Tonsillectomy increases the risk of retropharyngeal and parapharyngeal abscesses in adults, but not in children: A national cohort study

Effects of tonsillectomy and adenoidectomy on the immune system

Surgical removal of the tonsils and adenoids, important immune organs, is a frequent and recurrent class of surgery, and currently, there is no consensus on the effects these surgical procedures may have on the immune system. Here, we examine individual studies on tonsillectomy, adenoidectomy, and adenotonsillectomy, discuss their postoperative humoral and cellular immune changes, and explore their effects on the incidence of related diseases. There is evidence that these three surgeries have no negative effects on humoral immunity; however, there has been contrary results. Furthermore, these procedures seem to have no significant effects on cellular immunity, although tonsil and adenoid removal can cause an increased incidence of certain illnesses, especially infectious diseases. Based on this comprehensive review, we conclude that the removal of tonsils and adenoids does not negatively affect cellular and humoral immunity. However, surgery may lead to an increased incidence of related infectious diseases. This finding may inform the surgeon's decision to perform the procedure in a clinical setting.

Incidence of Late-Onset Psoriasis Following Tonsillectomy: A Longitudinal Follow-Up Study Using a National Health Screening Cohort

Tonsillectomy has been suggested as a potential intervention to resolve psoriasis; however, its preventive effects on the development of psoriasis remain unclear. This study aimed to investigate the risk of developing late-onset psoriasis among a Korean adult population who had undergone tonsillectomy. Data from the Korean National Health Insurance Service-Health Screening Cohort between 2002 and 2019 were utilized. Out of a total of 514,866 participants, 1082 participants aged 40 years or older who had undergone tonsillectomy were matched with 4328 control participants using overlap weighting adjustment based on the propensity score. The incidence and hazard ratio (HR) of psoriasis were calculated for both tonsillectomy and control groups. The incidence rates of psoriasis were 1.30% in the tonsillectomy group and 1.20% in the control group. The incidence of psoriasis (overlap-weighted HR = 1.08, 95% confidence of interval = 0.69-1.69, and p = 0.732) did not differ significantly between the patients who underwent tonsillectomy and those in the control group. The cumulative probability of developing psoriasis was not different between the two groups (Log-rank test: p = 0.440). These findings were consistent across subgroups divided by age, sex, income, and region of residence. We found that tonsillectomy did not confer a preventive effect on the development of late-onset psoriasis in the Korean adult population.

Associations between Peritonsillar Abscess and Deep Neck Infection in Chronic Periodontitis Patients: Two Nested Case-Control Studies Using a National Health Screening Cohort

Background/Introduction: Odontogenic infection is one of the main etiologies of deep neck infection (DNI). However, the relationship between chronic periodontitis (CP) and the incidence of DNI has not been examined. This study aimed to evaluate the incidence of DNI and peritonsillar abscess (PTA) after CP. Methods: The Korean National Health Insurance Service-National Sample Cohort 2002-2019 was used. In Study I, 4585 PTA patients were matched with 19,340 control I participants. A previous history of CP for 1 year was collected, and the odds ratios (ORs) of CP for PTA were analyzed using conditional logistic regression. In Study II, 46,293 DNI patients and 185,172 control II participants were matched. A previous history of CP for 1 year was collected, and conditional logistic regression was conducted for the ORs of CP for DNI. Secondary analyses were conducted in demographic, socioeconomic, and comorbidity subgroups. Results: In Study I, a history of CP was not related to the incidence of PTA (adjusted OR = 1.28, 95% confidence interval [CI] = 0.91-1.81). In Study II, the incidence of DNI was greater in participants with a history of CP (adjusted OR = 1.55, 95% CI = 1.41-1.71). The relationship between CP history and DNI was greater in groups with young, male, low-income, and rural residents. Conclusions: A prior history of CP was associated with a high incidence of DNI in the general population of Korea. Patients with CP need to be managed for the potential risk of DNI.

