A study on the Indications of Tonsillectomy as encountered in a Tertiary Government setup of Northeastern India

Transcription

1 International Journal of Advances in Health Sciences (IJHS) ISSN Vol 3, Issue 3, 2016, pp Research Article A study on the Indications of Tonsillectomy as encountered in a Tertiary Government setup of Northeastern India Debraj Dey, Sanchita Kalita and Avinava Ghosh 1 MS ENT, Medical Officer, Department of ENT (Tezpur Medical College) Former Registrar (Silchar Medical College) E mail: debraj.ent@gmail.com 2 Post Graduate Trainee (MS ENT) Department of ENT Silchar Medical College and Hospital E mail: drsanchitakalita@gmail.com 3 MS ENT (Silchar Medical College) E mail: avinava_90@hotmail.com Corresponding Author: Dr. Sanchita Kalita, E mail: drsanchitakalita@gmail.com [Received-02/08/2016, Accepted-10/08/2016, Published- 27/08/2016] ABSTRACT Introduction: Tonsillectomy is one of the commonly performed surgical procedure in Otolaryngology practice. Though there have been different studies and guidelines on the indications of tonsillectomy, doubt still persists in few cases; whether Tonsillectomy will be beneficial over conservative treatment. In this study, we endeavor to evaluate the existing and emerging trends of the Indications of Tonsillectomy, to identify patients who are the best candidates for Tonsillectomy, to evaluate whether Tonsillectomy is conducted keeping in view the standard available guidelines by comparing with the available evidence based literature. Materials and Methods: A 2 years prospective observational study was carried out in the Department of ENT, Silchar Medical College and Hospital, with 233 patients, who were selected as the candidates for Tonsillectomy, from April 2014 to March Results: Recurrent Tonsillitis (74.67%), meeting standard guidelines, was the most common indication of Tonsillectomy in our study, followed by Sleep Disordered Breathing (SDB) (14.59%) Other indications were Stylalgia, Suspected Neoplasia in unilateral Tonsillar enlargement, Recurrent Peritonsillar abscess, Recurrent Tonsillitis with Serous Otitis Media. There were a couple of Tonsillectomy cases in our study which did not meet the available guidelines. Conclusion: The different trends and guidelines followed for the indications of Tonsillectomy in different places and set-ups is attributed to the physicians varying practices and to the patients varying conditions and compliance. Further large scale studies are warranted to reach some unanimous guidelines for the indications of Tonsillectomy. Key words: Tonsillectomy, Indications, Guidelines, Recurrent Tonsillitis, SDB INTRODUCTION: The palatine tonsils are lymphoepithelial organs located at the junction of the oral cavity and the oropharynx which function as immunological barrier, their function being at their peak in the age group of 3-10 yrs. Tonsils are involved in antigen trapping, production of memory cells & immunoglobulin thud aiding in immunity. With recurrent tonsillitis, the process of antigen

2 transport and presentation is altered due to shedding of the M cells from the tonsil epithelium. The tonsillar lymphocytes become burdened with infection & become unable to respond to other antigens. Tonsil will no longer be able to appropriately reinforce the secretory immune system of the upper respiratory tract. There would therefore be a therapeutic advantage of removing recurrently or chronically diseased tonsils. Tonsillectomy is one the most commonly performed surgical procedure. It is defined as a surgical procedure that completely removes the tonsil including its capsule by dissecting the peritonsillar space between the tonsil and the muscular wall. Though a commonly performed procedure, there are still ongoing controversies on the indications of Tonsillectomy. There are large international differences in tonsillectomy rates suggesting different cultural attitudes towards tonsillectomy