Tonsillitis and sore throat in children

Prevalence of Acute Tonsillitis and Its Association With Oral Hygiene Among the Population of Taif City, Saudi Arabia

Introduction  Dental surfaces have dense bacterial deposits, and poor oral hygiene can exacerbate bacterial infections, causing acute tonsillitis. The study aims to quantify acute tonsillitis prevalence and assess its association with oral hygiene practices. Methods  A descriptive cross-sectional study aimed to assess the prevalence of acute tonsillitis and its association with oral hygiene was conducted among adults aged 20 and above in Taif City, Saudi Arabia. Illiterates and those unwilling to participate were excluded. We employed an Arabic online self-administered questionnaire that was disseminated conveniently via Google Forms to social media assessing oral hygiene such as last dental visit, age at starting dental care, number of toothbrushes per day, frequency of toothbrush change, and duration of brushing teeth, and acute tonsillitis characteristics of the participants. Results About 393 participated in the study. Of them, 54% were aged 20-30, 53% were males, and 70% had a university education. The prevalence of acute tonsillitis was 64%. Approximately 28% reported dental clinic visits within three months, and 21% initiated oral hygiene practices at age 20. Among participants, 43% brushed twice daily, with 33% spending one minute and 43% two minutes. About 31% replaced toothbrushes every three months, while 23% acknowledged having bad breath. Experiencing bad breath, changing toothbrushes every three months, and having dental visits within less than three months were associated with having acute tonsillitis (p<0.05). However, regression analysis revealed that experiencing bad breath (OR: 2.11, 95% CI: 1.23, 3.70) was associated with a higher risk of acute tonsillitis, while less frequent toothbrush changes correlated with a lower risk (OR: 0.54, 95% CI: 0.30, 0.94). Conclusion  This study revealed a substantial prevalence of acute tonsillitis among adults in Taif City. Oral care practices need improvement. There are significant associations between oral hygiene practices, bad breath, and the occurrence of acute tonsillitis. Addressing oral hygiene practices could be a key focus for preventative measures.

Bacteriology of Adenoids and Tonsils in Children With Recurrent Adenotonsillitis

INTRODUCTION

Recurrent adenotonsillitis (AT) commonly affects children and may be associated with various complications. Infections are common etiology, and microbial profiles may vary widely in different cases. In this study, we evaluated the bacterial profile and antibiotic sensitivity of pathogens identified in tonsil and adenoid core cultures in children with recurrent AT.

METHODS

In this cross-sectional, observational study, culture and antibiotic sensitivity were performed from tonsil and adenoid core samples obtained after adenotonsillectomy of children (5 to 18 years) with recurrent AT. Children who had received antibiotics within one week before surgery were excluded. Drug sensitivity was performed only for drugs available on the hospital panel list.

RESULTS

Bacterial growth was observed in 83 (91.2%) tonsil core cultures (n=91) and 43 (79.6%) adenoid core cultures (n=54). In the tonsil and adenoid core cultures, poly-microbial growth was seen in 25 (27.0%) and 11 (25.6%) children, respectively. From the tonsil core cultures, the majority of the bacteria were sensitive to ciprofloxacin, ampicillin, piperacillin-tazobactam, cefoperazone-sulbactam, ceftazidime, cefotaxime, levofloxacin. From the adenoid core culture, the majority of the bacteria were sensitive to ciprofloxacin, ampicillin, piperacillin-tazobactam, cefoperazone-sulbactam, cephalexin, and cefotaxime.

CONCLUSION

In recurrent AT, polymicrobial growth is not uncommon in both tonsil and adenoid core cultures. Identifying the correct pathogens and their antibiotic sensitivity patterns can help plan treatment strategies for the effective management of recurrent AT.

