Long-Term Results From Tonsillectomy in Adults

Evaluation of Guidelines For Tonsillectomy in Adults With Recurrent Acute Tonsillitis

OBJECTIVES

The criteria for selecting patients with recurrent acute tonsillitis (RT) for tonsillectomy remain unsettled and different guidelines are used internationally. We aimed to evaluate currently used guidelines for tonsillectomy in adults with RT and identify the best predictive parameters for improved throat-related quality of life (TR-QOL) after surgery.

METHODS

About 66 RT patients undergoing tonsillectomy was prospectively included and categorized into 3 groups based on which guideline(s) they met: Group 1: patients not meeting any of the Danish/Paradise/Scottish Intercollegiate Guideline Network (SIGN) guidelines. Group 2: patients meeting the Danish guidelines. Group 3: patients meeting the Paradise and/or the SIGN guidelines. TR-QOL was assessed using the Tonsillectomy Outcome Inventory 14 (TOI-14) before and 6 months after tonsillectomy as well as the Glasgow Benefit Inventory (GBI). Predictive parameters for improved TR-QOL were investigated using multiple linear regression.

RESULTS

About 61 (92%) patients completed the questionnaires. Patients in all groups had significant TR-QOL improvements (Group 1 (n = 20): ΔTOI-14 31.1; GBI 29.4; Group 2 (n = 31): ΔTOI-14 32.0; GBI 36.4; Group 3 (n = 10): ΔTOI-14 45.6; GBI 39.7) and satisfaction rates were high (94%-100%). Preoperative TOI-14 score was the best predictor for improved TR-QOL (P < .001, R2 = .80), followed by the number of tonsillitis episodes with physician verification within the previous 12 months (P = .002, R2 = .25).

CONCLUSIONS

Patients in all groups experienced massive TR-QOL improvements suggesting that currently used guidelines may be too restrictive. Preoperative TOI-14 score was the best parameter for predicting TR-QOL improvement, and this tool may be useful in the selection of adults with RT for tonsillectomy.

Oral Health Status and Salivary Properties among Children before and after Tonsillectomy

Objectives: Enlarged adenoids can lead to obstruction of the nasopharyngeal airway and subsequent oral respiration. Oral breathing can cause dry mouth, dehydration in gingival tissue, and resistance to plaque accumulation. This study aimed to evaluate the impact of tonsillectomy on oral health status, salivary pH and flow rate, and common complications caused by tonsillar hypertrophy in children. Materials and Methods: An analytical before-and-after study was conducted on 60 children aged 5-12 years who required tonsillectomy. We gathered data through a questionnaire and collected unstimulated saliva using the spitting method for five minutes. Salivary pH was measured by a pH meter and its volume was determined with a calibrated test tube. The plaque index, bleeding index and modified gingival index were determined using a disclosing tablet, Williams' probe and observational examination, respectively. All measurements were repeated one month after tonsillectomy. Paired t-test was used for data analysis. Results: We found a significant increase in mean pH and salivary flow rate after tonsillectomy and observed a decrease in oral health indices among the children one month after surgery. Over half of the children who reported complications such as dry mouth, itchy nose and throat, snoring, night sweats, and sleep disturbances experienced complete recovery after tonsillectomy. Conclusion: Based on the results obtained in the present study, children with enlarged adenoids showed significant improvements in salivary pH, salivary flow rate, and oral health indices, one month after tonsillectomy.

Evaluation of Staphylococcus aureus Colonization in Adult Patients Undergoing Tonsillectomy for Recurrent Tonsillitis

Background and objectives: Staphylococcus aureus (S. aureus) is often recovered from the pharynx. However, the role of this pathogen in the etiology of tonsillar inflammation is still unclear and complicated due to frequent carriage of S. aureus. The aim of the study was to evaluate the frequency and the clinical importance of S. aureus colonization and biofilm production ability in patients with recurrent tonsillitis (RT) using patient samples from tonsillar crypts during tonsillectomy, and from the throat, nasal cavity, and armpits after tonsillectomy. Materials and Methods: A case series study was carried out at a tertiary referral center among 16 patients diagnosed with RT who were undergoing tonsillectomy. Samples from tonsillar crypts were obtained during tonsillectomy, and samples from the throat, nasal cavity, and armpit were obtained a year after surgery. An evaluation of S. aureus incidence, biofilm formation, and antibacterial susceptibility was performed. Results: During tonsillectomy, 16 strains of S. aureus were isolated from 16 patients, while 15/16 S. aureus strains were biofilm producers. A year after tonsillectomy, 8 S. aureus strains were isolated from 6 out of 16 patients, while 6/8 S. aureus strains were biofilm producers. After tonsillectomy, 3 patients showed S. aureus in throat culture. Conclusions: In 10/16 cases S. aureus was the causative agent of RT, in 4/16 cases patients had a predisposition to colonization of S. aureus, and in 2/16 cases S. aureus was a part of the patients` oral microbiome. Tonsillectomy results in less frequent isolation of S. aureus strains.

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.

Effects of Osteopathic T9-T10 Vertebral Manipulation in Tonsillitis: A Randomized Clinical Trial

This study aimed to determine whether osteopathic manipulation of the T9-T10 vertebrae improves the evolution of tonsillitis. A randomized, stratified, controlled clinical trial with blinded patients, evaluator and data analyst was performed. The patients in the control group (CG) underwent a "sham" manipulation. A high-speed, low-amplitude technique was applied to the T9-T10 vertebrae in the osteopathic manipulative group (OMG) patients. The number of days needed to resolve the tonsillitis was significantly lower (p = 0.025) in the OMG (2.03 ± 0.95 days) than the CG (2.39 ± 0.82 days). Additionally, the number of episodes of tonsillitis after the treatment decreased significantly more in the OMG (0.8 ± 1.88 episodes/year in total) than the CG (2 ± 2.12) (p = 0.005). In the OMG, 60.8% had no recurrences of tonsillitis, compared to 22.5% of the CG, in the following year (χ2 (1) = 15.57, p < 0.001). No patients reported adverse effects. It has been concluded that during an episode of tonsillitis, the number of days to resolution was significantly lower after the application of an osteopathic manipulation of the T9-T10 vertebrae, compared to a sham manipulation. The number of subsequent year tonsillitis episodes was greatly reduced in both groups, significantly more in the OMG than in the CG patients.