Association between Tonsillectomy and Cardiovascular Diseases in Adults

This study aimed to evaluate the association between tonsillectomy and cardiovascular diseases (CVDs) in the Korean adult population. Using data from the 2002-2015 Korean National Health Insurance Service-Health Screening Cohort, a total of 1082 participants aged 40 years or older who had undergone tonsillectomy were matched with 4328 control individuals for age, sex, income, and region of residence. We evaluated the incidence of CVDs in both the tonsillectomy and control groups and calculated the hazard ratios (HRs) of stroke, ischemic heart disease (IHD), and heart failure (HF) for participants who underwent tonsillectomy using a stratified Cox proportional hazard model. The incidence rates of stroke (81.3 vs. 46.6 per 10,000 person-years) and IHD (112.3 vs. 64.9 per 10,000 person-years) were significantly higher in patients who had undergone tonsillectomy than in the control group. After adjustment, the tonsillectomy group exhibited a 1.78-fold and 1.60-fold higher occurrence of stroke (CI = 1.32-2.42, p < 0.001) and IHD (CI = 1.24-2.08, p < 0.001), respectively, compared to the control group. However, there was no significant difference in the incidence rate of tonsillectomy and control groups (11.1 vs. 6.1 per 10,000 person-years). The HR of HF did not differ significantly between the tonsillectomy and control groups in the adjusted model (p = 0.513). We identified a significant relationship between a history of tonsillectomy and occurrence of stroke/IHD in the Korean adult population.

The assessment and management of deep neck space infections in adults: A systematic review and qualitative evidence synthesis

OBJECTIVES

To summarise current practices in the diagnosis and management of deep neck space infections (DNSIs). To inform future studies in developing a framework in the management of DNSIs.

DESIGN

This review was registered on PROSPERO (CRD42021226449) and reported in line with PRISMA guidelines. All studies from 2000 that reported the investigation or management of DNSI were included. The search was limited to English language only. Databases searched included AMED, Embase, Medline and HMIC. Quantitative analysis was undertaken with descriptive statistics and frequency synthesis with two independent reviewers. A qualitative narrative synthesis was conducted using a thematic analysis approach.

SETTING

Secondary or tertiary care centres that undertook management of DNSIs.

PARTICIPANTS

All adult patients with a DNSI.

MAIN OUTCOME MEASURES

The role of imaging, radiologically guided aspiration and surgical drainage in DNSIs.

RESULTS

Sixty studies were reviewed. Thirty-one studies reported on imaging modality, 51 studies reported treatment modality. Aside from a single randomised controlled trial, all other studies were observational (n = 25) or case series (n = 36). Computer tomography (CT) was used to diagnose DNSI in 78% of patients. The mean percentage of management with open surgical drainage was 81% and 29.4% for radiologically guided aspiration, respectively. Qualitative analysis identified seven major themes on DNSI.

CONCLUSIONS

There are limited methodologically rigorous studies investigating DNSIs. CT imaging was the most used imaging modality. Surgical drainage was commonest treatment choice. Areas of further research on epidemiology, reporting guidelines and management are required.

Role of steroids in conservative treatment of parapharyngeal and retropharyngeal abscess in children

Purpose

To characterize the clinical features and outcomes of pediatric patients with retropharyngeal (RPA) or parapharyngeal abscesses (PPA) managed only with medical treatment and showing the importance of early symptoms and imaging studies in the diagnosis of deep neck space infections (DNIs) in children.

Methods

A retrospective analysis of all patients diagnosed with RPA and PPA between 2007 and 2017 was performed in Hospital Universitario Central de Asturias.

Results

30 children were identified, with 11 RPA and 19 PPA. 23 children (76.7%) were under 5 years old, and all were treated with intravenous amoxicillin/clavulanic acid and corticosteroids. Torticollis and fever were present in all patients. The mean length of hospital stay was 7.5 days. There were no complications associated.

Conclusion

DNIs can be treated in a conservative way, reserving the surgical drainage for cases with a complication associated (airway compromise, lack of response to antibiotic therapy, immunocompromised patients). Treatment with intravenous antibiotics and corticosteroids is a safe option, reducing the duration of symptoms and the length of hospital stay.

