Long-term effectiveness of tonsillotomy versus tonsillectomy: A 12-year follow-up study.

PURPOSE: To evaluate the long-term effectiveness of tonsillotomy (TT) compared to tonsillectomy (TE) with respect to disease-specific quality of life (QOL), sleep-disordered breathing symptoms, throat infections, and rate of reoperations over a median follow-up period of 12 years. METHODS: All patients < 16 years of age who underwent tonsil surgery between 2010 and 2011 at Helsinki University Hospital, Finland, were included in the study. In 2023, the patients answered a questionnaire concerning tonsil-related issues and a modified Tonsil and Adenoid Health Status Instrument (disease-specific QOL). Information about possible revisits and reoperations was gathered. RESULTS: The study population consisted of 189 respondents, of which 87 had undergone TT and 102 TE. The median follow-up was 11.8 years in the TT group and 12.4 years in the TE group. The disease-specific QOL was equally good in both groups. Throat infections had not been an issue for the vast majority of patients and occurred to the same extent after TT and TE. The majority of participants (79.0% TT, 86.9% TE) were satisfied with the surgery, with no significant differences between the groups. After TT and TE, there were only a few revisits due to tonsil-related problems, and the reoperation rate was 6.9% and 1.0%, respectively. CONCLUSION: Long-term clinical effectiveness of TT seems excellent. Compared to TE, with TT, equal disease-specific QOL can be achieved with a less invasive surgical method. Over a median follow-up period of 12-years, TT was not shown to be associated with an increased risk of tonsil infection problems.

Assessing outcomes after partial and total tonsillectomy for sleep-disordered breathing in children using Clinical Assessment Score-15.

INTRODUCTION: The Clinical Assessment Score-15 (CAS-15) is an office-based tool for assessing the risk of sleep disordered breathing (SDB), a relatively common condition in the pediatric population. Change in CAS-15 following total tonsillectomy (TT) has been shown to have a large effect size, but it is unclear how it varies following partial intracapsular tonsillectomy (PIT). Thus, the objective of the present study is to evaluate the utility of the CAS-15 score in assessing the effectiveness of PIT and how this compares to change after TT. MATERIAL METHODS: Children ages 2-18 undergoing PIT (N = 16) or TT (N = 8) with or without adenoidectomy for SDB completed the CAS-15 before surgery and at their post-operative follow-up visit. Changes in CAS-15 score were assessed by paired t-test. The mean difference in CAS-15 change between PIT and TT was evaluated by unpaired t-test for unequal variances. Differences in participant characteristics were determined via unpaired t-test for unequal variances. RESULTS: Participants undergoing PIT did not differ significantly than those undergoing TT with regard to age, sex, BMI percentile, pre-op CAS-15 score or tonsil size, or admission rates following surgery (p > 0.05). The median follow-up after surgery was 5.2 (PIT) and 4.4 (TT) weeks. CAS-15 score improved significantly following PIT (42.8 ± 12.3 vs. 9.4 ± 5.6, p < 0.0001) and TT (45.5 ± 13.3 vs. 7.9 ± 5.8, p < 0.0002). The decrease in CAS-15 for PIT did not differ from TT (33.3 ± 11.8 vs. 37.6 ± 15.0, p > 0.49). DISCUSSION: CAS-15 decreases drastically following PIT and TT, indicating significant improvement of SDB symptoms. Because the change in CAS-15 after PIT was similar to TT, PIT may be preferred due to the decreased morbidity of the procedure. Given the cost, time required, inconvenience, and other limitations of overnight polysomnography (PSG), which is the gold standard method of diagnosing SDB, CAS-15 may be a suitable replacement or adjunct for the assessment of SDB following PIT in addition to TT.

Feasibility of Powered Intracapsular Tonsillectomy in Pediatric Patients with Tonsil Problem, Including Recurrent Tonsillitis: A Single Surgeon's Experience.