and use of antibiotics. Tonsillectomy is the second most common ambulatory surgical procedure performed on children in the United States. Infections and obstruction, broadly speaking, are the most common indications for tonsillectomy the world over. For a very long time infection had been the most common indication for Tonsillectomy up until the 1980s; however recently, obstruction is more commonly reported as a primary indication specially in younger age groups. It was observed that obstruction as an indication was proportionally higher in younger children, while infection was proportionally higher in older children. (8)(9) Though there have been different studies on the indications for tonsillectomy, doubt still persists in few cases, whether Tonsillectomy will be beneficial over conservative treatment. In this study, we endeavor to evaluate the existing and emerging trends of the Indications of Tonsillectomy, to identify patients who are the best candidates for Tonsillectomy, to evaluate whether Tonsillectomy is conducted keeping in view the standard available guidelines by comparing with the available evidence based literature. AIMS AND OBJECTIVES: To study the existing and emerging trends of the Indications of Tonsillectomy and comparison with the available evidence based literature. This is to identify patients who are the best candidates for Tonsillectomy and to evaluate whether Tonsillectomy is conducted keeping in view the standard available guidelines. METHODOLOGY: A 2 years Prospective Observational Study has been conducted in the Department of ENT, Silchar Medical College and Hospital (SMCH), with 233 patients, ranging from 5 yrs to 65yrs, from April 2014 to March Inclusion Criteria All the standard indications for Tonsillectomy, absolute as well as relative, were taken into consideration while selecting the patients. It included: 1. Patients with recurrent tonsillitis : All of the following- Sore throats are the result of tonsillitis+ Five or more episodes of sore throats per year+ Symptoms last for at least 1 year+ The episodes of sore throat are disabling and prevent normal functioning (OR) 7 or more episodes of throat infections in last 1 yr; or 5 or more episodes in last 2 yrs; or 3 or more episodes in last 3 yrs; with qualifying features namely enlarged(>2cm) or tender cervical lymph node, or fever(38.2 C) or tonsillar exudates or +ve culture for Group A Beta Hemolytic Streptococci(GABHS); with each episode and its qualifying features being substantiated by clinical record or subsequent observance by the clinician of 2 episodes of throat infection. 2. Patients with repeated attacks of acute tonsillitis not meeting inclusion criteria 1., not responding or non-compliant to conservative Sanchita Kalita, et al. 214

3 management and adversely affecting quality of life. 3. Patients with Bilateral Tonsillar/Adenotonsillar enlargement causing SDB. 4. Patients having 2 or more episodes of Peritonsillar Abscess having undergone Incision and Drainage 5. Patients having unilateral enlargement of tonsil suspicious of neoplasia. 6. Patients having stylalgia, supported by digital palpation with extended neck, confirmed by radiography 7. Patients with 2 or more episodes of SOM due to enlarged tonsils, not relieved by conservative treatment including Grommet insertion. 8. Patients who would be requiring Tonsillectomy as an adjunct or to accomplish another surgery, eg Uvulopalatopharyngoplasty, Glossopharyngeal neurectomy. Exclusion Criteria 1. Patients with throat infection features lesser than Inclusion Criteria 1. and Patients with repeated throat infections(not involving tonsils) due to obvious causes like Gross Deviated Nasal Septum(DNS), Congenital Anomalies of Nose and Oral cavity 3. Patients with SDB due to causes other than due to Tonsillar/Adenotonsillar enlargement. 