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Pediatric tonsillectomy: A short-term and long-term comparison of intracapsular versus extracapsular techniques
Journal Pre-proof Pediatric Tonsillectomy: A Short-term and Long-term Comparison of Intracapsular versus Extracapsular Techniques Ashley L. Soaper, Zrria L. Richardson, Judy L. Chen, Mark E. Gerber PII:
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DOI:
https://doi.org/10.1016/j.ijporl.2020.109970
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PEDOT 109970
To appear in:
International Journal of Pediatric Otorhinolaryngology
Received Date: 17 October 2019 Accepted Date: 22 February 2020
Please cite this article as: A.L. Soaper, Z.L. Richardson, J.L. Chen, M.E. Gerber, Pediatric Tonsillectomy: A Short-term and Long-term Comparison of Intracapsular versus Extracapsular Techniques, International Journal of Pediatric Otorhinolaryngology, https://doi.org/10.1016/ j.ijporl.2020.109970. This is a PDF file of an article that has undergone enhancements after acceptance, such as the addition of a cover page and metadata, and formatting for readability, but it is not yet the definitive version of record. This version will undergo additional copyediting, typesetting and review before it is published in its final form, but we are providing this version to give early visibility of the article. Please note that, during the production process, errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain. © 2020 Published by Elsevier B.V.
Pediatric Tonsillectomy: A Short-term and Long-term Comparison of Intracapsular versus Extracapsular Techniques Ashley L. Soaper, MD3; Zrria L. Richardson, MD4; Judy L. Chen, MD1; Mark E. Gerber, MD2 1. Northshore University HealthSystem, Evanston, Illinois 2. Phoenix Children’s Hospital, Phoenix, AZ 3. University of Illinois at Chicago, Chicago, Illinois 4. Kaiser Permanente, Fontana, California
Corresponding Author: Mark E. Gerber, MD 1920 E. Cambridge Ave Suite 201 Phoenix, AZ 85006 602-933-3277 [email protected] Keywords: pediatric tonsillectomy, post-tonsillectomy hemorrhage, intracapsular tonsillectomy Disclosures/Conflicts of Interest: none Acknowledgements: Patricia Park, Clinical Research Associate, Northshore University HealthSystem
1 1
Abstract:
2
Objective: To review a cohort of over 2500 patients and investigate the short and long-
3
term outcomes of intracapsular as compared to extracapsular tonsillectomy, and show if
4
the complication rates are comparable between methods.
5
Study Design: A multicenter, retrospective chart review was conducted, evaluating
6
pediatric tonsillectomies performed from 2004-2014. The electronic medical record was
7
reviewed through December 2018, providing up to 14 years of follow-up data.
8
Setting: Two tertiary care, academic medical centers
9
Subjects and Methods: A retrospective chart review was conducted to identify children
10
undergoing tonsillectomy and adenotonsillectomy. A chart review was first performed of
11
patients by a single surgeon (MEG) and then the analysis was repeated using enterprise
12
data warehouse (EDW) to search for complications and interventions using International
13
Classification of Diseases, ninth revision, (ICD-9) and Current Procedural Terminology
14
(CPT) codes. The second surgeon’s patients (JLC) patients were added to increase the
15
cohort. Patients were excluded from the review of long-term outcomes if there was less
16
than two-year follow-up. Short-term outcomes examined included rate of post-
17
tonsillectomy hemorrhage and re-presentation for dehydration, while long-term outcomes
18
included rates of peritonsillar abscess and tonsillar regrowth requiring revision
19
tonsillectomy.
20
Results: A total of 2508 pediatric patients were identified who had undergone
21
tonsillectomy or adenotonsillectomy. In 1456 (58.1%) of these patients, the intracapsular
22
technique was used and in 1052 (41.9%) patients, the extracapsular technique was used.
23
The mean documented follow-up time was 8.2 years. Thirty-five patients (1.4%) were
2 24
identified with post-tonsillectomy hemorrhage, 2 of these patients (5.7%) with primary
25
hemorrhage and 33 patients (94.3%) with secondary hemorrhage. 11 underwent
26
intracapsular tonsillectomy and 24 underwent extracapsular tonsillectomy (p=0.0042).
27
The rate of post-tonsillectomy hemorrhage with intracapsular tonsillectomy was 0.76%,
28
compared to 2.3% in the extracapsular group.
29
Three patients (0.12%) undergoing intracapsular tonsillectomy required revision
30
tonsillectomy; no patients in the extracapsular group required revision surgery. Three
31
patients (0.12%) developed peritonsillar abscess post-operatively, following intracapsular
32
tonsillectomy and one following extracapsular tonsillectomy.
33
Conclusion: This retrospective review comparing the intracapsular and extracapsular
34
techniques for tonsillectomy provides further evidence of the benefits of this technique.
35
It is worthwhile to continue offering intracapsular tonsillectomy to patients and their
36
families during pre-operative discussions.
37 38 39 40 41 42 43 44 45 46
3 47 48
Introduction: Tonsillectomy is one of the most frequently performed operations in the United
49
States, with over 289,000 procedures completed annually for a variety of indications1.
50
Today, the most common surgical indications include obstructive sleep apnea and
51
infection. Intracapsular and extracapsular methods for tonsillectomy are both widely
52
used, however intracapsular tonsillectomy has yet to obtain widespread acceptance and
53
inclusion in published clinical practice guidelines.
54
Celsus was the first to describe tonsillectomy in the first century B.C., when he
55
removed the tonsils via a combination of finger dissection and a scalpel2. Intracapsular
56
tonsillectomy, also known as intracapsular tonsillotomy and partial intracapsular
57
tonsillectomy and adenoidectomy (PITA), was first introduced in 1910, but was not
58
widely accepted at that time. In 2003, intracapsular tonsillectomy was revived by Koltai
59
using a microdebrider-assisted technique3.
60
The benefits of intracapsular tonsillectomy have been increasingly reported in the
61
literature and have primarily focused on short-term outcomes including post-operative
62
pain control, fewer admissions for dehydration, and decreased rates of post-tonsillectomy
63
hemorrhage. Solares et al. (2004) demonstrated a lower bleeding rate, lower rate of
64
readmission for dehydration, and lower rate of major complications with intracapsular
65
when compared to extracapsular tonsillectomy (mean follow-up: 1.2 years)4. Derkay et
66
al. (2006) found a significant decrease in time to return to normal activity and length of
67
time taking pain medication (duration of follow-up: 1 month)5. Wilson et al. (2009) noted
68
a shorter post-operative recovery time with intracapsular as compared to extracapsular
69
tonsillectomy6. In a systematic review of the literature, Acevedo et al. (2012)
4 70
demonstrated there was a significant decrease in post-operative morbidity, however there
71
was a lack of quality data regarding the incidence of dehydration and rate of tonsillar
72
regrowth7.
73
There remains a paucity of literature evaluating long-term outcomes of
74
intracapsular tonsillectomy. Critics often cite the potential for tonsillar regrowth and
75
possible contribution of any residual tonsillar tissue to reduce the successful elimination
76
of obstructive sleep apnea as disadvantages of this method. Tonsillar regrowth rates have
77
been cited between 3-16.6% in the literature, occurring 19 months on average after initial
78
surgery8. Odhagen et al. (2016) found that the risk of reoperation for intracapsular
79
tonsillectomy was 7-times higher than extracapsular methods9. Mukhatiyar et al. (2016)
80
showed that patients with medical comorbities are more likely to have recurrent
81
obstructive sleep apnea (OSA) symptoms with intracapsular tonsillectomy as compared
82
to extracapsular (duration of follow-up: 1-6 years)10. Several small studies have disputed
83
this finding showing convincing results to support the practice of intracapsular
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tonsillectomy. Reilly et al. (2009) showed a statistically significant improvement in
85
apnea-hypopnea index (AHI) in patients treated with microdebrider tonsillectomy
86
(median follow-up time: 0.7 years)11. In a 5-year retrospective analysis, Friedman et al.
87
(2009) also looked at various polysomnogram outcomes and noted that AHI and
88
percentage of sleep time snoring decreased, while oxygen nadir while sleeping increased
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after PITA, and these OSA outcomes were comparable to traditional tonsillectomy
90
results12. Eviatar et al. (2008) showed that there is no difference in snoring, tonsillar
91
regrowth, and recurrent tonsillitis in extracapsular versus intracapsular tonsillectomy in
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patients with 10 years of post surgical followup13. Chan et al. (2004) showed a significant
5 93
decrease in post-operative morbidity without significant re-growth rates (duration of
94
follow-up: 12 months)14. Doshi et al. (2011) showed minimal re-growth rate with
95
intracapsular tonsillectomy with an average follow-up time of 5.98 months15.