The Effect of Chitohem Bleeding Inhibitor Powder on Pain and Bleeding After Tonsillectomy by Suturing Method

Study Design and Objectives: This study aimed to investigate Triamcinolone ointment's effect on pain and bleeding after tonsillectomy by suturing method. Methods: The present study was performed as a single-blind clinical trial on 200 patients who underwent a total tonsillectomy in the ENT department of Loghman Hakim Hospital in Tehran during 2016. Candidates for total tonsillectomy were randomized into 2 groups one by one. Participants were randomly divided into 2 groups. Both groups matched homologically. Patients in both groups (intervention and control) underwent cold dissection total tonsillectomy. In addition to suturing, in the intervention group, Triamcinolone ointment was used to control the local bleeding at the surgical site. In the control group, only sutures were used to control bleeding. The studied variables included: bleeding and pain 24 hours after surgery, Time to start oral feeding. Result: The frequency of bleeding cases in the first 24 hours are included: 4 patients (5.63%) in the intervention group and 6 patients (8.45%) in the control group (P = 0.01). The average time to start eating for patients who were treated with topical triamcinolone ointment was significantly less than those who were not treated with this ointment. Only 2 patients (2.77%) in the intervention group took analgesics in the first 24 hours after surgery, while and 11 patients (15.3%) in the control group received analgesics in the same time period. Conclusion: In general, the results of this study showed that the use of Triamcinolone ointment in total tonsillectomy could reduce bleeding, analgesics usage, and the time of feeding onset.

The Association between Adenotonsillectomy and Frequency of Vaso-Occlusive Crises in Patients with Sickle Cell Disease

Sickle cell disease (SCD) typically manifests in early childhood as attacks of pain known as vaso-occlusive crises. Infection and hypoxemia have been linked with these recurrent episodes and with prolonged hospitalization in SCD patients. However, adenoids and tonsils as sources of infection and causes of hypoxemia have not been adequately investigated in association with vaso-occlusive crises in SCD. To assess the association between adenotonsillectomy and frequency of vaso-occlusive crisis in SCD patients who underwent this procedure at our Hospital, and between adenotonsillectomy and frequency of blood transfusions and emergency department and intensive care unit admissions. We used medical record data to conduct a retrospective review of SCD patients who underwent adenoidectomy and/or tonsillectomy between 2005 and 2017. Eligible subjects were assessed for frequency of vaso-occlusive crises, blood transfusions, and emergency department and intensive care unit admissions. Using the Wilcoxon signed rank test, we compared the frequencies of each outcome preoperatively and 1, 3, 5, and 10 years postoperatively. Of 524 records reviewed, 40 eligible patients were included in the study. Minimal reduction was observed in the frequency of vaso-occlusive crisis episodes within 1 and 3 years after adenotonsillectomy (p = 0.337 and p = 0.549, respectively). Although the 5- and 10-year postoperative vaso-occlusive crisis frequency tended to be higher than that in the preoperative period, none of the results reached statistical significance. The number of emergency department admissions showed a statistically significant increase 3 years postoperatively compared with that in the preoperative period (P = 0.043). There were no statistically significant differences in perioperative blood transfusion frequency or number of intensive care unit admissions in any period. Adenotonsillectomy in SCD patients does not seem to be related to the frequency of vaso-occlusive crises, blood transfusions, or emergency department or intensive care unit admissions. Prospective studies with larger sample sizes are recommended to further evaluate these findings.

Differential Effects of Toll-Like Receptor Signaling on the Activation of Immune Responses in the Upper Respiratory Tract

