Tonsillectomy and adenotonsillectomy for recurrent throat infection in moderately affected children

[Diagnosis and Treatment of recurrent acute Tonsillitis]

When surgery on the palatine tonsils is indicated in children and adults with recurrent acute tonsillitis (RAT) is still the subject of debate. The aim of this article on specialist knowledge is to provide an overview of evidence-based decision-making for optimal diagnosis and treatment of RAT based on current studies and the new S3 guideline on tonsillitis. The diagnosis of a new episode of acute tonsillitis / sore throat should always include a classification with a scoring system (Centor, McIssac, FeverPain score) to assess the likelihood of bacterial tonsillitis, mainly due to group A streptococci (GAS). In unclear cases, a point-of-care test (POCT) for a GAS smear is helpful. Accurate counting of episodes is important in patients with RAT, as the cumulative frequency is the most important marker for or against tonsil surgery to date. In addition, a specific quality of life questionnaire should be used for each episode. Conservative symptomatic treatment of an episode includes a combination of paracetamol and/or non-steroidal anti-inflammatory drugs. If there is a high probability of bacterial tonsillitis, especially in high-risk patients, antibiotic treatment is initiated directly or by delayed prescription. Tonsillectomy is indicated and highly effective if the patient had ≥7 adequately treated episodes of RAT in the previous year or ≥5 such episodes in each of the previous two years or ≥3 such episodes in each of the previous three years. Whether a tonsillotomy is equivalent to a tonsillectomy in these cases will only be answered once the TOTO study has been completed. Standardized pain management is an essential part of the operation, as most patients are likely to experience severe postoperative pain. Nowadays, evidence-based treatment of patients with RAT is readily available.

Assessment of recurrent fever among children undergoing tonsillectomy

BACKGROUND

Recurrent tonsillitis is a common indication for tonsillectomy in children and has phenotypic overlap with periodic fever, aphthous stomatitis, pharyngitis, and cervical adenitis (PFAPA) syndrome. We sought to characterize symptoms associated with PFAPA among children undergoing tonsillectomy.

METHODS

Parents/guardians of children undergoing tonsillectomy at Vanderbilt Children's Hospital over a six-week period were queried regarding symptoms of recurrent fever. Follow-up questionnaires were administered 3 and 12 months after tonsillectomy.

RESULTS

82% (120/147) of patients who underwent tonsillectomy during the study period participated. Provider-documented indications for tonsillectomy were obstructive sleep apnea in 88% and recurrent tonsillitis in 33%. 11% (13/120) reported[Formula: see text]6 episodes of stereotypical fever in a one-year period. During febrile episodes among these 13 subjects, 11 had tonsillitis, 5 had cervical adenitis, 3 had aphthous stomatitis, and three reported regular and predictable episode timing. In addition, participants with ≥3 episodes/year of recurrent febrile tonsillitis (N = 33) had a significantly higher prevalence of recurrent aphthous ulcers than those without recurrent tonsillitis (24% vs. 9%, p = 0.04). All participants, including those with recurrent fever, reported fewer febrile tonsillitis episodes one year after tonsillectomy.

CONCLUSIONS

In our survey of children undergoing tonsillectomy, a subpopulation had frequent, stereotypical fever episodes with recurrent tonsillitis, aphthous stomatitis, or regular timing like patients with PFAPA. Although we cannot diagnose such patients with PFAPA in this limited retrospective study, pediatricians and otolaryngologists evaluating patients for tonsillectomy should be aware of the clinical signs of PFAPA that may warrant additional evaluation and therapeutic approaches.

The Analysis of Neutrophil to Lymphocyte Ratio (NLR), Lymphocyte to Monocyte Ratio (LMR), and Platelet to Lymphocyte Ratio (PLR) in Patients with Adenoidectomy and Tonsillectomy

Background/Objectives: Adenoidectomy and tonsillectomy are among the most commonly performed procedures in ENT practice. The neutrophil-to-lymphocyte ratio (NLR), lymphocyte-to-monocyte ratio (LMR), and platelet-to-lymphocyte ratio (PLR) are recognized inflammatory markers. This study aims to evaluate the changes in NLR, PLR, and LMR in patients undergoing adenoidectomy and tonsillectomy. Methods: The study group consisted of 980 patients who underwent adenoidectomy and/or tonsillectomy. Preoperative and postoperative inflammatory markers were measured in all patients. The NLR, LMR, and PLR values were then calculated and analyzed. Results: In patients undergoing adenoidectomy and/or tonsillectomy, the postoperative NLR was significantly lower than the preoperative NLR. Similarly, the postoperative LMR was significantly higher, and the postoperative PLR was significantly lower compared to their preoperative values. Conclusions: The significant changes in NLR, LMR, and PLR following adenoidectomy and/or tonsillectomy suggest a reduction in systemic inflammation post-surgery. These findings indicate that these procedures may contribute to the improvement of inflammatory status in patients, highlighting the potential role of these markers in monitoring surgical outcomes.

Subcutaneous Emphysema Following Tonsillectomy: A Rare Complication of a Common Surgery

Post-tonsillectomy emphysema is an infrequent yet critical complication that follows tonsillectomy - a prevalent surgical procedure for treating conditions like recurrent tonsillitis and obstructive sleep apnea. While tonsillectomy is generally safe, it is not without risks, including the rare occurrence of postoperative emphysema, where air accumulates abnormally in the neck and head's soft tissues, potentially leading to severe respiratory distress. We present a case of a middle-aged female who underwent tonsillectomy and subsequently developed symptoms indicative of post-tonsillectomy emphysema. Diagnosed through a combination of physical examination and imaging, her treatment involved conservative management and careful monitoring, ultimately resulting in full recovery without the need for surgical intervention.

To Evaluate the Indications for Adenotonsillectomy Surgery and the Quality-of-Life Post-Surgery- A Descriptive, Cross-Sectional Study

Aim

To determine the indications of adenotonsillectomy and to evaluate the quality-of-life post-adenotonsillectomy surgery.

Materials and Methods

This is a descriptive cross-sectional study done in the department of ENT, Indira Gandhi Medical College and Research Institute (IGMCRI), Puducherry among patients who underwent adenotonsillectomy surgery from the year 2015 to 2022. The data regarding their clinical profile and indications for surgery were collected from the medical case records and these patients were contacted through telephone to know their quality of life using a standardized questionnaire.

Results

A total of 98 patients were included in the study, 43 males and 55 females, between the age of 4 to 48 years. Adenotonsillitis (infection) was the indication for adenotonsillectomy in 69 out of 98 patients (70.4%), and Adenotonsillar hypertrophy (Obstruction) in 29 out of 98 patients (29.5%). Postoperatively, the symptoms like frequency of episodes of throat pain had decreased from 6.162.08 to 1.240.44 (p<0.001), snoring (72-1%), mouth breathing (70.4-3.1%), average number of doctor visits due to throat pain (3.911.44 to 1) and average number of days absent to school/ work (3.81 1.26 to nil) had decreased significantly.

Conclusion

Adenotonsillitis (Infection) as an indication is more common than adenotonsillar hypertrophy (Obstruction) for performing adenotonsillectomy in our study. Majority of the patient's symptoms had markedly decreased post-surgery and hence a significant improvement in overall quality of life, both physical and general well-being.

Supplementary Information

The online version contains supplementary material available at 10.1007/s12070-023-04113-5.

Effect of the German tonsillitis guideline on indication for tonsil surgery in patients with recurrent acute tonsillitis: a population-based study

Evidence-based indication for tonsil surgery in patients with recurrent acute tonsillitis (RAT) is an ongoing matter of debate. Since introduction of the German tonsillitis guideline in 2015, the indication criteria for tonsil surgery have become much stricter. It is unclear, if this has changed the indication policy. A retrospective population-based study was performed including all 1398 patients with RAT admitted for tonsil surgery in all Thuringian hospitals in 2011, 2015, and 2019. Changes over the years concerning patients' characteristics, number of tonsillitis episodes in the last 12 months treated with antibiotics (T12), and decision for tonsillectomy or tonsillotomy were analyzed using univariable and multivariable statistics. The surgical rates decreased from 28.56/100,000 population in 2011 to 23.57 in 2015, and to 11.60 in 2019. The relative amount of patients with ≥ 6 T12 increased from 14.1% in 2011 over 13.3% in 2015 to 35.9% in 2019. Most patients received a tonsillectomy (98% of all surgeries). Decision for tonsillotomy was seldom (1.2%). Multinomial logistic regression analysis with the year 2011 as reference showed that compared to the year 2015, the age of the patients undergoing surgery increased in 2015 (Odds ratio [OR] = 1.024; 95% confidence interval [CI] = 1.014-1.034; p < 0.001), and also in 2019 (OR 1.030: CI 1.017-1.043; p < 0.001). Compared to 2011, the number T12 was not higher in 2015, but in 2019 (OR 1.273; CI 1.185-1.367; p < 0.001). Stricter rules led to lower tonsil surgery rates but to a higher proportion of patients with ≥ 6 T12 before surgery. Tonsillectomy remained the dominating technique.

Treatment of recurrent acute tonsillitis-a systematic review and clinical practice recommendations

Background

There is an ongoing debate on the indications for tonsil surgery in both children and adults with recurrent acute tonsillitis. The aim is to provide practical recommendations for diagnostics and treatment for recurrent acute tonsillitis including evidence-based decision making for tonsillectomy.

