Specified data for tonsil surgery in Germany

Complications of canine tonsillectomy by clamping technique combined with monopolar electrosurgery - a retrospective study of 39 cases

Background

Canine tonsillectomy is performed due to acute or chronic tonsillitis, neoplasia, trauma or occasionally brachycephalic obstructive airway syndrome. Several tonsillectomy techniques are used but information about surgical complications is scarce. This retrospective study of patient records at the University Animal Hospital aimed to investigate complications related to canine tonsillectomy performed by 20-min clamping combined with monopolar electrosurgery.

Inclusion criteria were bilateral tonsillectomy performed with “20-min clamping technique combined with monopolar electrosurgery without suture or ligation”. Exclusion criteria were unilateral tonsillectomy, tonsillar neoplasia, additional surgical procedures other than tonsillectomy, cases where sutures were used initially, and cases where unspecified or other methods of tonsillectomy were used. The search of the patient records of the University Animal Hospital included a 10-year period. Complications that required additional anaesthesia were defined as major complications. Minor complications were handled during surgery or after surgery without surgical intervention.

Results

Of 39 dogs that fulfilled the inclusion criteria, 11 dogs had complications and out of those 1 dog had two complications. Altogether, of the 12 complications, 2 were classified as major complications and 10 as minor.

The most frequent complication was bleeding from the surgical site, in total 11 incidences; 10 dogs had an incidence of bleeding and out of those, 1 dog bled twice, both during and after surgery. Of these 10 dogs that bled, seven incidences of bleeding occurred during surgery and four incidences occurred after surgery. The two dogs with major complications were re-anaesthetized due to bleeding after surgery. No lethal complications occurred and all dogs survived to discharge.

Conclusions

Bleeding during and after surgery was a common complication in dogs after bilateral tonsillectomy using “20-min clamping technique combined with monopolar electrocautery”. Revision intervention was often needed, sometimes urgently. Although no comparison was made with another technique, the studied technique should be used with caution.

Impact of the COVID-pandemic on the incidence of tonsil surgery and sore throat in Germany

Purpose

To longitudinally evaluate the impact of the COVID-19-pandemic on the incidence of inpatient tonsil surgery and outpatient primary care of sore throat in Germany.

Methods

A retrospective interrupted time-series analysis was conducted. The national database of the Hospital Remuneration System was used to retrieve the number of operations performed between January 2019 and September 2021 including elective and non-elective cases with the exception of malign diseases. Three episodes were compared on a weekly basis: before, during, and after the first national lockdown (March 16–May 3, 2020). We also analysed the number of outpatient doctor contacts of sore throat patients in 2019 and 2020.

Results

Overall, 144,069 surgical cases were included in the analysis. The first lockdown resulted in an abrupt and significant decrease of all types of tonsil surgery (p < 0.01). The incidence of tonsillectomy decreased from 556 (before) to 111 (during) and 326 (after) cases per week (relative risk 0.24; 95% CI 0.19–0.30, and 0.82; 95% CI 0.73–0.92). After the lockdown, the incidence persisted on a lower level compared to 2019. The number of doctor contacts decreased from 2,967,322 in 2019 to 1,976,617 in 2020 (− 33.4%).

Conclusions

The first lockdown was associated with a significant decrease of all types of tonsil surgery. A return to pre-pandemic surgical activity was not identified. The findings were accompanied by a significant decrease of outpatient doctor contacts of sore throat patients in primary care, particularly in the subgroup of children and adolescents. The impact of the second lockdown, starting in December 2020, was by far not comparable.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00405-022-07308-8.