96
The most recent tonsillectomy clinical practice guidelines published in February
97
2019 by the American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS)
98
Foundation did not include any specific recommendations regarding intracapsular
99
tonsillectomy. The authors explain: “further prospective outcomes studies for PIT (partial
100
intracapsular tonsillectomy) are needed to determine generalizability and applicability to
101
guideline development”16. As a frequently performed procedure at our two institutions,
102
we aim to strengthen the body of evidence regarding the utility of intracapsular
103
tonsillectomy so that, in the future, intracapsular tonsillectomy will be included in the
104
clinical practice guidelines.
105
The purpose of our study was to review a large cohort of over 2500 patients from
106
two primary surgeons at two tertiary care institutions comparing the short-term and long-
107
term outcomes of intracapsular and extracapsular tonsillectomy and compare the
108
complication rates between both methods.
109
Methods:
110
A retrospective chart review was conducted to review 2508 pediatric patients who
111
underwent tonsillectomy between 2004 and 2014 at two large, tertiary care centers for a
112
variety of indications including sleep disordered breathing/obstructive sleep apnea and
113
chronic tonsillitis. The electronic medical records of these patients were reviewed
114
through December 2018 to provide up to 14 years of long-term follow-up data.
115
Institutional review board (IRB) approval was obtained from both institutions. Patients
6 116
were identified via both manual chart review of all patients undergoing
117
adenotonsillectomy followed by electronic enterprise data warehouse (EDW) search
118
using Current Procedural Terminology (CPT) and International Classification of
119
Diseases, ninth revision, (ICD-9) codes. Patients of two fellowship-trained pediatric
120
otolaryngologists were evaluated (M.E.G. and J.L.C.). Surgeon A performed both
121
intracapsular and extracapsular tonsillectomy, while Surgeon B performed only
122
extracapsular tonsillectomy. Extracapsular tonsillectomy was performed via similar
123
technique by both surgeons. Demographic information was obtained including age of
124
patient, gender, method of tonsillectomy, and length of documented follow-up. The
125
electronic medical record was also reviewed for complications including re-presentation
126
for dehydration, post-tonsillectomy hemorrhage, peritonsillar abscess and tonsillar
127
regrowth requiring revision tonsillectomy. Patients were excluded from short-term
128
complication data (admission for dehydration and hemorrhage) if there was no
129
documented follow-up. Patients were excluded from long-term complications (tonsillar
130
regrowth, peritonsillar abscess or need for revision tonsillectomy) if there was less than
131
two years of documented follow-up identified in the electronic medical records. The
132
following ICD-9 codes were used to identify patients with post-tonsillectomy
133
complications using EDW: 784.8, 998.11, and 998.2 for post-tonsillectomy hemorrhage,
134
276.52 for dehydration, and 475 for peritonsillar abscess. The following CPT codes were
135
used using EDW: 42700 for incision and drainage of peritonsillar abscess, 42825 and
136
42826 for tonsillectomy, and 42820 and 42821 for adenotonsillectomy. Statistical
137
analysis was performed.
7 138
Extracapsular tonsillectomy technique: A blade tip electrocautery is used on
139
setting of 8-12 watts to remove the tonsillar tissue and the suction bovie used on same
140
settings to control bleeding points.
141
Intracapsular Tonsillectomy Surgical Technique: A straight Allis retractor is
142
initially used to grasp the superior pole of the tonsillar tissue and medialize the tonsil.
143
The microdebrider (Medtronic: Minneapolis, Minnesota) at a variable speed (maximum:
144
1500 rpm), oscillating, is used to remove the tonsillar tissue in a medial to lateral fashion,
145
taking care to avoid the vascular pedicle as well as the tonsillar capsule and pillars. Once
146
the majority of the tonsillar tissue is removed, the remaining tissue is released from the
147
Allis retractor, the pillars are manipulated with a Heard retractor, and additional tonsillar
148
tissue removed with the microdebrider leaving a thin rim along with the capsule. The
149
suction bovie at 20 watts is used to cauterize the residual tonsil bed and control bleeding
150
points.
151
Results:
152
A total of 2508 pediatric patients were identified who had undergone
153
tonsillectomy between 2004-2014. 1456 (58.1%) of these patients underwent
154
intracapsular tonsillectomy and 1052 (41.9%) underwent extracapsular tonsillectomy.
155
The average age of the patients was 7.1 years, with an average age of 6.1 years for
156
intracapsular tonsillectomy and 9.7 years for extracapsular tonsillectomy. Using manual
157
chart review, 1107 patients (55.5%) were male, including 845 males (58.0%) in the
158
intracapsular group and 262 males (48.8%) in the extracapsular group (Figure 1). A total
159
of 1009 patients (40.2%) had over 10 years of documented follow-up in our electronic
8 160
medical record. The mean documented follow-up time for our cohort of patients was 8.2
161
years.
162
Short-term outcomes included post-tonsillectomy hemorrhage and dehydration
163
(Figure 2). Thirty-five patients (1.4%) were identified with post-tonsillectomy
164
hemorrhage. Two of these patients (0.08%) had primary hemorrhage (<1 day post-
165
operatively); both patients with primary hemorrhage were in the extracapsular
166
tonsillectomy group. Thirty-three patients (1.3%) experienced secondary hemorrhage (≥ 1
167
day post operatively), with 11 of these patients (0.76%) undergoing intracapsular
168
tonsillectomy and 24 patients (2.3%) undergoing extracapsular tonsillectomy (p=0.0042,
169
Figure 2). This is extrapolated to a relative risk of 0.3362 (95% confidence interval (CI):
170
0.1654-0.6833) of post-tonsillectomy hemorrhage with intracapsular as compared to
171
extracapsular tonsillectomy (p=0.0026). Number needed to treat (NNT) is 67.5 patients.
172
Relative risk of primary post-tonsillectomy hemorrhage is 0.1448 (95% CI: 0.0070-
173
3.0135, p=0.2121) and relative risk of secondary hemorrhage is 0.3661 (95% CI: 0.1783-
174
0.7516, p=0.0062) for intracapsular versus extracapsular tonsillectomy (Figure 3). Our
175
overall incidence of post-tonsillectomy hemorrhage with intracapsular tonsillectomy is
176
0.76% and is 2.3% in the extracapsular group.
177
One patient (0.04%) with primary hemorrhage required return to operating room
178
for control and 12 patients (0.48%) required return to operating room for secondary
179
hemorrhage. Four patients (0.27%) undergoing intracapsular tonsillectomy and 8 patients
180
(0.76%) undergoing extracapsular required return to the operating room (p=.0.0517). One
181
patient (0.01%) with post-tonsillectomy hemorrhage who underwent extracapsular
9 182
tonsillectomy required blood transfusion for hemoglobin of 6.0 g/dL, while no patients
183
undergoing intracapsular tonsillectomy required transfusion.
184
Eleven patients (0.44%) re-presented for dehydration, and of these 4 patients
185
(0.27%) underwent intracapsular and 7 patients (0.67%) underwent extracapsular
186
tonsillectomy. This difference did not reach statistical significance (p=0.0814). Five of
187
these patients (0.20%) required hospital admission for intravenous fluids, 3 (0.21%) in
188
the intracapsular tonsillectomy group and 2 (0.19%) in the extracapsular tonsillectomy
189
group (Figure 2).
190
Long-term outcomes measured included tonsillar regrowth requiring revision
191
tonsillectomy and peritonsillar abscess formation. Three patients (0.21%) in the
192
intracapsular tonsillectomy group had symptomatic tonsillar regrowth prompting revision
193
tonsillectomy, resulting in a relative risk of 3.6086 (95% CI: 0.1734-75.0920, p=0.4073,
194
Figure 4). The timing between initial surgery and revision tonsillectomy of these three
195
patients was 110 months, 36 months, and 38 months (average: 61 months). The first
196
patient had initial tonsillectomy at age 10 and required revision tonsillectomy for chronic
197
tonsillitis at age 19. The second patient underwent adenotonsillectomy at age 3 and
198
required revision adenotonsillectomy at age 5. The last patient had surgery at age 2 and
199
underwent revision adenotonsillectomy and bilateral nasal turbinoplasty at age 5 (Figure
200
5).
201
Three patients (0.12%) developed peritonsillar abscess post-operatively, 2
202
(0.14%) underwent intracapsular tonsillectomy and 1 (0.10%) extracapsular
203
tonsillectomy. This extrapolates to a relative risk of 2.1667 (0.883-53.1371, p=0.474,
204
Figure 4). The timespan from initial surgery to presentation with peritonsillar abscess for
10 205
our three patients was 130 months, 110 months, and 101 months (average: 114 months).
