Tonsillectomy Shows Short-term Benefits for Apnea, Sore Throat

Diana Swift

January 18, 2017

Two systematic reviews including thousands of children found that the common pediatric procedure of tonsillectomy can reduce recurrent throat infections and obstructive sleep-disordered breathing (OSDB), but only in the short term.

According to one review, sore throats, streptococcal infections, healthcare visits, and school absenteeism improved in the first year after children underwent tonsillectomy for recurrent sore throat vs those managed with watchful waiting and supportive care.

Specifically, the tonsillectomy group had 1.74 episodes of sore throat or throat infection vs the nonsurgical group's 2.93 episodes, Anna Morad, MD, an assistant professor of pediatrics at Vanderbilt University in Nashville, Tennessee, and colleagues report in an article published online January 17 in Pediatrics.

They caution, however, that much of the data lacked strength, information on longer-term outcomes was limited, and quality-of-life scores improved regardless of surgery, with no differences seen at any point.

"Additional research to assess longer-term benefits of tonsillectomy compared with no surgery, as well as subgroups of children who may experience greater benefit, is needed to inform decision-making for caregivers and clinicians," Dr Morad and colleagues write.

No Gold Standard for Diagnosis

They note that recurrent or severe tonsillitis has been defined as follows: seven or more sore throat episodes in the preceding year, five or more episodes in the each of the preceding 2 years, or three or more episodes in each of the preceding 3 years, but diagnosis remains unclear. "No gold standard diagnostic test exists, however, to predictably attribute symptoms to tonsillitis," they write.

Although the evidence for tonsillectomy was stronger among children meeting the criterion of at least three infections per year for 3 years, the reviewers also included studies of children with fewer infections.

Using large databases, the researchers identified seven eligible analyses, including randomized controlled trials and prospective or retrospective cohort studies, published in English. These addressed mainly mild to moderate recurrent infection (at least three episodes) in the previous 1 to 3 years. In studies reporting baseline data, infections and sore throats decreased from baseline in both the surgical and nonsurgical group, although children who had had surgery showed moderately greater decreases in sore throat days, clinician contacts, group A streptococcal infections, and school absences within the first 12 months.

It appears tonsillectomy may be of greater benefit to more severely affected children. "Studies including children with a well-documented greater number of infections, such as the seminal Paradise et al study, may provide evidence for more marked benefits but were excluded from this review due to high risk of bias (due to potential selection bias and high attrition)," Dr Morad and associates write.

They also point to the lack of published evidence on the natural history of recurrent throat infections, which could help determine the possible long-term benefits for tonsillectomy. Solid data on the potential for natural resolution of recurrent infections and on variables such as severity might distinguish patients who might outgrow the need for intervention from candidates who require surgery.

"Long-term data are needed to enable caregivers to weigh the benefits of surgery versus the reality of managing their child's condition as they wait for it to resolve," they write. They acknowledge, however, that collecting long-term data may be difficult, given the high rate of attrition observed after 6 months in most studies included in the current review.

Early Improvements in Apnea

A meta-analysis, also published online January 17 in Pediatrics, from the same Vanderbilt group, showed that tonsillectomy produced generally better short-term outcomes than watchful waiting in children with OSDB.

OSDB includes a constellation of symptoms that includes snoring, obstructive sleep apnea, and upper airway resistance syndrome and has been associated with decreased IQ, hypersomnolence, emotional lability, shorter attention span, small stature, enuresis, cardiopulmonary conditions, and school absence.

Sivakumar Chinnadurai, MD, MPH, a Vanderbilt assistant professor of otolaryngology, and colleagues analyzed 11 English-language studies, also of mixed design. In five of these studies, children with polysomnography-confirmed OSDB showed improvement in apnea-hypopnea index (AHI) scores after tonsillectomy, relative to watchful waiting. Most studies entailed follow-up of less than 12 months.

Dr Chinnadurai and colleagues note that tonsillectomy, or adenotonsillectomy, currently accounts for more than 15% of all surgical procedures in US children younger than 15 years. Yet, as previously reported by Medscape Medical News, a 2015 meta-analysis showed that almost 20% of children suffer complications after tonsillectomy, including respiratory compromise.

In the current meta-analysis, the researchers found a 4.8-point improvement in AHI score in tonsillectomized children vs those with no surgical intervention. "This change is statistically significant and may be most clinically evident in children with mild or moderate OSDB (ie, AHI scores of 1–10)," the group writes.

In addition, tonsillectomy had a positive effect on impaired sleep-related quality of life, which is a chief concern for patients' parents and was associated with fewer negative psychological behaviors such as anxiety and mood fluctuations. Changes in children's executive function did not significantly differ between groups.

Firmer conclusions, however, were not possible, the authors said, because of the dearth of published data comparing tonsillectomy with nonsurgical care and the lack of information on longer-term clinical outcomes, as well as the sparse information on patient characteristics and pretonsillectomy treatments such as nasal steroids.

"Additional research to define more precisely the population of children most likely to benefit from tonsillectomy compared with supportive care and to refine outcome measures to incorporate patient-focused assessment are key future research needs," the Vanderbilt researchers write.

Both studies were supported by the Agency for Healthcare Research and Quality and the National Institutes of Health. The authors of both studies have disclosed no relevant financial relationships.

Pediatrics. Published online January 17, 2017. Morad abstract, Chinnadurai abstract

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