Long-term complications after tonsil surgery: an analysis of 54,462 patients from the Swedish Quality Register for Tonsil Surgery.

Objective: This study aims to evaluate long-term complications after tonsil surgery using an exploratory retrospective cohort study design based on data from the Swedish Quality Register for Tonsil Surgery (SQTS). Methods: All patients registered in the SQTS between 1 January 2009 and 31 May 2021 were eligible for the study. In this study, a long-term complication is defined as any complication persisting for a minimum of 6 months after surgery. The definition of a complication was based on individual patient reports, provided in a free text format, of any remaining issues 6 months after tonsil surgery. Complications were categorized as follows: disturbed taste or sense of smell, dysphagia, miscellaneous and general symptoms and signs, miscellaneous throat problems, pain or discomfort in the mouth or throat, problems with jaws or teeth, problems with the ears or hearing, problems with the nose or sinuses, problems with throat secretions or throat clearing, problems with voice or speech, and sensory symptoms. A multivariable logistic regression analysis was used to identify independent predictors of long-term complications. Results: In total, 54,462 patients were included in the study. A total of 3,780 patients (6.9%) reported one or more long-term complications. The most frequent long-term complications, with a plausible connection to the surgery, were found in the following categories: pain or discomfort in the mouth or throat (1.9%), problems with throat secretions or throat clearing (0.8%), dysphagia (0.6%), and problems with voice or speech (0.6%). Tonsillotomy was associated with a lower risk of long-term complications than tonsillectomy. Conclusion: This study suggests that subjective long-term complications after tonsil surgery, in general, are relatively common (6.9%). However, complications with a plausible connection to the surgery were less common (4.0%), and specific complications seemed to be relatively rare, with no single specific problem reaching a prevalence of ≥0.6%.

A validation study of data in the National Tonsil Surgery Register in Sweden: high agreement with medical records ensures that data can be used to monitor clinical practices and outcomes.

BACKGROUND: The ambition of the National Tonsil Surgery Register in Sweden (NTSRS) is to improve otorhinolaryngological care by monitoring trends in the clinical practices, complications, and outcomes of tonsil surgery. The NTSRS collects data from both surgeons and patients and provides the participating clinics with daily updated data on a publicly available website. On the website, national and local results can be compared and monitored. The use of NTSRS data necessitates that the data is valid, but the NTSRS has not yet been validated. With approximately half of the registered patients responding to the postoperative questionnaires, an analysis of responders and non-responders is also necessary. The aim of this study was to assess the criterion validity of NTSRS data. Another aim was to compare the characteristics and rates of complications between postoperative questionnaire responders and non-responders. METHODS: Data in the NTSRS were compared with data in electronic medical records. The 200 most recent surgeries, up to 31 Dec 2019, in each of 11 surgical units were included. Criterion validity was analysed in terms of observed agreement, Cohens kappa, Gwet's AC1, and positive and negative agreement. The sign test was used to analyse systematic differences between the NTSRS and the medical records. Comparisons of rates between groups were made with Fisher's exact test, the chi-square test, and Fisher's non-parametric permutation test. RESULTS: A total of 1991 registrations were included in the study. All variables showed very high observed agreement ranging from 0.91 to 1.00, and all variables had AC1 values corresponding to almost perfect agreement. The analysis of questionnaire responders and non-responders showed no statistically significant differences regarding age, indication, or type of surgery. The proportion of women was higher in the responder group. The rate of reoperation due to bleeding was higher in the responder group, but there were no differences regarding other complications. CONCLUSIONS: The results of this study show that data in the NTSRS have criterion validity. The NTSRS is thus well suited for monitoring the clinical practices and outcomes of tonsil surgery. The quality of the data also implies that the registry can be used in both clinical improvement projects and research.

Tonsil surgery in Sweden 2013-2015. Indications, surgical methods and patient-reported outcomes from the National Tonsil Surgery Register.