Isolated oropharyngeal abscess with hypopharyngeal extension recurring 12 years after initial surgical management: A case report and review of the literature

Pharyngeal abscesses require urgent management as they have the propensity to cause severe and life-threatening complications. The introduction of antibiotics has led to a dramatic decline in the incidence of these infections. Regardless, abscess formation continues to be observed in the peritonsillar, parapharyngeal, and retropharyngeal spaces. Oropharyngeal and hypopharyngeal abscesses that cause airway obstruction are scarcely reported and tend to be secondary to other processes. Herein, we describe the case of an 83-year-old man presenting with an idiopathic, obstructive, oropharyngeal wall abscess, extending from the infratonsillar region to the hypopharynx, which recurred after initial surgical management 12 years prior for the same process. He required reintervention during both episodes for rapid reaccumulation. A detailed electronic literature search of PubMed and MedLine was performed for studies reporting on recurrent pharyngeal abscesses and their management. Results were limited to articles published in English from inception to August 2021. The timely management of pharyngeal infections acutely obstructing the airway is crucial. Physicians should adopt close and frequent monitoring and have a low threshold for reimaging should symptoms worsen or fail to improve after the initial surgical intervention.

Tonsillectomy in Adults over 40 Years of Age Does Not Increase the Risk of Pneumonia: A Three-Year Longitudinal Follow-Up Study

To evaluate the effect of tonsillectomy on the subsequent risk of pneumonia in an adult population, a longitudinal follow-up case control study was conducted using a national health screening cohort dataset between 2003 and 2012. A total of 1005 tonsillectomy participants were 1:4 matched with 4020 control participants for age, sex, income, and region of residence. The number of pneumonia diagnoses were counted from the index date (ID) to the date after the first-year (post-ID 1y), second-year (post-ID 2y), and third-year (post-ID 3y) periods. Simple linear regression and multiple linear regression were conducted to calculate estimated values (EVs) and 95% confidence intervals for each post-ID pneumonia and compared between the two groups. Subgroup analyses were performed according to age, sex, and the number of pneumonia cases during the year prior to the ID (pre-ID 1y). In the simple linear regression model, post-ID pneumonia did not show a significant correlation with tonsillectomy (post-ID 1y: EV = 0.003; post-ID 2y: EV = 0.007; post-ID 3y: EV = 0.013; all p > 0.05). In the multiple regression model, post-ID pneumonia also did not show a significant correlation with tonsillectomy (post-ID 1y: EV = 0.001; post-ID 2y: EV = 0.006; post-ID 3y: EV = 0.011; all p > 0.05). In the subgroup analyses, tonsillectomy did not show a significant correlation with post-ID pneumonia in either the simple linear regression or multiple linear regression models (all p > 0.05). Tonsillectomy performed in the adult population did not show any effect in increasing the incidence of pneumonia during the first three postoperative years.

Tonsillitis, tonsillectomy, and deep neck space infections in England: the case for a new guideline for surgical and non-surgical management

INTRODUCTION

Tonsillectomy is a common surgical procedure performed chiefly for recurrent tonsillitis. The Scottish Intercollegiate Guidance Network (SIGN) introduced guidelines in 1998 to improve patient selection for tonsillectomy and reduce the potential harm to patients from surgical complications such as haemorrhage. Since the introduction of the guidance, the number of admissions for tonsillitis and its complications has increased. National Hospital Episode Statistics over a 20-year period were analysed to assess the trends in tonsillectomy, post-tonsillectomy haemorrhage, tonsillitis and its complications with reference to the guidance, procedures of limited clinical value and the associated costs and benefits.

MATERIALS AND METHODS

A literature search was conducted via PubMed and the Cochrane Library to identify relevant research. Hospital Episode Statistics data were interrogated and relevant data compared over time to assess trends related to the implementation of national guidance.

