Age-related tonsillar regrowth in children undergoing powered intracapsular tonsillectomy

Objectives

To review our experience with intracapsular tonsillectomy using powered instrumentation (PIT) in the management of tonsillar hypertrophy.

Design

Retrospective database review of pediatric patients undergoing PIT.

Methods

The medical records of 636 patients under 11 years of age who underwent PIT performed by the senior author (RFW), predominantly for obstructive sleep disturbance, were reviewed. Data were subsequently analyzed from 559 of these patients for clinical evidence of tonsillar regrowth, post-operative tonsillar hemorrhage, and post-operative dehydration due to pain. Specific information for possible correlation of age at the time of surgery and any increased rate of regrowth was primarily examined.

Results

There were a total of 33 patients who had clinical evidence of regrowth. Children less than 5 years of age had 5 times the incidence of regrowth (p < 0.001). Out of the group that exhibited regrowth, 5 patients exhibited evidence of recurrent upper airway obstruction and underwent a complete tonsillectomy. The age of this complete tonsillectomy group ranged from 1.1 to 2.7 years. Out of all patients undergoing PIT, there was 1 incident of delayed post-operative dehydration due to emesis but not due to pain. There were 2 incidents of delayed post-operative tonsillar bleeds. All three complications were self-limited and did not require re-hospitalization.

Conclusions

PIT is a safe procedure with a small risk of tonsillar regrowth being age related. The incidence of postoperative complications following PIT is relatively low (0.54%).     

Long term outcome of tonsillar regrowth after partial tonsillectomy in children with obstructive sleep apnea

Objective

We investigated the long-term effects of partial tonsillectomy, and potential risk factors for tonsillar regrowth in children with obstructive sleep apnea hypopnea syndrome (OSAHS).

Methods

Children affected by OSAHS with obstructive hypertrophic tonsils underwent partial tonsillectomy or total tonsillectomy with radiofrequency coblation. Polysomnography was performed prior to and 5 years following surgery. Blood samples from all participants were taken prior to and 1 month following surgery to assess immune function. All participants were interviewed 5 years following surgery to ascertain effects of the surgery, rate of tonsillar regrowth, and potential risk factors.

Results

All parents reported alleviation of breathing obstruction. Postoperative hemorrhage did not occur in the partial tonsillectomy group compared to 3.76% in the total tonsillectomy group. Tonsillar regrowth occurred in 6.1% (5/82) in children following partial tonsillectomy. Palatine tonsil regrowth occurred a mean of 30.2 months following surgery, and 80% of children with tonsillar regrowth were younger than 5 years of age. All five patients had a recurrence of acute tonsillitis prior to enlargement of the tonsils. Four of the five had an upper respiratory tract allergy prior to regrowth of palatine tonsils. There were no differences in IgG, IgM, IgA, C3, or C4 levels following partial tonsillectomy or total tonsillectomy.

Conclusion

Partial tonsillectomy is sufficient to relieve obstruction while maintaining immunological function. This procedure has several post-operative advantages. Palatine tonsils infrequently regrow. Risk factors include young age, upper respiratory tract infections, history of allergy, and history of acute tonsillitis prior to regrowth.     

Tonsillar regrowth following partial tonsillectomy with radiofrequency

OBJECTIVES: To assess regrowth potential of the tonsils following partial tonsillectomy performed by using radiofrequency. METHODS: Follow-up results of 42 children (aged from 1 to 10 years) who consecutively had partial tonsillectomy with radiofrequency due to obstructive sleep apnea or snoring were evaluated for regrowth of the tonsils. RESULTS: Regrowth of the remaining tonsillar tissue was observed in 7 of 42 patients (16.6%). The upper respiratory tract obstruction symptoms recurred in 5 of these 7 patients while the remaining 2 patients were asymptomatic. The tonsils of symptomatic patients were removed completely. CONCLUSION: Partial tonsillectomy may have a significant potential for regrowth and thereby recurrence of the obstructive symptoms. Although the cause of this regrowth remains unknown, this problem should be remembered by the surgeons, and an informed consent should be obtained from the families prior to radiofrequency tonsillotomy.     

