What's New with Tubes, Tonsils, and Adenoids?

Evidence-based recommendations are constantly being updated for various pediatric surgical procedures, including the role for tympanostomy tubes, as well as indications for adenoidectomy and tonsillectomy. With a growing body of research available on some of the most prevalent pediatric conditions, an update on the current concepts surrounding management is warranted.

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.

Past and Present Instrument Use in Pediatric Adenotonsillectomy

OBJECTIVE: Examine changing trends/instrument usage for pediatric adenotonsillectomy.

STUDY DESIGN AND SETTING: Survey of 300 members of the American Society of Pediatric Otolaryngology assessing instruments used in adenotonsillectomy currently and over the past 15 years.

RESULTS: A total of 120 surveys were returned. The most common total tonsillectomy instruments for obstruction/infection were: monopolar electrocautery (ME) (53.1%/54.5%) and coblation (CT) (16.0%/16.1%). The most common subtotal tonsillectomy instrument for obstruction/infection was microdebrider (51.4%/30.8%). Over the past 15 years, ME predominated, cold utilization declined, and CT rose. The most common adenoidectomy instruments were ME (25.0%/25.0%), curette with touch-up ME (22.4%/22.4%), and microdebrider with touch-up ME (19.0%/14.7%). Over the past 15 years, curette with touch-up ME predominated early, curette utilization alone declined, and ME, microdebrider, and CT have risen.

CONCLUSION: Pediatric otolaryngologist technique/instrument use for adenotonsillectomy has changed over the past 15 years. This study may be limited by the low survey response rate.

Coblation Adenotonsillectomy: An Improvement Over Electrocautery Technique?

OBJECTIVES: To compare postoperative complication rates of coblation and electrocautery adenotonsillectomies.

STUDY DESIGN: Retrospective chart review.

RESULTS: From January 2000 to June 2004, 1997 pediatric patients underwent adenotonsillectomy. 745 coblation, and 1252 electrocautery tonsillectomies were performed. Primary bleed, secondary bleed, and dehydration were seen in 3, 35, and 23 coblation, and 9, 41, and 64 electrocautery tonsillectomies, respectively. Data analysis revealed no significant difference in primary and secondary hemorrhage rate, but a higher dehydration rate in the electrocautery group ( P = 0.0423). A total of 602 coblation, 763 curette/cautery, and 632 electrocautery adenoidectomies were performed. Neck pain was seen in 0, 17, and 3 patients, respectively. Data analysis showed a higher incidence of neck pain with the curette/cautery technique compared with coblator and cautery techniques ( P = 0.0006 and P = 0.0119, respectively).

CONCLUSIONS: Coblation tonsillectomy had similar rates of primary and secondary hemorrhage when compared with electrocautery tonsillectomy but a lower incidence of postoperative dehydration. Coblation adenoidectomy caused less postoperative neck pain than curette/cautery adenoidectomy without significant advantage over cautery adenoidectomy.

EBM rating: B-3b

[The evolution of adenoidectomy]

The critical analysis of publications concerning methods designed for the surgical treatment of adenoids is presented. Various surgical techniques are considered with special reference to their indications for use, invasiveness, effectiveness, and safety. Recent developments in this field give evidence that evolution of adenoidectomy brought about highly efficacious (up to 99%) mini-invasive and safe surgical procedures producing the minimal risk of relapses and postoperative complications. All these advancements became possible due to the introduction of endoscopic intraoperative control, general anesthesia, and the use of modern surgical instruments. Modern approaches make unnecessary radical removal of the lymphoid tissue.

Variability of adenoidectomy/tonsillectomy rates among children of the Veneto Region, Italy

BACKGROUND

Despite national guidelines in 2003 aimed at limiting the recourse to tonsillectomy and/or adenoidectomy (A/T), the latter are among the most frequent pediatric surgeries performed in Italy. Aim of the study is to investigate variability of A/T rates among children of the Veneto Region, Italy.

METHODS

All discharges of Veneto residents with Diagnosis-Related Groups 57-60 and ICD9-CM intervention codes 28.2 (tonsillectomy), 28.3 (adenotonsillectomy), 28.6 (adenoidectomy) were selected in the period 2000-2006 for a descriptive analysis. A multilevel Poisson regression model was applied to estimate Incidence Rate Ratios (IRR) with 95% Confidence Intervals (CI) for A/T surgery among children aged 2-9 years in 2004-2006, while taking into account clustering of interventions within the 21 Local Health Units.