4. Patients with less than 2 episodes of Peritonsillar abscess 5. Patients with SOM due to causes other than due to Adenotonsillitis like Nasopharyngeal neoplasm, Antro-Choanal Polyp 6. All the patients of Tonsillar pathology who were undergoing conservative traetment were excluded from the study 7. Polysomnography(Apnoeic index), as a tool for the diagnosis for OSA, was excluded, as it was not available in our centre. 8. Biopsy confirmed tonsillar malignancies where growth extended beyond the muscular layer were excluded. 9. Positive throat swab for KLB. 10. Positive Monospot test. A Proforma was prepared with the Inclusion and Exclusion Criteria to aid in the selection of patients. Proper history, physical & local examination, investigations including routine blood investigations, culture from throat swab(including Monospot test and swab for KLB), radiological investigations, FNAC, endoscopic evaluation, biopsy in concerned patients, and documentation of medical records were given importance in all the patients. After careful case selection and a thorough preoperative work-up, the patients were planned for Tonsillectomy. Cold blunt dissection method and electrocautery have been employed where the tonsil with its capsule is dissected out from the tonsillar bed. Efforts have been to regularly follow up the patients postoperatively after discharge, at 1 week, 2 weeks, 1 month and 6 months. RESULTS: A total of 233 patients underwent Tonsillectomy, using Cold Blunt Dissection Technique under General Anaesthesia(GA) in the Department of ENT, SMCH, during the study period. The various indications for which Tonsillectomy was performed in the Department of ENT,SMCH, were evaluated and were found to be as follows- Recurrent Tonsillitis in 174 patients. Tonsillar/Adenotonsillar enlargement causing Sleep Disordered Breathing(SDB) in 34 patients. Peritonsillar Abscess in 8 patients. Unilateral Growth( Suspected Neoplasia) of Tonsil in 5 patients. Recurrent Tonsillitis with Stylalgia in 4 patients. Recurrent Tonsillitis causing Recurrent Secretory Otitis Media(SOM) in 4 patient. Acute Tonsillitis(Recurrent Attacks not meeting standard guidelines and not responding to Conservative Management) in 4 patients. The surgical technique employed for Tonsillectomy was Cold Blunt Dissection method in most of the patients (199/233) and Electrocautery (34/233). Sanchita Kalita, et al. 215

4 Table I: Showing the various indications of Tonsillectomy with their incidences INDICATIONS NO. OF PATIENTS PERCENTAGE Recurrent Tonsillitis % Sleep Disordered Breathing(SDB) % Peritonsillar Abscess 8 3.4% Unilateral Enlargement of Tonsil 5 2.1% Recurrent Tonsillitis with Stylalgia 4 1.7% Recurrent Tonsillitis causing Recurrent SOM 4 1.7% Acute Tonsillitis not responding to Medical Mx 4 1.7% TOTAL=233 Table II: COMPARISON OF THE MOST COMMONLY OBSERVED INDICATIONS OF TONSILLECTOMY WITH A STUDY CONDUCTED IN ANOTHER DEVELOPING COUNTRY (19) OUR STUDY GROUP REFERENCE STUDY GROUP INFECTION 74.67%% 92.6% OBSTRUCTION 14.59% 7.4% Table III: COMPARISON WITH A 5 YEARS STUDY (20) Department of Otolaryngology, Umraniye Training and Research Hospital, Istanbul, Turkey. OUR STUDY GROUP Chronic Infection 74.67% 76.5% Adenotonsillar hypertrophy leading to Upper airway obstruction 14.59% 18.5% Suspected Neoplasm 2.1%% 5% Table IV:AGE WISE DISTRIBUTION REFERENCE STUDY GROUP 5-15y 16-25y 26-35y 36-45y 46-55y 56-65y Recurrent Tonsillitis SDB -B/L Enlarged Tonsils -B/L enlarged tonsils with hypertrophied Adenoids Peritonsillar Abscess Unilaterally Enlarged Tonsil Stylalgia Recurrent Tonsillitis causing SOM Acute Tonsillitis not responding to Medical Mx Total: Sanchita Kalita, et al. 216

