Assessment of changes in Streptococcus pyogenes levels using N-acetylgalactosamine-6-sulfatase marker and pharyngeal airway space with appliance therapy in mouth breathers - An ELISA-based study.

Background: The frequency of adenotonsillar hypertrophy in mouth-breathing children when compared to the average found in the general population is considered to be higher. Mouth breathing is considered as one of the causative factors for tonsillitis in children. Through continuous irritation on tonsillar wall, tonsils swell up and inflammation develops. Purpose: The purpose of the study is to evaluate Streptococcus pyogenes count using colony-forming units (CFUs) and N-acetylgalactosamine-6-sulfatase side chain marker on ELISA (enzyme linked immunosorbent assay) in mouth breathers and to establish its correlation with pharyngeal airway space pre- and post-oral screen appliance therapy. Materials and Methods: A total number of 24 (n) mouth breathers aged between 5 and 12 years were included in the study and given oral screen appliance therapy. The subjects were evaluated for the various parameters before the delivery of a habit-breaking appliance and then reevaluated for the same parameters (presence of S. pyogenes and its counts, size of tonsils, and pharyngeal airway space dimensions) after 6 months of appliance usage. Results: A statistically significant difference was seen in levels of S. pyogenes using ELISA and CFUs. Furthermore, statistically significant difference was observed in Friedman tonsil scoring and pharyngeal airway space and pre- and post-oral screen appliance therapy. Conclusion: Oral screen appliance therapy reduced the frequency of occurrence of tonsillitis in mouth breathers by decreasing the counts of S. pyogenes bacteria. Upper and lower pharyngeal airway space dimensions were increased after 6 months of appliance therapy in mouth breathers.

Tonsillitis, tonsillectomy, and deep neck space infections in England: the case for a new guideline for surgical and non-surgical management.

INTRODUCTION: Tonsillectomy is a common surgical procedure performed chiefly for recurrent tonsillitis. The Scottish Intercollegiate Guidance Network (SIGN) introduced guidelines in 1998 to improve patient selection for tonsillectomy and reduce the potential harm to patients from surgical complications such as haemorrhage. Since the introduction of the guidance, the number of admissions for tonsillitis and its complications has increased. National Hospital Episode Statistics over a 20-year period were analysed to assess the trends in tonsillectomy, post-tonsillectomy haemorrhage, tonsillitis and its complications with reference to the guidance, procedures of limited clinical value and the associated costs and benefits. MATERIALS AND METHODS: A literature search was conducted via PubMed and the Cochrane Library to identify relevant research. Hospital Episode Statistics data were interrogated and relevant data compared over time to assess trends related to the implementation of national guidance. RESULTS: Over the period analysed, the incidence of deep neck space infections has increased almost five-fold, mediastinitis ten-fold and peritonsillar abscess by 1.7-fold compared with prior to SIGN guidance. Following procedures of limited clinical value implementation, the incidence of deep neck space infections has increased 2.4-fold, mediastinitis 4.1-fold and peritonsillar abscess 1.4-fold compared with immediately prior to clinical commissioning group rationing. The rate of tonsillectomy and associated haemorrhage (1-2%) has remained relatively constant at 46,299 (1999) compared with 49,447 (2009) and 49,141 (2016), despite an increase in the population of England by seven million over the 20-year period. DISCUSSION: The rise in admissions for tonsillitis and its complications appears to correspond closely to the date of SIGN guidance and clinical commissioning group rationing of tonsillectomy and is on the background of a rise in the population of the UK. The move towards daycase tonsillectomy has reduced bed occupancy after surgery but this has been counteracted by an increase in admissions for tonsillitis and deep neck space infections, sometimes requiring lengthy intensive care stays and a protracted course of rehabilitation. The total cost of treating the complications of tonsillitis in England in 2017 is estimated to be around £73 million. The cost of tonsillectomy and treating post-tonsillectomy haemorrhage is £56 million by comparison. The total cost per annum for tonsillectomy prior to the introduction of SIGN guidance was estimated at £71 million with tonsillitis and its complications accounting for a further £8 million.