Intracapsular vs. extracapsular tonsillectomy: a comparison of pain

OBJECTIVE: To measure differences in postoperative pain in children undergoing intracapsular tonsillectomy vs. extracapsular tonsillectomy. STUDY DESIGN: Prospective clinical trial carried out at a tertiary children's hospital over 1 year. METHODS: The study included 43 patients age 5 to 19 years with adenotonsillar hypertrophy, 27 undergoing extracapsular tonsillectomy and 16 undergoing intracapsular tonsillectomy. Tonsillectomy was performed in either an intracapsular or extracapsular fashion using bipolar electrosurgical scissors and monopolar suction cautery for hemostasis. Residents under faculty supervision performed all operations. Postoperative pain was assessed using the Wong-Baker Faces Pain Scale through postoperative day 10. The patients recorded in a standardized diary pain scores and analgesic use. The main outcome measure was postoperative pain as measured by the Wong-Baker Faces Pain Scale. The quantity of postoperative pain medicine consumed was a secondary outcome measure. RESULTS: Average postoperative pain for extracapsular tonsillectomy was 5.21 on a 10-point scale versus 2.75 for intracapsular tonsillectomy (P < .0001). CONCLUSIONS: Intracapsular tonsillectomy with bipolar scissors results in less postoperative pain than extracapsular tonsillectomy with bipolar scissors in children age 5 to 19 years.     

Efficacy of powered intracapsular tonsillectomy and adenoidectomy

Objectives/Hypothesis: We sought to determine the effectiveness of powered intracapsular tonsillectomy and adenoidectomy (PITA) in the treatment of children with moderately severe obstructive sleep apnea and to measure changes in quality of life that occur with such treatment. Study Design: Prospective, nonrandomized clinical trial in an academic pediatric otolaryngology practice. Methods: Convenience sample of children ages 3 to 12 years diagnosed with obstructive sleep apnea of moderate severity, defined as an apnea‐hypopnea index (AHI) between 5 and 20 on polysomnography. Children with recurrent streptococcal pharyngitis, chromosomal abnormalities, craniofacial abnormalities, neuromotor disease, sickle cell disease, obesity, or coagulopathy were excluded. PITA was performed by using the microdebrider. Polysomnography was performed before surgery and repeated 4 to 8 weeks after surgery. The Obstructive Sleep Apnea (OSA)‐18 questionnaire was completed at surgery and at the time of postoperative polysomnography to assess quality of life changes. The main outcome measure was cure of obstructive sleep apnea, as defined by a postoperative AHI of 1 or less for complete cure and less than 5 for partial cure. Improvements in quality of life were assessed by changes in the OSA‐18 questionnaire. Results: Nineteen children underwent PITA for moderate obstructive sleep apnea syndrome (OSAS), and 14 completed postoperative polysomnography. All 14 subjects who completed the study achieved at least partial cure. Thirteen of 14 (93%) subjects had a complete cure of OSAS after PITA. The median preoperative AHI was 7.9, and the median AHI after surgery was 0.1. The mean number of arousals per hour before surgery was 9.5, and this was reduced to a mean of 5.6 after surgery. Quality of life measures on OSA‐18 also improved, with large improvements in total quality of life scores and in all five domains seen after surgery. Conclusions: PITA cures otherwise healthy children with obstructive sleep apnea of moderate severity, at least in the short‐term, as documented by postoperative polysomnography. Improvements in quality of life measures, as documented by changes in OSA‐18, were seen in all children as well.     

