Tonsillotomy versus tonsillectomy on young children: 2 year post surgery follow-up

Ericsson et al. Journal of Otolaryngology - Head and Neck Surgery 2014, 43:26 http://www.journalotohns.com/content/43/1/26 ORIGINAL RESEARCH ARTICLE Open Access Tonsillotomy versus tonsillectomy on young children: 2 year post surgery follow-up Elisabeth Ericsson1, Jonas Graf2,3, Inger Lundeborg-Hammarstrom4 and Elisabeth Hultcrantz3* Abstract Objectives: To study the long-term effect of tonsillotomy and tonsillectomy in young children after two years in comparison to the results after six months. Method: Children, age 4-5 with Sleep Disordered Breathing (SDB) and tonsil hyperplasia, were randomized to TE (32) or TT (35). TT was performed ad modum Hultcrantz with radiofrequency technique (Ellman). An adenoidectomy with cold steel was performed in the same session for 80% of cases. The patients were assessed prior to surgery, at six and 24 months postoperatively. Effects of surgery were evaluated clinically, through questionnaire (general health/snoring/ENT-infections), Quality of Life (QoL), survey of pediatric obstructive sleep apnea with OSA-18, and children’s behavior with the Child Behavior Checklist. Results: After two years there was still no difference between the groups with respect to snoring and frequency or severity of upper airway infections. Both TT and TE had resulted in large improvement in short and long term QoL and behavior. Three TT-children and one TE child had been re-operated due to recurrence of obstructive problems, the TE-child and one of the TT-children with adenoidectomy and two of the TT-children with tonsillectomy. Three of the TT-children had tonsil tissue protruding slightly out of the tonsil pouch and twelve TE-children had small tonsil remnants within the tonsil pouches, but with no need for surgery. Conclusion: Younger children have a small risk of symptom-recurrence requiring re-surgery within two years after TT. For the majority, the positive effect on snoring, infections, behavior and quality of life remain and is similar to TE. Keywords: Tonsillotomy, Tonsillectomy, Quality of life, Methodology Introduction At present, the most common indication for tonsil surgery in children is upper airway obstruction causing Sleep Disordered Breathing (SDB) [1]. SDB is a symptom-complex including not only snoring and sleep apnea, but also restless sleep, frequent awakenings, failure to thrive and behavioral disturbances. Oral breathing is often associated with SDB and may cause subsequent bite aberrations [2]. Daytime health related quality of life (HRQL) and level of functioning have been found to be affected by SDB [3-7]. Simple snoring without other symptoms of SDB, usually does not qualify a child or an adult for tonsil-surgery. * Correspondence: 3 Division of Otorhinolaryngology, Department of Clinical and Experimental Medicine, Linköping University, Linköping, Sweden Full list of author information is available at the end of the article SDB in children is most commonly caused by a relative hypertrophy of the Waldeyer ring, which usually peaks in size around the age of five [8-10]. That is why tonsil surgery due to SDB is especially common in the pre-school age groups [3]. During the past decade, tonsillotomy, or intracapsular tonsillectomy, partial removal of the tonsils, has become accepted as the surgical method for tonsil hyperplasia because it causes less surgical trauma, carries less risk for serious bleedings than total tonsillectomy, and allows for a more rapid recovery [1,11]. The aim of the present investigation is to study the long-term effect of tonsillotomy and tonsillectomy in young children after two years in comparison to the results after six months and to assess whether the beneficial effects persisted that were observed after six months [4] on snoring, infections, HRQL and behavior. © 2014 Ericsson et al.; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly credited. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Ericsson et al. Journal of Otolaryngology - Head and Neck Surgery 2014, 43:26 http://www.journalotohns.com/content/43/1/26 Methods The study was approved by the Human Research Ethics Committee at Linköping University. Subjects Children (4.5–5.5 yrs), who all had tonsil hypertrophy and obstructive problems (SBD), assessed by an ENT-surgeon and been put on the waiting-list for tonsil surgery, had been randomized to either TT(35) or TE(32) [4]. In accordance with Swedish praxis, no sleep studies had been performed on these “otherwise healthy” children, who were neither obese nor had signs of severe OSAS. Sixtyseven children were enrolled, 28 girls and 39 boys, aged 50–65 months (mean age, 56 months; 4.8 years old). Twenty per cent had had one or a few bacterial upper airway infections (tonsillitis) prior to the last three months before surgery. These infections did not exclude them from the study. Exclusion criteria were recurrent tonsil infections during the last few months, small tonsils, obesity, bleeding disorder or parents not speaking Swedish. No drop outs occurred after enrolment. Power analysis had been done based on the senior author’s previous study [12], but with more patients included to increase the power and thus make it possible to evaluate group differences in pain and general health. Randomization had been done from the waiting list (a sequentially numbered list generated by a computer), and families had been informed about the study and the randomization outcome by mail before giving informed consent [4]. Before surgery, the parents had also answered: a disease-specific quality of life questionnaire about general health, snoring, eating difficulties and infections [4,13,14], OSA-18 (Obstructive Sleep Apnea-18) [4,15], and a standardized assessment of child behavior, CBCL (Child Behavior Check List) [4,16]. TE had been performed on 22 boys and 10 girls and 17 boys and 18 girls underwent TT. 80% (28TT/25TE) underwent adenoidectomy at the same time as primary tonsil surgery and 10% (5TT/1TE) had had an adenoidectomy earlier. The tonsillectomies were all performed using cold steel. All tonsillotomies were performed ad modum Hultcrantz [13,17] with the Ellman 4.0 MHz Surgitron Dual Radio wave Unit (Ellman International Oceanside, NY) as follows: The patient was orally intubated and the mouth held open using a David-Myers mouth gag. A neutral electrode under either shoulder was connected to the radio wave unit. Local anesthesia with a vasoconstrictor (0.25% Marcain-adrenaline), was slowly injected into the tonsil tissue on both sides, avoiding leakage through the crypts. To protect the posterior pillars, a gauze strip was (...truncated)