Socioeconomic variables as a predictor of indication for pediatric adenotonsillectomy.

OBJECTIVES: Adenotonsillectomy (AT) is a common pediatric procedure performed for sleep disordered breathing (SDB) or chronic/recurrent tonsillitis. A better understanding of factors associated with clinical indications for AT would positively contribute to patient-centered care of these conditions. Our objective is to assess the relationships between race, ethnicity, and socioeconomic status (SES) and indications for adenotonsillectomy in pediatric patients. METHODS: A retrospective chart review was conducted for pediatric patients between the ages 0-18 years who underwent adenotonsillectomy between October 2012 and October 2017 at Boston Medical Center. Indication for surgery was categorized as sleep disordered breathing (SDB), tonsillitis, or other. Age, race, ethnicity, gender, language, distance to hospital and insurance type were collected as demographic variables. 9-Digit patient zip codes were matched to a corresponding area deprivation index (ADI) which combines 17 neighborhood level socioeconomic markers. Logistic regression analysis was performed to assess for association between demographic variables and indication for adenotonsillectomy. RESULTS: 1315 children were included in this study (mean age = 6.4 years, 0-18 years). African American (OR = 3.90, p-value <0.0001), Latino (OR = 2.602, p-value < 0.0001), and Asian American (OR = 4.439, p-value = 0.0146) patients were more likely to have SDB as an indication than Caucasian patients. Among children undergoing AT for SDB, patients who received pre-operative polysomnogram were more likely to be under 2 years old, African American, Asian American, or of Hispanic ethnicity and have higher BMI than patients who were diagnosed clinically prior to surgery. There was no statistically significant association between indications for adenotonsillectomy and ADI, distance to hospital, insurance status or language. Males were more likely have to have SDB as an indication than females (OR = 1.67, p-value = 0.0014). Younger patients under two years of age were more likely to have SDB as an indication for surgery when compared to older patients. CONCLUSION: We found significant relationships between indications for adenotonsillectomy and race and ethnicity as well as gender and age. Additionally, our study showed that indication for AT was not associated with either ADI or insurance status. This suggests that race and ethnicity are predictors of indication independent of SES. Knowledge of predictive factors of adenotonsillectomy indications may help to improve patient centered care.

Tonsillectomy is not a procedure of limited value - the unseen costs of tonsillitis and quinsy on hospital bed consumption.

OBJECTIVES: To assess the impact of the introduction of the SIGN Clinical guidelines in 1999 and subsequent revision in 2005 on tonsillectomy, hospital admission with tonsillitis and peritonsillar abscess rates in four countries. METHODS: Retrospective analysis using English, Welsh, Australian and New Zealand National healthcare hospital admission databases between 2000 and 2013. Primary outcomes measures included tonsillectomy rates and hospital admission rates for tonsillitis and peritonsillar abscess. Secondary outcome measures included bed-day usage in England and Wales. Linear forecasting was used to identify the potential impact of any trends. RESULTS: Following guideline introduction for tonsillectomy, a significant decline in tonsillectomy rates in England (P < 0.01) and Wales (P < 0.05) was seen. Hospital admissions for acute tonsil infections increased in England (P < 0.01) and Wales (P < 0.01). In Australia and New Zealand, tonsillectomy and admission for tonsillitis rates both increased (P < 0.01). During this time, the increased rate of admission for tonsillitis in England and Wales was significantly greater than Australasia (P < 0.01). CONCLUSIONS: Following the introduction of these Clinical guidelines, there was a decrease in the rate of tonsillectomy in England and Wales and a presumed associated increase in admissions with tonsillitis. This did not occur in Australasia where tonsillectomy rates rose over time. If these trends continue, it is likely that they will have a significant deleterious impact on healthcare spending in the future.