RESULTS

Over the period analysed, the incidence of deep neck space infections has increased almost five-fold, mediastinitis ten-fold and peritonsillar abscess by 1.7-fold compared with prior to SIGN guidance. Following procedures of limited clinical value implementation, the incidence of deep neck space infections has increased 2.4-fold, mediastinitis 4.1-fold and peritonsillar abscess 1.4-fold compared with immediately prior to clinical commissioning group rationing. The rate of tonsillectomy and associated haemorrhage (1-2%) has remained relatively constant at 46,299 (1999) compared with 49,447 (2009) and 49,141 (2016), despite an increase in the population of England by seven million over the 20-year period.

DISCUSSION

The rise in admissions for tonsillitis and its complications appears to correspond closely to the date of SIGN guidance and clinical commissioning group rationing of tonsillectomy and is on the background of a rise in the population of the UK. The move towards daycase tonsillectomy has reduced bed occupancy after surgery but this has been counteracted by an increase in admissions for tonsillitis and deep neck space infections, sometimes requiring lengthy intensive care stays and a protracted course of rehabilitation. The total cost of treating the complications of tonsillitis in England in 2017 is estimated to be around £73 million. The cost of tonsillectomy and treating post-tonsillectomy haemorrhage is £56 million by comparison. The total cost per annum for tonsillectomy prior to the introduction of SIGN guidance was estimated at £71 million with tonsillitis and its complications accounting for a further £8 million.

A Nationwide Population-Based Study on the Incidence of Parapharyngeal and Retropharyngeal Abscess-A 10-Year Study

This study aimed to investigate the annual incidence of parapharyngeal and retropharyngeal abscess (PRPA) based on 10-year population-based data. Patients with PRPA were identified from the Taiwan Health Insurance Research Database, a database of all medical claims of a randomly selected, population-representative sample of over two million enrollees of the National Health Insurance system that covers over 99% of Taiwan’s citizens. During 2007–2016, 5779 patients received a diagnosis of PRPA. We calculated the population-wide incidence rates of PRPA by sex and age group (20–44, 45–64, and >64) as well as in-hospital mortality. The annual incidence rate of PRPA was 2.64 per 100,000 people. The gender-specific incidence rates per 100,000 people were 3.34 for males and 1.94 for females with a male:female gender ratio of 1.72. A slight increase in incidence rates among both genders over the study period was noted. Age-specific rates were lowest in the 20–44 age group with a mean annual incidence of 2.00 per 100,000 people, and the highest rates were noted in the age groups of 45–64 and >64 years with mean annual incidences of 3.21 and 3.20, respectively. We found that PRPA is common in Taiwan, males and older individuals are more susceptible to it, and incidence has increased in recent years.

Increased risk of appendectomy due to appendicitis after tonsillectomy in women: A longitudinal follow-up study using a national sample cohort

The purpose of this study was to evaluate the risk of appendectomy due to appendicitis after tonsillectomy in Koreans using national cohort data. Using the national cohort study from the Korean Health Insurance Review and Assessment Service, 1:4 matched tonsillectomy participants (9015) and control participants (36,060) were selected. The Cox-proportional hazard model was used. In this analysis, a crude and adjusted model for age, sex, income, region of residence, and the past medical histories of hypertension, diabetes mellitus, and dyslipidemia were used. For the subgroup analyses, the participants were divided as follows: children (≤14 years old) vs adolescents and adults (≥15 years old) and men vs women. The adjusted hazard ratio (HR) of tonsillectomy for appendectomy was 1.06 (95% confidence interval, CI = 0.89-1.27, P = .517). In the subgroup analysis, the HR was 1.03 (95% CI = 0.82-1.30, P = .804) in children and 1.10 (95% CI = 0.84-1.47, P = .468) in adolescents and adults. In another subgroup analysis, the HR was 0.89 (95% CI = 0.70-1.12, P = .314) in men and 1.39 (95% CI = 1.06-1.83, P = .018) in women. The risk of appendectomy was higher in the tonsillectomy group but only in women.