Tonsilloplasty Versus Tonsillectomy in Children With Sleep-Disordered Breathing: Short- and Long-Term Outcomes

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1 The Laryngoscope VC 2012 The American Laryngological, Rhinological and Otological Society, Inc. Tonsilloplasty Versus Tonsillectomy in Children With Sleep-Disordered Breathing: Short- and Long-Term Outcomes Konstantinos S. Chaidas, MD; Athanasios G. Kaditis, MD; Chariton E. Papadakis, MD; Nikolaos Papandreou, MD; Petros Koltsidopoulos, MD; Charalampos E. Skoulakis, MD Objectives/Hypothesis: Adenoidectomy and tonsillectomy (TE) is the standard treatment for obstructive sleepdisordered breathing (SDB) in children with adenotonsillar hypertrophy. Tonsilloplasty (TP) is a new surgical technique that includes partial TE. The purpose of this study was to assess the short- and long-term outcomes of TP compared to TE. Study Design: A comparison study. Methods: Children with SDB and tonsillar hypertrophy underwent TP or TE. The two groups were compared regarding immediate postoperative course and long-term effects. Results: Fifty-one children (age, years) underwent TE, and 50 children (age, years) had TP. The TP group had significantly less intraoperative bleeding compared to the TE group ( vs ml, P <.001). Subjects with TP were pain free earlier than children with TE ( vs days, P <.001) and returned to a normal diet sooner ( vs days, P <.001). By the 3rd to 4th postoperative night, upper airway obstruction was relieved in all participants. Six years postoperatively, 48 of 51 children in the TE group and 43 of 50 children in the TP group participated in a telephone survey. No significant differences were found between the two groups regarding the frequency of recurrent snoring (30.2% in TP vs. 25% in TE), apneas (4.7% vs. 0%), and upper airway infections per year (P >.05). Conclusions: TP is an alternative surgical method for treatment of SDB related to tonsillar hypertrophy with favorable postoperative course and comparable long-term results. Key Words: Partial tonsillectomy, sleep-disordered breathing, tonsillar hypertrophy, tonsillectomy, tonsilloplasty. Level of Evidence: 2c. Laryngoscope, 123: , 2013 From the Department of Otorhinolaryngology Head and Neck Surgery, General Hospital of Volos, Volos (K.S.C., N.P., P.K.); First Department of Pediatrics, Pediatric Pulmonology Unit, Sleep Disorders Laboratory, University of Athens School of Medicine and Aghia Sophia Children s Hospital, Athens (A.G.K.); Department of Otorhinolaryngology Head and Neck Surgery, General Hospital of Chania, Chania (C.E.P.); and Department of Otorhinolaryngology Head and Neck Surgery, University of Thessaly School of Medicine and Larissa University Hospital, Larissa (C.E.S.), Greece. Editor s Note: This Manuscript was accepted for publication October 10, The authors have no funding, financial relationships, or conflicts of interest to disclose. K.S.C. and A.G.K. contributed equally to the preparation of the manuscript. Send correspondence to Konstantinos S. Chaidas, 10C Zavalidi St., Larissa 41335, Greece. konchaidas@gmail.com DOI: /lary INTRODUCTION Tonsillectomy (TE) with or without adenoidectomy is one of the most common surgical procedures performed in children. 1,2 Indications for TE include recurrent tonsillitis, peritonsillar abscess, and obstructive sleep-disordered breathing (SDB). 1 For many years, recurrent tonsillar infections and rheumatic fever were the primary indications for TE. 3 However, as a result of early antibiotic treatment for tonsillar infections during the past decades, the frequency of TE due to recurrent tonsillitis has gradually declined. At the same time, obstructive SDB has become a major indication for the surgical removal of tonsils in children. 2,4 The term SDB in childhood is used to describe a spectrum of breathing abnormalities during sleep, ranging from primary snoring to obstructive sleep apnea and hypopnea. 5,6 There has been considerable controversy over the optimal surgical technique for the treatment of obstructive symptoms associated with tonsillar hypertrophy. Different approaches have been proposed regarding the details of the surgical technique as well as the amount of tissue that needs to be removed (partial or total TE). Various traditional and modern surgical instruments have been used for the volume reduction of tonsils, including blunt dissection, laser, radiofrequency, Coblator, and others All techniques aim at relieving the upper airway obstruction caused by tonsillar hypertrophy and avoiding the complications of total TE. Despite the reduction of postoperative pain when using partial TE (tonsillotomy) instead of total TE, a prolonged period of postoperative recovery lasting up to 2 weeks is standard, and there is always the risk of bleeding. 14 In 2007, a new technique was reported for partial removal of the tonsillar tissue, called tonsilloplasty (TP). 15 Skoulakis et al. have applied this technique for the treatment of SDB in children with tonsillar hypertrophy, reporting an appreciable reduction in the immediate postoperative morbidity. 15 Nevertheless, there are several unanswered questions. In the long run,