206
The first patient had intracapsular tonsillectomy with adenoidectomy at 22 months of age,
207
and presented with peritonsillar abscess with required needle aspiration at age 12. The
208
second patient had intracapsular tonsillectomy with adenoidectomy at age 8 and had
209
needle aspiration of peritonsillar abscess at age 18. The last patient had extracapsular
210
adenotonsillectomy at age 19 and required incision and drainage of peritonsillar abscess
211
at age 27 (Figure 5).
212
Discussion:
213
Intracapsular tonsillectomy is becoming an increasingly accepted technique for
214
removal of the palatine tonsils. Short-term outcomes have been well described in
215
previous smaller studies, with obvious benefits including improved pain control,
216
decreased rates of dehydration, and lower incidence of post-tonsillectomy
217
hemorrhage4,7,14. There has been a lack of robust, long-term data reviewing the outcomes
218
and complications of this method. The 2019 AAO-HNS Foundation pediatric
219
tonsillectomy clinical practice guidelines held off on providing recommendations
220
regarding intracapsular tonsillectomy due to the lack of this long-term data. Our up to14
221
years of long-term data provides additional evidence showing the limited risk of tonsillar
222
regrowth requiring revision surgery for either upper airway obstructive symptoms or to
223
manage abscess formation following intracapsular tonsillectomy.
224
Post-tonsillectomy hemorrhage is one of the most serious complications following
225
tonsillectomy and can be life-threatening. Our short term results add to the previously
226
published evidence showing a statistically significant decrease in post-tonsillectomy
227
hemorrhage in the intracapsular as compared to the extracapsular tonsillectomy patients
11 228
with a relative risk of 0.3362 (p=0.0026). There is a 0.76% risk of hemorrhage for
229
intracapsular as compared to 2.3% for extracapsular tonsillectomy in our cohort. This is
230
cited at 1-20% in the literature for all tonsillectomies17. Our post-tonsillectomy
231
hemorrhage rate is also lower than other quoted rates of intracapsular tonsillectomy,
232
which are around 1%7. The slightly lower risk in our study may be a statistical variance
233
related to the rarity of the event but may also be related to the technique of eversion of
234
the tonsil tissue using the Allis clamp and avoidance of the vascular pedicle when using
235
the microdebrider. Regardless, the comparison of the intracapsular versus extracapsular
236
tonsillectomy bleeding rate combined with the rarity of regrowth requiring revision
237
surgery strongly supports this method as an important, and perhaps superior, method in
238
an appropriately selected patient.
239
Previous studies have reported a significant reduction in admission for
240
dehydration2,3,14. In our cohort, there were 4 children (0.27%) seen in the emergency
241
room or admitted following intracapsular tonsillectomy and 5 (0.48%) following
242
extracapsular tonsillectomy. The difference between methods was not statistically
243
significant.
244
The average published rate of tonsillar regrowth following intracapsular
245
tonsillectomy is 3.2% and most sources site the regrowth rate after extracapsular
246
tonsillectomy as nearly 0%18,19. Our rate of regrowth requiring revision surgery after
247
intracapsular tonsillectomy is considerably lower at 0.21%. This is likely related to the
248
near complete removal of tonsillar tissue using the Allis Clamp to retract and assist with
249
dissection of the tonsillar tissue. Our findings are in agreement with Chan et al. (2004)
250
and Doshi et al. (2012), but with increased power14,15.
12 251
Our average time between initial tonsillectomy and revision tonsillectomy was 61
252
months. There does not seem to be any correlation between age at initial surgery and time
253
from initial surgery to revision surgery from our small sample of patients. Given that we
254
have up to 14 years of long-term follow-up, we are confident that our data is an accurate
255
depiction of the low risk of regrowth in intracapsular tonsillectomy with our method. The
256
low incidence of revision surgery may be related to the intracapsular technique used in
257
this study under the direction of a single surgeon (M.E.G).
258
There was no significant difference in the rate of peritonsillar abscess formation
259
after surgery in the intracapsular tonsillectomy group as compared to the extracapsular
260
group. Using our method of near complete removal of tonsillar tissue to the level of the
261
capsule, there is minimal tissue remaining. Only three patients (0.12%) developed
262
peritonsillar abscess post-operatively, two in the intracapsular group and one in the
263
extracapsular group. This was not a statistically significant difference (p=0.474). Of the
264
patients who presented with peritonsillar abscess, none had any concerns until 8-10 years
265
post operatively, which may have been missed without the extensive long-term follow-up
266
of our study patients. The two intracapsular patients who developed peritonsillar abscess
267
had their complications at 130 and 110 months post-operatively, and the extracapsular
268
patient presented with peritonsillar abscess at 101 months, thus the intracapsular versus
269
extracapsular methods did not show a substantial difference in the timing of this
270
complication. It is unclear why a patient in the extracapsular group developed
271
peritonsillar abscess. Possible theories include involvement of minor salivary glands
272
contributing to abscess formation and or residual lymphoid tissue20.
13 273
Our review provides up to 14 years of long-term follow-up after tonsillectomy,
274
providing valuable insight to the potential short and long-term risks of the intracapsular
275
versus extracapsular methods. Without this extensive follow-up, many of these long-term
276
complications may have been missed.
277
There are some limitations to our study. The retrospective nature of the chart
278
review (both electronic and manual) showed that we did not have enough consistent
279
documentation of early concerns such as post-operative pain control, time to return to
280
normal activity, or return to normal diet to include in our analysis. Fortunately, our study
281
involved two major healthcare systems in the same region making it likely that any
282
complications and/or revision surgery was captured by our chart review. However, there
283
is still a small chance that long-term data may be underestimated due to patients
284
relocating their care to another medical center outside our region. Additionally, there is a
285
potential for bias given that the inclusion criteria for having significant tonsil regrowth
286
requires that both the surgeon and the patient family agree to proceed with revision
287
surgery.
288
Conclusion:
289
This study provides additional evidence justifying the growing number of
290
surgeons performing intracapsular tonsillectomies. We have again demonstrated that
291
there is a significant reduction in post-tonsillectomy hemorrhage, both primary and
292
secondary. The lack of significance in the episodes of dehydration may be related to the
293
overall low incidence of this complication seen in our population. Most importantly, this
294
study contributes to current literature by documenting the long-term natural history
295
following intracapsular tonsillectomy by showing a low rate of symptomatic regrowth
14 296
requiring revision surgery. We feel that intracapsular tonsillectomy is a useful technique
297
that should be offered to patients and their families as an effective option.
298
We hope that future tonsillectomy clinical practice guidelines will include this
299
method as not only an option, but as a recommendation for the appropriately selected
300
patient.
301
References:
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2. Younis RT & Lazar RH. History and Current Practice of Tonsillectomy. Laryngoscope. August 2002: 112.
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3. Koltai PJ, Solares CA, Koempel JA, Hirose K, Abelson T, Krakovitz PR, Chan J, Xu M, Mascha EJ. Intracapsular Tonsillar Reduction (Partial Tonsillectomy): Reviving a Historical Procedure for Obstructive Sleep Disordered Breathing in Children. Otolaryngol Head Neck Surg. 2003;129 (5), 532-538.
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4. Solares CA, Koempel JA, Hirose K, Abelson TI, Relily JS, Cook SP, April MM, Ward RF, Bent JP 3rd, Xu M, Koltai PJ. Safety and efficacy of powered intracapsular tonsillectomy in children: a multicenter retrospective case series. Int J Ped Otorhinolaryngol. 2005 Jan:69(1):21-6. Epub 2004 Nov 5.
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5. Derkay CS, Darrow DH, Welch C, Sinacori JT. Post-Tonsillectomy Morbidity and Quality of Life in Pediatric Patient with Obstructive tonsils and Adenoid: Microdebrider vs Electrocautery. Otolaryngol Head Neck Surg. 2006; 134, 114-120.
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7. Acevedo JL, Ashok K, Shah and Scott E, Brietzke. Systemic Review of Complications of Tonsillotomy vs Tonsillectomy. Otolaryngol Head Neck Surg. 2012 June; 146(6):8719. doi: 10.1177/0194599812439017. Epub 2012 Mar 6.
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8. Windfuhr JP, Werner JA. Tonsillotomy: it’s time to clarify the facts. Eur Arch Otorhinolaryngol. 2013;270 (12), 2985-2996.