INTRODUCTION: Powered intracapsular tonsillectomy (PIT) is a technique that protects the tonsillar capsule by using a microdebrider, resulting in faster wound-healing and reduced suffering. Many studies have found PIT to be effective, particularly in pediatric patients with obstructive sleep apnea (OSA). However, previous studies have not included patients with a history of recurrent tonsillitis. OBJECTIVE: The aim of this study was to determine the efficacy of PIT in pediatric patients even with a history of recurrent tonsillitis, and therefore, we want to expand the indication for PIT and reveal its safety. METHODS: A total of 886 pediatric patients underwent PIT between February 2013 and March 2016. All patients rated their postoperative pain using a visual analog scale (VAS) and completed the Korean obstructive sleep apnea (KOSA)-18 questionnaire for assessment of their quality of life (QOL). There were 539 males and 347 females. Their mean age was 6.2 years (range 2-14 years). The majority (77.7%) underwent the operation for OSA, and the rest (22.3%) had a history of recurrent tonsillitis. To compare the efficacy of PIT with traditional tonsillectomy, we selected 191 patients who underwent extracapsular tonsillectomy (ECT), a conventional technique, during the same time period. The median follow-up period was 16.7 months. During the follow-up period, instances of delayed bleeding and recurrent pharyngitis were monitored. RESULTS: In comparison to the patients who underwent ECT, the PIT group showed significantly fewer cases of postoperative bleeding (p = 0.027). Thirteen patients in the PIT group (1.5%) visited the hospital during the follow-up period for pharyngitis, while 8 in the ECT group (4.2%) visited for pharyngitis. The mean postoperative pain score, as assessed by a VAS, was 4.6 ± 3.2, and pain improved within an average of 2.9 days after surgery in the PIT group. The mean KOSA-18 score for the QOL of the patients was 65.9 preoperatively and 35.6 postoperatively in the PIT group. CONCLUSIONS: Pediatric tonsillectomy using PIT is valid for reducing postoperative pain and improving the QOL of OSA patients. PIT is also effective and safe for patients with a history of recurrent tonsillitis.

Clinical practice guideline: tonsillitis II. Surgical management.

In 2013, a total of 84,332 patients had undergone extracapsular tonsillectomies (TE) and 11,493 a tonsillotomy (TT) procedure in Germany. While the latter is increasingly performed, the number of the former is continually decreasing. However, a constant number of approximately 12,000 surgical procedures in terms of abscess-tonsillectomies or incision and drainage are annually performed in Germany to treat patients with a peritonsillar abscess. The purpose of this part of the clinical guideline is to provide clinicians in any setting with a clinically focused multi-disciplinary guidance through the surgical treatment options to reduce inappropriate variation in clinical care, improve clinical outcome and reduce harm. Surgical treatment options encompass intracapsular as well as extracapsular tonsil surgery and are related to three distinct entities: recurrent episodes of (1) acute tonsillitis, (2) peritonsillar abscess and (3) infectious mononucleosis. Conservative management of these entities is subject of part I of this guideline. (1) The quality of evidence for TE to resolve recurrent episodes of tonsillitis is moderate for children and low for adults. Conclusions concerning the efficacy of TE on the number of sore throat episodes per year are limited to 12 postoperative months in children and 5-6 months in adults. The impact of TE on the number of sore throat episodes per year in children is modest. Due to the heterogeneity of data, no firm conclusions on the effectiveness of TE in adults can be drawn. There is still an urgent need for further research to reliably estimate the value of TE compared to non-surgical therapy of tonsillitis/tonsillo-pharyngitis. The impact of TE on quality of life is considered as being positive, but further research is mandatory to establish appropriate inventories and standardized evaluation procedures, especially in children. In contrast to TE, TT or comparable procedures are characterized by a substantially lower postoperative morbidity in terms of pain and bleeding. Although tonsillar tissue remains along the capsule, the outcome appears not to differ from TE, at least in the pediatric population and young adults. Age and a history of tonsillitis are not a contraindication, abscess formation in the tonsillar remnants is an extremely rare finding. The volume of the tonsils should be graded according to Brodsky and a grade >1 is considered to be eligible for TT. The number of episodes during 12 months prior to presentation is crucial to indicate either TE or TT. While surgery is not indicated in patients with less than three episodes, a wait-and-see policy for 6 months is justified to include the potential of a spontaneous healing before surgery is considered. Six or more episodes appear to justify tonsil surgery. (2) Needle aspiration, incision and drainage, and abscess tonsillectomy are effective methods to treat patients with peritonsillar abscess. Compliance and ability of the patient to cooperate must be taken into account when choosing the surgical method. Simultaneous antibiotic therapy is recommended but still subject of scientific research. Abscess tonsillectomy should be preferred, if complications have occurred or if alternative therapeutic procedures had failed. Simultaneous TE of the contralateral side should only be performed when criteria for elective TE are matched or in cases of bilateral peritonsillar abscess. Needle aspiration or incision and drainage should be preferred if co-morbidities exist or an increased surgical risk or coagulation disorders are present. Recurrences of peritonsillar abscesses after needle aspiration or incision and drainage are rare. Interval TE should not be performed, the approach is not supported by contemporary clinical studies. (3) In patients with infectious mononucleosis TE should not be performed as a routine procedure for symptom control. TE is indicated in cases with clinically significant upper airway obstruction resulting from inflammatory tonsillar hyperplasia. If signs of a concomitant bacterial infection are not present, antibiotics should not be applied. Steroids may be administered for symptom relief.

