Partial Intracapsular Tonsillectomy Research Articles

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

IntroductionThe 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 methodsChildren 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. ResultsParticipants 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). DiscussionCAS-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.

Partial intracapsular tonsillectomy in the treatment of pediatric obstructive sleep apnea/hypopnea syndrome: a prospective study with 5-year follow-up.

ObjectiveTo assess efficacy and safety of tonsil reduction with bipolar forceps electrocautery as treatment of paediatric obstructive sleep apnea/hypopnea syndrome (OSAHS).Study designProspective interventional study.MethodsTwo hundred and sixty-three children aged 4–10 years with OSAHS and an apnea hypopnea index (AHI) > 3 were enrolled from March 2013 to January 2016. Pre-operative evaluation included oropharyngeal clinical examination with fiberoptic nasopharyngoscopy, OSA-18 questionnaire and overnight sleep study. All children were treated with adenoidectomy and tonsillotomy with bipolar forceps. OSA-18 questionnaire and overnight sleep study were performed 30 days after surgery.ResultsPre-operative average of the OSA-18 questionnaires was of 70.3 (SD = 9.7); 30-day post-operative score was 23.15 (SD = 8.2; p = 0.045). Pre-operative average Apnea Hypopnea Index (AHI) score was 9.41 (SD = 4.1); 30-day post-operative average of AHI score was of 1.75 (SD = 0.8; p = 0.012). Oxygen Desaturation Index (ODI) rate changed from 7.39 (SD = 4) to 1.34 (30-day post-operative) (SD = 4.7; p = 0.085). NADIR rate changed from 79% (SD = 6.32) to 90% (30-day post-operative) (SD = 5.18; p = 0.00012). Peri- and post-operative complications in our sample were mainly pain (average 75 doses of paracetamol), while bleeding did not occur (0%). All patients received a follow-up examination 5 years after surgery to evaluate tonsil size; at this time-point, a reduction in tonsil size from 3.6 (3–4; SD = 4.2) to 1.3 (1–2; SD = 5.5) was found, while tonsil regrowth was observed in five children (2%).ConclusionThis study showed that partial tonsillotomy with bipolar forceps electrocautery associated to adenoidectomy is an effective technique in treating OSAHS symptoms in children and ensures less complications in terms of hemorrhage, postoperative pain and infections compared to traditional adenotonsillectomy. The very low tonsillar regrowth rate reported in this study may support the routine use of this technique.

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

ObjectivePartial 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. MethodsRetrospective 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. Results315 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. ConclusionsOur 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.

Comparison of the Postoperative Outcome for Pediatric Obstructive Sleep Apnea According to the Type of the Tonsillectomy

Background and Objectives Partial intracapsular tonsillectomy and adenoidectomy (PITA) has become a well-recognized technique for tonsillectomy in children. Several studies have reported that PITA shows better postoperative morbidity compared to the conventional technique. However, there is still concern about the regrowth of remnant tonsil tissues. The authors evaluated the postoperative results of PITA, combined extracapsular and intracapsular tonsillectomy, and conventional tonsillectomy. Subjects and Method The authors studied 97 children (male: 62, female: 35) aged 2 to 13 years old, who underwent tonsillectomy and adenoidectomy (PITA, combined extracapsular and intracapsular tonsillectomy, and conventional tonsillectomy). The degree of adenotonsillar hypertrophy, apnea-hypopnea index and lowest oxygen saturation was confirmed for all subjects. Operation time, quality of life, scale for postoperative pain, frequency of postoperative bleeding, and recurrence with tonsillar regrowth were compared after surgery performed by different surgical procedures. Results Regardless of the surgical technique, all the cases presented significant improvement in the quality of life before and after surgery. On the day of surgery and four days after surgery, PITA showed superior results in terms of postoperative pain level compared to the conventional technique. There were no statistically significant results with respect to the operation time and postoperative bleeding. Six months after the surgery, the recurrence of sleep apnea due to the regrowth of remaining tonsil was not obvious. Conclusion Tonsillectomy technique preserving tonsillar capsule may show better results on early postoperative pain. It can be a good alternative to the conventional technique in surgical treatment for pediatric obstructive sleep apnea in terms of early postoperative pain control. Key words: Obstructive sleep apnea ㆍ Pediatrics ㆍ Postoperative pain ㆍ Tonsillectomy

Why Is There No Statement Regarding Partial Intracapsular Tonsillectomy (Tonsillotomy) in the New Guidelines?