RESULTS

Through 2000-2006, the overall number of A/T surgeries decreased (-8%); there was a decline of adenoidectomies (-20%) and tonsillectomies (-8%), whereas adenotonsillectomies raised (+18%). Analyses on children aged 2-9 resulted in an overall rate of 14.4 surgeries per 1000 person-years (16.1 among males and 12.5 among females), with a wide heterogeneity across Local Health Units (range 8.1-27.6). At random intercept Poisson regression, while adjusting for sex and age, intervention rates were markedly lower among foreign than among Italian children (IRR = 0.57, CI 0.53-0.61). A/T rates in the 10-40 age group (mainly tonsillectomies) computed for each Local Health Unit and introduced in the regression model accounted for 40% of the variance at Local Health Unit level of pediatric rates (mainly adenoidectomies and adenotonsillectomies).

CONCLUSION

A/T rates in the Veneto Region, especially adenoidectomies among children aged 2-9 years, remain high notwithstanding a decrease through 2000-2006. A wide heterogeneity according to nationality and Local Health Units is evident. The propensity to A/T surgery of each Local Health Unit is similar in different age groups and for different surgical indications.

[Trend changes in the adenotonsillar surgery]

In order to evaluate possible trend changes in the epidemiological factors of adenotonsillar surgery, a total of 1,958 operations performed between 1992 and 2002 were reviewed.

RESULTS

One third of the operations were to remove tonsils in comparison with the two thirds that were to remove adenoids. Three procedures were used: 59% adenoidectomies, 28% adenotonsillectomies and 13% tonsillectomies. During the study period, the percentage of adenotonsillectomies decreased, whereas the number of adenoidectomies increased. In general, this kind of surgery is mainly performed on males.

CONCLUSIONS

Although we have not discovered variations regarding gender and average age for the operations, adenotonsillar surgery has increased over recent years and the percentage ratio of the various procedures has altered as a result of new indications.

Large international differences in (adeno)tonsillectomy rates

This article compares recent paediatric and adolescent (adeno)tonsillectomy (T +/- Ads) rates in several countries of the European Union, the US, Canada and Australia. Trends in paediatric and adolescent surgical rates in the Netherlands and UK from 1974 to 1998 are studied as well. In 1998, the paediatric T +/- Ads rate varied from 19 per 10000 children in Canada to 118 per 10000 in Northern Ireland, while the adolescent rate varied from 19 per 10000 adolescents in Canada to 76 per 10000 in Finland. In the Netherlands, the paediatric T +/- Ads rate decreased rapidly between 1974 and 1985 and remained similar since. Ten years later, between 1985 and 1998, the adolescent T +/- Ads rate increased. In the UK, on the other hand, an increase in T +/- Ads was observed both in children and in adolescents. This study shows that paediatric and adolescent T +/- Ads rates still vary considerably between countries. There is no definitive evidence that decreasing rates of T +/- Ads in childhood are associated with tonsil-related disease, necessitating surgery, in later life.

Indications for tonsillectomy and adenoidectomy

OBJECTIVE

To review recent clinical trials that provide a foundation on which clinicians can base decisions regarding adenotonsillar surgery for their patients.

STUDY DESIGN

Review.

METHODS

An evidence-based approach was used to review recent clinical trials addressing indications for adenotonsillectomy, tonsillectomy, and adenoidectomy.

RESULTS

Absolute indications for tonsillectomy and adenoidectomy include adenotonsillar hyperplasia with obstructive sleep apnea, failure to thrive, or abnormal dentofacial growth; suspicion of malignant disease; and (for tonsillectomy) hemorrhagic tonsillitis. Relative indications for both procedures are adenotonsillar hyperplasia with upper airway obstruction, dysphagia, or speech impairment, and halitosis. Otitis media and recurrent or chronic rhinosinusitis or adenoiditis are relative indications for adenoidectomy but not tonsillectomy. Recurrent or chronic pharyngotonsillitis, peritonsillar abscess, and streptococcal carriage are relative indications for tonsillectomy but not adenoidectomy.

