoea

INTRODUCTION

Obstructive sleep apnea (OSA) is now a more common indication for tonsillectomy than recurrent tonsillitis (RT) [1,2]. Few studies have addressed possible differences in pathogenesis between these two conditions. Children with RT and OSA are often being treated in the community with multiple courses of antibiotics before surgery. Current understanding of the role of bacteria in disorders of the tonsils is mainly based on the culture of tonsil swabs. Swab cultures reflect only a very small fraction of the bacteria present on the mucosal surface and may not represent the bacterial communities within the tonsil crypts [3,4]. This study aimed to evaluate the local lymphocyte response and associations with bacterial community composition using molecular techniques of the tonsils removed from children for RT or OSA.

METHOD

The palatine tonsils were removed by extracapsular dissection from 24 patients with age range one to ten years, 14 of whom had RT and 10 had OSA. The fixed tonsil tissues were evaluated for bacteria by Gram-staining and presence of connective tissue by safranin staining. B lymphocytes and T lymphocytes were also measured immunohistochemically. Finally, previously published bacterial community data for this cohort were reassessed for associations with RT and OSA, and with the observed lymphocyte patterns.

RESULTS

In tonsils from patients with RT, large micro-colonies of bacteria were observed in the tonsil crypts, and a large number of B and T lymphocytes were noted immediately adjacent to the tonsil crypt itself. In marked contrast, the tonsils from patients with OSA had no bacteria identified, and no significant skewing of lymphocytes based on site (such as follicles or crypts). We observed that the majority of lymphocytes surrounding the bacterial micro-colonies were B lymphocytes with a mean ratio of 109:55 (B lymphocytes: T lymphocytes). Bacterial community diversity was not different between the two cohorts; however, there were significant differences in bacterial community composition. Children with RT had a higher relative abundance of members from the genera Parvimonas, Prevotella, and Treponema. While children with OSA had a higher relative abundance of Haemophilus, and Capnocytophaga.

CONCLUSION

These results demonstrate significant differences in the local lymphocyte response and bacterial community composition in tonsil tissue between RT and OSA patients. It suggests that the response to antibiotics used in the treatment of these two conditions may be different. Furthermore, the presence of lymphocytes in RT within the tonsil crypt outside the tonsil epithelium is a unique observation of the location of these cells.

Population-based survey of inpatient pediatric tonsillectomy and postoperative hemorrhage in Taiwan, 1997-2012

OBJECTIVE

Tonsil surgery in children is a common surgical procedure, and is mostly performed as an inpatient procedure in Taiwan. This study elucidates the epidemiology and postoperative hemorrhage of inpatient tonsillectomies in Taiwanese children.

METHODS

This study used the Taiwan National Health Insurance Research Database for analysis. From 1997 to 2012, all in-hospital children (aged <18 years) who underwent tonsillectomies were identified through the International Codes of Diseases (9th Revision). Incidence rates and trends of inpatient pediatric tonsillectomies during the study period were identified. Major complications, including readmission, reoperation, and mortality were identified. The factors associated with major complications were analyzed.

RESULTS

From 1997 to 2012, 17326 children received inpatient tonsillectomies (mean age, 8.6 ± 3.8 y; 65% boys). The overall incidence rate was 20.6 per 100,000 children. The incidence rate was highest in children who were 6-8 years of age, and boys exhibited a higher rate than girls (P < 0.001). Longitudinal data indicated that the incidence rate increased from 1997 (15.7/100,000 children) to 2012 (19.2/100,000 children) (P trend < 0.001). The proportions of readmission for any reason, readmission for bleeding, and reoperation were 1.8%, 0.9%, and 0.3%, respectively. No mortality occurred within 30 days of the tonsillectomy. A multivariable logistic model indicated that toddlers were associated with an increased risk of readmission for any reason (OR, 2.70; 95% CI 1.60-4.56), and adolescents were at risk of bleeding-related readmission (OR, 2.81; 95% CI 1.91-4.14) and reoperation (OR, 2.86; 95% CI 1.47-5.55). Children with comorbidities (OR, 3.14; 95% CI 1.93-5.09) or a surgical indication of tumor (OR, 11.73; 95% CI 4.93-27.91) had a higher risk of readmission. The use of nonsteroidal anti-inflammatory drugs or steroids is associated with an increased risk of readmission or reoperation. Moreover, concurrent procedures (i.e., adenoidectomy, ear surgery, or nasal surgery) did not increase the risk of readmission or reoperation.

CONCLUSIONS

The incidence rate and indications of obstructive sleep disorders for inpatient pediatric tonsillectomy increased during 1997-2012 in Taiwan. Postoperative readmission and reoperation were rare. Age, surgical indication, comorbidities, and drug administration were associated with readmission or reoperation in this study cohort.

Reducing post-tonsillectomy haemorrhage rates through a quality improvement project using a Swedish National quality register: a case study

Purpose

Tonsillectomy (TE) is one of the most frequently performed ENT surgical procedures. Post-tonsillectomy haemorrhage (PTH) is a potentially life-threatening complication of TE. The National Tonsil Surgery Register in Sweden (NTSRS) has revealed wide variations in PTH rates among Swedish ENT centres. In 2013, the steering committee of the NTSRS, therefore, initiated a quality improvement project (QIP) to decrease the PTH incidence. The aim of the present study was to describe and evaluate the multicentre QIP initiated to decrease PTH rates.