5 Tonsillectomy yrs yrs yrs yrs yrs 5-15 yrs Tonsillectomy Table V: SEX WISE DISTRIBUTION MALE(M) FEMALE(F) Recurrent Tonsillitis 72(41.3%) 102(58.6%) SDB B/L Tonsillar enlargement 21(61.8%) 13(38.2%) Hypertrophied Adenoids Peritonsillar Abscess 4(50%) 4(50%) Unilaterally Enlarged Tonsil 3(60%) 2(40%) Stylalgia 2(50%) 2(50%) Recurrent Tonsillitis causing SOM 3(75%) 1(25%) Acute Tonsillitis not responding to Medical Mx 3(75%) 1(25%) Total:108(46.35%) 125(53.64%) DISCUSSION: AVAILABLE GUIDELINES ON THE INDICATIONS OF TONSILLECTOMY Summary of SIGN(Scottish Intercollegiate Guidance Network) Guidelines (28) Patients should meet all of the following criteria to be considered for tonsillectomy for recurrent infections: Sore throats are the result of tonsillitis Five or more episodes of sore throats per year Symptoms last for at least 1 year The episodes of sore throat are disabling and prevent normal functioning Guidelines given by American Academy of Otolaryngology, Head And Neck Surgery(AAO-HNS) (6) The guideline includes the following statements- Sanchita Kalita, et al. 217

6 a) Recurrent throat infection with documentation: Frequency of at least 7 episodes in the past year or at least 5 episodes per year for 2 years or at least 3 episodes per year for 3 years with one or more of the following: temperature >38.3oC, cervical adenopathy, tonsillar exudates, or positive test for Group A Beta Haemolytic Streptococcus. b) Watchful waiting for recurrent throat infection: Clinicians should recommend watchful waiting for recurrent throat infection lesser than in Criteria a) c) Tonsillectomy for recurrent infection with modifying factors like multiple antibiotic allergy/ intolerance PFAPA (periodic fever, aphthous stomatitis, pharyngitis, and adenitis), or history of peritonsillar abscess parapharyngeal abscess severe infection with dehydration requiring IV fluids, or severe infections that may aggravate co-morbid conditions (eg, seizure disorder) excessive absences from school d) Tonsillectomy for sleep-disordered breathing e) Tonsillectomy and Polysomnography: Clinicians should counsel caregivers about tonsillectomy as a means to improve health in children with abnormal polysomnography who also have tonsil hypertrophy and sleep-disordered breathing f) Hypertrophy causing dental malocclusion or adversely affecting orofacial growth g) Hypertrophy causing severe dysphagia or cardiopulmonary complications h) Peritonsillar abscess unresponsive to medical management and drainage documented by surgeon i) Halitosis due to chronic tonsillitis not responsive to medical therapy and for which other causes have been eliminated or treated j) Unilateral tonsil hypertrophy presumed neoplastic k)recurrent suppurative or chronic otitis media with effusion: Adenoidectomy alone. l) Chronic sinusitis in pediatric population not responding to maximal medical therapy. Paradise Criteria for Tonsillectomy (29)(33) Criterion Definition Minimum frequency of sore throat episodes 7 or more episodes in the preceding year, OR 5 or more episodes in each of the preceding 2y, OR 3 or more episodes in each of the preceding 3y Clinical features (sore throat plus the presence of one or more qualifies as a counting episode) Temperature > 38.3 C, OR Cervical lymphadenopathy (tender lymph nodes or >2 cm), OR Tonsillar exudate, OR Positive culture for group A beta hemolytic streptococcus Some other Indications not listed in the above Guidelines (15) As a part of Uvulopalatopharyngoplasty (UPPP) or Laser-assisted Uvulopalatoplasty. Severe infectious mononucleosis with upper airway obstruction. As long-term management of IgA nephropathy. The long-term prognosis is no longer regarded as benign but with pulsed steroid therapy and tonsillectomy significant increases in clinical remission rates can be obtained (25 percent with tonsillectomy, 13 percent without) also with significant increases in renal survival. INDICATIONS OF TONSILLECTOMY IN OUR STUDY GROUP- RECURRENT ACUTE TONSILLITIS: In the study group who had undergone Tonsillectomy, most of the patients (74.67%) had Recurrent Acute Tonsillitis. Diagnosis was as per the above mentioned criteria. Of the 174 cases; M=41.3%, F=58.6%; M>F. Maximum no. of cases were seen in the age group of 26 to 35 yrs. This is in accordance with available studies, which says incidence of infections as an indication of tonsillectomy increases above 18 yrs.(19) Sanchita Kalita, et al. 218