Effect of erythritol and xylitol on Streptococcus pyogenes causing peritonsillar abscesses

Polyols are effective against caries-causing streptococci but the effect on oropharynx-derived pyogenic streptococci is not well characterised. We aimed to study the effect of erythritol (ERY) and xylitol (XYL) against Streptococcus pyogenes isolated from peritonsillar abscesses (PTA). We used 31 clinical isolates and 5 throat culture collection strains. Inhibition of bacterial growth by polyols at 2.5%, 5% and 10% concentrations was studied and the results were scored. Amylase levels in PTA pus were compared to polyol effectivity scores (PES). Growth curves of four S. pyogenes isolates were analysed. Our study showed that XYL was more effective than ERY inhibiting 71–97% and 48–84% of isolates, respectively, depending of concentrations. 48% of clinical and all throat strains were inhibited by polyols in all concentrations (PES 3). PES was negative or zero in 26% of the isolates in the presence of ERY and in 19% of XYL. ERY enhanced the growth of S. pyogenes isolated from pus with high amylase levels. Polyols in all concentrations inhibited the growth in exponential phase. In conclusion, ERY and XYL are potent growth inhibitors of S. pyogenes isolated from PTA. Therefore, ERY and XYL may have potential in preventing PTA in the patients with frequent tonsillitis episodes.

Silent Infection of B and CD8+ T Lymphocytes by Influenza A Virus in Children with Tonsillar Hypertrophy

Influenza A viruses (IAVs) cause more than 2 million annual episodes of seasonal acute respiratory infections (ARI) and approximately 500,000 deaths worldwide. Depending on virus strain and host immune status, acute infections by IAV may reach sites other than the respiratory tract. In the present study, IAV RNA and antigens were searched for in tissues of palatine tonsils and adenoids removed from patients without ARI symptoms. A real-time reverse transcriptase PCR (RT-PCR) screening revealed that 8 tissue samples from 7 patients out of 103 were positive for IAV. Positive samples were subjected to next-generation sequencing (NGS) and 3 of 8 tissues yielded complete IAV pH1N1 genomes, whereas in 5 samples, the PB1 gene was not fully assembled. Phylogenetic analysis placed tonsil-derived IAV in clusters clearly segregated from contemporaneous Brazilian viruses. Flow cytometry of dispersed tissue fragments and serial immunohistochemistry of paraffin-embedded sections of naturally infected biopsies indicated that CD20⁺ B lymphocytes, CD8⁺ T lymphocytes, and CD11c⁺ cells are susceptible to IAV infection. We sought to investigate whether these lymphoid tissues could be sites of viral replication and sources of viable virus particles. MDCK cells were inoculated with tissue lysates, enabling recovery of one IAV isolate confirmed by immunofluorescence, reverse transcriptase quantitative PCR (RT-qPCR), and NGS. The data indicate that lymphoid tissues not only harbor expression of IAV proteins but also contain infectious virus. Asymptomatic long-term infection raises the possibility of IAV shedding from tonsils, which may have an impact on host-to-host transmission.IMPORTANCE Influenza A virus (IAV) infections are important threats to human health worldwide. Although extensively studied, some aspects of virus pathogenesis and tissue tropism remain unclear. Here, by different strategies, we describe the asymptomatic infection of human lymphoid organs by IAV in children. Our results indicate that IAV was not only detected and isolated from human tonsils but displayed unique genetic features in comparison with those of contemporaneous IAVs circulating in Brazil and detected in swabs and nasal washes. Inside the tissue microenvironment, immune cells were shown to be carrying IAV antigens, especially B and T CD8⁺ lymphocytes. Taken together, these results suggest that human lymphoid tissues can be sites of silent IAV infections with possible impact on virus shedding to the population.

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.

Do changing trends in tonsil surgery affect hemorrhage rates? A longitudinal study covering 1,452,637 procedures

PURPOSE

To evaluate whether changing trends in tonsil surgery between 2005 and 2017 in Germany were associated with different age- and gender-specific hemorrhage rates.

METHODS

A longitudinal population-based inpatient cohort study was performed including all patients who had undergone tonsillectomy (with or without adenoidectomy), tonsillotomy, abscess-tonsillectomy, removal of tonsillar remnants and surgical treatment to achieve hemostasis following tonsil surgery. The population was stratified by age (groups of 5 years) and gender. Operation rates were calculated in relation to the end-year population number according to the German Federal Office of Statistics.