Methods

A systematic literature search in PubMed, Embase, Web of Science, and ScienceDirect from 2014 until April 2023 resulted in 68 articles. These were the basis for the review and a comprehensive series of consensus statements on the most important diagnostics and indications for both non-surgical and surgical therapy. A consensus paper was circulated among the authors and members of the International Head and Neck Scientific Group until a final agreement was reached for all recommendations.

Results

The differentiation between sore throat and tonsillitis patient episodes is mostly not feasible and hence is not relevant for diagnostic decision making. Diagnostics of a tonsillitis/sore throat episode should always include a classification with a scoring system (Centor, McIssac, FeverPAIN score) to estimate the probability of a bacterial tonsillitis, mainly due to group A streptococcus (GAS). In ambiguous cases, a point-of-care test GAS swab test is helpful. Consecutive counting of the tonsillitis/sore throat episodes is important. In addition, a specific quality of life score (Tonsillectomy Outcome Inventory 14 or Tonsil and Adenoid Health Status Instrument) should be used for each episode. Conservative treatment includes a combination of paracetamol and/or non-steroidal anti-inflammatory drugs. In case of high probability of bacterial tonsillitis, and only in such cases, especially in patients at risk, standard antibiotic treatment is initiated directly or by delayed prescription. Tonsillectomy is indicated and is highly effective if the patient has had ≥7 adequately treated episodes in the preceding year, ≥5 such episodes in each of the preceding 2 years, or ≥3 such episodes in each of the preceding 3 years. An essential part of surgery is standardized pain management because severe postoperative pain can be expected in most patients.

Conclusion

It is necessary to follow a stringent treatment algorithm for an optimal and evidence-based treatment for patients with recurrent acute tonsillitis. This will help decrease worldwide treatment variability, antibiotic overuse, and avoid ineffective tonsillectomy.

Estimated Probability Distribution of Bleeding After Pediatric Tonsillectomy: A Retrospective National Cohort Study of US Children

Importance

The American Academy of Otolaryngology-Head and Neck Surgery Foundation has recommended yearly surgeon self-monitoring of posttonsillectomy bleeding rates. However, the predicted distribution of rates to guide this monitoring remain unexplored.

Objective

To use a national cohort of children to estimate the probability of bleeding after pediatric tonsillectomy to guide surgeons in self-monitoring of this event.

Design, Settings, and Participants

This retrospective cohort study used data from the Pediatric Health Information System for all pediatric (<18 years old) patients who underwent tonsillectomy with or without adenoidectomy in a children's hospital in the US from January 1, 2016, through August 31, 2021, and were discharged home. Predicted probabilities of return visits for bleeding within 30 days were calculated to estimate quantiles for bleeding rates. A secondary analysis included logistic regression of bleeding risk by demographic characteristics and associated conditions. Data analyses were conducted from August 7, 2022 to January 28, 2023.

Main Outcomes and Measures

Revisits to the emergency department or hospital (inpatient/observation) for bleeding (primary/secondary diagnosis) within 30 days after index discharge after tonsillectomy.

Results

Of the 96 415 children (mean [SD] age, 5.3 [3.9] years; 41 284 [42.8%] female; 46 954 [48.7%] non-Hispanic White individuals) who had undergone tonsillectomy, 2100 (2.18%) returned to the emergency department or hospital with postoperative bleeding. The predicted 5th, 50th, and 95th quantiles for bleeding were 1.17%, 1.97%, and 4.75%, respectively. Variables associated with bleeding after tonsillectomy were Hispanic ethnicity (OR, 1.19; 99% CI, 1.01-1.40), very high residential Opportunity Index (OR, 1.28; 99% CI, 1.05-1.56), gastrointestinal disease (OR, 1.33; 99% CI, 1.01-1.77), obstructive sleep apnea (OR, 0.85; 99% CI, 0.75-0.96), obesity (OR,1.24; 99% CI, 1.04-1.48), and being more than 12 years old (OR, 2.48; 99% CI, 2.12-2.91). The adjusted 99th percentile for bleeding after tonsillectomy was approximately 6.39%.

Conclusions and Relevance

This retrospective national cohort study predicted 50th and 95th percentiles for posttonsillectomy bleeding of 1.97% and 4.75%. This probability model may be a useful tool for future quality initiatives and surgeons who are self-monitoring bleeding rates after pediatric tonsillectomy.

Variation in paediatric tonsillectomy rates between Scottish health board areas, 2001-2018: is socio-economic deprivation to blame?

BACKGROUND

Tonsillectomy is one of the commonest operations in children. Routinely collected national data were used to assess variations in the paediatric tonsillectomy rate across Scotland, and to determine if socio-economic deprivation is the cause.

METHOD

The Scottish Morbidity Records were reviewed for all children (0-16 years) undergoing tonsillectomy from 2001 to 2018.

RESULTS

The mean annual tonsillectomy rate was 2.64 per 1000 children. Rates in each health board area varied from 1.24 to 3.9 per 1000. Half of this variation resulted from transfers between regions. There was a 1.75-fold difference between tonsillectomy rates in the most and least deprived population quintiles, but this did not account for the geographical variation.

CONCLUSION

Half the variance in paediatric tonsillectomy rates is associated with children being transferred between regions for treatment. After accounting for this, there is a 1.5-fold difference in rate between health board areas, which is not related to socio-economic deprivation and is currently unexplained.

Estimations of Inpatient and Ambulatory Pediatric Tonsillectomy in the United States: A Cross-sectional Analysis

OBJECTIVE

To estimate the incidence of inpatient and ambulatory pediatric tonsillectomies in the United States in 2019.

STUDY DESIGN

Cross-sectional analysis.

SETTING

Healthcare Cost and Utilization Project databases.

METHODS

We determined national incidences of hospital-based ambulatory procedures, inpatient admissions, and readmissions among pediatric tonsillectomy patients, ages 0 to 20 years, using the Kids Inpatient Database, Nationwide Ambulatory Surgery Sample, and Nationwide Readmission Database. We described the demographics, commonly associated conditions, complications, and predictors of readmission.

RESULTS

An estimated 559,900 ambulatory and 7100 inpatient tonsillectomies were performed in 2019. Among inpatients, the majority were male (59%) and the largest ethnic group was white (37%). Adenotonsillar hypertrophy (ATH), 79%, and obstructive sleep apnea (OSA), 74%, were the most frequent diagnosis and Medicaid (61%) was the most frequent primary payer. The majority of ambulatory tonsillectomy patients were female (52%) and white (65%); ATH, OSA, and Medicaid accounted for 62%, 29%, and 45% of cases, respectively, (all p < .001 when compared to inpatient cases). Common inpatient complications were bleeding (2%), pain/nausea/vomiting (5.6%), and postprocedural respiratory failure (1.7%). On the other hand, ambulatory complications occurred in less than 1% of patients. The readmission rate was 5.2%, with pain/nausea/vomiting and bleeding accounting for 35% and 23% of overall readmissions. All Patient Refined Diagnosis Related Groups severity of illness subclass predicted readmission (odds ratio = 2.18, 95% confidence interval = 1.73-2.73, p < .001).

CONCLUSION

A total of 567,000 pediatric ambulatory and inpatient tonsillectomies were performed in 2019; the majority were performed in ambulatory settings. The index admission severity of illness was associated with readmission risk.

Prevalence of Gram positive bacteria in the affected individuals of Otitis media with effusion from the indigenous population of Southern Punjab, Pakistan: first report

Otitis media with effusion (OME) is a type of otitis media (OM) characterized by the presence of fluid behind intact tympanic membrane and is one of the most common diseases of early childhood. It is an infectious disease associated with the presence of many pathogenic bacteria in the middle ear of affected individuals. This study was aimed to determine the prevalence of Gram-positive bacteria from the middle ear of OME patients in the population of Southern Punjab, Pakistan. The incidence of OME under comprehensive healthcare setting was investigated in patients who consulted at the department of ear, throat and nose, Bahawal Victoria Hospital (BVH), Bahawalpur, from December, 2019 to May, 2021. Ear swabs were taken from affected and normal individuals. After culturing bacteria from the ear swabs, microscopic analysis and biochemical tests were performed to characterize the cultured Gram-positive bacteria. Out of 352 patients examined, 109 (30.9%) patients had OME. Age of the participants ranged from 14 to 50 years; individuals between the ages of 14 and 22 years had the highest infection rates, while individuals between 40 and 50 years had the lowest rate of infection. Tympanic membrane perforation, fever, cough, sore throat, ear pain and hearing problem showed association with symptoms of OME. Microscopic analysis and biochemical characterization showed the presence of streptococci and staphylococci in all the studied samples. The most frequently isolated bacteria were Streptococcus pneumoniae, Streptococcus pyogenes, and Staphylococcus aureus with percentage of 53.3%, 20% and 13.3% respectively. Enterococcus faecalis (6.6%) and Staphylococcus epidermidis (6.6%) were also identified in the studied samples. This study will help in the better medical administration of OME affected individuals.

Revisiting systematic geographical variations in tonsils surgery in children in the Spanish National Health System: spatiotemporal ecological study on hospital administrative data

OBJECTIVE

To provide new evidence on how tonsils surgery in children has geographically varied over time in the context of the Spanish National Health System.

DESIGN

Observational ecological spatiotemporal study on geographical variations in medical practice, using linked administrative datasets, including virtually all surgeries performed from 2003 to 2015.