Methods

Six ENT centres, all with PTH rates above the Swedish average, participated in the 7-month quality improvement project. Each centre developed improvement plans describing the intended changes in clinical practice. The project’s primary outcome variable was the PTH rate. Process indicators, such as surgical technique, were also documented. Data from the QIP centres were compared with a control group of 15 surgical centres in Sweden with similarly high PTH rates. Data from both groups for the 12 months prior to the start of the QIP were compared with data for the 12 months after the QIP.

Results

The QIP centres reduced the PTH rate from 12.7 to 7.1% from pre-QIP to follow-up; in the control group, the PTH rate remained unchanged. The QIP centres also exhibited positive changes in related key process indicators, i.e., increasing the use of cold techniques for dissection and haemostasis.

Conclusions

The rates of PTH can be reduced with a QIP. A national quality register can be used not only to identify areas for improvement but also to evaluate the impact of subsequent improvement efforts and thereby guide professional development and enhance patient outcomes.

[The application of different non-steroidal anti-inflammatory drugs for the elimination of pain syndrome during the early postoperative period in the children following the surgical interventions on palatine tonsils]

The present clinical study included 120 children at the age varying from 6 to 18 tears who had undergone radiowave tonsillotomy followed by symptomatic therapy during the early postoperative period with the application of different non-steroidal anti-inflammatory drugs. All the patients were randomly allocated to four groups each comprised of the equal number of patients. Those of group 1 were treated with ketoprofen lysine salt (КLS) in the form of a solution for oral intake in case of complaints of severe pain in the throat. The patients of group 2 received courses of ketoprofen lysine salt therapy per os thrice daily during 3 days after the surgical intervention. The patients of group 3 were given ibuprofen per os up to three times every day in case of complaints of severe pain in the throat. The patients of group 4 were treated with ketoprofen lysine salt in the form of a solution for the local application twice daily during 3 days after the surgical intervention. The results of the analysis with the use of the analog-visual scale have demonstrated that a decrease in pain intensity within 24 hours after surgery was much more pronounced in the patients of group 2 in comparison with those of the remaining three groups (р<0.05). The difference of pain intensity in the throat evaluated based on the analog-visual scale between the patients of groups 1, 3, and 4 was insignificant (p>0.05). None of the children exhibited the signs of bleeding throughout the entire observation period. It can be concluded that a course of therapy with the use of ketoprofen lysine salt for oral intake during the early period after the surgical intervention for radiowave palatine tonsillotomy has some advantages over a single intake of the analogous preparation (for alleviation of strong pain in the throat), an ibuprofen syrup or a ketoprofen lysine salt solution for throat wash.

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

AIM

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

METHOD

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

RESULTS

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

CONCLUSIONS

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

Adherence to Swedish guidelines for pain treatment in relation to pediatric tonsil surgery: A survey of the multidisciplinary team

BACKGROUND

Pain management in children after tonsil surgery is essential, and optimal pain treatment has been discussed for many years. Data from the National Tonsil Register in Sweden (NTRS) and a national mapping have demonstrated the need for national pain treatment guidelines for pediatric tonsil surgery. As a result, Swedish national guidelines, together with updated patient information on the website tonsilloperation.se, were developed and implemented in 2013.

OBJECTIVES

The objective of this study was to evaluate the professionals' opinions of and adherence to pain treatment guidelines for pediatric tonsil surgery patients in a two-year follow-up.

METHOD

This descriptive cross-sectional study was based on data from an inter-professional questionnaire, which was validated by an expert group using a content validity index (S-CVI 0.93). The questionnaire was sent to all Swedish ear, nose and throat (ENT) departments (n = 49) that the NTRS identified as performing tonsil surgery on children younger than 18 years of age. In each clinic, we asked for responses from staff in each of the following professions: ENT physicians, anesthesia physicians, registered nurse anesthetists, and registered nurses in the ENT departments.

RESULTS

Respondents from 48 ENT departments participated, and 139/163 (85%) completed questionnaires were returned. The guidelines were reported as being clear, ensuring patient safety and providing optimal pharmacological treatment. Treatment was given according to the guidelines: Half of the departments gave pre- or intraoperative treatment with clonidine, betamethasone and high-dose paracetamol (acetaminophen). A multimodal pain approach (paracetamol and COX-inhibitors) after hospital discharge was prescribed by all departments after tonsillectomy and, extensively, after tonsillotomy. One-third of the departments prescribed paracetamol with a higher normal dose for the first three postoperative days. Half of the departments prescribed rescue analgesics, clonidine or opioids after tonsillectomy. None of the departments prescribed codeine or tramadol, drugs that are discouraged in the guidelines. The majority of the departments used the website tonsilloperation.se to provide information to the patients and their caregivers.

CONCLUSION

The respondents' opinions of and the ENT departments adherence to the Swedish national guidelines were considered to be good. The national implementation process in Sweden has impacted the manner in which ENT departments treat pain after tonsil surgery.

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

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

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

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

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

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