Partial intracapsular tonsillectomy (PIT) was revisited in 2003 as an alternate surgical option to total tonsillectomy for the treatment of tonsillar hypertrophy. However, evaluation of the existing literature on PIT reveals that it is largely focused on comparing perioperative outcomes after PIT and total tonsillectomy, with few data regarding long-term outcomes. The goal of this commentary is to explain why PIT was not incorporated into the 2019 American Academy of Otolaryngology-Head and Neck Surgery Foundation clinical practice guideline for tonsillectomy, while acknowledging its use and potential advantages and disadvantages and outlining future research opportunities.

Cost-Effectiveness Analysis of Intracapsular Tonsillectomy and Total Tonsillectomy for Pediatric Obstructive Sleep Apnea.

We performed an economic evaluation using a decision-tree model to analyze the relative cost effectiveness from the United States Centers for Medicare and Medicaid Services (CMS) perspective of two different methods of tonsillectomy (traditional total tonsillectomy and partial intracapsular) for pediatric obstructive sleep apnea (OSA). Procedural costs were drawn from published literature and Medicare values. Effectiveness and probabilities were drawn from medical literature. Primary intervention was monopolar-technique total tonsillectomy or microdebrider-assisted partial intracapsular tonsillectomy. Secondary interventions included operative control of hemorrhage, treatment of severe dehydration, or revision tonsillectomy. The decision model starts with pediatric patients with OSA, choosing between total and partial tonsillectomy. Outcomes were measured by costs (US dollars), effectiveness [quality-adjusted life year (QALY)], and a willingness-to-pay threshold of US$100,000/QALY. Base case analysis, probabilistic sensitivity analysis (PSA) and deterministic sensitivity analyses were performed. Primary outcome was incremental cost-effectiveness ratio (ICER) for each of the two tonsillectomy techniques. Base case analysis demonstrated that total tonsillectomy was more cost effective at US$12,453.40 per QALY gained. In PSA, 82.84% of the simulations show total tonsillectomy to be the more cost-effective strategy. Deterministic sensitivity analyses showed that when the rate of OSA recurrence is lower than 3.12%, partial tonsillectomy would be more cost effective. When the failure rate of partial tonsillectomy is below 1.0%, it is more cost effective even when total tonsillectomy is 100% successful. Study results suggest that overall monopolar-technique total tonsillectomy is more cost effective. However, with varying adjustments for disutility caused by procedural complications, intracapsular tonsillectomy could become a more cost-effective technique for treating pediatric OSA.

Impact of partial and total tonsillectomy on adenoid regrowth

To compare the rates of adenoid regrowth in children who underwent total tonsillectomy and adenoidectomy (TA) versus partial intracapsular tonsillectomy and adenoidectomy (ITA). Retrospective cohort study. 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. 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). 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. 4. Laryngoscope, 127:753-756, 2017.

Coblation total tonsillectomy and adenoidectomy versus coblation partial intracapsular tonsillectomy and adenoidectomy in children