Vaccination through the upper respiratory tract (URT) is highly effective for the prevention of respiratory infectious diseases. Toll-like receptor (TLR)-based adjuvants are immunostimulatory and considered potential adjuvant candidates. However, the patterns of immune response to different TLRs at the URT have not been revealed. In this study, SPF mice were preexposed to TLR agonists intranasally to simulate the status of humans. Inflammatory response to TLR agonists and TLR signal-mediated adaptive immune responses were analyzed. The results revealed that similar to human tonsils, inflammatory response to stimulation with TLR4 or TLR2 agonist was attenuated in agonist-exposed mice but not in mice without this exposure. In contrast, TLR9 or TLR3 agonist preexposure did not affect the inflammatory response to restimulation by matching agonists. For the adaptive immune response, after agonist preexposure the antibody response to antigens adjuvanted with TLR4 or TLR2 agonist was substantially restricted, whereas, both antibody and T cell responses to antigens adjuvanted with TLR9 or TLR3 agonist were activated as robustly as in mice without agonist exposure. Moreover, we demonstrate that the mechanisms underlying the differential activation of TLRs are regulated at the level of TLR expression in innate and adaptive immune cells. These results indicate that TLRs on the cell surface (TLR4 and 2) and in the endolysosomal compartments (TLR9 and 3) display distinct immune response patterns. The findings provide important information for the use of TLR agonists as mucosal adjuvants and enhance our understanding of immune responses to bacterial and viral infections in the respiratory mucosa. IMPORTANCE Agonists of TLRs are potential adjuvant candidates for mucosal vaccination. We demonstrated that the TLR-mediated inflammatory and antibody responses in the URT of SPF mice exposed to extracellular TLR agonists were substantially restricted. In contrast, inflammatory and adaptive immune responses, including B and T cell activation, were not desensitized in mice exposed to intracellular TLR agonists. The distinct responsive patterns of extra and intracellular TLRs regulated at TLR expression in immune cells. The results indicated that TLRs differentially impact the innate and adaptive immune response in the URT, which contributes to the selection of TLR-based mucosal adjuvants and helps understand the difference between the immune response in bacterial and viral infections.

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.

A randomized, open-label, multicentre, comparative study of therapeutic efficacy, preventive potential and tolerability of BNO 1030 extract, containing Althea root, Chamomile flowers, horsetail herb, walnut leaves, yarrow herb, oak bark, dandelion herb in the treatment of acute non-bacterial tonsillitis in children aged 6 to 18 years

Abstract

Acute tonsillitis tends to recur. In cases where patients do not meet the Paradise criteria, the possibilities of non-surgical treatment are more often considered. The objective of this study was to evaluate the therapeutic efficacy during the long-term follow-up and the effect on the recurrence of the phytoneering extract BNO 1030 (Imupret®) in patients with acute non-bacterial tonsillitis.

Methods

In this Randomized, Open-Label, Multicentre, Comparative Study, 238 outpatients aged 6–18 years were randomized to receive either BNO 1030 (Imupret®) for 4 weeks in addition to standard symptomatic treatment, or to receive standard treatment. Evaluation criteria: reduction in the symptom severity less than 1 point, the number of tonsillitis recurrences at each control point after 3, 6 and 12 months during the one-year follow-up.

Results

A significant reduction in the severity of local symptoms and the general condition at each control point within the year of follow-up and a significant decrease (by 66.56%) in the recurrence rate of tonsillitis were noted. The anti-recurrent action was manifested during within the year of follow-up. All patients tolerated phytotherapy well; no adverse reactions were noted.

Conclusions

BNO 1030 (Imupret®) is a safe and effective medicinal product for acute non-bacterial tonsillitis in children aged 6–18 years. In addition to the main symptomatic treatment, it leads to a significant reduction in the clinical manifestations and the number of recurrences of tonsillitis within the year of follow-up.

Trial registration

This trial was registered in German Clinical Trials Register retrospectively on June 27, 2018.

Trial Acronym: ATi-1

DRKS-ID: DRKS00015020

Direct and Indirect Costs of Non-surgical Treatment for Acute Tonsillitis in Children in Southeast Nigeria

BACKGROUND

Acute tonsillitis has become one of the main reasons why children visit healthcare facilities in Nigeria. Presently, there is no information on the costs of its treatment, and this study aimed at determining these costs.

METHODS

The study was conducted in two hospitals located in southeast Nigeria. The information was obtained in two ways: (1) retrospectively from the medical records of children treated for acute tonsillitis over a period of 5 years and (2) cross-sectionally from children who presented with complaints of acute tonsillitis over a period of 7 months. The information obtained was the costs of self-medication and hospital treatment, and the payment mechanisms used to settle these costs. The human capital method approach was used to estimate the indirect cost (loss in productivity) from the caregivers' absenteeism from work.