Management of Periodic Fever, Aphthous Stomatitis, Pharyngitis, Adenitis with Intracapsular Tonsillectomy.

OBJECTIVE: This study aimed to present 2 children clinically diagnosed with periodic fever, aphthous stomatitis, pharyngitis, and adenitis (PFAPA) syndrome and treated with intracapsular tonsillectomy with adenoidectomy (ITA). METHODS: We conducted a retrospective analysis of 2 children who were referred for an otolaryngology consultation between 2019 and 2022 for surgical treatment of PFAPA syndrome. Both patients had symptoms strongly suggestive of PFAPA and were at risk for total tonsillectomy (TT) complications. ITA was performed using a microdebrider. Both patients were followed up postoperatively to assess for symptomatic resolution and complications. RESULTS: Two children exhibited recurrent febrile episodes prior to ITA. The procedure was efficacious in both patients, with neither experiencing postoperative complications or recurring PFAPA symptoms for over 1 year after surgery. CONCLUSION: Our study reported on the use of ITA as a surgical treatment option for PFAPA. We showed that ITA eliminated febrile attacks and was safely performed without postoperative complications in 2 pediatric patients after 1-year follow-up. Future studies involving larger cohorts of PFAPA patients and lengthier follow-ups will need to be conducted to further evaluate ITA as a surgical option. Laryngoscope, 134:1967-1969, 2024.

Intracapsular Versus Total Tonsillectomy in Patients with Trisomy 21.

OBJECTIVES: Intracapsular tonsillectomy and adenoidectomy (iTA) has become a popular alternative to extracapsular tonsillectomy and adenoidectomy (TT) for the treatment of pediatric obstructive sleep apnea (OSA) due to improved recovery and fewer complications. The objective of this study was to compare surgical recovery and impact on OSA of iTA versus TT in patients with Trisomy 21 (T21). METHODS: This is a case series with chart review of all T21 patients who underwent iTA or TT at our institution between July 1, 2015 and August 15, 2022. Data collected included demographics, comorbidities, preoperative sleep studies, intraoperative data, complications and recovery, postoperative sleep studies, and follow-up data. RESULTS: There were 62 (21.7%) patients who underwent iTA and 224 (78.3%) patients who underwent TT. The iTA group had significantly lower pain scores (p < 0.001), decreased use of narcotics (p < 0.001), shorter length of stay (p = 0.003), and faster return to oral intake (p = 0.01) during their postoperative hospital admission, and fewer 30-day complications (p = 0.009) compared to the TA group. Both groups showed significant improvements in their sleep studies. For 41 (66.1%) of iTA patients who had follow-up, median follow-up was 1.8 years and for 169 (75.4%) TT patients, median follow-up was 2.6 years. At follow-up, 21 of 41 (51.2%) iTA patients and 83 of 169 (49.1%) TT patients exhibited OSA symptoms (p = 0.084) and tonsillar regrowth was not significantly different between the two groups (p = 0.12). CONCLUSION: Patients with T21 experience less pain and fewer postoperative respiratory complications from iTA than from TT. The short-term impact of iTA versus TT on OSA, as measured by poysomnography, does not differ between the two techniques. LEVEL OF EVIDENCE: 3 Laryngoscope, 134:2430-2437, 2024.

Endoscopic Powered Intracapsular Tonsillectomy and Adenoidectomy in Pediatric Obstructive Sleep Apnea With High-Risk Comorbid Disease Conditions: A Case Series.