SETTING

The Spanish National Health System, a quasi-federal structure with 17 autonomous communities (ACs), and 203 healthcare areas (HCAs).

PARTICIPANTS

Patients aged 19 and younger residing in the HCAs and ACs.

INTERVENTIONS

Tonsillectomy with adenoidectomy (T&A); and tonsillectomies alone (T). MAIN ENDPOINTS: (1) Evolution of T&A and T rates; (2) spatiotemporal variation in the risk of receiving T&A or T surgery at regional level (ACs) and HCAs; and (3) the fraction of the variation (FV) attributed to each of the components of variation-ACs, HCAs, year and interaction ACs year.

RESULTS

T&A age-sex standardised rates increased over the period of analysis from 15.2 to 20.9 (5.7 points per 10 000 inhabitants). T alone remained relatively lower than T&A rates, evolving from 3.6 in 2003 to 3.9 in 2015 (0.3 points per 10 000 inhabitants). Most of the risk variation was captured at the HCAs level in both procedures (FV: 55.3% in T&A and 72.5% in T). The ACs level explained 27.6% of the FV in the risk in T&A versus 8% in T. The interaction ACs year was similar in both procedures (FV: 15.5% in T&A and 17.5% in T). The average trend hardly explained 1.46% and 1.83% of the variation, respectively.

CONCLUSION

Our study showed wide persistent variations with a steady increase in rates and risk of T&A and a stagnation of T alone, where most of the variation risk was explained at HCA level.

Hydrogen Peroxide as a Haemostatic Agent in Tonsillectomy Bleed: An Overview

Tonsillectomy as a surgical procedure has been practiced by ENT surgeons for a very long time. A common indication for Tonsillectomy is Chronic Tonsillitis, among others. The surgery is largely safe irrespective of the method used. Haemorrhage can be a life-threatening complication post Tonsillectomy if it is not identified and treated immediately. Various techniques are used to achieve haemostasis and prevent haemorrhage including surgical tie, cautery, local application of adrenaline or hydrogen peroxide among others. To understand the vasoconstrictive and haemostatic properties of Hydrogen Peroxide in Tonsillectomy bleed. One hundred and thirty-three (133) patients undergoing Tonsillectomy for Chronic Tonsillitis were part of the study. Dissection and Snare technique was performed. 23 patients needed the use of cautery/knot for haemostasis and were then excluded from the study. To avoid bias, dissection of the right tonsil was taken as Group 1 and left tonsil as Group 2. Normal Saline soaked cotton ball was used to give local pressure in the tonsillar fossa in Group 1 and 3% Hydrogen Peroxide soaked cotton ball was used in Group 2. Blood loss and time taken to dissect were taken as parameters of study. In Group 1, it took 14.29 min on an average from first incision to completion. In Group 2, it took 12.15 min on an average from first incision to completion. The time in Group 2 was 14.97% lesser than Group 1. The average blood loss in Group 1 was 56.47 ml and in Group 2 the same value stood at 47.41 ml. The blood loss in Group 2 was 16.04% lesser than in Group 1. There were no complications encountered. Powered by Editorial Manager® and ProduXion Manager® from Aries Systems Corporation 3% Hydrogen Peroxide is a potent agent for antimicrobial activity and haemostasis when introduced in the tonsillar fossa post tonsillectomy. When used in moderation, it is very effective in preventing blood loss. Also, there are no serious complications associated with the use of Hydrogen Peroxide as a haemostatic agent.

A Brief Review of Local Bacteriotherapy for Preventing Respiratory Infections

Recurrent respiratory infections (RRIs) account for relevant economic and social implications and significantly affect family life. Local Bacteriotherapy (LB) represents an innovative option in preventing RRIs. Local bacteriotherapy consists of administering “good” and safe bacteria (probiotics) by nasal or oral route. In particular, two strains (Streptococcus salivarius 24SMB and Streptococcus oralis 89a) are commonly used. The present article presents and discusses the literature concerning LB. Infections of airways include the upper and lower respiratory tract. A series of clinical trials investigated the preventive role of LB in preventing upper and lower RIs. These studies demonstrated that LB safely reduced the prevalence and severity of RIs, the use of antibiotics, and absences from school. Therefore, Local Bacteriotherapy may be considered an interesting therapeutic option in RRI prevention.

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.

Tonsillectomy and Adenoidectomy - Pediatric Clinics of North America

Tonsillectomy and adenoidectomy are among the most commonly performed major pediatric operations in the United States, with more than 500,000 procedures performed annually. This procedure can be performed with or without adenoidectomy. These procedures were traditionally performed for recurrent tonsillitis; however, the vast majority of tonsillectomies are currently performed for obstructive symptoms. When performed for appropriate indications, tonsillectomy and adenoidectomy can greatly improve a child's quality of life and general health. Given the prevalence of these conditions and subsequent surgical procedures, evidence-based recommendations are regularly evaluated and updated. As such, familiarity with these guidelines is necessary for pediatric practitioners. This review summarizes the indications, complications, and outcomes for tonsillectomy and adenoidectomy, as well as provides a brief overview of operative techniques.

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.

Regional and hospital variation in commonly performed paediatric otolaryngology procedures in the Netherlands: a population-based study of healthcare utilisation between 2016 and 2019

OBJECTIVE

In the past few decades, there has been an increase in high-quality studies providing evidence on the effectiveness of commonly performed procedures in paediatric otolaryngology. We believe that now is the time to re-evaluate the care process. We aimed to analyse (1) the regional variation in incidence and referrals of adenoidectomies, tonsillectomies and ventilation tube insertions in children in the Netherlands between 2016 and 2019, (2) whether regional surgical rates, referral rates and in-hospital surgical rates were associated with one another, and (3) the hospital variation in healthcare costs, which indicates the utilisation of resources.

DESIGN

Repeated cross-sectional analysis.

SETTING

Four neighbouring Dutch provinces comprising 2.8 million inhabitants and 14 hospitals.

PARTICIPANTS

Children aged 0-15 years.

OUTCOME MEASURES

We analysed variation in regional surgical rates and referral rates per 1000 inhabitants and in-hospital surgical rates per 1000 clinic visitors, adjusted for age and socioeconomic status. Furthermore, the relationships between referral rates, regional surgical rates and in-hospital surgical rates were estimated. Lastly, variation in resource utilisation between hospitals was estimated.

RESULTS

Adenoidectomy rates differed sixfold between regions. Twofold differences were observed for adenotonsillectomy rates, ventilation tube insertion rates and referral rates. Referral rates were negatively associated with in-hospital surgical rates for adenotonsillectomies, but not for adenoidectomies and ventilation tube insertions. In-hospital surgical rates were positively associated with regional rates for adenoidectomies and adenotonsillectomies. Significant variation between hospitals was observed in costs for all resources.

CONCLUSIONS

We observed low variation in tonsillectomies and ventilation tube insertion and high variation in adenoidectomies. Indications for a tonsillectomy and ventilation tube insertion are well defined in Dutch guidelines, whereas this is not the case for an adenoidectomy. Lack of agreement on indications can be expected and high-quality effectiveness research is required to improve evidence-based guidelines on this topic.

Paediatrics: how to manage pharyngitis in an era of increasing antimicrobial resistance

The goal of this narrative review of pharyngitis is to summarize the practical aspects of the management of sore throat in children in high- and middle-income countries. A traditional review of the literature was performed. Most cases of pharyngitis are viral and self-limited, although rarely viral pharyngitis due to Epstein–Barr leads to airway obstruction. Bacterial pharyngitis is usually due to group A streptococcus (GAS), occurs primarily in children aged 5–15 years, and presents as sore throat in the absence of rhinitis, laryngitis or cough. Again, most cases are self-limited; antibiotics hasten recovery by only 1–2 days. Guidelines vary by country, but antibiotics are commonly recommended for proven GAS pharyngitis as they may prevent rare but severe complications, in particular rheumatic fever (RF). In this era of antimicrobial stewardship, it should be extremely rare that antibiotics are prescribed for presumed GAS pharyngitis until GAS has been detected. Even with proven GAS pharyngitis, it is controversial whether children at low risk for RF should routinely be prescribed antibiotics as the number needed to treat to prevent one case of RF is undoubtedly very large. When treatment is offered, the antibiotics of choice are penicillin or amoxicillin as they are narrow spectrum and resistance resulting in clinical failure is yet to be documented. A 10-day oral course is recommended as shorter courses appear to be less likely to clear carriage of GAS. However, the evidence that one needs to clear carriage to prevent RF is low quality and indirect.

Adenotonsillectomy Does not Alter the Risk of Upper Airway Infections in Children

OBJECTIVE

Given the conflicting evidence regarding adenotonsillectomy and the risk of upper airway infections (UAIs), including acute pharyngitis (APT), rhinosinusitis (ARS), and otitis media (AOM), we evaluated the risk of developing UAIs following adenotonsillectomy in a childhood population.

METHODS

In this population-based follow-up study, we used data from the National Health Insurance Service-National Sample Cohort. The adenotonsillectomy group (n = 2,377) included patients aged <10 years who underwent an adenotonsillectomy. For every patient with APT (n = 2,309), ARS (n = 2,308), and AOM (n = 2,207) who had an adenotonsillectomy, four participants were randomly selected for the control groups (n = 9,204, n = 9,196, and n = 8,788, respectively) using propensity score matching. The number of postoperative hospital visits for UAIs was recorded for 1 to 9 years, and the equivalence test was used to compare the number of visits between the adenotonsillectomy and control groups.