7 Worldwide, Recurrent Tonsillitis remains the most common indication for Tonsillectomy.(12) Follow-up of the patients till date, has shown that 121 cases yielded favourable results, 28 patients were seen non-compliant, 25 cases were lost to follow up. TONSILLAR/ADENOTONSILLAR ENLARGEMENT CAUSING SDB: In our study group, there were 34 cases (14.59%) of Bilaterally Enlarged Tonsils with or without Adenoid hypertrophy causing SDB. We have based our diagnosis of SDB and OSA on the features described above. Polysomnography was not done as it is unavailable in our centre. Of the patients, M=61.8%; F=38.2%, maximum no. of cases were seen scattered in the age group of 5 to 25 yrs. 29 cases, on being followed up, showed significant improvement of the concerned symptoms following Tonsillectomy/ Adenotonsillectomy. 3 patients were lost to follow up. In 1 patient, there was persistence of SDB. OSAS is one of the most common indications of Tonsillectomy. (18)(20)(22)( 23) Over the years, there has been a rising trend in the incidence of obstruction as an indication of Tonsillectomy, especially in the younger age groups, below 18 yrs. PERITONSILLAR ABSCESS: (3) In our study group, there were 8 cases (3.4%) of Peritonsillar Abscess who had undergone Interval Tonsillectomy. The primary treatment of Peritonsillar Abscess in our centre is Incision and Drainage/aspiration of abscess followed by antibiotic coverage; Tonsillectomy is reserved for cases who had at least a 2 nd time recurrence. Of the 4 cases, there were 2 males and 2 females; so M:F ratio was 1:1. The cases were found to be scattered in the age group of 5 to 45 yrs. All the 8 cases were suffering from recurrent PTA. They were initially treated with Incision and Drainage with Antibiotic coverage. Tonsillectomy was performed after the 2 nd episode of PTA, after about 6 weeks following resolution of the abscess. All the patients have been followed up after Tonsillectomy, have shown resolution of symptoms and signs. (1),(17). UNILATERAL ENLARGEMENT (SUSPECTED NEOPLASIA) OF TONSIL: There were 5 patients(2.1%), who had unilateral asymmetrically enlarged Tonsil with no palpable cervical lymph nodes. Bilateral Tonsillectomy was performed in the patients, and the excised specimen was sent for Histopathological Examination (HPE). HPE report showed Squamous Cell Carcinoma in 2 patients, 55 yrs and 62 yrs old males; Lymphoma in one 16 yrs old male patient; Tuberculosis in one 47 yrs old male patient; in one elderly patient HPE report was within normal limits. The patients with HPE proved malignancy have received post-operative Chemoradiation. The patient with Tuberculosis was started on Antitubercular Treatment. The patient with normal HPE report has been followed up at regular intervals for any signs of neoplasia. Though Tonsillar Tuberculosis is an unusual finding, Malignancy of Tonsil remains an absolute indication of Tonsillectomy worldwide.(19) STYLALGIA: There were 4 patients(1.7%); two of them had unilateral neck pain and foreign body sensation, and two patients had Recurrent Tonsillitis with symptoms of Stylalgia. In each case, the diagnosis of Stylalgia became highly likely after palpation of the tonsillar fossa, and confirmation of the diagnosis was established after an X-Ray Styloid process. 3 cases had bilaterally enlarged styloid process(>3cm) and 1 had unilateral enlargement. The cases were in the age group of 26 to 45 yrs, with equal sex distribution. Bilateral Tonsillo-Styloidectomy was performed in all the patients. On being followedup, there was significant improvement of the concerned symptoms in 3 patients, one patient was lost to follow up.(7)(25) Sanchita Kalita, et al. 219