RESULTS

The mean costs of self-medication and hospital treatment for acute tonsillitis in children were €3.85 and €13.48, respectively. The indirect cost was €11.31. The mean total cost of treatment of acute tonsillitis was €23.80. The proportion of households that suffered catastrophic health expenditure (CHE) from the treatment of acute tonsillitis was 55 (55%). CHE was highest [22 (91.7%)] in the lowest socio-economic quartile compared to households in the highest quartile [4 (16.7%)], and the difference was statistically significant (p = 0.02). Of the 72 participants whose payment mechanisms were documented, the proportion who paid out of pocket was 53 (73.6%), and 19 (26.4%) used the National Health Insurance Scheme.

CONCLUSION

The costs of treatment for children with acute tonsillitis were high, and most of these costs were settled out-of-pocket. The costs for laboratory investigations, drugs, and productivity loss contributed to these high costs. There is a need to cover the costs of non-surgical treatment of acute tonsillitis in social health insurance and improve efforts to increase the coverage of the health insurance scheme.

Knowledge and Awareness Among Parents of Pediatric Patients Regarding the Complications of Recurrent Adenotonsillitis and Its Surgical Treatment

Background Given that parents act as both decision-makers and caregivers for their children, focusing on their experiences in managing their child's complex postoperative recovery is important. Objective To evaluate the parents' awareness regarding adenotonsillar diseases and post-adenotonsillectomy complications in their children. Methods This was a cross-sectional descriptive study involving parents and guardians of pediatric patients aged 1-14 years scheduled to undergo adenotonsillectomy according to Paradise Criteria at Ohud Hospital, Al Madinah. A well-constructed, self-administered questionnaire, including questions regarding sociodemographic characteristics and those assessing the knowledge of parents/guardians regarding adenotonsillar diseases and post-adenotonsillectomy complications, was distributed to all participants. Results This study included 294 parents (mean ± standard deviation of age, 33.0 ± 6.9 years; range, 18 and 55 years), more than half of whom were males (153, 52%). Overall, 127 parents (43.2%) had a poor level of knowledge regarding the complications of recurrent adenotonsillitis and its surgical treatment. University/postgraduate parents were more knowledgeable than lower educated parents (p < 0.001). Participants with a family history of recurrent adenotonsillectomy were more knowledgeable than those who had no such history (p < 0.001 ). Conclusion The parents/guardians of children scheduled to undergo adenotonsillectomy had insufficient knowledge regarding the complications of recurrent adenotonsillitis and its surgical treatment, necessitating health education among such a demographic.

Increased levels of S100A8/A9, IL-1ß and IL-18 as a novel biomarker for recurrent tonsillitis

Background

Acute tonsillitis represents one of the most frequent reasons patients seek primary medical care and otorhinolaryngology consultation. Therefore, recurrent episodes of acute tonsillitis (RAT), also called chronic tonsillitis, exhaust a substantial amount of medical and financial resources. Diagnosis of tonsillitis depends on a physical examination, which therefore does not allow for a reliable differentiation between viral and bacterial infection. However, the frequency of bacterial infections during the previous three years is currently being used as the major deciding factor in patient selection for tonsillectomy. The aim of the present study was to determine an objective biomarker to help in the identification of patients suffering from recurrent tonsillitis.

Results

By analyzing a panel of cytokines and chemokines in serum and saliva of patients with RAT compared to healthy controls, increased levels of IL-1ß (153.7 ± 48.5 pg/ml vs 23.3 ± 6.6 pg/ml, p = 0.021), IL-18 (120.2 ± 16.5 vs 50.6 ± 9.3 pg/ml, p = 0.007) and/or S100A8/A9 (996 ± 102 ng/ml vs 546 ± 86 ng/ml, p = 0.042) could be observed in patients suffering from RAT. Cut-off values of these parameters were determined and combined to a new RAT-score allowing for reliable identification of patients suffering from recurrent tonsillitis with a sensitivity of 95% and a specificity of 88%.

Conclusion

The RAT-score represents the first objective criterion as a tool for the diagnosis of recurrent tonsillitis and it also improves patient selection for tonsillectomy.