RESULTS

There were no significant differences in the incidence of APT, ARS, or AOM at the margin of equivalence of difference (-0.5 < 95% confidence interval of difference < 0.5) between the two groups from postoperative year 1 to year 9. The hospital visits for these diseases gradually decreased over time in both groups. There was a significant decrease in the number of visits for APT, ARS, and AOM in the 5-9 years age group when compared with those in the <4 years age group (P < .01).

CONCLUSION

Our results suggest that adenotonsillectomy does not alter the frequency of UAIs in children.

LEVEL OF EVIDENCE

N/A Laryngoscope, 2021.

Tonsillar Microbiota: a Cross-Sectional Study of Patients with Chronic Tonsillitis or Tonsillar Hypertrophy

Chronic tonsillitis (CT) and tonsillar hypertrophy (TH) are common tonsillar diseases that are related to infection and inflammation. Little is known about tonsillar microbiota and its role in CT and TH. This study aims to identify palatine tonsillar microbiota both on the surface and in the core tissues of CT and TH patients. In total, 22 palatine tonsils were removed and collected from CT and TH patients who underwent surgery. The surface and core microbiota in the tonsils of CT and TH patients were compared using 16S rRNA gene sequencing of V3-V4 regions. Differential tonsillar microbiotas were found in the CT versus TH patients and surface versus core tissues. Further, a higher relative abundance of bacterial genera, including Haemophilus, Streptococcus, Neisseria, Capnocytophaga, Kingella, Moraxella, and Lachnospiraceae [G-2] in patients with TH and Dialister, Parvimonas, Bacteroidales [G-2], Aggregatibacter, and Atopobium in patients with CT, was observed. Of these, the differential genera of Dialister, Parvimonas, and Neisseria served as key factors in the tonsillar microbiota network. Notably, four representable tonsillar microbial types were identified, with one, consisting of a higher abundance of Haemophilus and Neisseria, exclusively detected in the TH patients. This study analyzed the different tonsillar microbiota from the surface and core tissues of CT and TH patients. Several bacteria and various microbial types related to CT and TH were identified, along with potential bacterial networks and related immune pathways.

IMPORTANCE The human microbiota has been shown to be functionally connected to infectious and inflammation-related diseases. So far, only limited studies had been performed on tonsillar microbiota, although tonsils play an essential role in the human immune defense system and encountered numerous microorganisms. Our work presented different tonsillar microbiota from surface and core tissues of chronic tonsillitis (CT) and tonsillar hypertrophy (TH) patients. Notably, one tonsillar microbiota type, which contains a higher abundance of Haemophilus and Neisseria, was only detected in the TH patients. Furthermore, certain bacteria, such as Haemophilus, Neisseria, Dialister, and Parvimonas, may serve as microbial biomarkers to discriminate CT patients from TH patients. These data provide important microbiota data in the tonsillar research area and are highly useful for researchers both in the oral microbiome field and clinical field.

The impact of new evidence on regional variation in paediatric tonsillectomy and adenoidectomy: a historical review

BACKGROUND

Tonsillectomy and adenoidectomy have been among the most commonly performed procedures in children for approximately 100 years. These procedures were the first for which unwarranted regional variation was discovered, in 1938. Indications for these procedures have become stricter over time, which might have reduced regional practice variation.

METHODS

This paper presents a historical review on practice variation in paediatric tonsillectomy and adenoidectomy rates. Data on publication year, region, level of variation, methodology and outcomes were collected.

RESULTS

Twenty-one articles on practice variation in paediatric tonsil surgery were included, with data from 12 different countries. Significant variation was found throughout the years, although a greater than 10-fold variation was observed only in the earliest publications.

CONCLUSION

No evidence has yet been found that better indications for tonsillectomy and adenoidectomy have reduced practice variation. International efforts are needed to reconsider why we are still unable to tackle this variation.

Local Bacteriotherapy - a promising preventive tool in recurrent respiratory infections

INTRODUCTION

Children with recurrent respiratory infections (RRI) represent a social issue for the economic burden and the negative family impact. Local Bacteriotherapy is an attractive therapeutic strategy that could be potentially effective in preventing infections. The current article remarks on the existing evidence of preventing RRI by Local Bacteriotherapy.

AREAS COVERED

The literature search methodology was based on the articles cited by PubMed from 1980 to 2020. Respiratory infections include rhino-pharyngitis, otitis media, rhinosinusitis, pharyngo-tracheitis, bronchitis, and pneumonia. Several studies were performed to investigate the effects of Local Bacteriotherapy in children with RRI. Both intranasal and oral Local Bacteriotherapy were evaluated. The findings showed that Local Bacteriotherapy significantly reduced the number of RI episodes, their severity, the use of antibiotics, and school absences.

EXPERT OPINION

Local Bacteriotherapy is a promising approach to RRI prevention and could be a profitable strategy to contrast infections in the future.

MRI evaluation of distance between tonsillary fossa and internal carotid artery in children

OBJECTIVES

The presence of the internal carotid artery (ICA) near tonsils can also cause severe bleeding during a tonsillectomy. We investigated the relationship between tonsil width and volume; and superior, middle and inferior tonsil-ICA distances in 5-9 and 10-15 years of age children.

METHODS

Cranial MRI images of 200 children between 5 and 15 years of age were evaluated retrospectively. There were 100 children in group 1 (5-9 years of age) and 100 children in group 2 (10-15 years of age). Palatine tonsil width and volume; and superior, middle and inferior tonsil-internal carotid artery (ICA) measurements were performed bilaterally.

RESULTS

Our results showed that bilateral tonsil width and volume; and left superior, middle and inferior tonsil-ICA distance of 5-9 years of age group were lower than those of the 10-15 year-of age group (p < 0.05). The nearest distance between ICA and palatine tonsil is at the inferior tonsil-ICA distance side in both age groups. Especially mean inferior and middle tonsil-ICA distances were lower than 8 mm in 5-9 years of age group and lower than 9 mm in 10-15 years of age group. Minimum middle tonsil-ICA distances were 2.0-2.50 mm in smaller children and 2.0-3.50 mm in older children. Similarly, the minimum inferior tonsil-ICA distances were 2.00 mm in smaller children and 2.20-3.00 mm in older children. There were positive correlations between tonsil width, volume, and superior tonsil-ICA distance; and middle and inferior tonsil-ICA distances (p < 0.05).

CONCLUSION

In younger children, lower tonsil width; and in all children, lower tonsil volume can be a warning sign in terms of lower tonsil superior-ICA distance. During tonsillectomies, working at the middle and inferior tonsillary fossa, maximum attention must be performed for the possibility of the ICA being very closer to the tonsil to avoid unwanted bleedings.

[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.

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.

The Association Between Vitamin D Deficiency and Recurrent Tonsillitis: A Systematic Review and Meta-analysis

OBJECTIVES

The role of vitamin D deficiency has been linked with recurrent upper respiratory tract infections, but its impact on the frequency of tonsillitis is not yet fully understood. The objective of this study is to determine the association between vitamin D deficiency and recurrent tonsillitis based on current literature.

DATA SOURCE

A systematic review was performed following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guideline. Data were collected from online medical databases (PubMed, MEDLINE, EMBASE, and Cochrane Collaboration Registry of Controlled Trials).

REVIEW METHODS

All studies addressing the association of vitamin D deficiency and recurrent tonsillitis prior to March 2019. The data were collected in different phases: screening review using search words and controlled vocabularies followed by detailed review of screened articles based on inclusion and exclusion criteria, then a full review that included screening the references of selected articles.

RESULTS

Fifty-three studies were potentially eligible; of these, 4 publications met the inclusion criteria and were included in the quantitative synthesis. There was a statistically significant reduction of vitamin D levels in patients with recurrent tonsillitis as compared to healthy controls (mean difference, -10.71; 95% CI, -19.12 to -2.31; P = .01). The odds of vitamin D insufficiency were significantly higher in patients with recurrent tonsillitis as compared to the control group (odds ratio, 4.37; 95% CI, 2.78-6.88; P < .001).

CONCLUSION

Vitamin D deficiency was present in patients with recurrent tonsillitis and might be associated with an increase in the risk of recurrent tonsillitis. There is a need to explore these findings via clinical trials based on large populations.

Simple hypertrophic tonsils have more active innate immune and inflammatory responses than hypertrophic tonsils with recurrent inflammation in children

Background

Tonsil hypertrophy has negative impact on children’s health, but its pathogenesis remains obscure despite the fact that numerous bacteriological studies have been carried out. Understanding the innate immune and inflammatory states of hypertrophic tonsils with different clinical manifestations is of great significance for defining the pathogenesis of tonsil hypertrophy and establishing treatment strategies. The present study was undertaken to examine the characteristics of innate immunity and inflammation in children with hypertrophic palatine tonsils and different clinical manifestations.

Methods

Tonsil tissues were surgically removed from the patients and classified based on the patients’ clinical manifestations. The patients were divided into three groups: 1) Control group; 2) Tonsil Hypertrophy (TH) group; and 3) Tonsil Hypertrophy combined with Recurrent Infection (TH + RI) group. The immune and inflammatory statuses of these tissues were characterized using qRT-PCR and ELISA methods.