8 RECURRENT TONSILLITIS CAUSING RECURRENT SOM: In our study group, there were 4 patients(1.7%), who had Recurrent Tonsillitis along with Recurrent Secretory Otitis Media(SOM). Possibility of nasopharyngeal pathology was ruled out in all the cases. All the cases had undergone rigorous treatment for SOM along with grommet insertion. The Recurrence of SOM, despite adequate conservative management & grommet, was attributed to the Recurrent attacks of Acute Tonsillitis, as the tonsils were enlarged and were possibly causing Eustachian Tube dysfunction. Bilateral Tonsillectomy was performed in the patients and on being followed up, there was favorable results in all the patients.(6) RECURRENT ATTACKS OF ACUTE TONSILLITIS NOT MEETING THE STANDARD GUIDELINES AND NOT RESPONDING TO CONSERVATIVE MANAGEMENT (6) In our study group, there were 4 patients (1.7%), who had recurrent attacks of Acute Tonsillitis, not responding adequately to conservative management. Frequent attacks and hospital visits of these patients adversely affected their social life, education, jobs. Though these 4 patients did not meet the standard available guidelines for chronic/recurrent tonsillitis warranting Tonsillectomy, keeping in view the financial constraint and non-compliance of the patients to medical management, Tonsillectomy was performed, aimed towards giving a better quality of life to the concerned patients. On follow-up, the 4 patients have had satisfactory results. SUMMARY: The Indications for which Tonsillectomy was conducted in our study group are- Recurrent Tonsillitis in 174 patients. Tonsillar/Adenotonsillar enlargement causing Sleep Disordered Breathing (SDB) in 34 patients. Peritonsillar Abscess in 8 patients. Unilateral Growth( Suspected Neoplasia) of Tonsil in 5 patients. Recurrent Tonsillitis with Stylalgia in 4 patients. Recurrent Tonsillitis causing Recurrent Secretory Otitis Media(SOM) in 4 patient. Acute Tonsillitis(Recurrent Attacks not meeting standard guidelines and not responding to Conservative Management) in 4 patients. Tonsillectomy, as a whole, was performed more in Females (53.64%), and maximum in the age group of 16 to 25 yrs. These indications were compared with the available evidence based literature works namelyi. Paradise Criteria for Tonsillectomy. ii. Scottish Intercollegiate Guidance Network Guidelines (SIGN). iii. National Health & Medical Research Council (NHMRC), Australia recommendations. iv. American Academy of Otolaryngologists Head And Neck Surgery recommendations. It was found that the indications of Tonsillectomy in most of the patients were found to comply with the above mentioned standard criteria. There were few cases in our study with (1)Recurrent attacks of Acute Tonsillitis not meeting standard guidelines for Tonsillectomy, and (2)Stylalgia; in whom Tonsillectomy indications were not in accordance with the standard guidelines. However, these cases, on being followed up post-operatively, had shown satisfactory results. There was one case, with the incidental finding of Tuberculosis of Tonsil following HPE of the dissected Tonsils, which is worth special mention, as it is a rare site for extrapulmonary Tuberculosis. (1)(17) CONCLUSION: Though there are many standard available guidelines regarding Indications of Tonsillectomy, it is still a debatable issue. In our study, we have attempted to evaluate the indications for which Sanchita Kalita, et al. 220