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9. Odhagen E, Sunnergren O, Hemlin C, Hessen Soderman AC, Ericsson E, Stalfors J. Risk of reoperation after tonsillotomy versus tonsillectomy: a population-based cohort study. Eur Arch Otorhinolaryngol. 2016 Oct;273(10):3263-8. doi: 10.1007/s00405-0153871-7. Epub 2016 Jan 4.
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10. Mukhatiyar P, Nandalike K, Cohen HW, Sin S, Gangar M, Bent JP, Arens R. Intracapsular and Extracapsular Tonsillectomy and Adenoidectomy in Pediatric Obstructive Sleep Apnea. JAMA Otolaryngol Head Neck Surg. 2016;142(1):25-31. doi: 10.1001/jamaoto.2015.2603.
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11. Reilly BK, Levin J, Sheldon S, Harsanyi K, Gerber ME. Efficacy of Microdebrider Intracapsular Adenotonsillectomy as Validated by Polysomnography. Laryngoscope. 2009; 119:7, 1391-1393, 2009
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12. Friedman M, Wilson MN, Friedman J, et al. Intracapsular coblation tonsillectomy and adenoidectomy for the treatment of pediatric obstructive sleep apnea/hypopnea syndrome. Otolaryngol Head Neck Surg. 2009;140: 358–362.
341 342 343
13. Eviatar E, Kessler A, Shlamkovitch N, Vaiman M, Zilver D, Gavriel H. Tonsillectomy vs. partial tonsillectomy for OSAS in children—10 years post-surgery follow-up. Int J Ped Otorhinolaryngol. 2009;73:637-640.
344 345 346 347
14. Chan KH, Friedman NR, Allen GC, Yaremchuk K, Wirtschafter A, Bikhazi N, Bernstein JM, Kelly PE, Lee KC. Randomized Controlled, Multisite study of Intracapsular Tonsillectomy using low-temperature plasma excision. Arch Otolaryngol Head Neck Surg. 2004;130:1303-1307.
348 349 350
15. Doshi HK, Rosow DE, Ward RF, April MM. Age-related tonsillar re-growth in Children Undergoing Powered intracapsular tonsillectomy. Int J Ped Otorhinolaryngol. 2011;75 1395-1398.
351 352 353 354
16. Parikh, S. R., Archer, S., Ishman, S. L., & Mitchell, R. B. (2019). Why Is There No Statement Regarding Partial Intracapsular Tonsillectomy (Tonsillotomy) in the New Guidelines? Otolaryngol Head Neck Surg. 160(2), 213–214. https://doi.org/10.1177/0194599818810507
355 356 357
17. Wang H, Fu Y, Feng Y, Guan J, Yin S (2015) Tonsillectomy versus Tonsillotomy for Sleep-Disordered Breathing in Children: A Meta Analysis. PLoS ONE 10(3): e0121500. doi:10.1371/journal.
358 359 360 361 362 363 364 365
18. Windfuhr JP, Savva K, Dahm JD, Werner JA. Tonsillotomy: facts and fiction. Eur Arch Otorhinolaryngol. 2015 Apr; 272(4): 949-969. https://doi.org/10.1007/s00405014-3010-x
366 367 368 369
20. El-Saied, S., Puterman, M., Kaplan, D. M., Cohen-Lahav, M., & Joshua, B.-Z. (2012). Involvement of Minor Salivary Glands in the Pathogenesis of Peritonsillar Abscess. Otol Head Neck Surg, 147(3), 472474. https://doi.org/10.1177/0194599812445552
19. Garetz SL. (2019). Adenotonsillectomy for obstructive sleep apnea in children. A.G. Hoppin (Ed.). UptoDate. Retrieved April 17, 2019 from https://www.uptodate.com/contents/adenotonsillectomy-for-obstructive-sleepapnea-in-children#H2865702283
16 370
1 1 Demographic Information for Pediatric Patients Undergoing Tonsillectomy/Adenotonsillectomy All
Intracapsular
Extracapsular
Number of Patients
2508
1456
1052
Average Age (years)
7.1
6.1
9.7
55.5%
58.0%
48.8%
Percent Male (%)
2 3 4 5 6 7 8 9 10 11 12 13
Figure 1. Demographic information for our patient cohort. A total of 2508 patients were reviewed via manual chart review and again with enterprise data warehouse (EDW) using ICD-9 codes. The average age of patients reviewed was 7.1 years, with the average age of intracapsular being slightly lower than extracapsular. Percentage of male patients was slightly higher in the intracapsular group as compared to the extracapsular group.
2
Incidence of Short-term Outcomes in Intracapsular and Extracapsular Tonsillectomy 0
10
20
30
40
Dehydration
Post-Tonsillectomy Hemorrhage
Intracapsular Extracapsular
Primary Post-Tonsillectomy Hemorrhage Secondary Post-Tonsillectomy Hemorrhage
14 15 16 17 18 19 20 21 22 23 24 25 26 27
Figure 2. A depiction of the rates of post-tonsillectomy hemorrhage and dehydration in intracapsular and extracapsular tonsillectomy. There were 4 patients with dehydration in the intracapsular group and 7 in the extracapsular group, with no statistically significant difference between the groups. A total of 35 of 2508 patients experienced posttonsillectomy hemorrhage, 11 in the intracapsular group and 24 in the extracapsular group. Two patients had primary hemorrhage (<1 day post-operatively), both who had received extracapsular tonsillectomy. Thirty-three patients total had secondary hemorrhage (≥ 1 day post-operatively), 11 in the intracapsular group and 22 in the extracapsular group.
3
Relative Risk of Post-Tonsillectomy Hemorrhage, Intracapsular vs. Extracapsular 3 2.5 2 1.5 1 0.5 0
All Hemorrhage
Primary Hemorrhage
Secondary Hemorrhage
28 29 30 31 32 33 34 35 36 37 38 39
Figure 3. A representation of the relative risk of post-tonsillectomy hemorrhage when comparing intracapsular to extracapsular tonsillectomy. When reviewing all hemorrhages, and then categorizing into primary (<1 day post-operatively) and secondary hemorrhage (≥ 1 day post operatively), all groups show a decrease in the relative risk of intracapsular as compared to extracapsular tonsillectomy. The relative risk of posttonsillectomy hemorrhage in all 2508 patients reviewed is 0.3362 (95% CI: 0.16540.6833). The relative risk of primary hemorrhage is 0.1448 (95% CI: 0.0070-3.0135, p=0.2121) and relative risk of secondary hemorrhage is 0.3661 (95% CI: 0.1783-0.7516, p=0.0062).
4
Relative Risk of Long-term Complications, Intracapsular vs. Extracapsular 5 4.5 4 3.5 3 2.5 2 1.5 1
Revision Tonsillectomy
Peritonsillar Abscess
40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59
Figure 4. A depiction of the relative risk of long-term complications including revision tonsillectomy and peritonsillar abscess in intracapsular versus extracapsular tonsillectomy. Both complications show an increased relative risk in the intracapsular group as compared to the extracapsular group, but with a small absolute number of complications. The relative risk of revision tonsillectomy for intracapsular versus extracapsular tonsillectomy is 3.6086 (95% CI: 0.1734-75.0920, p=0.4073) and the relative risk of formation of peritonsillar abscess in intracapsular versus extracapsular tonsillectomy is 2.1667 (0.883-53.1371, p=0.474). A total of three revision tonsillectomies were performed due to symptomatic tonsillar regrowth, all in the intracapsular group. Three patients developed peritonsillar abscess, two in the intracapsular group and one in the extracapsular group.
5 Age at Initial Surgery (Years)
Age at Complication (Years)
Time Between Initial Surgery and Complication (Months)
Patient 1
10
19
110
Patient 2
3
5
36
Patient 3
2
5
38
REVISION TONSILLECTOMY
Average: 61 months
Age at Initial Surgery (Years)
Age at Complication (Years)
Time Between Initial Surgery and Complication (Months)
Patient 1 (intracapsular)
1
12
130
Patient 2 (intracapsular)
8
18
110
Patient 3 (extracapsular)
19
27
101
PERITONSILLAR ABSCESS
Average: 114 months
60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75
Figure 5. The demographic information of the patients who developed long-term complications including need for revision tonsillectomy and formation of peritonsillar abscess. A total of three patients required revision tonsillectomy (0.12%) and a total of three patients developed peritonsillar abscess (0.12%). The average time between initial surgery and revision tonsillectomy was 61 months and the average time between initial surgery and formation of peritonsillar abscess was 114 months. There is no apparent correlation between age at initial surgery and age at complication for either complication.