2 Fig. 1. (A) Tonsil before tonsilloplasty; (B) resected wedge-shaped portion of the tonsil; (C) tonsil after tonsilloplasty. is partial resection as effective as complete TE? How high is the risk for regrowth of the remaining tonsillar tissue and recurrence of the patient s symptoms? Is the risk for throat infections higher after TP than after TE? Hence, the objective of the present study was to evaluate the short- and long-term effects of TP relative to TE in children with obstructive symptoms associated with enlarged tonsils. MATERIALS AND METHODS Patients Consecutive children who were scheduled for tonsillar resection due to adenotonsillar enlargement and upper airway obstruction were offered participation in the study between May 2003 and October The diagnosis of obstructive SDB was based on: 1) parental report of loud snoring >3 nights per week (habitual snoring) present for at least 6 months; and 2) tonsillar size 3þ (obstructing >50% of the oropharynx). The exclusion criteria were as follows: 1) history of neuromuscular or genetic disorders; 2) presence of craniofacial abnormalities; and 3) history of recurrent throat infections. The study was approved by the Ethics Committee of General Hospital of Volos. Informed consent was obtained from parents and child assent from subjects older than 7 years. Patients who agreed to participate were randomized to one of the two surgical procedures: TP or TE. Randomization was performed in subjects from the waiting list using a table of random numbers and the patient record number. Parents could refuse the randomly selected surgical method, but in that case the child was excluded from participation in the study. Surgical Technique The surgical technique has been described in detail previously. 15 In the TP group, under general anesthesia, the tonsil was grasped with forceps and retracted medially. Two incisions were performed in the tonsillar tissue parallel to the anterior and posterior tonsillar pillars and 3 to 4 mm away from them, using a No. 15 scalpel. In this way, a wedge-shaped part of the tonsil (75% 80%) was dissected and removed (Fig. 1B). The two tonsillar remnants were sutured together in such a way that the two dissected tonsillar surfaces were perfectly attached to each other, resulting in a reduction of the total tonsillar volume (Fig. 1C). Two to three rapidly absorbable sutures were usually required. At this step, care was taken so that the sutures were not placed into the muscle layers of the tonsillar pillars. Thus, the tonsillar surface covered by epithelium was still exposed to the oral cavity (Fig. 1C). In the TE group, after incision of the epithelium with a knife or scissors along the anterior tonsillar pillar, the tonsil was bluntly dissected outside the capsule until it was completely removed at the level of the tongue base. A suture at the lower pole was most often used. Participants in both groups had also an adenoidectomy 6 tympanotomy, using conventional surgical techniques. In both study groups, the duration of surgery and the amount of blood loss were recorded. Immediate Postoperative Period Minor analgesics (acetaminophen 15 mg/kg) were administered to children as needed postoperatively. Children were encouraged to eat and drink when the effects of anesthesia had passed, usually after 3 to 4 hours, and they were discharged in the evening of the same day or the next morning. Postoperative pain was evaluated using a 10-point visual analogue scale questionnaire, with 1 equating to no pain and 10 equating to most severe pain. All children had follow-up visits in the ear/nose/ throat (ENT) clinic on the 5th and 10th postoperative days. On the second postoperative visit, children and their parents brought with them a symptom record and provided their overall opinion about the procedure. Long-Term Follow-up Six years after surgery, families were contacted by phone and were asked to answer a nine-item questionnaire regarding the current health