9 Tonsillectomy is carried out in our centre. It is evident from the study that Infections (Recurrent/Chronic Tonsillitis) and Obstruction are the two most common indications of tonsillectomy, which is in accordance with the trend followed worldwide. Malignancy of Tonsil, undoubtedly remain an absolute indication of tonsillectomy. Interval Tonsillectomy, in our setting, is reserved for 2 or more episodes of Peritonsillar Abscess after adequate I&D/Aspiration along with Antibiotic coverage. Uncommon but standard indication which we encountered in our study was Recurrent Tonsillitis causing Recurrent SOM. Another indication which we encountered in one patient was Stylalgia. Though not a direct indication, elongated styloid process warranting Styloidectomy is usually coupled with Tonsillectomy (Tonsillo-Styloidectomy). Though some patients might not meet the standard protocol, keeping into account the magnitude of discomfort, economical constraints, and noncompliance of such patients to conservative management, it sometimes becomes imminent to modify the standard criteria for improving their quality of life, as was evident from our study. Lastly, there were four patients with consecutive attacks of Acute Tonsillitis, not meeting standard criteria, not responding adequately to and noncompliant to conservative treatment. Keeping into consideration the Quality of Life quotient, tonsillectomy was performed in the 4 patients. Of special mention is a case of unilateral enlargement of Tonsil who had undergone Tonsillectomy, whose HPE report showed Tuberculosis; this is not a common finding. On regular follow up of the patients postoperatively till date, good patient reviews have been obtained in terms of relief of symptoms, decrease in the outpatient visits, better school and job compliance, thus having a better quality of life for both the patients and their caregivers. Thus the different trends followed for the indications of Tonsillectomy in different places and set-ups is attributed to the physicians varying practices and to the patients varying conditions and compliance. Further large scale studies are warranted to reach some unanimous guidelines for the indications of Tonsillectomy. REFERENCES: 1. Das A, Das SK, Pandit S, Basuthakur S. Tonsillar Tuberculosis: A Forgotten Clinical Entity, J Family Med Prim Care, 2015 Jan-Mar 4(1): Ahmed AO, Aliyu I, Kolo ES. Indications for tonsillectomy and adenoidectomy: Our experience. Niger J Clin Pract 2014;17: Naik SM, Naik SS. Interval Tonsillectomy: 27 Cases of Peritonsillar Abscesses Managed in Medical College Hospital, Indian Journal of Clinical Practice, 2013 Sep, Vol. 24, No Karaman M, Tek A, Oysu C, Sheidaei S. Kulak Burun Bogaz Ihtis Derg. Adult tonsillectomy:relationship between indications and post operative haemorrhage,, Department of Otolaryngology, Umraniye Training and Research Hospital, Istanbul, Turkey, 2012 Jan- Feb 22(1): Parker NP, Walner DL. Trends in the indications for pediatric tonsillectomy or adenotonsillectomy. Int J Pediatr Otorhinolaryngol 2011;75: Wald R, Wall E, Sandberg G, Patel MM, Darrow, Giordano T, Litman RS, Li KK. "CLINICAL PRACTICE GUIDELINES: TONSILLECTOMY IN CHILDREN" American Academy of Otolaryngology- Head and Neck Surgery, 144: S1 7. Sullia; Naik SS and Naik SS. Tonsillo- Styloidectomy For Eagles s Syndrome; A Review of 15 cases in KVG Medical College, Oman Med J Mar; V.26(2); ; 8. INDICATIONS FOR TONSILLECTOMY: THE EVIDENCE BASED AND CURRENT UK PRACTICE British Journal of Hospital Medicine, 2009 Jun, Vol 70, No Britt K. Erickson, BS, Dirk R. Larson, MS, Jennifer L. St. Sauver, PhD, Ryan A. Sanchita Kalita, et al. 221

10 Meverden, BS, and Laura J. Orvidas, MD, Rochester. Changes in incidence and indications of tonsillectomy and adenotonsillectomy, MN Otolaryngology Head and Neck Surgery (2009) 140, Indications of Tonsillectomy:Position Paper ENT UK ; British Academic Conference in Otolaryngology(BACO) and British Association of Otorhinolaryngology- Head & Neck Surgery(BAO-HNS) A joint Position paper of the Paediatrics & Child Health Division of The Royal Australasian College of Physicians and The Australian Society of Otolaryngology, Head and Neck Surgery, 2008 Sydney Royal Australasian College of Physicians and Australian Society of Otolaryngology Head and Neck Surgery 12. Concise Indications for Adenoidectomy- Tonsillectomy in Children with Obstructive Sleep Apnea Syndrome :Shu-Chi Mu, I Cheng1, Rayleigh Ping-Ying Chiang4, Tseng- Chen Sung, Department of Pediatrics, Shin- Kong Wu Ho-Su Memorial Hospital, Taipei, Taiwan Medical College of Fu-Jen University, New Taipei City, Taiwan Institute of Clinical Medicine, National Yang-Ming University, Taipei, Taiwa Department of Otolaryngology, School of Medicine, Taipei Medical University; Department of Otolaryngology Head and Neck Surgery, Shin Kong Wu Ho-Su Memorial Hospital, Taipei, Taiwan 13. Goldstein NA et al. Quality of life after tonsillectomy in children with recurrent tonsillitis. Otolaryngology Head Neck Surgery. 