'Thinking that somebody's going to delay [a tonsillectomy] for one to two years is quite horrifying really': a qualitative feasibility study for the NAtional Trial of Tonsillectomy IN Adults (NATTINA Part 2).

OBJECTIVES: Level one evidence on the value of adult tonsillectomy versus non-surgical management remains scarce. Before embarking on a costly national randomised controlled trial, it is essential to establish its feasibility. DESIGN: Feasibility study with in-depth qualitative and cognitive interviews. SETTING: ENT staff and patients were recruited from nine hospital centres across England and Scotland. PARTICIPANTS: Patients who were referred for tonsillectomy (n = 15), a convenience sample of general practitioners (n = 11) and ear, nose and throat staff (n = 22). MAIN OUTCOME MEASURES: To ascertain whether ear, nose and throat staff would be willing to randomise patients to the treatment arms. To assess general practitioners' willingness to refer patients to the NAtional Trial of Tonsillectomy IN Adults (NATTINA) centres. To assess patients' willingness to be randomised and the acceptability of the deferred surgery treatment arm. To ascertain whether the study could progress to the pilot trial stage. RESULTS: Ear, nose and throat staff and general practitioners were willing to randomise patients to the proposed NATTINA. Not all ENT staff were in equipoise concerning the treatment pathways. Patients were reluctant to be randomised into the deferred surgery group if they had already waited a substantial time before being referred. CONCLUSIONS: Findings suggest that the NATTINA may not be feasible. Proposed methods could not be realistically assessed without a pilot trial. Due to the importance of the question, as evidenced by NATTINA clinicians, and strong support from ENT staff, the pilot trial proceeded, with modifications.

Antibacterial resistance in Streptococcus pyogenes (GAS) from healthy carriers and tonsillitis patients and association with antibacterial sale in the Faroe Islands.

The aim of this study was to investigate the antibacterial resistance of Streptococcus pyogenes (GAS), and correlate the findings with the sales of erythromycin and tetracycline. General practitioners in the Faroe Islands were recruited to send oropharyngeal swabs. From an ongoing pneumococcal study, nasopharyngeal swabs were sampled from healthy children 0-7 years of age. Erythromycin susceptibility data from Iceland were obtained from the reference laboratory at the Landspitali University Hospital. Susceptibility testing in the Faroe Islands and Iceland was performed according to CLSI methods and criteria. The resistance rate to erythromycin and tetracycline found in patients in the Faroe Islands in 2009/2010 was 6% and 30% respectively. Tetracycline resistance in patients declined significantly from 2009 to 2010 (37-10%, p-value = 0.006 < 0.05) and differed significantly between age groups (p-value = 0.03 < 0.05). In Iceland, there was a peak in erythromycin resistance in 2008 (44%) and a substantial decrease in 2009 (5%). Although the prevalence of erythromycin and tetracycline resistance in the Faroe Islands and Iceland may be associated with antimicrobial use, sudden changes can occur with the introduction of new resistant clones.

Healthcare costs of acute and chronic tonsillar conditions in the pediatric population in the United States.