OBJECTIVE: Pediatric obstructive sleep apnea (OSA) caused by adenoids or an enlarged palatine tonsil has a negative impact on physical and mental growth. Surgical removal of the tissue is effective but entails a life-threatening risk of postoperative bleeding, which is up to 30 times higher in chronic pediatric disease cases. However, endoscopes and resection devices provide safe, reliable surgical methods. Here, we report the efficacy and safety of endoscopic powered intracapsular tonsillectomy and adenoidectomy (PITA) for pediatric OSA in patients with high-risk comorbidities. METHODS: This retrospective case series included pediatric patients with OSA who underwent PITA at a single tertiary medical center between April 2017 and May 2023. Ten patients (three males and seven females; mean age 6.4 years, range 2-12 years) were included; all met the Japanese criteria for complex chronic pediatric conditions. RESULTS: The average operative time was 61 min; a microdebrider was used in eight cases and a coblator in two cases. Although there was no postoperative bleeding, one case experienced regrowth. CONCLUSIONS: Our data show that an endoscopic PITA approach could reduce the risk of severe bleeding and relieve the sleeping conditions of pediatric patients with complex chronic OSA.

Outcome of tonsillotomy in children with obstructive sleep-disordered breathing.

OBJECTIVE/BACKGROUND: Most children treated for obstructive sleep disordered breathing (oSDB) are not systematically assessed by polysomnography (PSG) nor by structuredsymptom quantification before surgical treatment. The main objective of this study wasto investigate the effect of adeno-tonsillotomy (ATO) on symptom burden and PSGparameters. METHODS: Children aged 2-10 years with oSDB were selected for ATO based uponclinical findings according to current standards of care in Denmark. Each childunderwent standardized assessment before and 3 months after surgery, including aPSG, tonsil size assessment, and the Pediatric Sleep Questionnaire -Sleep RelatedBreathing Disorder (PSQ) to quantify symptom burden. Obstructive sleep apnea (OSA)was defined as an obstructive apnea-hypopnea index (oAHI) ≥2/h. Successfultreatment was defined as post-surgery oAHI ≤5/h, and complete cure as oAHI ≤2/h. RESULTS: Fifty-two children were included. Mean age was 5.0 years (SD ± 1.76). Thirteen children were identified with baseline oAHI <2/h. Significant improvement inOSA severity was observed in children with moderate-to-severe OSA, in whom oAHI decreased from 15.7/h to 2.6/h (p < 0.001). Treatment success was obtained in 85% and cure was obtained in 42% of children. PSQ-score significantly improved from 0.52 (CI 0.47-0.56) to 0.26 (CI 0.21-0.32) (p < 0.001). Baseline OSA severity was notcorrelated to baseline symptom burden nor to symptom relief after ATO. There were noserious adverse events. CONCLUSIONS: Adeno-tonsillotomy significantly reduced symptom burden in otherwise healthy children with oSDB symptoms. Significant improvement in oAHI was observedonly in children with moderate-to-severe OSA. We recommend combining clinicalevaluation with PSQ and oAHI.

Efficacy of endoscopic powered intracapsular tonsillectomy and adenoidectomy for pediatric obstructive sleep apnea: A retrospective case-control study.

OBJECTIVE: Safe surgery for pediatric patients with obstructive sleep apnea (OSA) is important to decrease postoperative events and improve cost-effectiveness. Therefore, this study aimed to compare surgical efficacy and safety between powered intracapsular tonsillectomy and adenoidectomy (PITA) and extracapsular tonsillectomy and adenoidectomy for OSA in children. METHODS: In this retrospective case-control study, patient characteristics and postoperative outcomes were compared between 93 children with OSA who underwent PITA and 81 children who underwent conventional extracapsular tonsillectomy and adenoidectomy at a tertiary hospital. Data analysis using multivariate, multiple regression, and binomial logistic regression analyses was performed. RESULTS: PITA reduced the odds of postoperative hemorrhage by 8.95% (odds ratio [OR]: 5.69, p = 0.013) and of secondary hemorrhage by 8.8% (OR: 10.08, p = 0.006), decreased postoperative analgesia use by 0.35% (p < 0.001), and increased oral intake on postoperative day 1 by 17% (p < 0.001). There were no significant differences in early hemorrhage or regrowth rates between the groups. CONCLUSION: PITA could reduce the risk of secondary hemorrhage and improve postoperative quality of life, which are ideal clinical benefits of surgery in pediatric patients with OSA.

Tonsillectomy and Adenoidectomy - Pediatric Clinics of North America.

Tonsillectomy and adenoidectomy are among the most commonly performed major pediatric operations in the United States, with more than 500,000 procedures performed annually. This procedure can be performed with or without adenoidectomy. These procedures were traditionally performed for recurrent tonsillitis; however, the vast majority of tonsillectomies are currently performed for obstructive symptoms. When performed for appropriate indications, tonsillectomy and adenoidectomy can greatly improve a child's quality of life and general health. Given the prevalence of these conditions and subsequent surgical procedures, evidence-based recommendations are regularly evaluated and updated. As such, familiarity with these guidelines is necessary for pediatric practitioners. This review summarizes the indications, complications, and outcomes for tonsillectomy and adenoidectomy, as well as provides a brief overview of operative techniques.