Results

Viral protein 1 (VP1) was highly expressed in TH group, but not in TH + RI group. In TH group, elevated expression was observed in the innate immune mediators, including retinoic acid-inducible gene I (RIG-I), interferon alpha (IFN-α), mitochondrial antiviral-signaling protein (MAVS), NLR family pyrin domain containing 3 (NLRP3), toll-like receptor (TLR) 4 and TLR7. Consistent with the innate immune profile, the expression of inflammatory markers (IL-1β, NF-κB and IL-7) was also significantly elevated in TH group. Meanwhile, the COX-2/PGE2/EP4 signaling pathway was found to be involved in the inflammatory response and the formation of fibroblasts.

Conclusions

Innate immune and inflammatory responses are more active in simple hypertrophic tonsils, rather than hypertrophic tonsils with recurrent inflammation. A local relative immune deficiency in the hypertrophic tonsils may be a causative factor for recurrent tonsillitis in TH + RI. These differences, together with the patient’s clinical manifestations, suggest that tonsillar hypertrophy might be regulated by diverse immune and/or inflammatory mechanism through which novel therapeutic strategies might be created.

Tonsillotomy versus Tonsillectomy for Chronic Recurrent Tonsillitis in Children

Objective

This study was conducted to compare two different surgical methods; partial tonsil resection using the bipolar technique, tonsillotomy (TT), and total tonsillectomy (TE) (blunt dissection) for recurrent tonsillitis in children. The frequency of recurrent throat infections was determined during postoperative follow-up.

Methods

A total of 393 patients were included in this study. TT was performed on 174 patients (100 males, 74 females) and TE on 219 patients (112 males, 107 females). Following surgery, an analysis was made of treatment outcomes of patients with upper respiratory tract infections. The patients were followed up for 12-48 months. Their parents were also contacted by telephone to determine the frequency of reinfection and their satisfaction with the surgery. Also, parents of the patients completed a questionnaire pertaining to postoperative satisfaction (scale of 1-10).

Results

In the TT group, 14 (8.1%) patients had recurrent tonsillitis postoperatively. In the TE group, 12 (5.4%) patients required antibiotherapy due to recurrent pharyngitis after the surgery. There was no significant difference between the two groups in terms of the one-year infection recurrence rate after surgery (p=0.281). Three patients (1.6%) in the TT group and 12 (5.4%) in the TE group complained of bleeding within the first 24 hours. The rate of bleeding was significantly lower in the TT group than the TE group (p=0.001). There were no fatalities in either group.

Conclusion

In both groups, the rate of reinfection accorded with the requirement for postoperative antibiotics. For recurrent tonsillitis, TT was as effective as TE. However, TT was superior in terms of the risk of bleeding.

Increased Risk of Chronic Periodontitis in Chronic Rhinosinusitis Patients: A Longitudinal Follow-Up Study Using a National Health-Screening Cohort

This study compared the risk of chronic periodontitis (CP) between chronic rhinosinusitis (CRS) and non-chronic rhinosinusitis (control) patients using a national cohort dataset from the Korean Health Insurance Review and Assessment Service. CRS (n = 5951) and control participants (n = 23,804) were selected after 1:4 ratio matching for age, sex, income, region of residence, and preoperative CP visits. Postoperative CP visits were measured between 2002 and 2015. The margin of equivalence of the difference between the CRS and control groups was set between -0.5 and 0.5. Statistical significance was noted in the post-index date (ID) of the third, fourth, and fifth year periods. In subgroup analyses according to age and sex, statistical significance was observed in 40-59-year-old males in post-ID third, fourth, and fifth year periods, ≥60-year-old males in post-ID third and fourth year periods, and ≥60-year-old females in post-ID fifth year period (p < 0.05, each). In another subgroup analysis based on the number of pre-ID CP visits, statistical significance was observed for pre-ID CP (0 time) in the third, fourth, and fifth year periods (p < 0.05, each). This study revealed that CRS participants were likely to receive CP diagnosis and treatment.

Subcutaneous emphysema with pneumomediastinum after tonsillectomy: Case report and review of the literature

Subcutaneous emphysema is a rare complication of tonsillectomy.We report a case of post-tonsillectomy crepitus with radiographic extravasation of contrast from the tonsil fossa into the neck, subcutaneous emphysema, pneumomediastinum and small pneumothorax in a patient with Down Syndrome. Subsequent direct laryngoscopy showed no visible defect in the mucosal or muscle layers of the tonsil fossa. We explore common presenting symptoms, clinical course, and treatment of subcutaneous emphysema secondary to tonsillectomy.

Inflammation, infection, and allergy of upper airways: new insights from national and real-world studies

The upper airways (UA) should be considered as a functional unit. Current functional anatomy divides URT in three, mutually dependent, "junction boxes": i) the ostio-meatal complex (OMC), ii) the spheno-ethmoidal recess (SER), and iii) the rhinopharynx (RP). Correct ventilation and effective mucociliary clearance of these sites significantly affect the healthy physiology of the entire respiratory system. The OMC, SER, and RP obstruction is the first pathogenic step in the inflammatory/infectious cascade of UA disorders. The inflammation of the respiratory mucosa is the main pathogenic factor for airway obstruction. Moreover, bacterial biofilm (a strategy modality of bacterial survival) is an important local cause of systemic antibiotic ineffectiveness, recurrent infections, and antibiotic resistance. Health microbiota guarantees UA wellness; on the contrary, dysbiosis promotes and worsens UA infections. Allergy, namely type 2 inflammation, is a common cause of UA obstruction such as promoting in turn infections. Fiberoptic endoscopy is a mandatory diagnostic tool in clinical practice. Nasal cytology, mainly concerning flow cytometry, allows defining rhinitis phenotypes so allowing a precision medicine approach. Several conventional therapeutic approaches are available, but efficacy and safety should be ever properly considered before the prescription. Also, complementary medicine plays a fruitful role in the management of UA diseases. National and real-world studies are reported and discussed as they may be useful in daily clinical practice.

Clinical Practice Guideline: Tonsillectomy in Children (Update)

OBJECTIVE

This update of a 2011 guideline developed by the American Academy of Otolaryngology-Head and Neck Surgery Foundation provides evidence-based recommendations on the pre-, intra-, and postoperative care and management of children 1 to 18 years of age under consideration for tonsillectomy. Tonsillectomy is defined as a surgical procedure performed with or without adenoidectomy that completely removes the tonsil, including its capsule, by dissecting the peritonsillar space between the tonsil capsule and the muscular wall. Tonsillectomy is one of the most common surgical procedures in the United States, with 289,000 ambulatory procedures performed annually in children <15 years of age based on the most recent published data. This guideline is intended for all clinicians in any setting who interact with children who may be candidates for tonsillectomy.

PURPOSE

The purpose of this multidisciplinary guideline is to identify quality improvement opportunities in managing children under consideration for tonsillectomy and to create explicit and actionable recommendations to implement these opportunities in clinical practice. Specifically, the goals are to educate clinicians, patients, and/or caregivers regarding the indications for tonsillectomy and the natural history of recurrent throat infections. Additional goals include the following: optimizing the perioperative management of children undergoing tonsillectomy, emphasizing the need for evaluation and intervention in special populations, improving the counseling and education of families who are considering tonsillectomy for their children, highlighting the management options for patients with modifying factors, and reducing inappropriate or unnecessary variations in care. Children aged 1 to 18 years under consideration for tonsillectomy are the target patient for the guideline. For this guideline update, the American Academy of Otolaryngology-Head and Neck Surgery Foundation selected a panel representing the fields of nursing, anesthesiology, consumers, family medicine, infectious disease, otolaryngology-head and neck surgery, pediatrics, and sleep medicine.

KEY ACTION STATEMENTS

The guideline update group made strong recommendations for the following key action statements (KASs): (1) Clinicians should recommend watchful waiting for recurrent throat infection if there have been <7 episodes in the past year, <5 episodes per year in the past 2 years, or <3 episodes per year in the past 3 years. (2) Clinicians should administer a single intraoperative dose of intravenous dexamethasone to children undergoing tonsillectomy. (3) Clinicians should recommend ibuprofen, acetaminophen, or both for pain control after tonsillectomy. The guideline update group made recommendations for the following KASs: (1) Clinicians should assess the child with recurrent throat infection who does not meet criteria in KAS 2 for modifying factors that may nonetheless favor tonsillectomy, which may include but are not limited to multiple antibiotic allergies/intolerance, PFAPA (periodic fever, aphthous stomatitis, pharyngitis, and adenitis), or history of >1 peritonsillar abscess. (2) Clinicians should ask caregivers of children with obstructive sleep-disordered breathing and tonsillar hypertrophy about comorbid conditions that may improve after tonsillectomy, including growth retardation, poor school performance, enuresis, asthma, and behavioral problems. (3) Before performing tonsillectomy, the clinician should refer children with obstructive sleep-disordered breathing for polysomnography if they are <2 years of age or if they exhibit any of the following: obesity, Down syndrome, craniofacial abnormalities, neuromuscular disorders, sickle cell disease, or mucopolysaccharidoses. (4) The clinician should advocate for polysomnography prior to tonsillectomy for obstructive sleep-disordered breathing in children without any of the comorbidities listed in KAS 5 for whom the need for tonsillectomy is uncertain or when there is discordance between the physical examination and the reported severity of oSDB. (5) Clinicians should recommend tonsillectomy for children with obstructive sleep apnea documented by overnight polysomnography. (6) Clinicians should counsel patients and caregivers and explain that obstructive sleep-disordered breathing may persist or recur after tonsillectomy and may require further management. (7) The clinician should counsel patients and caregivers regarding the importance of managing posttonsillectomy pain as part of the perioperative education process and should reinforce this counseling at the time of surgery with reminders about the need to anticipate, reassess, and adequately treat pain after surgery. (8) Clinicians should arrange for overnight, inpatient monitoring of children after tonsillectomy if they are <3 years old or have severe obstructive sleep apnea (apnea-hypopnea index ≥10 obstructive events/hour, oxygen saturation nadir <80%, or both). (9) Clinicians should follow up with patients and/or caregivers after tonsillectomy and document in the medical record the presence or absence of bleeding within 24 hours of surgery (primary bleeding) and bleeding occurring later than 24 hours after surgery (secondary bleeding). (10) Clinicians should determine their rate of primary and secondary posttonsillectomy bleeding at least annually. The guideline update group made a strong recommendation against 2 actions: (1) Clinicians should not administer or prescribe perioperative antibiotics to children undergoing tonsillectomy. (2) Clinicians must not administer or prescribe codeine, or any medication containing codeine, after tonsillectomy in children younger than 12 years. The policy level for the recommendation about documenting recurrent throat infection was an option: (1) Clinicians may recommend tonsillectomy for recurrent throat infection with a frequency of at least 7 episodes in the past year, at least 5 episodes per year for 2 years, or at least 3 episodes per year for 3 years with documentation in the medical record for each episode of sore throat and ≥1 of the following: temperature >38.3°C (101°F), cervical adenopathy, tonsillar exudate, or positive test for group A beta-hemolytic streptococcus.