OBJECTIVE: To determine the prevalence and healthcare costs associated with the diagnosis and treatment of acute and chronic tonsillar conditions (ACT) in children. DESIGN: Cross-sectional analysis of the 2006, 2008, and 2010 Medical Expenditure Panel Surveys. METHODS: Pediatric patients (age < 18 years) were examined from the above mentioned database. From the linked medical conditions file, cases with a diagnosis of ACT were extracted. Ambulatory visit rates, prescription refills, and ambulatory healthcare costs were then compared between children with and without a diagnosis of ACT and acute versus chronic tonsillitis, with multivariate adjustment for age, sex, ethnicity, region, insurance coverage and comorbid conditions (e.g., asthma and otitis media). RESULTS: A total of 74.3 million children (mean age 8.55 years, 51% male) were sampled (raw N = 28,873). Of these, 804,229 children (1.1 ± 0.1%) were diagnosed with ACT annually (mean age 7.24 years, 49.1% male); 64.6 ± 2.0% had acute tonsillitis diagnoses and 35.4 ± 2.0% suffered from chronic tonsillitis. Children with ACT incurred an additional 2.3 office visits and 2.1 prescription fills (both p < 0.001) annually compared with those without ACT, adjusting for demographic variables and medical comorbidities, but did not have an increase in emergency department visits (p = 0.123). Children with acute tonsillar diagnoses carried total healthcare expenditures of $1303 ± 390 annually versus $2401 ± 618 for those with chronic tonsillitis (p = 0.193). ACT was associated with an incremental increase in total healthcare expense of $1685 per child, annually (p < 0.001). CONCLUSION: The diagnosis of ACT confers a significant incremental healthcare utilization and healthcare cost burden on children, parents and the healthcare system. With its prevalence in the United States, pediatric tonsillitis accounts for approximately $1.355 billion in incremental healthcare expense and is a significant healthcare utilization concern. LEVEL OF EVIDENCE: 2C.

Most common diseases diagnosed in primary care in Stockholm, Sweden, in 2011.

BACKGROUND: The most commonly reported diagnoses in primary care are useful to identify and meet health care needs in society. We estimated the rates of the most common diagnoses in primary health care in total and also by gender. METHODS: This was a cross-sectional study including all 2.0 million inhabitants living in Stockholm County, Sweden, on 1 January 2009. Data on all health care appointments made in primary care in 2011 and during 2009-11 were extracted from the Stockholm County Council data warehouse VAL (Vårdanalysdatabasen; Stockholm regional health care data warehouse). Primary care data were analysed by underlying population and age. Appropriate specialist open care and inpatient data were used for comparison. RESULTS: The five most common diagnoses in primary care (in 2011) were acute upper respiratory tract infections (6.0% of the population), essential hypertension (5.6%), coughing (2.6%), dorsalgia (2.6%) and acute tonsillitis (2.4%). Female-to-male ratios were higher for 27 of the 30 most common diagnoses, the exceptions being type 2 diabetes, unspecified types of diabetes and multiple wounds. CONCLUSIONS: The 30 most common diagnoses in primary care reflect the complexity of disorders cared for in the first line of health care. Knowledge of these patterns is important when aiming at using primary health care resources in a proper way.

Health costs and consequences: have UK national guidelines had any effect on tonsillectomy rates and hospital admissions for tonsillitis?

Tonsillectomy is a common therapeutic option in the management of recurrent tonsillitis. In 1999, the Scottish Intercollegiate Guidelines Network (SIGN) introduced SIGN 34 outlining appropriate indications for tonsillectomy. Following concerns of increasing hospital admissions for tonsillitis, in 2009 ENT UK suggested that too few tonsillectomies were being undertaken. This study analyses the effect the SIGN guidelines have had on trends in population rates of tonsillectomy and hospital admissions for tonsillitis and peritonsillar abscess in England, Scotland and Wales. A retrospective study was undertaken using the health databases of England, Scotland and Wales between 1999 and 2010. Tonsillectomy, acute tonsillitis and peritonsillar abscess were identified using national classification codes. Changes in rate of tonsillectomy and hospital admissions for tonsillitis and peritonsillar abscess were assessed using a linear regression model. 699,898 tonsillectomies were undertaken in the three national cohorts over the study period. Linear regression analysis suggested that implementation of SIGN 34 significantly reduced the population rate of tonsillectomy in England (p = 0.005) and Wales (p = 0.003) but not in Scotland (p = 0.24), and indicated there had been an increase in hospital admissions for acute tonsillitis in all cohorts (England p = 0.000008, Scotland p = 0.03, Wales p = 0.000005) and peritonsillar abscess in England (p < 0.05) and Wales (p = 0.03). SIGN 34 has reduced tonsillectomy rates in England and Wales but not in Scotland. This finding is associated with increasing hospital admissions for acute tonsillitis in all national cohorts, which may suggest that the current stipulated guidelines miss patients who would benefit from surgical intervention.