Predictive Pediatric Characteristics for Revision Tonsillectomy After Intracapsular Tonsillectomy.

OBJECTIVES: There is little research on the rate and risk factors for revision tonsillectomy after primary intracapsular tonsillectomy. Our study aimed to determine the revision rate following intracapsular tonsillectomy, identify patient characteristics that may increase the probability of revision surgery, and report the tonsillar hemorrhage rate after revision. STUDY DESIGN: Level III, retrospective case-control study. SETTING: A tertiary care pediatric center (Alfred I. duPont Hospital for Children, Wilmington, Delaware). METHODS: A case-control study of pediatric patients who underwent intracapsular tonsillectomy between January 1, 2004, and December 31, 2018, was performed. Patients aged 2 to 20 years were analyzed and compared with matched controls who underwent intracapsular tonsillectomy within 7 days of the same surgeon's case. In total, 169 revision procedures were included with 169 matched controls. RESULTS: A 1.39% revision rate was observed among a total of 12,145 intracapsular tonsillectomies. Among the 169 patients who underwent a revision procedure, the mean time between cases was 3.5 years. Tonsillitis was the most common diagnosis prompting revision tonsillectomy. Four (2.4%) patients underwent operative control of a postoperative tonsillar hemorrhage after revision surgery. Younger patients (P < .001) and patients with a history of gastroesophageal reflux disease (P = .006) were more likely to undergo revision tonsillectomy. CONCLUSION: Patients below age 4 years and patients with gastroesophageal reflux disease may be at increased risk of undergoing revision tonsillectomy after primary intracapsular tonsillectomy. These factors should be considered when selecting an intracapsular technique for primary tonsillectomy in pediatric patients.

Current Status and Future Trends: Pediatric Intracapsular Tonsillectomy in the United States.

OBJECTIVES: 1) To assess the current status of pediatric intracapsular tonsillectomy in the United States, and 2) To apply lessons from the scientific literature and adoption of surgical innovation to predict future trends in pediatric intracapsular tonsillectomy. METHODS: This was a cross-sectional survey study and literature review. An anonymous survey was sent to all members of the American Society of Pediatric Otolaryngology (ASPO) to determine current practices in pediatric tonsillectomy. Statistical analysis was performed to compare differences in individuals who perform intracapsular tonsillectomy as opposed to extracapsular tonsillectomy. A literature analysis of the adoption of new technological advancements and innovative surgical techniques was then performed. RESULTS: The survey was sent to 540 pediatric otolaryngologists with a response rate of 42%. Of all respondents, 20% currently perform intracapsular tonsillectomy. The primary reason cited for not performing the procedure was concern for tonsillar regrowth. Time in practice, practice setting, and fellowship status was not associated with an increased incidence of intracapsular tonsillectomy. CONCLUSIONS: Only 20% of pediatric otolaryngologist respondents in the United States perform intracapsular tonsillectomy. Based on the documented advantages of intracapsular tonsillectomy over extracapsular tonsillectomy and an analysis of adoption of novel surgical techniques, we predict a paradigm shift in the specialty toward intracapsular tonsillectomy. LEVEL OF EVIDENCE: 3 Laryngoscope, 131:S1-S9, 2021.

Does perioperative ketorolac increase bleeding risk after intracapsular tonsillectomy?