AIM: To describes how tonsil surgery was performed in Sweden from 2013 to 2015 with data from the National Tonsil Surgery Registry in Sweden (NTSRS). METHOD: The registry collects data from both professionals and patients through questionnaires. A total of 33,870 tonsil surgeries were analysed, comprising approximately 80% of all tonsil surgeries in Sweden from 2013 to 2015. RESULTS: The two most common procedures were tonsillectomy (41%) and tonsillotomy with adenoidectomy (38%). Tonsillectomy was most commonly performed to treat frequent tonsillitis, while the main indication for tonsil surgery with combined adenoidectomy and for tonsillotomy alone was upper airway obstruction. The most commonly used techniques were cold steel (70%) for tonsillectomy/adenotonsillectomy and radiofrequency (79%) for tonsillotomy/adenotonsillotomy. Ninety-five percent of patients reported symptom relief after 180 d. Day surgery was utilised in 70% of the surgeries. The rate of readmission due to post-tonsillectomy haemorrhage was 5.1%. Male patients more often underwent tonsil surgery at preschool ages due to upper airway obstruction; in comparison, female patients to a larger extent underwent surgery in their early teens because of previous infections. CONCLUSIONS: The NTSRS provides an opportunity to survey tonsil surgery in Sweden and to launch and follow up improvement programmes as desired.

Risk of reoperation after tonsillotomy versus tonsillectomy: a population-based cohort study.

Tonsil surgery to address upper airway obstruction in children can be performed either as a tonsillectomy (TE) or as a tonsillotomy/intracapsular/partial tonsillectomy (TT). The advantage of TT is a decreased risk of postoperative morbidity. The disadvantage is the risk of tonsil regrowth with recurrence of symptoms and/or problems with future tonsil infections, which may demand a reoperation of the tonsils. The aim of this study is to compare the risk of reoperation of the tonsils following TE and TT in children with tonsil-related upper airway obstruction. This is a retrospective register-based cohort study of the Swedish National Patient Register. All children aged 1-12 years who underwent TE or TT from 2007 to 2012 for the main indication of upper airway obstruction were included in the study. The unique Personal Identity numbers were used to follow patients over time in the register and identify additional tonsil surgery. A total of 27,535 patients were included in the study, contributing 76,054 person-years of follow-up. A total of 684 patients (2.5 %) underwent a second tonsil surgery during follow-up. The incidences of reoperation were 1.94 per 1000 person-years in the TE group and 16.34 per 1000 person-years in the TT group. The risk for reoperation was seven times higher (HR 7.16) after TT compared to TE. Younger age was significantly associated with reoperation for both TE and TT and the difference in risk between TE and TT gradually decreased with time. The most common indication for reoperation after both TE and TT was "Upper airway obstruction".

Mortality after tonsil surgery, a population study, covering eight years and 82,527 operations in Sweden.

The objective of this retrospective cohort study was to evaluate mortality rate and cause of death after tonsil surgery in Sweden. Two national registries were used, both run by The Swedish National Board of Health and Welfare, an agency of the Ministry of Health and Social Affairs. In the National Patient register all tonsil surgeries performed in Sweden from 2004 through 2011 were identified. The result from this search was matched with the National Cause of Death Register to identify all deaths that occurred within 30 days of tonsil surgery. Personal identity numbers were used to do the matching of registers. Details on the cause of death were obtained from the Swedish National Board of Health and Welfare. Two deaths were identified in 82,527 operations. Both patients were male, otherwise healthy, children under the age of five, operated due to tonsil-related upper airway obstruction/snoring with coblation technique. Cause of death was bleeding-related airway obstruction in both cases and hemodynamic failure caused by blood loss. Both deaths occurred after discharge from the hospital within the first postoperative week. No abnormal levels of analgesics were found in the postmortal investigations. Two deaths related to tonsil surgery (performed on benign indications) were identified in 82,527 operations (2004-2011) in a well-defined national population. Both deaths were due to postoperative bleeding. Based on our findings, the frequency of post-tonsil-surgery mortality in Sweden was 1/41,263, 2004-2011. Level of evidence 2b retrospective cohort study.

Radiofrequency tonsillotomy in Sweden 2009-2012.