Recurrent tonsillitis in adults: quality of life after tonsillectomy.

BACKGROUND: The aim of this study was to assess the effect of tonsillectomy in adults with recurrent tonsillitis on their quality of life and on their use of medical resources. METHOD: 114 patients who had had at least three episodes of acute tonsillitis in the 12 months preceding tonsillectomy were evaluated pre- and postoperatively with a questionnaire developed by the authors, and with the Glasgow Benefit Inventory. RESULTS: 97 patients (85%) filled out the questionnaires completely. The Glasgow Benefit Inventory revealed an improvement in the overall score (+19) and in the partial scores for general well-being (+18) and physical health (+39). The degree of support from friends and family was unchanged (±0). Significant decreases were observed in visits to a physician, analgesic and antibiotic consumption, days off from work, and episodes of sore throat. The number of visits to a physician because of sore throat decreased from an average of five preoperatively to one postoperatively; the number of episodes of sore throat, from seven to two; and the number of days taken off from work, from twelve to one per year. 65% of the patients surveyed took analgesics for sore throat preoperatively, 7% postoperatively. 95% took antibiotics for sore throat preoperatively, 22% postoperatively. CONCLUSION: Although this study had a number of limitations (small size, retrospective design, short follow-up), it was able to show that tonsillectomy for adults with recurrent tonsillitis improves health and quality of life and reduces the need to consume medical resources.

[Respiratory infections outside the hospital. DIRA study]. / Estudio de las infecciones respiratorias extrahospitalarias. Estudio DIRA.

INTRODUCTION: Most visits to the primary care center are for infection and particularly respiratory tract infection. Antimicrobial administration for these clinical processes is common and these agents are often used to treat viral infections. La Fundación para el Estudio de la Infección (Foundation for the Study of Infection) designed the DIRA (Día de la Infección Respiratoria del Adulto, Adult Respiratory Infection Day) Project to investigate and assess the impact of this problem. METHODS: The study design consisted of one-day cross sections with the participation of 720 physicians belonging to Primary Health Care Centers from the 17 Autonomic Regions of Spain, establishing a one-day cross section every three months for one year. Epidemiologic, clinical and therapeutic factors were evaluated. RESULTS: The total number of visits attended was 72 929, and 14 426 patients had infectious processes (43.9%). Among these, 9145 (63.4%) had a respiratory infection. The mean age of the patients was 44.6 years and 34.1% had an underlying condition. Common cold was the most frequent diagnosis. Antibiotics were prescribed in 53.2% of patients. Results were compared to those of a previous study. DISCUSSION: Infection in general and respiratory infection in particular is frequently attended in primary care. Antibiotics are widely used in our setting and self-medication is common.

Is the incidence of tonsillectomy influenced by the family medical or social history?

Previous reports have suggested that the incidence of tonsillectomy, and/or tonsillitis in children, is influenced by factors such as parental smoking, maternal health and previous parental tonsillectomy. The reports have considered single factors and have not considered the possible confounding effect of the factors upon one another. Previous studies have not investigated the influence of social class. This paper uses the background of a large case-control trial of children awaiting tonsillectomy for recurrent tonsillitis, and a normal control group to study the influence of parental smoking, parental surgical history, parental tonsillectomy, family atopy and social class upon the reported incidence of sore throats and tonsillitis. A multivariate analysis is used. The paper shows that parental smoking, previous parental surgery and social class have no effect upon the number of sore throat episodes. A history of parental tonsillectomy and a family history of atopy are both significant predictive factors for the number of reported sore throats and episodes of tonsillitis in children.

The histopathology of routine tonsillectomy specimens: results of a study and review of literature.