IMPORTANCE: Conflicting evidence exists regarding the post-tonsillectomy bleed risk associated with perioperative ketorolac use in the pediatric population. Surgical technique for tonsillectomy can further confound this risk. OBJECTIVE: The primary objective was to retrospectively quantify the post-tonsillectomy bleed rate after single-dose administration of ketorolac in pediatric patients following intracapsular tonsillectomy. The secondary objective was to determine if age, sex, body mass index, medical comorbidities, and indication for surgery increased post-tonsillectomy bleed risk. DESIGN: Retrospective cohort study of 1920 children who underwent intracapsular tonsillectomies between January 2017 and December 2018. SETTING: This study was completed at a tertiary-care pediatric referral center. PARTICIPANTS: 1920 children who underwent intracapsular tonsillectomies between January 2017 and December 2018 at a single tertiary-care children's hospital. EXPOSURES: Patients were divided into two cohorts: 1458 patients (75.9%) received ketorolac (K+), and 462 (24.1%) did not (NK). Age, sex, body mass index, comorbidities, and indication for surgery also were evaluated for association with post-tonsillectomy bleed risk. MAIN OUTCOME(S) AND MEASURE(S): Primary study outcome for both cohorts was post-tonsillectomy hemorrhage requiring operative intervention. RESULTS: 1920 study participants were included with an average age of 6.5 years; 51.5% of participants were males; and, 63.9% were white. Overall, the postoperative bleeding rate was 1.5%. However, there was no significant difference when comparing bleeding rates for the ketorolac group and the non-keterolac group (1.4%-1.7%; P = .82) Age, chronic tonsillitis, higher body mass index Z-scores, attention-deficit/hyperactivity disorder, and behavioral diagnoses were statistically significant risk factors for post-tonsillectomy hemorrhage. CONCLUSIONS AND RELEVANCE: Single-dose postoperative ketorolac does not appear to be associated with increased risk of post-tonsillectomy bleed in pediatric patients undergoing intracapsular tonsillectomy. Providers should not avoid using ketorolac in patients undergoing intracapsular tonsillectomy due to concerns over bleeding risk.

Considerations in Surgical Management of Pediatric Obstructive Sleep Apnea: Tonsillectomy and Beyond.

Obstructive sleep apnea (OSA) is an increasingly recognized disorder with a reported incidence of 5.7% in children. Tonsillectomy (with or without adenoidectomy) in pediatric OSA in otherwise healthy non-obese children has a success rate of approximately 75%. However, the cure rate reported for all children undergoing tonsillectomy varies from 51% to 83%. This article reviews the history of tonsillectomy, its indications, techniques, various methods, risks, and successes. The article also explores other surgical options in children with residual OSA post-tonsillectomy.

Subtotal intracapsular tonsillectomy may be the first choice for tonsillectomy in children.

OBJECTIVE: To investigate the effect and prognosis of subtotal intracapsular tonsillectomy. METHODS: All children (n=162) with tonsillar hypertrophy and chronic tonsillitis were randomly divided into two groups: tonsillectomy (n=75) and subtotal intracapsular tonsillectomy (n=87). Tonsillectomy: the tonsillar tissue was completely removed along with the tonsillar capsule. Subtotal intracapsular tonsillectomy: 80% to 90% of the tonsils and the complete epithelium of the tonsillar crypts were removed without damaging the tonsillar capsule. The Face, Legs, Activity, Cry, and Consolability (FLACC) and parents' postoperative pain measure (PPPM) scales were used to evaluate postoperative pain, and the obstructive sleep apnea (OSA)-18 questionnaire was used to assess the children's postoperative quality of life. The patients were followed-up for 2 years. RESULTS: 1. The FLACC and PPPM scales indicated that the children's postoperative pain after subtotal intracapsular tonsillectomy was significantly less than that of children undergoing tonsillectomy. 2. The OSA-18 scale scores indicated that subtotal intracapsular tonsillectomy significantly improved the children's quality of life. 3. Two years after subtotal intracapsular tonsillectomy, no patients required reoperation. CONCLUSION: Subtotal intracapsular tonsillectomy may be the first choice for tonsillar hypertrophy and chronic tonsillitis patients.

Pediatric tonsillectomy: A short-term and long-term comparison of intracapsular versus extracapsular techniques.