To evaluate the postoperative course of children who underwent coblation T&A versus those who underwent coblation partial intracapsular tonsillectomy and adenoidectomy (PITA). Retrospective cohort study. Records of children undergoing consecutive tonsillectomies from July 2009 to October 2012 were analyzed. All surgeries used a coblation device. Outcomes including intraoperative and postoperative bleeding, pain, and return to preoperative diet were analyzed comparing the coblation T&A and coblation PITA patients. Of 415 patients evaluated, 258 (62.2%) underwent coblation T&A and 157 (37.8%) underwent coblation PITA. Seventeen (4.1%) patients experienced postoperative hemorrhage, 15 (88.2%) of whom underwent T&A and two (11.8%) of whom underwent PITA (P = 0.024). Multivariate analysis demonstrated that coblation T&A was a significant contributor to postoperative hemorrhage, with an odds ratio of 4.8 (95% confidence interval [CI]: 1.08-21.21) compared to coblation PITA. Patients who underwent T&A resumed normal diets significantly later (8 days, SD 4.6) than those who underwent PITA (5.4 days, standard deviation [SD]: 3.4) (P = 0.022). In terms of pain severity, more T&A patients reported "severe" pain and more PITA patients reported "moderate" pain (P = 0.047). More T&A patients experienced a "post-op dip," defined as increased pain during postoperative days 5-9, than did PITA patients (P < 0.001). Coblation PITA is a safe procedure that has a lower incidence of intraoperative and postoperative bleeding in children compared to coblation T&A. Patients may have less pain and return to preoperative diets sooner than those undergoing coblation T&A.

Factors contributing to cost in partial versus total tonsillectomy

To examine differences between total tonsillectomy and partial intracapsular tonsillectomy techniques that may lead to differences in overall cost and resource utilization between these procedures. Preoperative, perioperative, and postoperative management and outcome factors were examined. Retrospective review at two university-based tertiary care hospitals from January 2007 to June 2010. Pediatric patients with obstructive symptoms were divided into those undergoing total tonsillectomy and those undergoing partial intracapsular tonsillectomy. The records of 289 patients who underwent total tonsillectomy and 289 patients who underwent partial intracapsular tonsillectomy were reviewed. The average age of patients undergoing total and partial tonsillectomies was 5.0 years for both groups. Significant differences for patients undergoing total versus partial tonsillectomies were as follows: operative time (32.4 vs. 26.4 minutes, P < .0001), postanesthesia care unit (PACU) time (174 vs. 91.6 minutes, P < .0001), percent admitted postoperatively (21.5% vs. 1.7%, P < .0001), number requiring pediatric intensive care unit stay (3.5% vs. 0.3%, P < .05), number of readmissions after discharge (3.5% vs. 0.3%, P < .05), and number of postoperative emergency room visits separate from those requiring readmission (4.8% vs. 0%, P < .05). Factors that were not found to be significantly different included number of patients with postoperative hemorrhage and number requiring second operations for tonsillar regrowth. Previous studies have shown equivalent effectiveness between these two procedures; our study suggests decreased cost and resource utilization with partial tonsillectomy through reduced operative and PACU times and number of postoperative admissions and emergency department visits. As in all retrospective reviews, the findings are potentially confounded by unmeasured variables, including patient and demographic factors.

Endoscope-Assisted Tonsillotomy (Partial Intracapsular Tonsillectomy): How We Do It

Objective. To describe our technique of performing tonsillotomy that increases visibility by providing a better view of the tonsils and related structures through the use of a 30-degree scope. Method. Patients had tonsillotomy with microdebrider with the aid of a 30-degree endoscope for both visualization and on-screen projection and magnification. Result. The endoscope-assisted technique provides a more detailed exposure of pharyngeal structures and their relationships with the tonsils. It is easier to clearly visualize the upper and lower poles. The magnification with the endoscope makes it easier to appreciate anatomic details and identify/deal selectively with minute bleeding points. Conclusion. The use of 30-degree endoscope in tonsillotomy provides better visualization of the upper and lower tonsil poles and may make the procedure easier for the surgeon and safer for the patient.