status of their child. The questionnaire (Appendix) was based on previous studies, 16,17 and included questions assessing snoring, presence of witnessed sleep apneas, eating difficulties, and ENT infections. Finally, parents were asked again about their satisfaction with the results of the selected procedure. All children with recurrent SDB symptoms were asked to return to the ENT clinic for a standard ENT examination and measurement of weight and standing height. Subjects with a body mass index (weight /[height] 2 ) value 85th percentile for age and gender were considered overweight. Statistics The two study groups were compared regarding subjects characteristics, intraoperative findings, and immediate postoperative and long-term results using chi-square test (categorical variables), Student t test (normally distributed continuous variables), Mann Whitney U test (not normally distributed continuous variables), or survival analysis (time-varying covariates). The comparisons were carried out using SPSS software for Windows version 16.0 (SPSS Inc, Chicago, IL). RESULTS One hundred eighteen children were candidates for participation in the study. Parents of all children agreed to participate. Seventeen subjects were excluded due to: craniofacial abnormalities (n ¼ 2), neuromuscular and neurologic disorders (n ¼ 2), and recurrent throat infection (n ¼ 13). Hence, a total of 101 participants were 1295

3 TABLE I. Subjects Characteristics and Intraoperative Findings in the Two Study Groups. Variables Children in TE Group, n ¼ 51 Children in TP Group, n ¼ 50 Age at surgery, yr Female gender (%) 25 (49) 23 (46) Snoring >3 nights/wk (%) 51 (100) 50 (100) Apnea >3 nights/wk (%) 24 (47.1) 29 (58) Eating difficulties (%) 36 (70.6) 34 (68) Adenoidectomy (%) 51 (100) 50 (100) Tympanotomy (%) 10 (19.6) 10 (20) Duration of surgical procedure, min Intraoperative bleeding, ml* Values are provided as mean 6 standard deviation or No. (%). *P <.001 for comparison between study groups; P >.05 for all other comparisons between groups. TE ¼ tonsillectomy; TP ¼ tonsilloplasty. randomized into two groups: 50 in the TP group and 51 in the TE group. All parents accepted their children having the randomly selected surgical procedure. Subjects characteristics and intraoperative findings are summarized in Table I. There were no significant differences between the two study groups regarding age at surgery, female to male ratio, frequency of SDB symptoms, eating difficulties, frequency of adenoidectomy or tympanotomy, and duration of surgical procedure. The same anesthetics were used in both groups. The TP group had significantly less intraoperative bleeding compared to the TE group (P <.001; Table I). Immediate Postoperative Period No postoperative bleeding was noted in subjects of either group. The immediate postoperative pain score was significantly lower in the TP group than in the TE group (Fig. 2). More specifically, children in the TP group were pain free earlier compared to children in the TE group ( days vs days, respectively; P <.001). Likewise, the TP group returned to a normal diet earlier than the TE group ( days vs days, respectively; P <.001; Fig. 3). At the first postoperative visit (5th postoperative day), in all children of the TP group, the postoperative wound was completely healed and fully epithelialized, without any signs of swelling or infection. In contrast, pediatric patients of the TE group at the second visit (10th postoperative day) still had signs of inflammation, with white covering of the wound, redness of the tonsillar pillars, and some edema of the area. Based on parental report, in all children of both groups, symptoms of obstructive SDB (i.e., snoring and apnea) were completely relieved by the 3rd to 4th postoperative night. Fig. 2. Pain recording with visual analogue scale during the first 10 postoperative days in the tonsilloplasty and tonsillectomy groups. telephone survey. Three (5.9%) subjects of the initial TE group and seven (14%) subjects of the initial TP group could not be reached (P >.05). There were no significant differences between subjects who participated in the long-term follow-up survey and those who did not participate regarding age, gender, or preoperative symptoms. Long-term follow-up results are summarized in Table II. Six years after the surgical intervention, no snoring was reported in the majority of children (69.8% of TP group vs. 75% of TE group; P >.05; Fig. 4). Most of the remaining subjects with recurrent snoring had the symptom less frequently. Two (4.7%) children in the TP group and none in the TE group had reported apneas postoperatively (P >.05). The incidence of ENT infections was similar in both groups during the 6-year postoperative period (Table II). Only three (7%) children in the TP group and one (2.1%) child in the TE group developed infections Long-Term Effects Six years after surgery, parents of 91 children of the 101 participants of the initial cohort could be contacted, and all of them agreed to participate in the Fig. 3. Comparison of the two study groups in terms of time required to return to a normal diet in the immediate postoperative period. 1296