The incidence of adenoidal regrowth after adenoidectomy and its effect on persistent nasal symptoms

Objective of the study is to evaluate the effectiveness of adenoidectomy for children, to asses the rates of adenoidal regrowth and find out if the regrowth of adenoidal tissue affects persistent nasal symptoms post-surgery. A prospective study was carried out in the period of 2005–2007. The inclusion criteria for patients in the study were hypertrophic adenoid tissue and moderate or severe persistent nasal obstruction. One hundred and fifty children had undergone an adenoidectomy using consistent technique and visual control. Medium-term follow-up results were conducted 12–24 months (the mean follow-up period was 17.1 months) post-surgery, performing transnasal fibroscopy and completing the questionnaire. A total of 104 (69.3%) out of 150 patients polled. Children’s parents answered the questions that were used for the subjective assessment of symptoms and to ascertain the history of the patient’s nasal obstruction and upper respiratory tract infection prior to surgery. The age range was from 3 to 15, of which, 68 (65.3%) of them had undergone a transnasal fibroscopy. There was a significant reduction in symptoms that were displayed by children prior to the operation: there were 5.8% patients with nasal obstruction after the surgery, while incidences of upper airway infections dropped from 79.8 to 7.7% after surgery (P < 0.001). Eighty-six (82.7%) parents considered their child’s well-being as “having improved” and they were “satisfied” with the results. Transnasal fibroscopy examinations identified some regrowth of adenoidal tissue in 13 cases (19.1%), with only 3 cases demonstrating adenoidal regrowth to grade 1. Adenoidal regrowth was correlative with the age of the patients (P = 0.048) and to numerous postoperative treatment with antibiotics (P = 0.032). Adenoids rarely regrow after surgery and where there were traces of adenoidal tissue, it did not manifest clinically. Nasal obstruction after the adenoidectomy is rhinogenic origin, not the cause of enlarged adenoids. Adenoidal regrowth more often occurs in children younger than five years old and in those patients who were treated postoperatively with antibiotics on numerous occasions.     

Complications of microdebrider-assisted powered intracapsular tonsillectomy and adenoidectomy

OBJECTIVES: To study complications of powered intracapsular tonsillectomy and adenoidectomy (PITA) in pediatric patients with obstructive sleep apnea (OSA). STUDY DESIGN: Retrospective chart review and long-term follow-up in office or by telephone interview. METHODS: We studied 278 patients who underwent PITA between September 2000 and October 2002. Outcome measures were postoperative bleeding, velopharyngeal insufficiency, need for hospital readmission, tonsil regrowth, and return of snoring or sleep apnea symptoms. RESULTS: All 278 children treated by PITA had immediate resolution of symptoms of OSA. Complications were noted in 11 patients (3.9%). Nine patients (3.2%) experienced tonsil regrowth with snoring, two of whom evolved to a return of OSA that was definitively managed by means of a complete tonsillectomy. Two patients (0.7%) had self-limited bleeding. None of the patients developed persistent velopharyngeal insufficiency or required hospital readmission. CONCLUSIONS: Microdebrider-assisted PITA is a safe and effective alternative for children otherwise treated with traditional tonsillectomy for symptoms of OSA due to adenotonsillar hypertrophy. This series suggests a 3.9% overall rate of complications, with the most common noted as tonsillar regrowth without recurrence of OSA. Prospective trials with longer follow-up may define higher complication rates.     

Subtotal bipolar tonsillectomy does not decrease postoperative pain compared to total monopolar tonsillectomy

OBJECTIVE: To determine whether a subtotal bovie tonsillectomy decreases postoperative pain following adenotonsillectomy. METHODS: A prospective, randomized, double-blinded clinical trial was undertaken at a University Pediatric Children's Hospital and included 39 otherwise healthy children, aged 2-12 years, undergoing adenotonsillectomy. Patients were randomized to receive either a subtotal or total removal of the tonsils utilizing an electrocautery technique. The main outcome measures included a visual analog scale (VAS) at rest and while eating, time to take 100 cm(3) of fluid, throat, neck, and ear pain, quantity of liquids, activity level and incidence of emesis and retching. RESULTS: A repeated measures analysis using a repeated measures ANOVA failed to demonstrate a statistically significant impact with either treatment for VAS at rest or while eating (p=0.52 and 0.48, respectively). A repeated measures analysis did not show either procedure significantly affecting throat, neck or ear pain, or liquid quantity. Time to take 100 cm(3) liquids and the incidence of emesis or retching were found not to be statistically significantly different between the treatment groups. CONCLUSION: Subtotal tonsillectomy via an electrocautery technique does not reduce postoperative pain or improve outcome parameters. Subtotal tonsillectomy with this technique is not recommended for this patient population.     