DIFFERENCES FROM PRIOR GUIDELINE

(1) Incorporating new evidence profiles to include the role of patient preferences, confidence in the evidence, differences of opinion, quality improvement opportunities, and any exclusion to which the action statement does not apply. (2) There were 1 new clinical practice guideline, 26 new systematic reviews, and 13 new randomized controlled trials included in the current guideline update. (3) Inclusion of 2 consumer advocates on the guideline update group. (4) Changes to 5 KASs from the original guideline: KAS 1 (Watchful waiting for recurrent throat infection), KAS 3 (Tonsillectomy for recurrent infection with modifying factors), KAS 4 (Tonsillectomy for obstructive sleep-disordered breathing), KAS 9 (Perioperative pain counseling), and KAS 10 (Perioperative antibiotics). (5) Seven new KASs: KAS 5 (Indications for polysomnography), KAS 6 (Additional recommendations for polysomnography), KAS 7 (Tonsillectomy for obstructive sleep apnea), KAS 12 (Inpatient monitoring for children after tonsillectomy), KAS 13 (Postoperative ibuprofen and acetaminophen), KAS 14 (Postoperative codeine), and KAS 15a (Outcome assessment for bleeding). (6) Addition of an algorithm outlining KASs. (7) Enhanced emphasis on patient and/or caregiver education and shared decision making.

The association between vitamin D status and infectious diseases of the respiratory system in infancy and childhood

PURPOSE

Respiratory tract infections (RTIs) are a major cause of illness worldwide and the most common cause of hospitalization for pneumonia and bronchiolitis. These two diseases are the leading causes of morbidity and mortality among children under 5 years of age. Vitamin D is believed to have immunomodulatory effects on the innate and adaptive immune systems by modulating the expression of antimicrobial peptides, like cathelicidin, in response to both viral and bacterial stimuli. The aim of this review is to summarize the more recently published data with regard to potential associations of 25-hydroxyvitamin D [25(OH)D] with infectious respiratory tract diseases of childhood and the possible health benefits from vitamin D supplementation.

METHODS

The literature search was conducted by using the PubMed, Scopus, and Google Scholar databases, with the following keywords: vitamin D, respiratory tract infection, tuberculosis, influenza, infancy, and childhood.

RESULTS

Several studies have identified links between inadequate 25(OH)D concentrations and the development of upper or lower respiratory tract infections in infants and young children. Some of them also suggest that intervention with vitamin D supplements could decrease both child morbidity and mortality from such causes.

CONCLUSIONS

Most studies agree in that decreased vitamin D concentrations are prevalent among most infants and children with RTIs. Also, normal to high-serum 25(OH)D appears to have some beneficial influence on the incidence and severity of some, but not all, types of these infections. However, studies with vitamin D supplementation revealed conflicting results as to whether supplementation may be of benefit, and at what doses.

Does tonsillectomy reduce medical care visits for pharyngitis/tonsillitis in children and adults? Retrospective cohort study from Sweden

OBJECTIVE

To assess the effectiveness of tonsillectomy/adenotonsillectomy in reducing medical care visits for pharyngitis or tonsillitis in children and adults with chronic/recurrent tonsillitis.

DESIGN

Retrospective cohort study.

SETTING

Data were retrieved from the VEGA register, a comprehensive regional cohort in Sweden.

PARTICIPANTS

1044 children (<15 years) and 2244 adults.

INTERVENTION

Tonsillectomy/adenotonsillectomy compared with no surgical treatment.

MAIN OUTCOME MEASURES

Changes in yearly mean rates of medical care visits due to pharyngitis/tonsillitis.

RESULTS

In children, there was a significant decrease in the yearly mean medical care visits rate from 1.93 (1.82 to 2.04) before surgery to 0.129 (0.099 to 0.165) after surgery, with a mean change of -1.80 (-1.90 to -1.69), p<0.0001. In patients who did not undergo surgery, the corresponding mean change was -1.51 (-1.61 to -1.41), resulting in a mean difference in the change in visit rates between the intervention and control groups of -0.283 (-0.436 to -0.135), p=0.0002. In adults, a significant decrease in the yearly mean medical care visit rate was observed from 1.45 (1.39 to 1.51) before surgery to 0.152 (0.132 to 0.173) after surgery, with a mean change of -1.30 (-1.36 to -1.24), p<0.0001, compared with -1.18 (-1.24 to -1.13) in the control group. The difference in the change in yearly mean visit rate between the surgical and non-surgical groups was -0.111 (-0.195 to -0.028), p=0.0097. The subgroup analysis showed a greater effect of surgery in children, in patients with a higher number of medical care visits before surgery and in the first year of follow-up.

CONCLUSION

In this cohort of patients moderately or less affected with chronic/recurrent tonsillitis, the effectiveness of tonsillectomy/adenotonsillectomy in reducing medical care visits for pharyngitis and tonsillitis compared with no surgical treatment was low and of questionable clinical value.

Clinical Practice Guideline: Tonsillectomy in Children (Update)-Executive Summary

OBJECTIVE

This update of a 2011 guideline developed by the American Academy of Otolaryngology-Head and Neck Surgery Foundation provides evidence-based recommendations on the pre-, intra-, and postoperative care and management of children 1 to 18 years of age under consideration for tonsillectomy. Tonsillectomy is defined as a surgical procedure performed with or without adenoidectomy that completely removes the tonsil, including its capsule, by dissecting the peritonsillar space between the tonsil capsule and the muscular wall. Tonsillectomy is one of the most common surgical procedures in the United States, with 289,000 ambulatory procedures performed annually in children <15 years of age, based on the most recent published data. This guideline is intended for all clinicians in any setting who interact with children who may be candidates for tonsillectomy.

PURPOSE

The purpose of this multidisciplinary guideline is to identify quality improvement opportunities in managing children under consideration for tonsillectomy and to create explicit and actionable recommendations to implement these opportunities in clinical practice. Specifically, the goals are to educate clinicians, patients, and/or caregivers regarding the indications for tonsillectomy and the natural history of recurrent throat infections. Additional goals include the following: optimizing the perioperative management of children undergoing tonsillectomy, emphasizing the need for evaluation and intervention in special populations, improving the counseling and education of families who are considering tonsillectomy for their children, highlighting the management options for patients with modifying factors, and reducing inappropriate or unnecessary variations in care. Children aged 1 to 18 years under consideration for tonsillectomy are the target patient for the guideline. For this guideline update, the American Academy of Otolaryngology-Head and Neck Surgery Foundation selected a panel representing the fields of nursing, anesthesiology, consumers, family medicine, infectious disease, otolaryngology-head and neck surgery, pediatrics, and sleep medicine.