4 TABLE II. Subjects Characteristics and Findings at the 6-Year Follow-up. Variables Children in TE Group, n ¼ 48 Children in TP Group, n ¼ 43 Age at telephone survey, yr Female gender (%) 23 (47.9) 20 (46.5) Snoring (%) 12 (25) 13 (30.2) Episodes of apnea (%) 0 (0) 2 (4.7) Eating difficulties (%) 0 (0) 0 (0) No. of ENT infections per 1 [0 1] 1 [0 1] year postoperatively [IQR] No. of throat infections per 0 [0 1] 0 [0 1] year postoperatively [IQR] Children with reduced frequency of ENT infections compared to preoperatively (%) 47 (97.9) 40 (93) Satisfaction of the parents with the results of the operation Very satisfied 35 (72.9) 29 (67.4) Satisfied 13 (27.1) 14 (32.6) Values are provided as mean 6 standard deviation, median [IQR], or No. (%). P >.05 for all comparisons between the two groups. ENT ¼ ear/nose/throat; IQR ¼ interquartile range; TE ¼ tonsillectomy; TP ¼ tonsilloplasty. postoperatively with the same frequency as before surgery (P >.05). Five (11.6%) children in the TP group had at least one episode of tonsillitis during the 6-year postoperative period (1 2 episodes per year). At the 6-year follow-up, all children of the TP group (n ¼ 13; 30.2%) and the TE group (n ¼ 12; 25%) who were reported to have recurrent obstructive symptoms were examined to investigate potential causes of upper airway obstruction. The findings are summarized in Table III. Tonsillar regrowth was diagnosed in six of 13 subjects with recurrent snoring in the TP group, and it Fig. 4. Comparison of the two study groups regarding changes in the frequency of snoring between the preoperative period and 6 years after surgery. TABLE III. Clinical Findings in Pediatric Patients With Recurrent Obstructive Symptoms at the 6-Year Follow-up. Variables Children in TE Group, n ¼ 12 Children in TP Group, n ¼ 13 Tonsillar regrowth (%) 6 (46.2) Allergic rhinitis (%) 4 (33.3) 3 (23.1) Deviated nasal septum (%) 2 (16.7) 1 (7.7) Overweight (%) 6 (50) 3 (23.1) Revision surgery (%) 0 (0) 2 (4.7) Values are provided as No. (%). P >.05 for all comparisons between the two groups. TE ¼ tonsillectomy; TP ¼ tonsilloplasty. was noted mainly unilaterally. Subgroups of subjects with relapse of snoring who underwent TP or TE did not differ significantly regarding risk factors for SDB (i.e., allergic rhinitis, deviated nasal septum, and overweight; Table III). Of note, two of 13 children with recurrence of SDB symptoms after TP (or 4.7% of all TP subjects with long-term follow-up) required a TE. Symptoms resolved completely following revision surgery. DISCUSSION In the present study, TP was compared to TE as a treatment intervention for upper airway obstruction caused by hypertrophic tonsils. Data from this study reveal that children undergoing TP have lower postoperative pain score, earlier return to normal diet, and more rapid healing and epithelization of the postoperative wound in relation to subjects undergoing TE. Six years after surgery, the two study groups do not differ in the frequency of SDB symptoms. However, some children with TP have tonsillar regrowth and episodes of tonsillitis. TE is a routine procedure in ENT surgery in which the tonsillar tissue is completely removed by anatomic dissection. This technique was developed in the 1940s and had widespread application for the prevention of recurrent tonsillitis. Over the past 20 years, surgical treatment is recommended for upper airway obstruction due to enlarged tonsils, especially during early childhood. The palatine tonsils are lymphoepithelial organs, and their greatest immunological activity occurs between the ages of 3 and 10 years. 18 Hence, many ENT surgeons perform partial and not complete removal of tonsillar tissue (tonsillotomy) 9,14,16 to maintain its immunological function. 19 During tonsillotomy, the dissected surface of the residual lymphoid tissue is left to heal by secondary intention without the protection of the epithelium, the regeneration of which is expected after the 10th postoperative day. TP has the same goals as tonsillotomy, that is, reduction of the total tonsillar volume and maintenance of immunological function. 16 However, the surgical technique and postoperative complications are quite different. In TP, the surgeon dissects and removes a wedge-shaped part of the excessive tissue from the middle of the tonsil. The original shape of the tonsil is reconstructed by bringing in contact and suturing 1297