The Swedish National Registry for Tonsil Surgery has been operational since 1997. All ENT clinics in Sweden are encouraged to submit data for all patients scheduled for tonsil surgery. Preoperatively, age, gender and indication are recorded. Postoperatively, method (tonsillectomy or tonsillotomy), technique, and perioperative complications are recorded. Postoperative bleedings, pain, infections, and symptom relief are assessed through questionnaires. An earlier report from this registry showed that tonsillotomy had become more common than tonsillectomy in children with tonsil-related upper airway obstruction. The aim of this study was to categorize which instruments were used for tonsillotomy in Sweden and to compare their outcome and complication rate. All children 2-18 years, reported to the registry from March 2009 until September 2012, who underwent tonsillotomy on the indication upper airway obstruction, were included in the study. 1,676 patients were identified. In 1,602 cases (96%), a radiofrequency instrument was used. The postoperative bleeding rate was low (1.2%) and the degree of symptom relief was high (95.1%). Three different radiofrequency instruments (ArthroCare Coblation(®), Ellman Surgitron(®), and Sutter CURIS(®)) were used in 96% of the patients. There were no significant differences in the number of postoperative bleedings, postoperative infections or symptom relief between the instruments. The only difference found was in the number of days on analgesics, where more days were registered after use of Coblation(®). In Sweden, radiofrequency tonsillotomy is the dominant surgical technique used for tonsil hypertrophy causing upper airway obstruction in children. There are no significant differences in outcome between the different radiofrequency instruments except for number of days on analgesics after surgery.

Paradigm shift in Sweden from tonsillectomy to tonsillotomy for children with upper airway obstructive symptoms due to tonsillar hypertrophy.

Tonsillotomy (TT) is now used more often than tonsillectomy (TE) for tonsil obstructive symptoms in Sweden. Both TE and TT give high patient satisfaction although TT results in fewer postoperative bleedings and shorter time when analgesics are needed. The objective of this study is to analyze the current prevalence of different tonsil surgery procedures, the rates of early and late bleeding and other complications. Data from the National Tonsil Surgery Register in Sweden were analyzed. Patients 1-15 years operated for symptoms due to tonsil hypertrophy were included. Surgical procedure, technique and bleedings during hospital stay were registered. Thirty days after surgery, unplanned contacts due to bleeding, infection or pain were reported as were symptom relief after 6 months. 24,083 patients were registered. Of the 10,826 children 1-15 years operated for obstructive symptoms, 64 % were TT or TT+A, and 34 % TE, TE+A. 69 % answered the 30-day questionnaire and 50 % the 6 months. Bleeding in hospital occurred in 1.38 %, late bleedings in 2.06 %: 3.7 % after TE+A, 0.8 % after TT+A. Differences in readmissions due to bleeding, number of days using analgesics, health care contacts due to pain and nosocomial infections were significant between TT and TE, but not differences with regard to symptom relief after 6 months.

Tonsil surgery efficiently relieves symptoms: analysis of 54 696 patients in the National Tonsil Surgery Register in Sweden.

CONCLUSION: Patients operated with tonsillar surgery report a high degree of symptom relief 6 months after surgery. OBJECTIVE: The purpose of this study was to analyze symptom relief 6 months after tonsil surgery in relation to age, indication, surgical procedure, primary bleeding and unplanned postoperative visits. The National Tonsil Surgery Register in Sweden offers data from 54,696 patients registered during 1997-2008. METHODS: This was a prospective assessment by questionnaire. Data were collected using three questionnaires, two completed by professionals and one 6 months postoperatively by the parents/patients. RESULTS: Among 54,696 patients, the most common surgical indications were obstruction (49.7%), followed by recurrent tonsillitis (35.2%). Symptom relief 6 months after surgery was high in all indication groups (>92%), and highest for patients operated on the indication peritonsillitis (>98%). The indications obstruction, recurrent tonsillitis or chronic tonsillitis reported a high degree (>96%) of symptom relief. Of the patients who underwent tonsillectomy with adenoidectomy, 97.5% were symptom-free compared to 96% of patients who had tonsillectomy alone and 96.1% who underwent tonsillotomy (p < 0.0001). In all, 13.9% of patients required an unplanned visit to the clinic postoperatively. Only 148 of 54,696 patients reported worsening of symptoms after surgery.

Reduced risk of primary postoperative hemorrhage after tonsil surgery in Sweden: results from the National Tonsil Surgery Register in Sweden covering more than 10 years and 54,696 operations.