OBJECTIVE: To review a cohort of over 2500 patients and investigate the short and long-term outcomes of intracapsular as compared to extracapsular tonsillectomy, and show if the complication rates are comparable between methods. STUDY DESIGN: A multicenter, retrospective chart review was conducted, evaluating pediatric tonsillectomies performed from 2004 to 2014. The electronic medical record was reviewed through December 2018, providing up to 14 years of follow-up data. SETTING: Two tertiary care, academic medical centers. SUBJECTS AND METHODS: A retrospective chart review was conducted to identify children undergoing tonsillectomy and adenotonsillectomy. A chart review was first performed of patients by a single surgeon (MEG) and then the analysis was repeated using enterprise data warehouse (EDW) to search for complications and interventions using International Classification of Diseases, ninth revision, (ICD-9) and Current Procedural Terminology (CPT) codes. The second surgeon's patients (JLC) patients were added to increase the cohort. Patients were excluded from the review of long-term outcomes if there was less than two-year follow-up. Short-term outcomes examined included rate of post-tonsillectomy hemorrhage and re-presentation for dehydration, while long-term outcomes included rates of peritonsillar abscess and tonsillar regrowth requiring revision tonsillectomy. RESULTS: A total of 2508 pediatric patients were identified who had undergone tonsillectomy or adenotonsillectomy. In 1456 (58.1%) of these patients, the intracapsular technique was used and in 1052 (41.9%) patients, the extracapsular technique was used. The mean documented follow-up time was 8.2 years. Thirty-five patients (1.4%) were identified with post-tonsillectomy hemorrhage, 2 of these patients (5.7%) with primary hemorrhage and 33 patients (94.3%) with secondary hemorrhage. 11 underwent intracapsular tonsillectomy and 24 underwent extracapsular tonsillectomy (p = 0.0042). The rate of post-tonsillectomy hemorrhage with intracapsular tonsillectomy was 0.76%, compared to 2.3% in the extracapsular group. Three patients (0.12%) undergoing intracapsular tonsillectomy required revision tonsillectomy; no patients in the extracapsular group required revision surgery. Three patients (0.12%) developed peritonsillar abscess post-operatively, two following intracapsular tonsillectomy and one following extracapsular tonsillectomy. CONCLUSION: This retrospective review comparing the intracapsular and extracapsular techniques for tonsillectomy provides further evidence of the benefits of this technique. It is worthwhile to continue offering intracapsular tonsillectomy to patients and their families during pre-operative discussions.

Identifying cohort differences in children undergoing partial intracapsular tonsillectomy vs traditional tonsillectomy for sleep disordered breathing.

OBJECTIVE: Partial intracapsular tonsillectomy (PIT) is a well-established technique for reducing post-operative morbidity in pediatric patients with sleep disordered breathing (SDB). Although tonsillar re-growth rates are reported as low, risks of symptom recurrence or need for completion tonsillectomy are clear disadvantages when compared to traditional tonsillectomy (TT). We aim to identify cohort differences to better guide clinical decision making and identify patient-specific factors that may influence this decision. A secondary aim was to evaluate potential risk factors for tonsillar regrowth. METHODS: Retrospective chart review of pediatric patients who underwent TT or PIT for SDB between 2015 and 2019 at a tertiary care academic medical center. Records were reviewed for age, gender, race, body mass index, comorbidities, diagnosis, apnea-hypopnea index, pre-operative Brodsky tonsil size, length of stay, post-operative hemorrhage, tonsillar regrowth, symptom recurrence, and need for completion tonsillectomy. RESULTS: 315 patients were included: 174 underwent TT and 141 underwent PIT. Patients undergoing TT were more likely to have a sleep study showing OSA (OR 3.01, p < 0.0001), asthma (OR 4.28, p = 0.000124), and other comorbidities (OR 4.06, p = 0.0258). The overall complication rate was 4.44% (14/315). Tonsillar regrowth was exclusive to the PIT group, occurring in 7/141 patients (4.96%). Age ≤4 years was significantly associated with increased risk of tonsillar regrowth (≤4 years: 7.69%, >4 years: 0%; p = 0.049). Race and pre-operative tonsil size were not associated with regrowth. CONCLUSIONS: Our study supports the low incidence of tonsillar regrowth in PIT and suggests an association with younger age. Moreover, we found that patients undergoing TT are more likely to be older, have OSA, asthma, and other comorbidities.

Impact of partial and total tonsillectomy on adenoid regrowth.

OBJECTIVES/HYPOTHESIS: To compare the rates of adenoid regrowth in children who underwent total tonsillectomy and adenoidectomy (TA) versus partial intracapsular tonsillectomy and adenoidectomy (ITA). STUDY DESIGN: Retrospective cohort study. METHODS: A medical database was used to retrieve the records of 5,120 children younger than 12 years of age who had an adenoidectomy in combination with a tonsil surgery between April 2008 and September 2014. Children who had symptomatic obstructive sleep apnea without a history of recurrent tonsillitis, and underwent an endoscopic adenoidectomy with a microdebrider, in addition to a traditional tonsillectomy or partial tonsillectomy with coblation, were included in the study. Adenoid regrowth was evaluated in the children who completed at least a 1-year follow-up. The sizes of adenoids were subjectively graded and reported based upon a numerical scale. RESULTS: In total, 1,504 and 1,340 children met the inclusion, and were comprised of ITA and TA groups, respectively. Adenoid regrowth was seen in 98 (7.3%) children in the TA group after 1-year follow-up. Symptomatic adenoid regrowth was seen in 19 (1.4%) children in the TA group. In the ITA group, although 71 (4.7%) children had adenoid regrowth, only one (0.06%) reached grade 3 hypertrophy that could be attributed to nasal obstruction at 1-year follow-up. Comparison of the regrowth rates of both groups at the end of the 1-year follow-up period showed a statistically significant difference (P < .001). CONCLUSIONS: ITA seems to be a safe procedure with a low incidence of regrowth of adenoid tissue in children with adenotonsillar hypertrophy when compared to TA. LEVEL OF EVIDENCE: 4. Laryngoscope, 127:753-756, 2017.