KEY ACTION STATEMENTS

The guideline update group made strong recommendations for the following key action statements (KASs): (1) Clinicians should recommend watchful waiting for recurrent throat infection if there have been <7 episodes in the past year, <5 episodes per year in the past 2 years, or <3 episodes per year in the past 3 years. (2) Clinicians should administer a single intraoperative dose of intravenous dexamethasone to children undergoing tonsillectomy. (3) Clinicians should recommend ibuprofen, acetaminophen, or both for pain control after tonsillectomy. The guideline update group made recommendations for the following KASs: (1) Clinicians should assess the child with recurrent throat infection who does not meet criteria in KAS 2 for modifying factors that may nonetheless favor tonsillectomy, which may include but are not limited to multiple antibiotic allergies/intolerance, PFAPA (periodic fever, aphthous stomatitis, pharyngitis, and adenitis), or history of >1 peritonsillar abscess. (2) Clinicians should ask caregivers of children with obstructive sleep-disordered breathing and tonsillar hypertrophy about comorbid conditions that may improve after tonsillectomy, including growth retardation, poor school performance, enuresis, asthma, and behavioral problems. (3) Before performing tonsillectomy, the clinician should refer children with obstructive sleep-disordered breathing for polysomnography if they are <2 years of age or if they exhibit any of the following: obesity, Down syndrome, craniofacial abnormalities, neuromuscular disorders, sickle cell disease, or mucopolysaccharidoses. (4) The clinician should advocate for polysomnography prior to tonsillectomy for obstructive sleep-disordered breathing in children without any of the comorbidities listed in KAS 5 for whom the need for tonsillectomy is uncertain or when there is discordance between the physical examination and the reported severity of obstructive sleep-disordered breathing. (5) Clinicians should recommend tonsillectomy for children with obstructive sleep apnea documented by overnight polysomnography. (6) Clinicians should counsel patients and caregivers and explain that obstructive sleep-disordered breathing may persist or recur after tonsillectomy and may require further management. (7) The clinician should counsel patients and caregivers regarding the importance of managing posttonsillectomy pain as part of the perioperative education process and should reinforce this counseling at the time of surgery with reminders about the need to anticipate, reassess, and adequately treat pain after surgery. (8) Clinicians should arrange for overnight, inpatient monitoring of children after tonsillectomy if they are <3 years old or have severe obstructive sleep apnea (apnea-hypopnea index ≥10 obstructive events/hour, oxygen saturation nadir <80%, or both). (9) Clinicians should follow up with patients and/or caregivers after tonsillectomy and document in the medical record the presence or absence of bleeding within 24 hours of surgery (primary bleeding) and bleeding occurring later than 24 hours after surgery (secondary bleeding). (10) Clinicians should determine their rate of primary and secondary posttonsillectomy bleeding at least annually. The guideline update group made a strong recommendation against 2 actions: (1) Clinicians should not administer or prescribe perioperative antibiotics to children undergoing tonsillectomy. (2) Clinicians must not administer or prescribe codeine, or any medication containing codeine, after tonsillectomy in children younger than 12 years. The policy level for the recommendation about documenting recurrent throat infection was an option: (1) Clinicians may recommend tonsillectomy for recurrent throat infection with a frequency of at least 7 episodes in the past year, at least 5 episodes per year for 2 years, or at least 3 episodes per year for 3 years with documentation in the medical record for each episode of sore throat and ≥1 of the following: temperature >38.3°C (101°F), cervical adenopathy, tonsillar exudate, or positive test for group A beta-hemolytic streptococcus.

DIFFERENCES FROM PRIOR GUIDELINE

Incorporating new evidence profiles to include the role of patient preferences, confidence in the evidence, differences of opinion, quality improvement opportunities, and any exclusion to which the action statement does not apply. There were 1 new clinical practice guideline, 26 new systematic reviews, and 13 new randomized controlled trials included in the current guideline update. Inclusion of 2 consumer advocates on the guideline update group. Changes to 5 KASs from the original guideline: KAS 1 (Watchful waiting for recurrent throat infection), KAS 3 (Tonsillectomy for recurrent infection with modifying factors), KAS 4 (Tonsillectomy for obstructive sleep-disordered breathing), KAS 9 (Perioperative pain counseling), and KAS 10 (Perioperative antibiotics). Seven new KASs: KAS 5 (Indications for polysomnography), KAS 6 (Additional recommendations for polysomnography), KAS 7 (Tonsillectomy for obstructive sleep apnea), KAS 12 (Inpatient monitoring for children after tonsillectomy), KAS 13 (Postoperative ibuprofen and acetaminophen), KAS 14 (Postoperative codeine), and KAS 15a (Outcome assessment for bleeding). Addition of an algorithm outlining KASs. Enhanced emphasis on patient and/or caregiver education and shared decision making.

Tantum verde mouthwash for tonsillectomy: A prospective, double-blind, randomized control trial

OBJECTIVES

Post-tonsillectomy pain control is still considered a challenge. Topical agents would seem to be an ideal, safe option. Our objective was to compare the efficacy of mouthwash preparation with anti-inflammatory, anesthetic, and analgesic properties (Tantum Verde^®, 0.15% benzydamine hydrochloride) with that of placebo in improving post-tonsillectomy morbidity.

METHODS

A prospective, double blind, randomized clinical trial was performed. Patients older than 12-years-of-age who underwent tonsillectomy were recruited. Participants were randomized into 2 groups to receive either 0.15% benzydamine hydrochloride (TV) mouthwash solution (study arm) or a placebo solution. They were instructed to gargle the intervention they received 3 times a day for 7 days following surgery. Primary outcomes were intensity and duration of post-operative pain (using VAS visual analogue score) during a 2-week follow-up period. Secondary outcomes were pain medication demand, readmission, incidence of post-operative bleeding, hospital stay duration, and time to resume normal solid diet.

RESULTS

Thirty-nine patients completed the study, of whom 23 received TV and 16 received placebo. The mean age was 23.1 years. There was no significant difference between the groups in the primary or secondary outcomes.

CONCLUSIONS

The data suggest that topical treatment with TV mouthwash solution was not found to be superior to placebo in the management of post-tonsillectomy pain, bleeding, and return to a regular solid diet. Further research studies should be designed to investigate the ideal treatment for reducing post-tonsillectomy morbidity.

CLINICAL TRIAL REGISTRATION

NIH identifier: NCT02190762; IRB NHR002814.

Incidence of indications for tonsillectomy and frequency of evidence-based surgery: a 12-year retrospective cohort study of primary care electronic records

BACKGROUND

Neither the incidence of indications for childhood tonsillectomy nor the proportion of tonsillectomies that are evidence-based is known.

AIM

To determine the incidence of indications for tonsillectomy in UK children, and the proportion of tonsillectomies meeting evidence-based criteria.

DESIGN AND SETTING

A retrospective cohort study of electronic medical records of children aged 0-15 years registered with 739 UK general practices contributing to a research database.

METHOD

Children with recorded indications for tonsillectomy were identified from electronic medical records. Evidence-based indications included documented sore throats of sufficient frequency and severity (Paradise criteria); periodic fever, aphthous stomatitis, pharyngitis, and cervical adenitis syndrome (PFAPA); or tonsillar tumour. Other indications were considered non-evidence-based. The numbers of children subsequently undergoing tonsillectomy was then identified. The numbers with evidence-based and non-evidence-based indications for surgery among children who had undergone tonsillectomy were determined.

RESULTS

The authors included 1 630 807 children followed up for 7 200 159 person-years between 2005 and 2016. Incidence of evidence-based indications for tonsillectomy was 4.2 per 1000 person years; 13.6% (2144/15 760) underwent tonsillectomy. Incidence of childhood tonsillectomy was 2.5 per 1000 person years; 11.7% (2144/18 281) had evidence-based indications, almost all with Paradise criteria. The proportion of evidence-based tonsillectomies was unchanged over 12 years. Most childhood tonsillectomies followed non-evidence-based indications: five to six sore throats (12.4%) in 1 year, two to four sore throats (44.6%) in 1 year, sleep disordered breathing (12.3%), or obstructive sleep apnoea (3.9%).

CONCLUSION

In the UK, few children with evidence-based indications undergo tonsillectomy and seven in eight of those who do (32 500 of 37 000 annually) are unlikely to benefit.

Factors associated with changing indications for adenotonsillectomy: A population-based longitudinal study

OBJECTIVE

Adenotonsillectomy (AT) is one of the most common surgical procedures performed in children and adults. We aim to assess the factors associated with changes in the incidence of and indications for AT using population-level data.

STUDY DESIGN

This retrospective cohort study investigated patients who underwent AT between 1997 and 2010 by using data from the Taiwan National Health Insurance Research Database. We examined surgical rates and indications by the calendar year as well as age, sex, hospital level, and insured residence areas for the correlating factors.

RESULTS

The average annual incidence rate of AT was 14.7 per 100,000 individuals during 1997-2010. Pediatric (<18 years) patients represented 48.2% of the total AT population. More than 99% of the patients underwent the AT procedures as an inpatient intervention. Longitudinal data demonstrated an increasing trend in the pediatric AT rates from 1997 (4.3/100,000) to 2010 (5.7/100,000) (p = 0.029). In the adult subgroup, a decreasing prevalence of infectious indications (p = 0.014) coincided with an increasing neoplastic indications (p = 0.001). In the pediatric subgroup, the prevalence of obstructive indications increased (p = 0.002). The logistic regression analyses indicated that the significant factors associated with the changing surgical indications for AT were the age in the adult subgroup and hospital level in the pediatric subgroup.

CONCLUSIONS

This study revealed a low AT rate in Taiwan than that in other countries. Pediatric AT incidence increased during 1997-2010. Although a rising prevalence of obstructive and neoplastic indications was noted, infection remained the most common indications for AT. Age in the adult subgroup and hospital level in the pediatric subgroup were factors associated with the changing indications for AT.

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

Objectives

The purpose of this study is to evaluate the risk of retropharyngeal and parapharyngeal abscesses (deep neck infection) after tonsillectomy in Koreans using national cohort data.

Methods

Using the national cohort study from the Korean Health Insurance Review and Assessment Service, participants who had undergone a tonsillectomy (5,299) and control participants (21,196) were selected and matched 1:4 (for age, sex, income, region of residence, and pre-operative upper respiratory infection visits). The Cox-proportional hazard model was used. A crude model and an adjusted model for age, sex, income, region of residence, hypertension, diabetes, and dyslipidemia were used in this analysis. For the subgroup analyses, the participants were divided into 2 groups: children (≤ 14 years old) and adolescents and adults (≥ 15 years old).