S0165-5876(20)30113-0
DOI:
https://doi.org/10.1016/j.ijporl.2020.109970
Reference:
PEDOT 109970
To appear in:
International Journal of Pediatric Otorhinolaryngology
Received Date: 17 October 2019 Accepted Date: 22 February 2020
Please cite this article as: A.L. Soaper, Z.L. Richardson, J.L. Chen, M.E. Gerber, Pediatric Tonsillectomy: A Short-term and Long-term Comparison of Intracapsular versus Extracapsular Techniques, International Journal of Pediatric Otorhinolaryngology, https://doi.org/10.1016/ j.ijporl.2020.109970. This is a PDF file of an article that has undergone enhancements after acceptance, such as the addition of a cover page and metadata, and formatting for readability, but it is not yet the definitive version of record. This version will undergo additional copyediting, typesetting and review before it is published in its final form, but we are providing this version to give early visibility of the article. Please note that, during the production process, errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain. © 2020 Published by Elsevier B.V.
Pediatric Tonsillectomy: A Short-term and Long-term Comparison of Intracapsular versus Extracapsular Techniques Ashley L. Soaper, MD3; Zrria L. Richardson, MD4; Judy L. Chen, MD1; Mark E. Gerber, MD2 1. Northshore University HealthSystem, Evanston, Illinois 2. Phoenix Children’s Hospital, Phoenix, AZ 3. University of Illinois at Chicago, Chicago, Illinois 4. Kaiser Permanente, Fontana, California
Corresponding Author: Mark E. Gerber, MD 1920 E. Cambridge Ave Suite 201 Phoenix, AZ 85006 602-933-3277 [email protected] Keywords: pediatric tonsillectomy, post-tonsillectomy hemorrhage, intracapsular tonsillectomy Disclosures/Conflicts of Interest: none Acknowledgements: Patricia Park, Clinical Research Associate, Northshore University HealthSystem
1 1
Abstract:
2
Objective: To review a cohort of over 2500 patients and investigate the short and long-
3
term outcomes of intracapsular as compared to extracapsular tonsillectomy, and show if
4
the complication rates are comparable between methods.
5
Study Design: A multicenter, retrospective chart review was conducted, evaluating
6
pediatric tonsillectomies performed from 2004-2014. The electronic medical record was
7
reviewed through December 2018, providing up to 14 years of follow-up data.
8
Setting: Two tertiary care, academic medical centers
9
Subjects and Methods: A retrospective chart review was conducted to identify children
10
undergoing tonsillectomy and adenotonsillectomy. A chart review was first performed of
11
patients by a single surgeon (MEG) and then the analysis was repeated using enterprise
12
data warehouse (EDW) to search for complications and interventions using International
13
Classification of Diseases, ninth revision, (ICD-9) and Current Procedural Terminology
14
(CPT) codes. The second surgeon’s patients (JLC) patients were added to increase the
15
cohort. Patients were excluded from the review of long-term outcomes if there was less
16
than two-year follow-up. Short-term outcomes examined included rate of post-
17
tonsillectomy hemorrhage and re-presentation for dehydration, while long-term outcomes
18
included rates of peritonsillar abscess and tonsillar regrowth requiring revision
19
tonsillectomy.
20
Results: A total of 2508 pediatric patients were identified who had undergone
21
tonsillectomy or adenotonsillectomy. In 1456 (58.1%) of these patients, the intracapsular
22
technique was used and in 1052 (41.9%) patients, the extracapsular technique was used.
23
The mean documented follow-up time was 8.2 years. Thirty-five patients (1.4%) were
2 24
identified with post-tonsillectomy hemorrhage, 2 of these patients (5.7%) with primary
25
hemorrhage and 33 patients (94.3%) with secondary hemorrhage. 11 underwent
26
intracapsular tonsillectomy and 24 underwent extracapsular tonsillectomy (p=0.0042).
27
The rate of post-tonsillectomy hemorrhage with intracapsular tonsillectomy was 0.76%,
28
compared to 2.3% in the extracapsular group.
29
Three patients (0.12%) undergoing intracapsular tonsillectomy required revision
30
tonsillectomy; no patients in the extracapsular group required revision surgery. Three
31
patients (0.12%) developed peritonsillar abscess post-operatively, following intracapsular
32
tonsillectomy and one following extracapsular tonsillectomy.
33
Conclusion: This retrospective review comparing the intracapsular and extracapsular
34
techniques for tonsillectomy provides further evidence of the benefits of this technique.
35
It is worthwhile to continue offering intracapsular tonsillectomy to patients and their
36
families during pre-operative discussions.
37 38 39 40 41 42 43 44 45 46
3 47 48
Introduction: Tonsillectomy is one of the most frequently performed operations in the United
49
States, with over 289,000 procedures completed annually for a variety of indications1.
50
Today, the most common surgical indications include obstructive sleep apnea and
51
infection. Intracapsular and extracapsular methods for tonsillectomy are both widely
52
used, however intracapsular tonsillectomy has yet to obtain widespread acceptance and
53
inclusion in published clinical practice guidelines.
54
Celsus was the first to describe tonsillectomy in the first century B.C., when he
55
removed the tonsils via a combination of finger dissection and a scalpel2. Intracapsular
56
tonsillectomy, also known as intracapsular tonsillotomy and partial intracapsular
57
tonsillectomy and adenoidectomy (PITA), was first introduced in 1910, but was not
58
widely accepted at that time. In 2003, intracapsular tonsillectomy was revived by Koltai
59
using a microdebrider-assisted technique3.
60
The benefits of intracapsular tonsillectomy have been increasingly reported in the
61
literature and have primarily focused on short-term outcomes including post-operative
62
pain control, fewer admissions for dehydration, and decreased rates of post-tonsillectomy
63
hemorrhage. Solares et al. (2004) demonstrated a lower bleeding rate, lower rate of
64
readmission for dehydration, and lower rate of major complications with intracapsular
65
when compared to extracapsular tonsillectomy (mean follow-up: 1.2 years)4. Derkay et
66
al. (2006) found a significant decrease in time to return to normal activity and length of
67
time taking pain medication (duration of follow-up: 1 month)5. Wilson et al. (2009) noted
68
a shorter post-operative recovery time with intracapsular as compared to extracapsular
69
tonsillectomy6. In a systematic review of the literature, Acevedo et al. (2012)
4 70
demonstrated there was a significant decrease in post-operative morbidity, however there
71
was a lack of quality data regarding the incidence of dehydration and rate of tonsillar
72
regrowth7.
73
There remains a paucity of literature evaluating long-term outcomes of
74
intracapsular tonsillectomy. Critics often cite the potential for tonsillar regrowth and
75
possible contribution of any residual tonsillar tissue to reduce the successful elimination
76
of obstructive sleep apnea as disadvantages of this method. Tonsillar regrowth rates have
77
been cited between 3-16.6% in the literature, occurring 19 months on average after initial
78
surgery8. Odhagen et al. (2016) found that the risk of reoperation for intracapsular
79
tonsillectomy was 7-times higher than extracapsular methods9. Mukhatiyar et al. (2016)
80
showed that patients with medical comorbities are more likely to have recurrent
81
obstructive sleep apnea (OSA) symptoms with intracapsular tonsillectomy as compared
82
to extracapsular (duration of follow-up: 1-6 years)10. Several small studies have disputed
83
this finding showing convincing results to support the practice of intracapsular
84
tonsillectomy. Reilly et al. (2009) showed a statistically significant improvement in
85
apnea-hypopnea index (AHI) in patients treated with microdebrider tonsillectomy
86
(median follow-up time: 0.7 years)11. In a 5-year retrospective analysis, Friedman et al.
87
(2009) also looked at various polysomnogram outcomes and noted that AHI and
88
percentage of sleep time snoring decreased, while oxygen nadir while sleeping increased
89
after PITA, and these OSA outcomes were comparable to traditional tonsillectomy
90
results12. Eviatar et al. (2008) showed that there is no difference in snoring, tonsillar
91
regrowth, and recurrent tonsillitis in extracapsular versus intracapsular tonsillectomy in
92
patients with 10 years of post surgical followup13. Chan et al. (2004) showed a significant
5 93
decrease in post-operative morbidity without significant re-growth rates (duration of
94
follow-up: 12 months)14. Doshi et al. (2011) showed minimal re-growth rate with
95
intracapsular tonsillectomy with an average follow-up time of 5.98 months15.
96
The most recent tonsillectomy clinical practice guidelines published in February
97
2019 by the American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS)
98
Foundation did not include any specific recommendations regarding intracapsular
99
tonsillectomy. The authors explain: “further prospective outcomes studies for PIT (partial
100
intracapsular tonsillectomy) are needed to determine generalizability and applicability to
101
guideline development”16. As a frequently performed procedure at our two institutions,
102
we aim to strengthen the body of evidence regarding the utility of intracapsular
103
tonsillectomy so that, in the future, intracapsular tonsillectomy will be included in the
104
clinical practice guidelines.