Pediatric coblation total tonsillectomy: intracapsular or extracapsular?

OBJECTIVES: To compare the results of coblation intracapsular total tonsillectomy (CITT) with those of conventional coblation extracapsular total tonsillectomy (CETT) in the treatment of tonsillar hypertrophy in children with regards to efficacy and complications. METHODS: Ninety children with adenotonsillar hyperplasia underwent tonsillectomy ± adenoidectomy (48 CITT and 42 CETT). Intraoperative situation was observed and recorded. Patients were reexamined regarding recovery condition and tonsil regrowth, and were followed for at least one year. RESULTS: Significant differences were observed in four clinical features when the CITT group was compared with the CETT group: intraoperative bleeding score, intraoperative tonsillar fossa score, color of white membrane one day postoperatively, and visual analogue scale (VAS) value one week postoperatively (p < .05). There were statistical correlations between intraoperative bleeding score and age, course of disease, surgery method, number of acute tonsillitis attacks per year, and intraoperative tonsillar fossae score (p < .05). Two significant differences were noted when the tonsil hypertrophy group was compared with the chronic tonsillitis group: color of white membrane at one day and one week postoperatively (p < .05). No regrowth of tonsil was found. CONCLUSIONS: Compared with conventional extracapsular tonsillectomy, CITT has the advantages of decreased pain and bleeding, and promote healing of wounds. No tonsillar regrowth was observed after at least one year of follow-up.

Tonsillectomy or tonsillotomy? A systematic review for paediatric sleep-disordered breathing.

BACKGROUND: Recent evidence has challenged the practice of tonsillectomy in children with sleep-disordered breathing. Tonsillotomy (subtotal/partial/intracapsular tonsillectomy) has been proposed as an alternative with equivalent effectiveness and decreased post-operative morbidity, thus improving cost-effectiveness. OBJECTIVE: To systematically review the literature comparing clinical efficacy, post-operative morbidity, and cost-effectiveness of tonsillotomy and tonsillectomy in paediatric (<16yo) patients with sleep-disordered breathing. DATA SOURCES: A systematic search of MEDLINE, EMBASE, and CENTRAL (1984-July 2014) was conducted. Papers in English directly comparing post-operative outcomes in tonsillectomy and tonsillotomy in children undergoing surgery for sleep-disordered breathing were included. REVIEW METHODS: Two authors independently assessed abstracts for relevance, with disagreements resolved by a third author. Selected studies were independently assessed regarding inclusion and exclusion criteria. RESULTS: Thirty-two studies satisfied inclusion and exclusion criteria (19 randomised, 13 non-randomised). Patient satisfaction, quality-of-life, and polysomnographic improvement post-surgery did not vary between tonsillotomy and tonsillectomy. Tonsillotomy reduced the odds of a secondary haemorrhage by 79% (OR 0.21, 95% CI 0.17-0.27, p < 0.01), decreased post-operative pain and reduced return to normal oral intake by 2.8 days (95% CI 1.08-4.52, p < 0.01). The odds of readmission were decreased by 62% (OR 0.38, 95% CI 0.23-0.60, p < 0.01). Tonsillotomy had a slightly higher rate of symptom recurrence (4.51%) than tonsillectomy (2.55%), the long-term impact of which was unclear. CONCLUSION: Current evidence supports tonsillotomy in children with obstructive surgical indications. It is likely to reduce post-operative haemorrhage, pain, and facilitate a faster return to normal diet and activity. Healthcare burden is decreased due to fewer post-operative complications and reduced need for medical re-contact. More research is necessary to assess the risk of recurrence, and further classification of secondary haemorrhage severity is required to fully clarify the clinical benefit of tonsillotomy.