2008, 138: S9-S Witsell DL et al. Quality of life after tonsillectomy in adults with recurrent or chronic tonsillitis, Otolaryngology Head Neck Surgery. 2008, 138: S1-S8 15. Serder Ugras, Ahmet Kutluhan, Ankara Ataturk. Chronic Tonsillitis can be diagnosed with histopathological findings, Education and Research Hospital,Dept of Pathology and Otolaryngology,Ankara,Turkey; Eur J Gen Med;2008, 5(2): Kant S, Verma SK, Sanjay. Isolated Tonsil Tuberculosis, Lung India 2008 Oct-Dec,.; 25(4): Wei JL, Mayo MS, Smith HJ, et al. Improved behavior and sleep after adenotonsillectomy in children with sleep-disordered breathing. Arch Otolaryngol Head Neck Surg. 2007;133: Sunkaraneni VS 1, Jones SE, Prasai A, Fish BM. Is unilateral tonsillar enlargement alone an indication for tonsillectomy? 2006 Jul, US National Library of Medicine, National Institutes of Health J Laryngol Otol. ;120(7):E Brietzke SE, Gallagher D. The effectiveness of tonsillectomy and adenoidectomy in the treatment of pediatric obstructive sleep apnea/hypopnea syndrome: a meta-analysis. Otolaryngol Head Neck Surg 2006;134: Leiberman A, Stiller-Timor L, Tarasiuk A, et al. The effect of adenotonsillectomy on children suffering from obstructive sleep apnea syndrome (OSAS): the Negev perspective. Int J Pediatr Otorhinolaryngol 2006;70: Epub 2006 Jul Shine NP, Coates HL, Lannigan FJ. Obstructive sleep apnea, morbid obesity, and adenotonsillar surgery: a review of the literature. Int J Pediatr Otorhinolaryngol 2005 Sep;69: Guilleminault C, Lee JH, Chan A. Pediatric obstructive sleep apnea syndrome. Arch Pediatr Adolesc Med 2005;159: Discolo CM, Darrow DH, Koltai PJ. Infectious indications for tonsillectomy. Pediatr Clin North Am 2003;50: Maru YK, Patidar K. Stylalgia and its surgical management by intra oral route-clinical experience of 332 cases, April-June 2003, Indian Journal of Otolaryngology and Head and Neck Surgery,vol.55,no2, Sanchita Kalita, et al. 222

11 25. Darrow DH, Siemens C. Indications for tonsillectomy and adenoidectomy. Laryngoscope 2002;112(8 pt 2 suppl 100): Daghistani KJ. Tonsillectomy in Saudi Arabia, Bahrain Medical Bulletin, 2002 Jun, Vol Mattila PS, Tahkokallio O, Tarkkanen J, et al. Causes of tonsillar disease and frequency of tonsillectomy operations. Arch Otolaryngol Head Neck Surg 2001;127: SIGN guideline No. 34 Management of sore throat and indications for tonsillectomy Scott Brown 7 th edition 30. Melton LJ 3rd. History of the Rochester Epidemiology Project. Mayo Clin Proc 1996;71: Derkay CS. Pediatric otolaryngology procedures in the United States: Int J Pediatr Otorhinolaryngol 1993;25(1-3): Rosenfeld RM, Green RP. Tonsillectomy and adenoidectomy: changing trends. Ann Otol Rhinol Laryngol 1990;99(3 pt 1): Paradise JL, Bluestone CD, Bachman RZ, Colborn DK, Bernard BS, Taylor FH et al. Efficacy of tonsillectomy for recurrent throat infection in severely affected children; Results of parallel randomized and nonrandomized clinical trials, N Engl J Med. 1984; 310(11): McCullagh P, Nelder JA. Generalized linear models. London: Chapman and Hall; Freeman JL, Jekel JF, Freeman DH Jr. Changes in age and sex specific tonsillectomy rates: United States, Am J Public Health 1982;72: Fleiss JL. Statistical methods for rates and proportions. 2nd ed. New York (NY): Wiley; p Landis JR, Koch GG. The measurement of observer agreement for categorical data. Biometrics 1977;33: Sanchita Kalita, et al. 223