105
The purpose of our study was to review a large cohort of over 2500 patients from
106
two primary surgeons at two tertiary care institutions comparing the short-term and long-
107
term outcomes of intracapsular and extracapsular tonsillectomy and compare the
108
complication rates between both methods.
109
Methods:
110
A retrospective chart review was conducted to review 2508 pediatric patients who
111
underwent tonsillectomy between 2004 and 2014 at two large, tertiary care centers for a
112
variety of indications including sleep disordered breathing/obstructive sleep apnea and
113
chronic tonsillitis. The electronic medical records of these patients were reviewed
114
through December 2018 to provide up to 14 years of long-term follow-up data.
115
Institutional review board (IRB) approval was obtained from both institutions. Patients
6 116
were identified via both manual chart review of all patients undergoing
117
adenotonsillectomy followed by electronic enterprise data warehouse (EDW) search
118
using Current Procedural Terminology (CPT) and International Classification of
119
Diseases, ninth revision, (ICD-9) codes. Patients of two fellowship-trained pediatric
120
otolaryngologists were evaluated (M.E.G. and J.L.C.). Surgeon A performed both
121
intracapsular and extracapsular tonsillectomy, while Surgeon B performed only
122
extracapsular tonsillectomy. Extracapsular tonsillectomy was performed via similar
123
technique by both surgeons. Demographic information was obtained including age of
124
patient, gender, method of tonsillectomy, and length of documented follow-up. The
125
electronic medical record was also reviewed for complications including re-presentation
126
for dehydration, post-tonsillectomy hemorrhage, peritonsillar abscess and tonsillar
127
regrowth requiring revision tonsillectomy. Patients were excluded from short-term
128
complication data (admission for dehydration and hemorrhage) if there was no
129
documented follow-up. Patients were excluded from long-term complications (tonsillar
130
regrowth, peritonsillar abscess or need for revision tonsillectomy) if there was less than
131
two years of documented follow-up identified in the electronic medical records. The
132
following ICD-9 codes were used to identify patients with post-tonsillectomy
133
complications using EDW: 784.8, 998.11, and 998.2 for post-tonsillectomy hemorrhage,
134
276.52 for dehydration, and 475 for peritonsillar abscess. The following CPT codes were
135
used using EDW: 42700 for incision and drainage of peritonsillar abscess, 42825 and
136
42826 for tonsillectomy, and 42820 and 42821 for adenotonsillectomy. Statistical
137
analysis was performed.
7 138
Extracapsular tonsillectomy technique: A blade tip electrocautery is used on
139
setting of 8-12 watts to remove the tonsillar tissue and the suction bovie used on same
140
settings to control bleeding points.
141
Intracapsular Tonsillectomy Surgical Technique: A straight Allis retractor is
142
initially used to grasp the superior pole of the tonsillar tissue and medialize the tonsil.
143
The microdebrider (Medtronic: Minneapolis, Minnesota) at a variable speed (maximum:
144
1500 rpm), oscillating, is used to remove the tonsillar tissue in a medial to lateral fashion,
145
taking care to avoid the vascular pedicle as well as the tonsillar capsule and pillars. Once
146
the majority of the tonsillar tissue is removed, the remaining tissue is released from the
147
Allis retractor, the pillars are manipulated with a Heard retractor, and additional tonsillar
148
tissue removed with the microdebrider leaving a thin rim along with the capsule. The
149
suction bovie at 20 watts is used to cauterize the residual tonsil bed and control bleeding
150
points.
151
Results:
152
A total of 2508 pediatric patients were identified who had undergone
153
tonsillectomy between 2004-2014. 1456 (58.1%) of these patients underwent
154
intracapsular tonsillectomy and 1052 (41.9%) underwent extracapsular tonsillectomy.
155
The average age of the patients was 7.1 years, with an average age of 6.1 years for
156
intracapsular tonsillectomy and 9.7 years for extracapsular tonsillectomy. Using manual
157
chart review, 1107 patients (55.5%) were male, including 845 males (58.0%) in the
158
intracapsular group and 262 males (48.8%) in the extracapsular group (Figure 1). A total
159
of 1009 patients (40.2%) had over 10 years of documented follow-up in our electronic
8 160
medical record. The mean documented follow-up time for our cohort of patients was 8.2
161
years.
162
Short-term outcomes included post-tonsillectomy hemorrhage and dehydration
163
(Figure 2). Thirty-five patients (1.4%) were identified with post-tonsillectomy
164
hemorrhage. Two of these patients (0.08%) had primary hemorrhage (<1 day post-
165
operatively); both patients with primary hemorrhage were in the extracapsular
166
tonsillectomy group. Thirty-three patients (1.3%) experienced secondary hemorrhage (≥ 1
167
day post operatively), with 11 of these patients (0.76%) undergoing intracapsular
168
tonsillectomy and 24 patients (2.3%) undergoing extracapsular tonsillectomy (p=0.0042,
169
Figure 2). This is extrapolated to a relative risk of 0.3362 (95% confidence interval (CI):
170
0.1654-0.6833) of post-tonsillectomy hemorrhage with intracapsular as compared to
171
extracapsular tonsillectomy (p=0.0026). Number needed to treat (NNT) is 67.5 patients.
172
Relative risk of primary post-tonsillectomy hemorrhage is 0.1448 (95% CI: 0.0070-
173
3.0135, p=0.2121) and relative risk of secondary hemorrhage is 0.3661 (95% CI: 0.1783-
174
0.7516, p=0.0062) for intracapsular versus extracapsular tonsillectomy (Figure 3). Our
175
overall incidence of post-tonsillectomy hemorrhage with intracapsular tonsillectomy is
176
0.76% and is 2.3% in the extracapsular group.
177
One patient (0.04%) with primary hemorrhage required return to operating room
178
for control and 12 patients (0.48%) required return to operating room for secondary
179
hemorrhage. Four patients (0.27%) undergoing intracapsular tonsillectomy and 8 patients
180
(0.76%) undergoing extracapsular required return to the operating room (p=.0.0517). One
181
patient (0.01%) with post-tonsillectomy hemorrhage who underwent extracapsular
9 182
tonsillectomy required blood transfusion for hemoglobin of 6.0 g/dL, while no patients
183
undergoing intracapsular tonsillectomy required transfusion.
184
Eleven patients (0.44%) re-presented for dehydration, and of these 4 patients
185
(0.27%) underwent intracapsular and 7 patients (0.67%) underwent extracapsular
186
tonsillectomy. This difference did not reach statistical significance (p=0.0814). Five of
187
these patients (0.20%) required hospital admission for intravenous fluids, 3 (0.21%) in
188
the intracapsular tonsillectomy group and 2 (0.19%) in the extracapsular tonsillectomy
189
group (Figure 2).
190
Long-term outcomes measured included tonsillar regrowth requiring revision
191
tonsillectomy and peritonsillar abscess formation. Three patients (0.21%) in the
192
intracapsular tonsillectomy group had symptomatic tonsillar regrowth prompting revision
193
tonsillectomy, resulting in a relative risk of 3.6086 (95% CI: 0.1734-75.0920, p=0.4073,
194
Figure 4). The timing between initial surgery and revision tonsillectomy of these three
195
patients was 110 months, 36 months, and 38 months (average: 61 months). The first
196
patient had initial tonsillectomy at age 10 and required revision tonsillectomy for chronic
197
tonsillitis at age 19. The second patient underwent adenotonsillectomy at age 3 and
198
required revision adenotonsillectomy at age 5. The last patient had surgery at age 2 and
199
underwent revision adenotonsillectomy and bilateral nasal turbinoplasty at age 5 (Figure
200
5).
201
Three patients (0.12%) developed peritonsillar abscess post-operatively, 2
202
(0.14%) underwent intracapsular tonsillectomy and 1 (0.10%) extracapsular
203
tonsillectomy. This extrapolates to a relative risk of 2.1667 (0.883-53.1371, p=0.474,
204
Figure 4). The timespan from initial surgery to presentation with peritonsillar abscess for
10 205
our three patients was 130 months, 110 months, and 101 months (average: 114 months).
206
The first patient had intracapsular tonsillectomy with adenoidectomy at 22 months of age,
207
and presented with peritonsillar abscess with required needle aspiration at age 12. The
208
second patient had intracapsular tonsillectomy with adenoidectomy at age 8 and had
209
needle aspiration of peritonsillar abscess at age 18. The last patient had extracapsular
210
adenotonsillectomy at age 19 and required incision and drainage of peritonsillar abscess
211
at age 27 (Figure 5).