OBJECTIVES/HYPOTHESIS: To analyze the incidence of primary bleeding following tonsil surgery and to evaluate risk factors. STUDY DESIGN: Register study of the results from the National Tonsil Surgery Register in Sweden covering the period 1997 to 2008 and 54,696 operations. METHODS: Data were collected by means of three questionnaires, two filled in by professionals and one 6 months postoperatively by the patient/parent. RESULTS: A total of 719 patients experienced primary postoperative bleeding during the hospital stay (1.3%). A number of independent factors were correlated with decreased risk of post-tonsillectomy hemorrhage: younger age (P < .0001), female sex (P < .0001), type of surgery (tonsillotomy) (P = .0006), and surgery performed on a day-surgery basis (P < .0001). Indication for surgery and number of operations performed at the department did not correlate with postoperative bleeding risk. A significant decrease in primary postoperative hemorrhage rate from 2% to 0.96% was found during the study period. CONCLUSIONS: Primary hemorrhage following tonsil surgery is rare. During the study period, a significant decrease in primary bleeding rates occurred. The changes in practice with an increasing proportion of day-surgery cases and tonsillotomy have contributed to the reduced risk, but cannot completely explain the reduction.

Ligasure versus diathermy scissors tonsillectomy: A controlled randomized study.

CONCLUSIONS: Ligasure tonsillectomies took longer than bipolar diathermy scissors tonsillectomies. Peroperative haemostasis was comparable in the two groups. Postoperative haemorrhage was higher than expected, which needs to be further investigated. A new handpiece, specifically designed for tonsillectomy, could probably improve surgical performance regarding operative time. OBJECTIVE: To compare tonsillectomy using Ligasure with bipolar diathermy scissors with regard to operative time, blood loss and complications. METHODS: This was a prospective study; 150 patients (> 15 years of age) undergoing tonsillectomy were randomized to tonsillectomy using either Ligasure or bipolar diathermy scissors. Operative time, peroperative blood loss, postoperative pain and complications were recorded and evaluated. RESULTS: A total of 149 cases were included, 75 randomized to Ligasure tonsillectomy and 74 to bipolar diathermy scissors tonsillectomy. Peroperative blood loss was similar in both groups. On average the operative time was 8 min longer in the Ligasure group. Postoperative pain was similar in the two groups. Twenty patients (13%) experienced postoperative haemorrhage, which is higher than our previous material. Slightly fewer patients experienced postoperative haemorrhage in the Ligasure group compared with the diathermy scissors group but the difference was not significant. Two of the 20 patients that experienced postoperative haemorrhage required a return to theatre to stop the bleeding, fewer than previously observed. No other complications were seen.

A 4-year consecutive study of post-tonsillectomy haemorrhage.

OBJECTIVE: To analyse consecutive material over a period of 4 years concerning the incidence and consequences of post-tonsillectomy haemorrhages (PTH). DESIGN: Prospective study. SETTING: University hospital. PARTICIPANTS: All non-oncological cases of tonsillectomy (TE) and adenotonsillectomy (TA) performed at the ENT department at the Karolinska University Hospital between March 2000 and April 2004. MAIN OUTCOME MEASURES: Rate, timing and classification of PTH. RESULTS: During the study period, 2,813 cases (mean age 13 + or - 12.8 years; SD) of TE and TA were included. The majority (62%) were children aged below 12 years, and 69% were performed as day surgery. In total, 212 (7.5%) patients were readmitted due to PTH, of which 98 (3.4%) presented with ongoing haemorrhage. The rates of primary and secondary bleeding were 1.9 and 5.5%, respectively. The PTH occurred in 0-19 days post-operatively, in a typical twin peak mode around the day of surgery and then days 4-7. No case of serious PTH was noted. Multiple bleedings (2-3 times) occurred in 19 patients. Only a minority (31%) of the single PTH patients required active treatment, surgery in the theatre (35 patients) or diathermy under local anaesthesia in the emergency room (24 patients). However, almost all received systemic haemostatic treatment. Three patients required blood transfusion due to repeated PTH. Of the 114 patients that did not present with an active PTH, only 1 returned to the operating theatre due to later bleeding. Almost half (43%) of the patients with multiple episodes of PTH had also experienced primary bleedings. CONCLUSIONS: A primary PTH seems to indicate a risk of further episodes of bleedings, and should necessitate extra post-operative observation. Patients with a history of a single self-limiting PTH showed low risk of developing a haemorrhage requiring return to the theatre.