CONCLUSION

Good clinical evidence regarding indications for tonsillectomy and adenoidectomy is available. Clinicians should make recommendations for surgery on the basis of this evidence.

Changing trends in adenotonsillectomy at San Pablo Hospital 1983 vs. 1993

The purpose of this paper is to review the changing trends in Adenotonsillectomies performed in San Pablo Medical Center during the last ten years. We have reviewed using a 25 variable questionnaire all patients undergoing this surgical procedure during the first six months in 1983 and compared the information with the patients having this procedure during the first six months of 1993. We conclude that the number of interventions, the indications, prior medical history and cost effects have changed substantially. Our data supports the accuracy of some of the trends being reported in the literature regarding this surgical intervention.

Obstructing adenoids in adolescents: changing trends?

The number of adolescents undergoing surgery for obstructing adenoids has increased significantly in our practice in recent years. Over an 11-year period during which 539 adenoidectomies were performed, the mean age of patients increased progressively from 4.6 years in 1980 to 7.88 years in 1990. The median age gradually increased over the same period from 4 to 7 years, and the standard deviation from 4.95 to 19.38. Enlarged adenoids should be considered in the differential diagnosis of adolescents suffering from nasal obstruction, snoring or obstructive sleep apnea.

Tonsillectomy and adenoidectomy in-hospital charges, 1991

Trends in tonsillectomy and adenoidectomy (T&A) procedure rates show a steady national decline since 1970. MetLife hospital T&A claims experience is analyzed for group policyholders and dependents during 1991. The total claims charges increased over the years while the number of in-hospital procedures decreased. The average cost to MetLife for a T&A in 1991 was $3,440, $2,910 in 1990 and $2,580 in 1989 among 625, 1,193 and 1,683 patients, respectively. The 1991 charges were the highest in the Pacific area and the lowest in the East North Central geographic area. Among states with ten or more T&As, Illinois led with charges 37 percent above the average. The lowest claims charges were reported in Maryland, 30 percent below the U.S. total. Average U.S. physician fees were $1,230 and comprised 36 percent of the total charges. This proportion varied from half of the total T&A charges in New York to one-quarter in South Carolina. Ancillary fees accounted for 77 percent of the hospital charges and ranged from just over half in California to 90 percent in South Carolina. Length of stay increased from 1.1 days in both 1989 and 1990 to 1.2 days in 1991. As increasing numbers of surgeons and patients are aware of and comfortable with the concept of outpatient surgeries and as more insurance plans include incentives for ambulatory surgeries, it seems clear that fewer uncomplicated T&As will be performed on an inpatient basis.

Tonsillectomy and adenoidectomy: changing trends

A review of 1,722 tonsil and adenoid procedures performed between 1978 and 1986 is presented. Each year there has been a progressive decrease in the number of procedures performed; the incidence of adenoidectomy has declined particularly. Although infection remains the predominant indication for surgery, there has been a dramatic rise in obstructive sleep apnea as a significant indication, from 0% in 1978 to 19% in 1986. At present, this trend promises to continue as physicians become increasingly aware of the prevalence and seriousness of adenotonsillar hypertrophy as a cause of sleep apnea, particularly in the general pediatric population.

Ten-year trends in Canada for selected operations

Of 16 operations common in Canada the national rates over a 10-year period for the 9 discretionary procedures varied much more than those for the nondiscretionary operations. The rates of tonsillectomy and adenoidectomy, hemorrhoidectomy, varicose vein stripping and appendectomy decreased substantially, whereas those of extraction of lens, cesarean section and colectomy increased. The rates of hysterectomy and cholecystectomy first increased and then decreased. With the exception of Newfoundland the provinces generally followed these trends. Neither the Canadian nor the provincial rates were significantly associated with the availability of hospital beds or surgeons. Factors other than resources probably accounted for much of the variation among the provinces.

Tonsillectomy and adenoidectomy. Are there any indications?

Tonsillectomy and adenoidectomy have become quite controversial within the past two decades. Physicians disagree about the need for and benefits derived from these procedures, and well-designed studies to resolve the matter have been lacking. The authors describe conditions for which they believe each surgery is indicated.