212
Discussion:
213
Intracapsular tonsillectomy is becoming an increasingly accepted technique for
214
removal of the palatine tonsils. Short-term outcomes have been well described in
215
previous smaller studies, with obvious benefits including improved pain control,
216
decreased rates of dehydration, and lower incidence of post-tonsillectomy
217
hemorrhage4,7,14. There has been a lack of robust, long-term data reviewing the outcomes
218
and complications of this method. The 2019 AAO-HNS Foundation pediatric
219
tonsillectomy clinical practice guidelines held off on providing recommendations
220
regarding intracapsular tonsillectomy due to the lack of this long-term data. Our up to14
221
years of long-term data provides additional evidence showing the limited risk of tonsillar
222
regrowth requiring revision surgery for either upper airway obstructive symptoms or to
223
manage abscess formation following intracapsular tonsillectomy.
224
Post-tonsillectomy hemorrhage is one of the most serious complications following
225
tonsillectomy and can be life-threatening. Our short term results add to the previously
226
published evidence showing a statistically significant decrease in post-tonsillectomy
227
hemorrhage in the intracapsular as compared to the extracapsular tonsillectomy patients
11 228
with a relative risk of 0.3362 (p=0.0026). There is a 0.76% risk of hemorrhage for
229
intracapsular as compared to 2.3% for extracapsular tonsillectomy in our cohort. This is
230
cited at 1-20% in the literature for all tonsillectomies17. Our post-tonsillectomy
231
hemorrhage rate is also lower than other quoted rates of intracapsular tonsillectomy,
232
which are around 1%7. The slightly lower risk in our study may be a statistical variance
233
related to the rarity of the event but may also be related to the technique of eversion of
234
the tonsil tissue using the Allis clamp and avoidance of the vascular pedicle when using
235
the microdebrider. Regardless, the comparison of the intracapsular versus extracapsular
236
tonsillectomy bleeding rate combined with the rarity of regrowth requiring revision
237
surgery strongly supports this method as an important, and perhaps superior, method in
238
an appropriately selected patient.
239
Previous studies have reported a significant reduction in admission for
240
dehydration2,3,14. In our cohort, there were 4 children (0.27%) seen in the emergency
241
room or admitted following intracapsular tonsillectomy and 5 (0.48%) following
242
extracapsular tonsillectomy. The difference between methods was not statistically
243
significant.
244
The average published rate of tonsillar regrowth following intracapsular
245
tonsillectomy is 3.2% and most sources site the regrowth rate after extracapsular
246
tonsillectomy as nearly 0%18,19. Our rate of regrowth requiring revision surgery after
247
intracapsular tonsillectomy is considerably lower at 0.21%. This is likely related to the
248
near complete removal of tonsillar tissue using the Allis Clamp to retract and assist with
249
dissection of the tonsillar tissue. Our findings are in agreement with Chan et al. (2004)
250
and Doshi et al. (2012), but with increased power14,15.
12 251
Our average time between initial tonsillectomy and revision tonsillectomy was 61
252
months. There does not seem to be any correlation between age at initial surgery and time
253
from initial surgery to revision surgery from our small sample of patients. Given that we
254
have up to 14 years of long-term follow-up, we are confident that our data is an accurate
255
depiction of the low risk of regrowth in intracapsular tonsillectomy with our method. The
256
low incidence of revision surgery may be related to the intracapsular technique used in
257
this study under the direction of a single surgeon (M.E.G).
258
There was no significant difference in the rate of peritonsillar abscess formation
259
after surgery in the intracapsular tonsillectomy group as compared to the extracapsular
260
group. Using our method of near complete removal of tonsillar tissue to the level of the
261
capsule, there is minimal tissue remaining. Only three patients (0.12%) developed
262
peritonsillar abscess post-operatively, two in the intracapsular group and one in the
263
extracapsular group. This was not a statistically significant difference (p=0.474). Of the
264
patients who presented with peritonsillar abscess, none had any concerns until 8-10 years
265
post operatively, which may have been missed without the extensive long-term follow-up
266
of our study patients. The two intracapsular patients who developed peritonsillar abscess
267
had their complications at 130 and 110 months post-operatively, and the extracapsular
268
patient presented with peritonsillar abscess at 101 months, thus the intracapsular versus
269
extracapsular methods did not show a substantial difference in the timing of this
270
complication. It is unclear why a patient in the extracapsular group developed
271
peritonsillar abscess. Possible theories include involvement of minor salivary glands
272
contributing to abscess formation and or residual lymphoid tissue20.
13 273
Our review provides up to 14 years of long-term follow-up after tonsillectomy,
274
providing valuable insight to the potential short and long-term risks of the intracapsular
275
versus extracapsular methods. Without this extensive follow-up, many of these long-term
276
complications may have been missed.
277
There are some limitations to our study. The retrospective nature of the chart
278
review (both electronic and manual) showed that we did not have enough consistent
279
documentation of early concerns such as post-operative pain control, time to return to
280
normal activity, or return to normal diet to include in our analysis. Fortunately, our study
281
involved two major healthcare systems in the same region making it likely that any
282
complications and/or revision surgery was captured by our chart review. However, there
283
is still a small chance that long-term data may be underestimated due to patients
284
relocating their care to another medical center outside our region. Additionally, there is a
285
potential for bias given that the inclusion criteria for having significant tonsil regrowth
286
requires that both the surgeon and the patient family agree to proceed with revision
287
surgery.
288
Conclusion:
289
This study provides additional evidence justifying the growing number of
290
surgeons performing intracapsular tonsillectomies. We have again demonstrated that
291
there is a significant reduction in post-tonsillectomy hemorrhage, both primary and
292
secondary. The lack of significance in the episodes of dehydration may be related to the
293
overall low incidence of this complication seen in our population. Most importantly, this
294
study contributes to current literature by documenting the long-term natural history
295
following intracapsular tonsillectomy by showing a low rate of symptomatic regrowth
14 296
requiring revision surgery. We feel that intracapsular tonsillectomy is a useful technique
297
that should be offered to patients and their families as an effective option.
298
We hope that future tonsillectomy clinical practice guidelines will include this
299
method as not only an option, but as a recommendation for the appropriately selected
300
patient.
301
References:
302 303 304 305
1. Mitchell, R. B., Archer, S. M., Ishman, S. L., Rosenfeld, R. M., Coles, S., Finestone, S. A., … Nnacheta, L. C. (2019). Clinical Practice Guideline: Tonsillectomy in Children (Update). Otolaryngol Head Neck Surg, 160(1_suppl), S1– S42. https://doi.org/10.1177/0194599818801757
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2. Younis RT & Lazar RH. History and Current Practice of Tonsillectomy. Laryngoscope. August 2002: 112.
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3. Koltai PJ, Solares CA, Koempel JA, Hirose K, Abelson T, Krakovitz PR, Chan J, Xu M, Mascha EJ. Intracapsular Tonsillar Reduction (Partial Tonsillectomy): Reviving a Historical Procedure for Obstructive Sleep Disordered Breathing in Children. Otolaryngol Head Neck Surg. 2003;129 (5), 532-538.
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4. Solares CA, Koempel JA, Hirose K, Abelson TI, Relily JS, Cook SP, April MM, Ward RF, Bent JP 3rd, Xu M, Koltai PJ. Safety and efficacy of powered intracapsular tonsillectomy in children: a multicenter retrospective case series. Int J Ped Otorhinolaryngol. 2005 Jan:69(1):21-6. Epub 2004 Nov 5.
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5. Derkay CS, Darrow DH, Welch C, Sinacori JT. Post-Tonsillectomy Morbidity and Quality of Life in Pediatric Patient with Obstructive tonsils and Adenoid: Microdebrider vs Electrocautery. Otolaryngol Head Neck Surg. 2006; 134, 114-120.
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6. Wilson YL, Merer DM, Moscatello AL. Comparison of three common tonsillectomy techniques: a prospective randomized, double-blinded clinical study. Laryngoscope. 2009 Jan;119(1):162-70. Dol: 10.1002/lary/20024
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7. Acevedo JL, Ashok K, Shah and Scott E, Brietzke. Systemic Review of Complications of Tonsillotomy vs Tonsillectomy. Otolaryngol Head Neck Surg. 2012 June; 146(6):8719. doi: 10.1177/0194599812439017. Epub 2012 Mar 6.