Impact of Diabetes Mellitus Following Tonsillectomy in Adults: A National Surgical Quality Improvement Program Analysis

OBJECTIVES

To identify 30-day complication rates specific to patients with diabetes mellitus following tonsillectomy.

METHODS

The American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database was used to identify patients undergoing tonsillectomy between 2005 and 2018. Patients were stratified into 3 cohorts: insulin-dependent diabetes mellitus (IDDM), non-insulin-dependent diabetes mellitus (NIDDM), and non-diabetes mellitus (NODM). Coarsened-exact-matching was utilized to account for baseline differences between cohorts. Outcomes studied included post-operate complications, prolonged hospitalization, and unplanned readmissions.

RESULTS

A total of 986 DM and 26 774 NODM patients were included, and the mean age of patients undergoing tonsillectomy was 29.5 ± 11.6 and 28.7 ± 11.0 years, respectively. The majority of patients were female (70.5% for both DM and NODM cohorts) and White/Caucasian (89.2% vs 89.3%). Among patients undergoing tonsillectomy, a greater proportion of DM patients experienced an operative time greater than or equal to the 75th percentile (35 minutes; 25.9% vs 22.8%, P = .024), overall morbidity (12.6% vs 5.4%, P < .001), pneumonia (0.6% vs 0.2%, P = .036), and reoperation (10.2% vs 3.5% P < .001) in comparison to NODM patients. In an analysis between IDDM (n = 379) and NIDDM (n = 211) patients, IDDM patients were at an increased risk for prolonged hospitalization (1.4% vs 0.0%, P = .045), pneumonia (5.2% vs 0.5%, P < .001), urinary tract infections (3.3% vs 0.3% P = .004), major complications (15.6% vs 7.7%, P = .002), minor complications (19.9% vs 8.2%, P < .001), and overall complications (10.0% vs 1.3%, P < .001).

CONCLUSION

DM patients are at a heightened risk for complications following tonsillectomy. Standardized protocols, careful pre-operative planning, and stringent glycemic management may help optimize patient outcomes.

Normative tonsillectomy outcome inventory 14 values as a decision-making tool for tonsillectomy

Purpose

The study aimed to determine normative values for the Tonsillectomy Outcome Inventory 14 (TOI-14) in a healthy middle-European cohort. We also compared these generated values with TOI-14 scores from a patient population with recurrent tonsillitis (RT) and explored the factorial structure of the TOI-14.

Methods

We systematically studied the responses of healthy individuals (reference cohort) and patients with RT (clinical cohort) to the TOI-14 survey. The reference cohort contained 1000 participants, who were recruited using the Respondi panel for market and social science research. This subsample was quoted to the population distribution of the German Microcensus and selected from a non-probability panel. Tonsillitis patients were assessed before and 6 and 12 months after tonsillectomy.

Data were analysed using principal component and exploratory factor analyses.

Results

The PCA revealed three TOI-14 domains (physiological, psychological and socio-economic), which explained 73% of the total variance. The reference cohort perceived a good quality of life (QOL) with a TOI-14 total score of 11.8 (physiological: 8.0, psychological: 5.8, and socio-economic subscale score: 13.9). TOI-14 scores were higher in the patient cohort, indicating that the TOI-14 discriminates between patients with RT and healthy individuals with no RT. Age and female gender significantly influenced the total TOI-14 score, especially in the psychological (age) and socio-economic (gender) subscales.

Conclusion

We have developed a set of normative values that, together with the TOI-14, can determine the disease burden indicating tonsillectomy.

Structured literature review of patient-reported outcome (PRO) instruments in adult tonsillectomy or tonsillotomy

BACKGROUND

Instruments that measure the patient-reported outcome and quality of life are essential to assess the treatment success of any medical intervention. This review represents valid and reliable outcome assessment instruments for tonsillectomy (TE) and tonsillotomy (TO) in adult patients as TE/TO still belong to one of the most common performed surgical procedures.

METHODS

A systematic review of the literature in the MEDLINE, PubMed, Web of Science and Cochrane Library was conducted. Studies describing reliable and valid patient-reported outcome measures (PROM) in adults with regard to the perioperative as well as postoperative follow-up after TE/TO were examined. Thus, studies without PROMs or PROMs only relating to children as well as studies in non-English/non-German language or without any detailed information were excluded.

RESULTS

Four thousand four hundred forty studies were identified. Thirteen reliable and valid patient-reported outcome assessment instruments presenting the perioperative and postoperative outcome were analysed. Four generic questionnaires are included that are used to measure the outcome after TE/TO in adults. Four disease-specific questionnaires relating to obstructive sleep apnea (OSA) and sleep disordered breathing (SDB) as well as two TE/TO specific questionnaires are validated for adults. With regard to the perioperative outcome including parameters like pain, nausea, vomiting, satisfaction three assessment instruments are analysed.

CONCLUSION

This review describes the currently available, reliable and valid generic and disease-specific instruments assessing the perioperative as well as postoperative outcome to evaluate the treatment success after TE/TO in adult patients. Therefore, this study improves the selection of the appropriate patient-reported outcome assessment instrument to assess the quality of life in adults undergoing TE/TO.

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.