5 together the two dissected surfaces of the tonsillar remnants. Therefore, the tonsillar remnants are not buried, but their surfaces, which are covered by epithelium, remain exposed to the oral cavity (Fig. 1). 15 In that way, rapid restoration of the epithelium continuity is achieved (primary healing of the wound) along with reduction in tonsillar volume. After TP, the tonsillar shape and the anatomy of the pharynx and palate are preserved. There are no apparent differences during examination of the oral cavity between children after TP and those without history of tonsillar surgery. The present study demonstrates that TP is significantly less painful than TE. The cushion of residual tonsillar tissue protects the pharyngeal muscles from injury and inflammation. 9,14,16 In contrast, during TE, the tonsillar capsule is removed with the tonsil, and inevitably, some muscle is traumatized. Pharyngeal muscle disruption results in more intense postoperative pain. Less intraoperative bleeding occurs in the TP group as compared to the TE group. This difference can be attributed to the tonsillar capsule with its vessels not being excised in TP. Moreover, the remaining parts of the tonsillar tissue are sutured together in such a way that the two dissected sites are perfectly attached to each other. Children who undergo TP are pain-free and return to a normal diet approximately 3 days earlier compared to TE. This means less suffering for the child and fewer days of absence from work for the parent. Moreover, a limited number of instruments and no new, expensive equipment are required for TP. In contrast, CO 2 laser, radiofrequency, microdebrider, or Coblation are employed in other methods of partial tonsillectomy These instruments are costly, require maintenance, and need to be replaced over time. Long-term effects of TP were also favorable. Six years after the operation, > 2 = 3 of children who participated in the telephone survey did not snore. No significant difference was found regarding frequency of snoring or apneas between subjects who underwent TE or TP. It is important to note that all parents, irrespective of the type of surgery or the need for revision operation, were very satisfied with the results of the operation at the end of the 6-year follow-up. In half of the children who underwent TP and had recurrent snoring at 6 years postoperatively, tonsillar regrowth was found, mostly unilaterally. This complication has been reported in 3% to 17% of children after partial tonsillectomy. 10,11,13,20,21 The tonsillar remnant after partial tonsillectomy in children has a tendency to grow back, probably due to upper respiratory tract infections. 22 Overall, in the current report, 4.7% of subjects in the TP group with long-term follow-up required revision TE. The TE technique was not modified, because previous TP does not change the anatomy of the area. An appreciable proportion of subjects in both the TE (50%) and TP (23.1%) groups who were reported to have relapse of SDB symptoms were overweight at the 6-year follow-up. Overweight could be one of the factors contributing to recurrent upper airway obstruction during sleep postoperatively. In addition to regrowth of tonsillar tissue, recurrent throat infections and episodes of tonsillitis are other potential unfavorable outcomes in children undergoing TP. Subjects with TE or TP did not differ in frequency of ENT infections during the 6 years after surgery. Rather, the incidence of ENT infections decreased during the 6- year postoperative period in both groups. Nevertheless, there was a risk for one to two episodes of tonsillitis per year in a subgroup (11.6%) of subjects with TP, most likely related to the tonsillar tissue left during the procedure. Two potential limitations of the current study should be noted. First, the evaluation for SDB was based on parents response to a questionnaire and not on nocturnal polysomnography. As children grow up, they tend to sleep more often in their own room, thus reducing the chance that snoring and apneas will be noticed by parents. For this reason, obstructive airway symptoms in the long-term evaluation