An Up-to-Date Review on Bio-Resource Therapeutics Effective against Bacterial Species Frequently Associated with Chronic Sinusitis and Tonsillitis

Upper respiratory tract infections include inflammations of the nose, sinuses (sinusitis), pharynx (tonsillitis, pharyngitis) and larynx (laryngitis) with bacteria or viruses as the main cause of these conditions. Due to their repetitive nature, chronic respiratory infections represent a global problem which is often a result of improper treatment. If not treated adequately, these conditions may have serious consequences. On the other hand, mis - and overuse of antibiotics has reduced their efficiency and accelerated the development of resistant bacterial strains, which further complicates the treatment of infections. This literature review will focus on current knowledge regarding medicinal plants and mushrooms which have been traditionally used in the treatment of infections caused by chronic sinusitis and tonsillitis commonly linked to bacteria - Staphylococcus aureus, Streptococcus pneumoniae, Streptococcus pyogenes, Fusobacterium nucleatum, Haemophilus influenzae and Moraxella catarrhalis. The present literature overview might be considered as a starting point for the development of novel, natural antimicrobial products with potential practical use in the treatment of chronic tonsillitis and sinusitis.

Analysis of Biochemical Parameters in Children with Chronic Tonsillitis

Chronic tonsillitis are frequent in pediatric pathology with numerous involved risk factors and pathogenic mechanisms. In this study, epidemiological data and biochemical values addressed to inflammation and mineral, lipid and hepatic metabolism were analyzed for 37 children of school age with chronic tonsillitis. We found that in the majority of cases, chronic tonsillitis was associated with increasing number of blood circulating inflammatory cells, high values of transaminases, cholesterol, triglycerides and low values of procalcitonin, C-reactive protein, calcium, vitamin D and serum iron. The results indicated relations of the biochemical profile analyzed with risk factors and systemic mechanisms for initiation and maintenance of chronic tonsillitis, aspects that can be used to optimize the prognosis of chronic tonsillitis in children.

Difensil Immuno Reduces Recurrence and Severity of Tonsillitis in Children: A Randomized Controlled Trial

Oral supplements (OS) support the immune system in fighting upper airways infection. This study aimed to analyze the effect of Difensil Immuno (DI) on the recurrence of tonsillitis and fever in children. A multicentric randomized clinical trial was conducted. One-hundred and twenty children with chronic tonsillitis were randomly assigned to group A, B or control. Patients in group A were treated with 10 mL of DI for 90 consecutive days, patients in group B underwent treatment with 15 mL of DI for 45 consecutive days. The following data were collected at baseline (T0), T1 and T2: tonsillitis and fever episodes, tonsillar volume, blood test results. One-way ANOVA was used to analyze within and between variances. Patients in group A and B statistically improved their clinical parameters (episode of tonsillitis and fever, tonsillar volume) when compared to control group both at T1 and T2. However, T1 variances were more consistent in group A than in group B. All patients in the study groups improved their clinical outcomes. No statistically significant variances were observed in blood parameters both at T1 and T2. Our results suggest that children treated with DI had fewer episodes of tonsillitis and fever and a reduction in their tonsillar volume.

Involvement of Vitamin D in Chronic Infections of the Waldeyer`s Ring in the School Aged Child

Chronic infections of the Waldeyer`s lymphatic ring constitute a frequent pathology in school age, one of the pathogenic mechanisms involving low levels of vitamin D. In this study, we analyzed integrated the clinico-epidemiological aspects, the risk factors and the serum level of vitamin D for 51 school aged children who presented chronic inflammation in various levels of the Waldeyer`s ring. Most inflammations were present in females patients (80.4%), from the urban areas (66.6%), being localized in palatine tonsils (64.7%), in patients with deficient prophylaxis of hypovitaminosis D (68.6%) and low serum levels of vitamin D (72.5%). The results highlight the importance of maintaining a normal status of vitamin D, especially in recurrent infectious context.

A NEW TREATMENT MODALITY TO REDUCE ACUTE TONSILLITIS HEALING TIME

BACKGROUND AND OBJECTIVE

Acute tonsillitis is one of the most common reasons for application to otorhinolaryngology clinics. In the treatment of acute tonsillitis, supportive therapies are mostly used. As antibiotic therapy, penicillin or erythromycin can be used. The aim of this study is to decrease the clinical recovery time of acute tonsillitis by providing parenteral treatment and daily cleaning of tonsillar lesions.