Controversy continues to attend the routine histologic examination of tonsillectomy specimens. We performed a retrospective evaluation of 400 tonsil specimens removed from 200 patients. We found that 68.3% of the specimens contained reactive lymphoid hyperplasia, 13.5% had follicular hyperplasia, 10.0% represented acute or chronic tonsillitis, and 7.5% were normal. Only one case of malignancy was detected: a non-Hodgkin's lymphoma in one tonsil of a patient who was a cigarette smoker and who had asymmetric tonsils. The results of our study, taken in combination with data already published in the literature, indicate that routine histologic examination of tonsillectomy specimens is unnecessary and results only in added costs and a loss of man-hours. However, in patients who have certain preoperative risk factors, a histopathologic evaluation of tonsillar specimens remains mandatory.

Assessment of clinical features predicting streptococcal pharyngitis.

A total of 133 patients who consulted 4 general practitioners in Bergen 1988/89 for sore throat were examined. 8 clinical parameters with expected predictive value for identifying streptococcal tonsillopharyngitis were recorded. Clinical examination was validated against bacteriologic examination at a microbiological laboratory. The prevalence of streptococcal infection (group A, C and G) was 29%. An algorithm was constructed which identifies 3 groups with varying probabilities of streptococcal infection. A positive predictive value of 62% in the group with highest prevalence and a negative predictive value of 90% in the group with lowest prevalence was found. The consequences of performing a confirmative test only on patients in the group with uncertain prediction for streptococcal disease was elaborated. Although slightly reduced accuracy was demonstrated, due to diminished sensitivity, selective testing is recommended. Another algorithm was constructed for use in situations where no confirmative testing is available. The positive predictive value in the group with highest probability of streptococcal infection was 51%, and the negative predictive value in the group with lowest probability was 84%.

Physician response to the United Mine Workers' cost-sharing program: the other side of the coin.

The effect of cost sharing on health services utilization is analyzed from a new perspective, that is, its effects on physician response to cost sharing. A primary data set was constructed using medical records and billing files from a large multispecialty group practice during the three-year period surrounding the introduction of cost sharing to the United Mine Workers Health and Retirement Fund. This same group practice also served an equally large number of patients covered by United Steelworkers' health benefit plans, for which similar utilization data were available. The questions addressed in this interinsurer study are: (1) to what extent does a physician's treatment of medically similar cases vary, following a drop in patient visits as a result of cost sharing? and (2) what is the impact, if any, on costs of care for other patients in the practice (e.g., "spillover effects" such as cost shifting)? Answers to these kinds of questions are necessary to predict the effects of cost sharing on overall health care costs. A fixed-effects model of physician service use was applied to data on episodes of treatment for all patients in a private group practice. This shows that the introduction of cost sharing to some patients in a practice does, in fact, increase the treatment costs to other patients in the same practice who remain under stable insurance plans. The analysis demonstrates that when the economic effects of cost sharing on physician service use are analyzed for all patients within a physician practice, the findings are remarkably different from those of an analysis limited to those patients directly affected by cost sharing.

Housing standards, social group, and respiratory infections in children of Upernavik, Greenland.

During one year, contacts with the health service due to respiratory infections--including diseases of ear, nose, and throat--were studied in the 310 children of Upernavik town. 166 contacts were recorded. Children from low socio-economic groups had been expected to have a higher overall contact rate than other children, but this did not prove to be so. The disease pattern of these children was characterized by a low level of contacts due to certain acute respiratory infections and a high level of contacts due to chronic purulent otitis media, compared with children from higher socio-economic groups. The differences did not reach statistical significance, however.

Tonsillectomy prevalences in South African schoolchildren.

Tonsillectomy prevalences, using questionnaires, were determined on series of school pupils (total number 10,271), aged 16-18 years, in four South African ethnic groups. Prevalence were, approximately: rural Blacks 2%, urban Blacks 3%, Indians 8%, Coloureds (Eur-African-Malay) 9% and Whites 44%. The inter-ethnic profile of differences is similar to the inter-ethnic profiles of other differences (e.g. in appendicectomy prevalences).