might have been underestimated. Second, the investigators were not blinded to the type of surgical procedure for each participant. Moreover, in the current study, similar to previous reports, the long-term follow-up was extended to a period of 6 years. The duration of follow-up was still relatively short, and it is unknown whether the residual tonsillar tissue will be associated with complications in late adolescence or adulthood. CONCLUSION TP is a surgical method that can be used alternatively to TE for the treatment of children with tonsillar hypertrophy and obstructive symptoms of the upper airway. It has a favorable postoperative course, with less pain, earlier return to a normal diet, and faster healing relative to standard tonsillectomy, and with comparable results at 6 years postoperatively. BIBLIOGRAPHY 1. Bluestone CD. Current indications for tonsillectomy and adenoidectomy. Ann Otol Rhinol Laryngol Suppl 1992;155: Rosenfeld RM, Green RP. Tonsillectomy and adenoidectomy: changing trends. Ann Otol Rhinol Laryngol 1990;99(3 pt 1): Fry J. Are all T s and A s really necessary? BMJ 1957;1: Baugh RF, Archer SM, Mitchell RB, et al. Clinical practice guideline: tonsillectomy in children. Otolaryngol Head Neck Surg 2011;144(1 suppl): American Thoracic Society. Cardiorespiratory sleep studies in children. Establishment of normative data and polysomnographic predictors of morbidity. Am J Respir Crit Care Med 1999;160: American Academy of Pediatrics. Clinical practice guideline: diagnosis and management of childhood obstructive sleep apnea syndrome. 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6 14. Hultcrantz E, Linder A, Markstrom A. Tonsillectomy or tonsillotomy? A randomized study comparing postoperative pain and long term effects. Int J Pediatr Otorhinolaryngol 1999;51: Skoulakis CE, Papadakis CE, Manios AG, Moshotzopoulos PD, Theos EA, Valagiannis DE. Tonsilloplasty in children with obstructive symptoms. J Otolaryngol 2007;36: Hultcrantz E, Linder A, Markstrom A. Long-term effects of intracapsular partial tonsillectomy (tonsillotomy) compared with full tonsillectomy. Int J Pediatr Otorhinolaryngol 2005;69: Eviatar E, Kessler A, Shlamkovitch N, et al. Tonsillectomy vs. partial tonsillectomy for OSAS in children 10 years post-surgery follow-up. Int J Pediatr Otorhinolaryngol 2009;73: Richardson MA. Sore throat, tonsillitis, and adenoiditis. Med Clin North Am 1999;83: Scadding GK. The immunology of the tonsil. In: Scadding GK ed. Immunology of ENT Disorders. Dordrecht, the Netherlands: Kluwer Academic; 1994: Vlastos IM, Parpounas K, Ekonomides J, Helmis G, Koudoumnakis E, Houlakis M. Tonsillectomy versus tonsillotomy performed with scissors in children with tonsillar hypertrophy. Int J Pediatr Otorhinolaryngol 2008;72: Reichel O, Mayr D, Winterhoff J, de la Chaux R, Hagedorn H, Berghaus A. Tonsillotomy or tonsillectomy? A prospective study comparing histological and immunological findings in recurrent tonsillitis and tonsillar hyperplasia. Eur Arch Otorhinolaryngol 2007;264: Zagolski O. Why do palatine tonsils grow back after partial tonsillectomy in children? Eur Arch Otorhinolaryngol 2010;267: APPENDIX Questionnaire for Follow-up at 6 Years After Tonsillar Surgery 1. Has your child had snoring over the past 6 months? Yes No Do not know If yes, how often does your child snore, compared to preoperatively? Less frequently About the same More often Do not know 2. Has your child had apneas during sleep over the past 6 months? Yes No Do not know If yes, how often has your child had apneas during sleep, compared to preoperatively? Less frequently About the same More often Do not know 3. Does your child have eating difficulties? Yes No Do not know 4. What is the number of ear, nose, or throat infections that your child has had over the 6-year period following surgery? (Fill in a number): Do not know 5. How often has your child been affected by ear, nose, or throat infections, compared to preoperatively? No infections Less frequently About the same More often Do not know 6. How many of these infections were throat infections? (Fill in a number): 7. In case of tonsilloplasty, how many of these infections were episodes of tonsillitis? (Fill in a number): Do not know Do not know 8. How satisfied are you and your child with the results of the operation on the tonsils? Very satisfied Satisfied Somewhat satisfied Less than satisfied Not satisfied at all Do not know 9. Do you have any comments to the above questions or anything to mention about the operation or about the 6-year period following the operation? 1299