MATERIAL AND METHODS

Patients with an age range of 15-60 years were included in the study. The patients were divided into two groups. The first group used an i.v. combination of ampicillin + sulbactam and the tonsillar membranes of patients were cleaned daily. The second group used only the i.v. combination of ampicillin + sulbactam.

RESULTS

Patients who received antibiotherapy and debridement had a clinical improvement of 90% on the 2nd treatment day and 95% on the 5th treatment day. The patients receiving only antibiotics had a clinical improvement of 65% on the 5th treatment day and 75% on the 7th treatment day. The recovery time of both groups was significantly different (p < 0.05).

CONCLUSION

The solution and technique used in this clinical study showed that patients with acute tonsillitis could recover in a very short time without any complications.

Impact of Superantigen-Producing Bacteria on T Cells from Tonsillar Hyperplasia

Staphylococcus aureus and Group A Streptococcus (GAS) are common occupants of the tonsils and many strains produce potent exotoxins (mitogens) that directly target T cells, which could be a driver for tonsillar hyperplasia. Tonsil tissues from 41 patients were tested for these bacteria in conjunction with profiling of B and T cells by flow cytometry. S. aureus and GAS were detected in tonsil tissue from 44% and 7%, respectively, of patients by bacteriological culture; immuno-histology showed bacteria in close proximity to both B and T lymphocytes. The presence of tonsillar S. aureus did not alter B or T cell populations, whereas peripheral blood mucosal-associated invariant T (MAIT) cells were significantly increased in S. aureus culture positive individuals (p < 0.006). Alterations of tonsil CD4⁺ TCR Vβ family members relative to peripheral blood were evident in 29 patients. Three patients had strong TCR Vβ skewing indicative of recent exposure to superantigens, their tonsils contained mitogenic bacteria, and supernatants from these bacteria were used to partially recapitulate the skewing profile in vitro, supporting the notion that superantigens can target tonsillar T cells in situ. Tonsils are a reservoir for superantigen-producing bacteria with the capacity to alter the composition and function of key immune cells.

Chronic tonsillitis and biofilms: a brief overview of treatment modalities

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

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

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

Treatment Challenges of Group A Beta-hemolytic Streptococcal Pharyngo-Tonsillitis

Introduction  Despite its in vitro efficacy, penicillin often fails to eradicate Group A β-hemolytic streptococci (GABHS) from patients with acute and relapsing pharyngo-tonsillitis (PT). Objective  This review of the literature details the causes of penicillin failure to eradicate GABHS PT and the therapeutic modalities to reduce and overcome antimicrobial failure. Data Synthesis  The causes of penicillin failure in eradicating GABHS PT include the presence of β lactamase producing bacteria (BLPB) that "protect" GABHS from any penicillin; the absence of bacteria that interfere with the growth of GABHS; co-aggregation between GABHS and Moraxella catarrhalis; and the poor penetration of penicillin into the tonsillar tissues and the tonsillo-pharyngeal cells, which allows intracellular GABHS and Staphylococcus aureus to survive. The inadequate intracellular penetration of penicillin can allow intracellular GABHS and S. aureus to persist. In the treatment of acute tonsillitis, the use of cephalosporin can overcome these interactions by eradicating aerobic BLPB (including M. catarrhalis), while preserving the potentially interfering organisms and eliminating GABHS. Conclusion  In treatment of recurrent and chronic PT, the administration of clindamycin, or amoxicillin-clavulanic acid, can eradicate both aerobic and anaerobic BLPB, as well as GABHS. The superior intracellular penetration of cephalosporin and clindamycin also enhances their efficacy against intracellular GABHS and S. aureus.

Tonsillectomy Does Not Reduce Upper Respiratory Infections: A National Cohort Study

Objectives

The objective of this study was to compare post-operative visits for upper respiratory infections (URIs) between tonsillectomy and non-tonsillectomy participants (controls).

Methods

Using the national cohort study from the Korean Health Insurance Review and Assessment Service, 1:4 matched (age, sex, income, region, and pre-operative URI visit) tonsillectomy participants (5,831) and control participants (23,324) were selected. Post-operative visits for URI were measured from 1 to 9 years post-op. The equivalence test was used. The margin of equivalence of the difference (Tonsillectomy—Control group group) was set to -0.5 to 0.5.