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8. Windfuhr JP, Werner JA. Tonsillotomy: it’s time to clarify the facts. Eur Arch Otorhinolaryngol. 2013;270 (12), 2985-2996.
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9. Odhagen E, Sunnergren O, Hemlin C, Hessen Soderman AC, Ericsson E, Stalfors J. Risk of reoperation after tonsillotomy versus tonsillectomy: a population-based cohort study. Eur Arch Otorhinolaryngol. 2016 Oct;273(10):3263-8. doi: 10.1007/s00405-0153871-7. Epub 2016 Jan 4.
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10. Mukhatiyar P, Nandalike K, Cohen HW, Sin S, Gangar M, Bent JP, Arens R. Intracapsular and Extracapsular Tonsillectomy and Adenoidectomy in Pediatric Obstructive Sleep Apnea. JAMA Otolaryngol Head Neck Surg. 2016;142(1):25-31. doi: 10.1001/jamaoto.2015.2603.
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11. Reilly BK, Levin J, Sheldon S, Harsanyi K, Gerber ME. Efficacy of Microdebrider Intracapsular Adenotonsillectomy as Validated by Polysomnography. Laryngoscope. 2009; 119:7, 1391-1393, 2009
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12. Friedman M, Wilson MN, Friedman J, et al. Intracapsular coblation tonsillectomy and adenoidectomy for the treatment of pediatric obstructive sleep apnea/hypopnea syndrome. Otolaryngol Head Neck Surg. 2009;140: 358–362.
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13. Eviatar E, Kessler A, Shlamkovitch N, Vaiman M, Zilver D, Gavriel H. Tonsillectomy vs. partial tonsillectomy for OSAS in children—10 years post-surgery follow-up. Int J Ped Otorhinolaryngol. 2009;73:637-640.
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14. Chan KH, Friedman NR, Allen GC, Yaremchuk K, Wirtschafter A, Bikhazi N, Bernstein JM, Kelly PE, Lee KC. Randomized Controlled, Multisite study of Intracapsular Tonsillectomy using low-temperature plasma excision. Arch Otolaryngol Head Neck Surg. 2004;130:1303-1307.
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15. Doshi HK, Rosow DE, Ward RF, April MM. Age-related tonsillar re-growth in Children Undergoing Powered intracapsular tonsillectomy. Int J Ped Otorhinolaryngol. 2011;75 1395-1398.
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16. Parikh, S. R., Archer, S., Ishman, S. L., & Mitchell, R. B. (2019). Why Is There No Statement Regarding Partial Intracapsular Tonsillectomy (Tonsillotomy) in the New Guidelines? Otolaryngol Head Neck Surg. 160(2), 213–214. https://doi.org/10.1177/0194599818810507
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17. Wang H, Fu Y, Feng Y, Guan J, Yin S (2015) Tonsillectomy versus Tonsillotomy for Sleep-Disordered Breathing in Children: A Meta Analysis. PLoS ONE 10(3): e0121500. doi:10.1371/journal.
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18. Windfuhr JP, Savva K, Dahm JD, Werner JA. Tonsillotomy: facts and fiction. Eur Arch Otorhinolaryngol. 2015 Apr; 272(4): 949-969. https://doi.org/10.1007/s00405014-3010-x
366 367 368 369
20. El-Saied, S., Puterman, M., Kaplan, D. M., Cohen-Lahav, M., & Joshua, B.-Z. (2012). Involvement of Minor Salivary Glands in the Pathogenesis of Peritonsillar Abscess. Otol Head Neck Surg, 147(3), 472474. https://doi.org/10.1177/0194599812445552
19. Garetz SL. (2019). Adenotonsillectomy for obstructive sleep apnea in children. A.G. Hoppin (Ed.). UptoDate. Retrieved April 17, 2019 from https://www.uptodate.com/contents/adenotonsillectomy-for-obstructive-sleepapnea-in-children#H2865702283
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1 1 Demographic Information for Pediatric Patients Undergoing Tonsillectomy/Adenotonsillectomy All
Intracapsular
Extracapsular
Number of Patients
2508
1456
1052
Average Age (years)
7.1
6.1
9.7
55.5%
58.0%
48.8%
Percent Male (%)
2 3 4 5 6 7 8 9 10 11 12 13
Figure 1. Demographic information for our patient cohort. A total of 2508 patients were reviewed via manual chart review and again with enterprise data warehouse (EDW) using ICD-9 codes. The average age of patients reviewed was 7.1 years, with the average age of intracapsular being slightly lower than extracapsular. Percentage of male patients was slightly higher in the intracapsular group as compared to the extracapsular group.
2
Incidence of Short-term Outcomes in Intracapsular and Extracapsular Tonsillectomy 0
10
20
30
40
Dehydration
Post-Tonsillectomy Hemorrhage
Intracapsular Extracapsular
Primary Post-Tonsillectomy Hemorrhage Secondary Post-Tonsillectomy Hemorrhage
14 15 16 17 18 19 20 21 22 23 24 25 26 27
Figure 2. A depiction of the rates of post-tonsillectomy hemorrhage and dehydration in intracapsular and extracapsular tonsillectomy. There were 4 patients with dehydration in the intracapsular group and 7 in the extracapsular group, with no statistically significant difference between the groups. A total of 35 of 2508 patients experienced posttonsillectomy hemorrhage, 11 in the intracapsular group and 24 in the extracapsular group. Two patients had primary hemorrhage (<1 day post-operatively), both who had received extracapsular tonsillectomy. Thirty-three patients total had secondary hemorrhage (≥ 1 day post-operatively), 11 in the intracapsular group and 22 in the extracapsular group.
3
Relative Risk of Post-Tonsillectomy Hemorrhage, Intracapsular vs. Extracapsular 3 2.5 2 1.5 1 0.5 0
All Hemorrhage
Primary Hemorrhage
Secondary Hemorrhage
28 29 30 31 32 33 34 35 36 37 38 39
Figure 3. A representation of the relative risk of post-tonsillectomy hemorrhage when comparing intracapsular to extracapsular tonsillectomy. When reviewing all hemorrhages, and then categorizing into primary (<1 day post-operatively) and secondary hemorrhage (≥ 1 day post operatively), all groups show a decrease in the relative risk of intracapsular as compared to extracapsular tonsillectomy. The relative risk of posttonsillectomy hemorrhage in all 2508 patients reviewed is 0.3362 (95% CI: 0.16540.6833). The relative risk of primary hemorrhage is 0.1448 (95% CI: 0.0070-3.0135, p=0.2121) and relative risk of secondary hemorrhage is 0.3661 (95% CI: 0.1783-0.7516, p=0.0062).
4
Relative Risk of Long-term Complications, Intracapsular vs. Extracapsular 5 4.5 4 3.5 3 2.5 2 1.5 1
Revision Tonsillectomy
Peritonsillar Abscess
40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59
Figure 4. A depiction of the relative risk of long-term complications including revision tonsillectomy and peritonsillar abscess in intracapsular versus extracapsular tonsillectomy. Both complications show an increased relative risk in the intracapsular group as compared to the extracapsular group, but with a small absolute number of complications. The relative risk of revision tonsillectomy for intracapsular versus extracapsular tonsillectomy is 3.6086 (95% CI: 0.1734-75.0920, p=0.4073) and the relative risk of formation of peritonsillar abscess in intracapsular versus extracapsular tonsillectomy is 2.1667 (0.883-53.1371, p=0.474). A total of three revision tonsillectomies were performed due to symptomatic tonsillar regrowth, all in the intracapsular group. Three patients developed peritonsillar abscess, two in the intracapsular group and one in the extracapsular group.
5 Age at Initial Surgery (Years)
Age at Complication (Years)
Time Between Initial Surgery and Complication (Months)
Patient 1
10
19
110
Patient 2
3
5
36
Patient 3
2
5
38
REVISION TONSILLECTOMY
Average: 61 months
Age at Initial Surgery (Years)
Age at Complication (Years)
Time Between Initial Surgery and Complication (Months)
Patient 1 (intracapsular)
1
12
130
Patient 2 (intracapsular)
8
18
110
Patient 3 (extracapsular)
19
27
101
PERITONSILLAR ABSCESS
Average: 114 months
60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75
Figure 5. The demographic information of the patients who developed long-term complications including need for revision tonsillectomy and formation of peritonsillar abscess. A total of three patients required revision tonsillectomy (0.12%) and a total of three patients developed peritonsillar abscess (0.12%). The average time between initial surgery and revision tonsillectomy was 61 months and the average time between initial surgery and formation of peritonsillar abscess was 114 months. There is no apparent correlation between age at initial surgery and age at complication for either complication.