The relation between tonsillectomy and snoring

The aim of this study was to determine the relation between snoring and tonsillectomy. The grossly enlarged tonsils of a heavily snoring child or adult with upper airway obstruction is usually sufficient indication for tonsillectomy. The authors wondered if tonsillectomy could affect snoring, no matter what the age and the indication for surgery. One thousand people took part in this study: a random sample of patients, aged between 2 and 89 years of age, and those accompanying them in the ENT outpatients. The prevalence of snoring was 12.5–48%, mainly in men. The degree of snoring was graded from non-snorers to mild, moderate and severe snorers. In 19.8% of the sample tonsillectomy had already been performed, usually in childhood. The authors conclude that tonsillectomy does not reduce the likelihood of becoming a snorer.     

Multiparametric comparison of cold knife tonsillectomy, radiofrequency excision and thermal welding tonsillectomy in children

OBJECTIVE: This is a prospective study evaluating certain intraoperative and postoperative parameters, comparing the relatively new technique of thermal welding tonsillectomy with cold knife tonsillectomy, and radiofrequency excision in pediatric population. METHODS: Ninety children aged from 5 through 13 years were enrolled a randomized prospective trial comparing cold knife tonsillectomy, radiofrequency excision, and thermal welding tonsillectomy. Indications included recurrent acute tonsillitis and/or obstructive sleep apnea syndrome. All techniques were compared by means of length of surgery time, blood loss, postoperative bleeding and postoperative pain. RESULTS: Sixty-eight patients underwent tonsillectomy for obstructive sleep apnea, whereas 22 children underwent tonsillectomy due to recurrent acute tonsillitis. Median values of all variables tested, length of surgery time, blood loss, postoperative bleeding and postoperative pain, were found to differ significantly among the three surgical techniques (P<0.001). Particularly, a statistically significant higher median duration (P<0.001) and intraoperative blood loss (P<0.001), as well as, a statistically significant lower median pain score in each day tested (P<0.001) of the cold knife group, compared to each one of the other two groups, were found. Tissue welding and radiofrequency groups did not differ significantly in any aspect tested. CONCLUSIONS: Both thermal welding and radiofrequency excision techniques have shown comparable results regarding intraoperative blood loss, postoperative hemorrhage, and pain. Compared with cold knife tonsillectomy, welding and radiofrequency excision techniques were associated with less intraoperative blood loss and duration, though cold knife tonsillectomy seems to prevail over the two techniques in terms of the postoperative pain.     

The effect of adenoid and tonsil surgery on nasalance

The change in nasalance following adenoidectomy, tonsillectomy and adenotonsillectomy was studied in 44 children. A subjective assessment of each child's naso-pharyngeal airway was made preoperatively based on a questionnaire completed by the parents. There was no significant change in the nasalance of children following adenoidectomy, but there was a significant increase in the nasalance following tonsillectomy (P = 0.02) and after adenotonsillectomy (P = 0.001). There was no relationship between the change in nasalance and the adenoid volume removed at operation. There was good agreement between the parental subjective assessment of the naso-pharyngeal airway and the preoperative nasalance score, with the best correlation in the adenoidectomy group (r = -0.8) and the adenotonsillectomy group (r = -0.7). Nasalance is more closely related to the size of the naso-pharyngeal airway than to the actual adenoid volume, and measurements of nasalance are of no benefit in predicting adenoid volume. Tonsillectomy had a significantly greater effect on nasalance than adenoidectomy, and adenotonsillectomy had the greatest effect. Further studies are needed to relate nasalance to the size of the naso-pharyngeal airway, but it appears to relate well to the subjective assessment of the airway and may be of use in patient selection for surgery.     