RESULTS

The surgical rates per 100,000 had significantly decreased from 170.39 to 90.95 (46.62%) in female patients and from 147.33 to 88.19 (40.14%) in male patients within the study period (p < 0.001). A total of 42.352 female patients had required surgical treatment to achieve hemostasis following 783,005 procedures (5.41%). In contrast, only 669,632 operations were performed in male patients but were complicated by hemorrhage in 51.185 cases (7.64%) which was significantly different (p < 0.001). The male-to-female ratio of the surgical rates had increased from 0.86:1 to 0.93:1. Hemorrhage rates differed significantly between age groups (p < 0.001). Male gender is a significant risk factor for bleeding at all ages < 85 years with greatest differences in 20- to 25-year-old patients (12.19% male vs. 6.26% female).

CONCLUSIONS

Changing trends in tonsil surgery are not associated with increased rates of bleeding complications. Hemorrhage following tonsil surgery is significantly related to age and gender and this should be noted when reported hemorrhage rates in the literature are appraised by the reader.

Hospital admissions for acute throat and deep neck infections versus tonsillectomy rates in Germany

PURPOSE

To evaluate trends in hospital admissions in Germany for acute infections of the upper airway and deep neck in the context of the number of tonsil-related surgical procedures between 2005 and 2017.

METHODS

A retrospective longitudinal population-based cohort study was performed including all unplanned admissions for acute pharyngitis/tonsillitis, abscess formation of the peritonsillar or retropharyngeal/parapharyngeal space. Elective procedures included tonsillectomy (with or without adenoidectomy), secondary tonsillectomy, and tonsillotomy. Emergency operations encompassed abscess-tonsillectomy and transoral drainage procedures of the peritonsillar/parapharyngeal/retropharyngeal space.

RESULTS

553.600 admissions were registered in total with a significant, stepwise increase between 2005 and 2017, including retropharyngeal/parapharyngeal abscess (47.0%), acute tonsillitis (30.8%), acute pharyngitis (26.5%) and peritonsillar abscess (7.9%). There were 1.323.984 elective operations with a significant decrease during the study period. A total of 188.316 emergency operations were done, a significant decrease in the number of abscess-tonsillectomies was compensated by the increased number of transoral peritonsillar abscess drainages. The number of transoral parapharyngeal and retropharygeal abscess drainage procedures did not change significantly (p = 0.846; p = 0.846). Negative correlation was significant between admissions for chronic tonsillitis and emergency admissions (Pearson correlation coefficient = - 0.879, p < 0.001) and also between elective and emergency operations (r = - 0.667; p = 0.013).

CONCLUSIONS

Concerning infections of the upper airway and deep neck spaces, German Hospitals have to prepare strategies for the increasing challenge by unplanned admissions and emergency operations. Further research is required to clarify whether this phenomenon is caused by the significant decrease in the number of elective operations.

Peritonsillar abscess is frequently accompanied by sepsis symptoms

PURPOSE

To evaluate how many patients with peritonsillar abscess (PTA) fulfill sepsis criteria and if there is any difference in risk factors and treatment results between patients with and without sepsis symptoms. We also aimed to evaluate the utility of several clinical and laboratory markers for diagnosing PTA.

METHODS

Study group consisted of 92 patients with PTA undergoing bilateral emergency tonsillectomy. Blood samples, pus samples and clinical data were collected. Patients were evaluated for sepsis criteria based on 2001 International Sepsis Definitions Conference.

RESULTS

Sepsis diagnostic criteria were fulfilled in half of patients (51.1%). Smokers (p = 0.016) and patients who had not received antibiotic treatment (p = 0.003) had more sepsis symptoms. Procalcitonin levels were moderate and there was no difference between the groups. In majority of the patients, the pus samples contained undetectable or mild levels of amylase while 12 patients had pus amylase at least twice higher than in blood serum and among them, the levels were remarkably high in 9 patients.

CONCLUSION

Half of the patients with PTA meet the diagnostic criteria for sepsis. The risk factors for the latter include current smoking and not receiving antibiotic treatment before hospitalization. PTA treatment outcome does not differ between the patients with and without sepsis clinical picture in case of surgical treatment. C-reactive protein appears to be better diagnostic marker for PTA than procalcitonin. A portion of the PTA patients have remarkably high amylase level in the pus indicating possible association with Weber's salivary glands infection.

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.