Results

The adjusted hazard ratio of deep neck infection after tonsillectomy was 1.43 (95% confidence interval, CI = 1.18–1.72, P < 0.001). In subgroup analysis, this ratio was 1.12 (95% CI = 0.86–1.47, P = 0.390) in children and 1.87 (95% CI = 1.43–2.45, P < 0.001) in adolescents and adults. The crude hazard ratios were almost the same as the adjusted ratios.

Conclusion

The risk of deep neck infection was higher in the tonsillectomy group. The subgroup analysis showed a similar finding in the adolescent and adult group but not in the child group.

Relation Between the Type of Hospitals and the Decision of Adenotonsillectomy Indication

OBJECTIVE

This study aims to apply tonsillectomy criteria, symptoms and outcomes proposed in earlier studies to investigate patients who were given tonsillectomy indications at different clinical centers but were treated in our clinical center.

METHODS

The prospective sample of patients at the ear, nose, and throat clinic within our hospital consisted of 855 male patients and 684 female patients (1539 in total) with ages between 3 and 16 years old who had been given a tonsillectomy or adenotonsillectomy indication. The patients were allocated to 1 of 3 groups, depending on whether they had been treated in a public hospital, a private hospital, or a university/training research hospital.

RESULTS

Of the total of 1539 patients, tonsillectomy indication criteria were exhibited by 966 of them (62.8%) but were absent in the rest of 573 patients (37.2%). Most of the 966 patients with tonsillectomy indication criteria had been treated in private hospitals (n = 546; 56.5%), while the others were treated in public hospitals (n = 309; 31.9%) or in university/training research hospitals (n = 111; 15.9%). Furthermore, the majority of the 966 patients (84.1%) received the tonsillectomy indication in just 1 examination, while some of them (n = 154; 15.9%) received it after follow-up appointments.

CONCLUSION

Tonsillectomy decisions can pose difficulties for ear, nose, and throat specialists. Therefore, such decisions should be made based on assessment of clinical evaluation and follow-up, information from patients' parents, and the results of examination against the criteria outlined in the literature.

Tonsillectomy-Comparative Study of Various Techniques and Changing Trend

Tonsillectomy is a major surgical procedure in terms of volume in the general otolaryngological practice. It is a 3000-year-old surgical operation, referred in Hindu medicine. There has been a conceptual change in the indications and surgical technique in the last 40 years. A comparative study between the various methods of tonsillectomy was done. The study was carried out in the single institutional set up by the same surgeon but using different techniques. The study aimed at comparing the intra-operative factors (blood loss, time taken for surgery), postoperative results (pain, bleeding, dehydration, time taken for complete healing), and other complications like vomiting and hospitalization time between different groups of surgical methods. This study was done in 2500 patients undergoing tonsillectomy with or without adenoid removal in a period of 35 years (1979-2013). The majority of the patients (approximately 41%) in the first half of this period underwent cold steel tonsillectomy whereas 39% underwent microdebrider assisted tonsillectomy. Microdebrider assisted tonsil surgery was done as day care procedure in 90%. In 21% of the patients, other methods viz coblation, radio frequency and laser were used. Microdebrider intracapsular tonsillectomy is associated with lower mortality and morbidity as compared to cold steel, coblation, electrodissection, laser and radio frequency.

Effectiveness of an add-on treatment with the homeopathic medication SilAtro-5-90 in recurrent tonsillitis: An international, pragmatic, randomized, controlled clinical trial

OBJECTIVE

To investigate the effectiveness and safety of the homeopathic product SilAtro-5-90 in recurrent tonsillitis.

METHODS

In this international, pragmatic, controlled clinical trial, 256 patients (6-60 years) with moderate recurrent tonsillitis were randomized to receive either SilAtro-5-90 in addition to standard symptomatic treatment, or to receive standard treatment only. The primary outcome was the mean time period between consecutive acute throat infections (ATI) within 1 year (analyzed via repeated events analysis).

RESULTS

During the evaluation year, the risk of getting an ATI was significantly lower (hazard ratio: 0.45, proportional means model, p = 0.0002, ITT) with SilAtro-5-90 compared to control. Tonsillitis-specific symptoms were significantly reduced (p < 0.0001, ITT) and the need of antibiotics to treat acute throat infections (p = 0.0008; ITT) decreased. 3 non-serious adverse drug reactions were reported for SilAtro-5-90.

CONCLUSIONS

An integrative treatment approach where SilAtro-5-90 is given alongside mainstream symptomatic treatment may bring therapeutic benefit to patients suffering from recurrent tonsillitis.

TRIAL REGISTRATION

ISRCTN registry: Registration number ISRCTN19016626, registered 23 January 2013.

Decreased clinic visits for acute respiratory infections following an adult tonsillectomy: A population-based study

PURPOSE

This study attempted to investigate the effects of a tonsillectomy on utilization of medical resources for acute respiratory infections by comparing numbers and costs of clinic visits within 1year before and after a tonsillectomy.

MATERIALS AND METHODS

Data for this study were retrieved from the Taiwan Longitudinal Health Insurance Database 2005. The study includes 481 patients aged 18-80years who underwent a tonsillectomy and 481 comparison patients. A multivariate regression model employing difference-in-difference was carried out to assess the independent association between a tonsillectomy and the number and costs of clinic visits.

RESULTS

We found that for patients who underwent a tonsillectomy, the mean number of clinic visits for acute respiratory care 1year before and after the index date significantly decreased from 7.3 to 4.2 (p<0.001). However, for the comparison group, there was no significant difference in the number (p=0.540) or costs (p=0.221) of clinic visits for acute respiratory care 1year before and after the index date. A multivariate regression model revealed that a tonsillectomy was associated with a reduction of 3.38 in the mean number of clinic visits for acute respiratory care (p<0.001). In other words, a tonsillectomy reduced by 46.3% (3.38/7.3) the number of clinic visits for acute respiratory care after adjusting for sociodemographic characteristics and medical comorbidities compared to comparison patients.

CONCLUSIONS

This study demonstrated that a tonsillectomy was of substantial benefit to adult patients in that it provides decreased healthcare utilization for acute respiratory infections.

Postoperative Bleeding and Associated Utilization following Tonsillectomy in Children

Objective To assess posttonsillectomy hemorrhage (PTH), associated nonoperative readmissions/revisits, and reoperations in children. Data Sources MEDLINE, EMBASE, and the Cochrane Library. Review Methods Two investigators independently screened studies against predetermined criteria and extracted key data. Investigators independently assessed study risk of bias and the strength of the evidence of the body of literature. We calculated unadjusted pooled estimates of PTH frequency and conducted a Bayesian meta-analysis to estimate frequency of primary and secondary PTH and PTH-associated reoperation and revisits/readmissions by partial and total tonsillectomy and surgical approach. Results In meta-analysis, the frequency of primary and secondary PTH associated with total and partial tonsillectomy was <4% for any technique and with overlapping confidence bounds. Pooled frequencies of PTH were also <5% overall (4.2% for total tonsillectomy, 1.5% for partial tonsillectomy) in comparative studies. Fewer PTH episodes occurred with tonsillectomy for obstructive sleep-disordered breathing than for throat infection. In meta-analysis, frequency of PTH-associated nonoperative revisits/readmission or reoperation ranged from 0.2% to 5.7% for total tonsillectomy and from 0.1% to 3.7% for partial tonsillectomy. At least 4 deaths were reported in case series including 1,778,342 children. Conclusions PTH occurred in roughly 4% of tonsillectomies in studies included in this review. Although studies typically did not report bleeding severity or amount, relatively few episodes of PTH necessitated reoperation for hemostasis. Nonetheless, tonsillectomy is not without risk of harm. Frequency of PTH across techniques was similar; thus, we cannot conclude that a given technique is superior.

Prevalence of M75 Streptococcus pyogenes Strains Harboring slaA Gene in Patients Affected by Pediatric Obstructive Sleep Apnea Syndrome in Central Italy

Recently we reported an association between pediatric obstructive sleep apnea syndrome (OSAS) and Group A streptococcus (GAS) sub-acute chronic tonsil colonization. We showed that GAS may contribute to tonsil hyperplasia via a streptolysin O (SLO)-dependent cysteinyl leukotrienes (CysLTs) production, which can trigger T and B cell proliferation. In the present study, we characterized the GAS strains isolated from pediatric OSAS patients in comparison with a panel of age and sex matched GAS strains unrelated to OSAS, but isolated in the same area and during the same period ranging from 2009 to 2013. We found that slaA gene, previously reported to be associated to CysLTs production pathway, was significantly associated to GAS OSAS strains. Moreover, the most numerous group (32%) of the GAS OSAS strains belonged to M75 type, and 6 out of 7 of these strains harbored the slaA gene. Multilocus Sequence Typing (MLST) experiments demonstrated that the clone emm75/ST49/ smeZ, slaA was associated to OSAS cases. In conclusion, we found an association between slaA gene and the GAS OSAS strains, and we showed that the clone emm75/ST49 harboring genes smeZ and slaA was exclusively isolated from patients affected by OSAS, thus suggesting that this genotype might be associated to the pathogenesis of OSAS, although further studies are needed to elucidate the possible role of SlaA in tonsil hypertrophy development.