The cost-burden of paediatric pneumococcal disease in Sweden and the potential cost-effectiveness of prevention using 7-valent pneumococcal vaccine.

AIMS: A cost-effectiveness model was used to estimate the change in disease burden that might be expected if PCV7 was included as part of the routine 3-dose vaccination schedule in Sweden. METHODS: An economic model was populated with data from the main clinical PCV7 efficacy trials, demographic data from government sources, surveillance and epidemiologic data from the US and Nordic region, and average treatment costs, considering the impact of disease on the whole national population. RESULTS: The model estimated that PCV7 would prevent 18,856 cases of AOM, 684 of pneumonia, 86 of pneumococcal bacteraemia and 21 cases of pneumococcal meningitis in children <10 years, further 221 cases of IPD would be avoided in older children and adults and 397 cases of pneumonia in adults aged 18-39 years. Annually, 4 childhood (<10 years) deaths and 39 deaths in older children and adults would be prevented, resulting in an annual saving of 632 life years. The reduction of cost for the society was estimated to 27.9 (-205, +160) million SEK. The sensitivity analysis showed that it was most sensitive to the efficacy of the vaccine against AOM, the cost of managing infections and the incidence of all disease. CONCLUSION: This model demonstrates that implementing a universal vaccine programme in Sweden with PCV7 would be cost-effective with an estimated net reduction of costs for the society.

IgE-positive plasma cells are present in adenoids of atopic children.

CONCLUSIONS: We demonstrated the presence of IgE(+) plasma cells in the adenoids of atopic children. Our data suggest that adenoids are capable of local production of IgE and support the role of adenoids as an inductive site for allergic reactions. OBJECTIVE: We have previously demonstrated increased numbers of IgE(+) cells in the adenoids of atopic children and also found support for an IL-4-induced class switch to IgE production in adenoids. In search of further evidence of adenoids being involved in IgE-mediated sensitization, we investigated the distribution of plasma cells and macrophages positive for IgE in adenoids. MATERIAL AND METHODS: Adenoid tissue from atopic and non-atopic children was examined using immunohistochemical markers for IgE, plasma cells (CD138) and macrophages (CD68). The distribution of positive cells was determined in the extrafollicular area and in the follicles of adenoids. Co-localization of IgE and CD138(+) plasma cells and CD68(+) macrophages was examined using immunohistochemical double-staining methods. RESULTS: Non-atopic adenoids contained no or very few IgE(+) cells. In contrast, IgE(+) cells were found in high numbers in atopic adenoids, mainly in the extrafollicular area. Higher numbers of IgE(+) plasma cells and IgE(+) macrophages were also found in the adenoids of atopic children.

Increased levels of IL-2 and IL-4 in stimulated adenoidal lymphocytes of atopic children.

BACKGROUND: The adenoid is involved in the defence against airway pathogens and its surface is also exposed to airborne allergens. The knowledge about reactions taking place in the lymphatic tissue of this organ is, however, limited. To elucidate the influence of atopy we investigated the cellular and cytokine profile of in vitro-stimulated adenoid lymphocytes. METHODS: Adenoid tissue cells from 13 atopic and 8 non-atopic children were cultured and stimulated with ionomycin and 4beta-phorbol 12-myristate 13-acetate. Supernatants were collected after 4 and 20 h of stimulation and interleukin-2 (IL-2), IL-4 and interferon-gamma (IFN-gamma) were analysed by ELISA. Flow cytometry was used to quantify the leukocyte markers CD3, CD19, CD25 and HLA-DR. RESULTS: Increased levels of IL-2 and IL-4 but not IFN-gamma were detected in the supernatants of adenoid cell cultures from atopic children after 20 h of stimulation (p < 0.05) and a significant correlation with a positive regression between IL-2 and IL-4 was found. Atopy was also associated with a greater increase in the percentage of CD19-positive B cells after stimulation (p < 0.05). CONCLUSIONS: A difference in the reactivity of adenoidal lymphoid cells in children was observed between atopic and non-atopic subjects. Atopy was associated with an increased production of IL-2 and IL-4 as well as a more pronounced increase of B cells.