Results

There was no difference between the tonsillectomy and control group in 1- to 9-year post-op visits (-0.5 < 95% CI of difference < 0.5). URI visits gradually decreased from 5.5/2 years (pre-op) to 2.1/year (at 1 year post-op) and 1.4/year (at 9 years post-op) in both tonsillectomy and control groups. In the subgroup analysis (children Vs adolescent and adults; rare Vs frequent pre-operative URI), there was no difference in the number of post-op visits for URI between the tonsillectomy and control groups (-0.5 < 95% CI of difference < 0.5).

Conclusion

Tonsillectomy does not provide a decrease in the number of post-operative visits for URI, and URI decreased over time whether or not a tonsillectomy was performed.

Self-reported post-operative recovery in children: development of an instrument

RATIONALE, AIMS AND OBJECTIVES

According to the United Nations (1989), children have the right to be heard and to have their opinions respected. Since post-operative recovery is an individual and subjective experience and patient-reported outcome measures are considered important, our aim was to develop and test an instrument to measure self-reported quality of recovery in children after surgical procedures.

METHODS

Development of the instrument Postoperative Recovery in Children (PRiC) was influenced by the Quality of Recovery-24, for use in adults. Eighteen children and nine professionals validated the items with respect to content and language. A photo questionnaire was developed to determine whether the children's participation would increase compared with the text questionnaire. The final instrument was distributed consecutively to 390 children, ages 4-12 years, who underwent tonsil surgery at four hospitals in Sweden.

RESULTS

A total of 238 children with a mean age of 6.5 years participated. According to the parents, 23% circled the answers themselves and 59% participated to a significant degree. However, there was no significant difference in participation between those who received a photo versus a text questionnaire. Psychometric tests of the instrument showed that Cronbach's alpha for the total instrument was 0.83 and the item-total correlations for 22 of the items were ≥0.20.

CONCLUSION

Our results support use of the PRiC instrument to assess and follow-up on children's self-reported post-operative recovery after tonsil operation, both in clinical praxis as well in research.

Clinical practice guideline: tonsillitis I. Diagnostics and nonsurgical management

More than 120,000 patients are treated annually in Germany to resolve repeated episodes of acute tonsillitis. Therapy is aiming at symptom regression, avoidance of complications, reduction in the number of disease-related absences in school or at work, increased cost-effectiveness and improved quality of life. The purpose of this part of the guideline is to provide clinicians in any setting with a clinically focused multi-disciplinary guidance through different conservative treatment options in order to reduce inappropriate variation in clinical care, improve clinical outcome and reduce harm. Surgical management in terms of intracapsular as well as extracapsular tonsillectomy (i.e. tonsillotomy) is the subject of part II of this guideline. To estimate the probability of tonsillitis caused by β-hemolytic streptococci, a diagnostic scoring system according to Centor or McIsaac is suggested. If therapy is considered, a positive score of ≥3 should lead to pharyngeal swab or rapid test or culture in order to identify β-hemolytic streptococci. Routinely performed blood tests for acute tonsillitis are not indicated. After acute streptococcal tonsillitis, there is no need to repeat a pharyngeal swab or any other routine blood tests, urine examinations or cardiological diagnostics such as ECG. The determination of the antistreptolysin O-titer (ASLO titer) and other antistreptococcal antibody titers do not have any value in relation to acute tonsillitis with or without pharyngitis and should not be performed. First-line therapy of β-hemolytic streptococci consists of oral penicillin. Instead of phenoxymethylpenicillin–potassium (penicillin V potassium), also phenoxymethlpenicillin–benzathine with a clearly longer half-life can be used. Oral intake for 7 days of one of both the drugs is recommended. Alternative treatment with oral cephalosporins (e.g. cefadroxil, cefalexin) is indicated only in cases of penicillin failure, frequent recurrences, and whenever a more reliable eradication of β-hemolytic streptococci is desirable. In cases of allergy or incompatibility of penicillin, cephalosporins or macrolides (e.g. Erythromycin-estolate) are valuable alternatives.