低温等离子射频扁桃体部分切除术治疗儿童阻塞性睡眠呼吸暂停低通气综合征

目的:探讨低温等离子射频扁桃体部分切除术治疗儿童阻塞性睡眠呼吸暂停低通气综合征(OSAHS)的可行性并观察疗效。方法:回顾性分析91例OSAHS患儿的临床资料,所有患儿无反复咽痛及扁桃体炎表现,主要阻塞病变为扁桃体及腺样体肥大,应用低温等离子射频行扁桃体部分切除术及腺样体消融术治疗。结果:术中出血1～2ml,无原发及继发性出血,术后疼痛轻微。随访12～22个月,所有患儿睡眠打鼾及张口呼吸均消失,无扁桃体再生及反复炎症发作。结论:低温等离子射频切除部分扁桃体治疗儿童OSAHS微创、安全、有效,适用于各年龄段的扁桃体为增生肥大病变的患儿,是一种较好的儿童OSAHS治疗方法。     

A review of malpractice cases after tonsillectomy and adenoidectomy

Objective

To examine sources of litigation following tonsillectomy and/or adenoidectomy.

Study design

Analysis of malpractice claims filed after tonsillectomy or adenoidectomy provided by 16 medical liability insurance companies.

Setting

Not applicable.

Subjects and methods

Data was obtained from 16 members of the Physician Insurers Association of America. All claims were either filed or closed between 1985 and 2006. Claims were evaluated and categorized according to the type of complication.

Results

One hundred and fifty-four claims were identified between 1985 and 2006. Six categories were created based on frequency of claims (bleeding complication n = 27 [17.5%], airway fire n = 2 [1.5%], burns n = 28 [18.2%], consent related n = 9 [5.8%], medication related n = 9 [5.8%] and residual tissue/recurrence n = 9 [5.8%]). Other less frequent claims were grouped as miscellaneous n = 70 [45.5%].

Conclusions

A significant portion of malpractice claims following tonsillectomy or adenoidectomy are related to complications not commonly discussed in the literature.     

Comparison of treatment outcomes between intracapsular and total tonsillectomy for pediatric obstructive sleep apnea

BackgroundIntracapsular tonsillectomy (IT) has been advocated as a treatment for pediatric obstructive sleep apnea (OSA). However, evidence in the literature utilizing polysomnography (PSG) is limited.ObjectiveTo examine the experience at a tertiary children's hospital to evaluate the effectiveness and risks of intracapsular tonsillectomy compared to total tonsillectomy (TT) for treating pediatric OSA.MethodsA retrospective study was undertaken of pediatric tonsillectomy cases performed for OSA at a tertiary children's hospital from 2005 to 2010. Patients with recurrent tonsillitis, craniofacial abnormalities, chromosomal abnormalities, neuromuscular disease, and congenital malformations were excluded. Main outcome measures were apnea-hypopnea index (AHI), minimum oxygen saturation (minO₂), and surgical complications.ResultsOf the 1583 patients reviewed in this study, there were 75 IT and 93 TT patients with pre- and post-operative PSG results. The IT patients were younger, had lower BMI, larger tonsil size, lower pre-operative (AHI) and lower post-operative AHI (p < 0.05). There was a similar percentage of patients that showed improvement in AHI and minimum oxygen saturation between the IT and TT groups. There were statistically similar average change in AHI and minimum oxygen saturation between the IT and TT groups at 5.6 ± 8.6 and 8.6 ± 12.9, respectively (p = 0.8) as well as similar improvement in minimum oxygen saturation between the two groups at 3.3% ± 4.3% and 3.0% ± 5.2%, respectively (p = 0.66). Of TT patients, 2.9% experienced post-operative bleeding with 1.6% requiring OR for control of hemorrhage. Of IT patients, 2.2% were found to have tonsillar regrowth with 2.0% returning to the OR for secondary tonsillectomy.ConclusionsIntracapsular tonsillectomy, like total tonsillectomy, is effective in improving polysomnogram results in appropriately selected children. Intracapsular tonsillectomy is a suitable option for the surgical treatment of pediatric OSA consequent to its demonstrated efficacy in relieving OSA and its favorable safety profile.