Polysomnography outcomes for partial intracapsular versus total tonsillectomy

Objective To demonstrate similar improvement in pediatric sleep-disordered breathing (SDB) as determined by polysomnography (PSG) with microdebrider-assisted partial intracapsular tonsillectomy and adenoidectomy (PITA) versus Bovie electrocautery complete tonsillectomy and adenoidectomy (T&A). Methods In this retrospective cohort study, 30 children found to have SDB by PSG who have undergone either PITA (15 participants) or T&A (15 participants) as treatment were evaluated with standardized history and physical examination and unattended home overnight PSG. Results Median change in apnea–hypopnea index (AHI) was 1.7 (−4.9 to 29.8) for the PITA group and 2.3 (−10.9 to 64.1) for the T&A group, although there was substantially more variability in the T&A group. A mixed linear model evaluating the relation of surgical group with change in AHI demonstrated no significant differences in group means ( F[1,13] = 0.31, P = .590) but the variances differed significantly (residual likelihood ratio chi-square = 5.24, df = 1, P = .022). Five of 15 (33%) PITA patients and 4 of 15 (27%) T&A patients had postoperative AHI scores of ≤5; this difference was not statistically significant (Fisher exact test P = 1.000). There was no significant interaction or substantial confounding effect of age, sex, race, preoperative tonsil size, preoperative AHI, or body mass index in the model relating surgery type to reduction of postoperative AHI to ≤5. Conclusions Our study demonstrates no clinically or statistically significant differences in PSG and clinical outcomes between PITA and T&A for treatment of pediatric SDB in otherwise healthy children.

Post-operative bleeding is less after partial intracapsular tonsillectomy than bipolar total procedure

Objective To compare bleeding after partial intracapsular tonsillectomy (PIT) and bipolar diathermy tonsillectomy (BDT). Design Retrospective chart review. Setting Stollery Children's Hospital, tertiary pediatric referral centre. Patients All children (≤17 years of age) who had tonsillectomy. Patients who had incomplete information or less than 2-weeks follow-up were excluded. Main outcome measure (1) Post-tonsillectomy bleeding, (2) other data collected included demographics, length of follow-up, indication(s) for surgery, other procedures performed, and co-morbidities. Results Over a 4.5-year period 677 patients (333 BDT, 344 PIT) were identified in our search, and 77 (38 BDT, 39 PIT) were excluded. The mean age was 7.7 ± 3.8 years in the BDT group and 6.5 ± 3.2 years in the PIT group. Sex distribution was similar in the 2 groups (chi square p = 0.61). Twenty (6.8%) BDT patients experienced post-tonsillectomy bleeding, compared to three (0.98%) of PIT patients ( p = 0.0001, 95% CI 1.52–2.18, OR = 7.32). Over 3 times as many PIT patients (153) had co-morbid conditions than BDT patients (44); this was statistically significant (chi square p < 0.00001, 95% CI 1.78–2.38). Conclusion PIT results in significantly less post-tonsillectomy bleeding than BDT. These findings favor partial over total techniques with respect to reducing this important complication.

The evolution of tonsil surgery and rethinking the surgical approach to obstructive sleep-disordered breathing in children

Within the last 10 to 15 years, a significant amount of research in tonsil surgery has focused on reduction of post-operative pain and recovery time. In order to minimize or avoid morbidity, a number of otolaryngologists in the United States and Europe have revived a historical procedure, previously known as 'tonsillotomy', specifically for those patients with obstructive sleep-disordered breathing (OSDB) due to adenotonsillar hypertrophy. More recently, surgeons have used terms such as partial tonsillectomy, partial intracapsular tonsillectomy or subtotal tonsillectomy to describe their procedure and have employed a variety of modern instrumentation. This return to a 'partial' procedure has generated a debate similar to that which occurred amongst tonsil surgeons about 100 years ago, when tonsillotomy was the most commonly performed procedure. Today, concerns about regrowth and problems with infection of the remaining tonsillar tissue have been raised. Such concerns, combined with an incomplete understanding of why the 'partial' procedure was abandoned in the early twentieth century, may explain why tonsil surgeons hesitate to change their approach to patients with OSDB due to adenotonsillar hypertrophy. These issues can be addressed in a meaningful way only through a detailed review of the evolution of tonsil surgery, which is presented here. This information, along with a summary of the last 10 years' experience with these techniques, supports the use of a 'partial' procedure in children with OSDB due to adenotonsillar hypertrophy. Future areas of research are also discussed.