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Powered intracapsular tonsillotomy vs. conventional extracapsular tonsillectomy for pediatric OSA: A retrospective study about efficacy, complications and quality of life
G Model
PEDOT-7571; No. of Pages 5 International Journal of Pediatric Otorhinolaryngology xxx (2015) xxx–xxx
Contents lists available at ScienceDirect
International Journal of Pediatric Otorhinolaryngology journal homepage: www.elsevier.com/locate/ijporl
Powered intracapsular tonsillotomy vs. conventional extracapsular tonsillectomy for pediatric OSA: A retrospective study about efficacy, complications and quality of life Claudio Vicini a, Mohamed Eesa b,*, Ehsan Hendawy b, Milena Pari a, Giovanni D’Agostino a, Saleh AlGhamdi c, Giuseppe Meccariello a a
Department of Special Surgery, ENT and Oral Surgery Unit, G.B. Morgagni – L. Pierantoni Hospital, University of Pavia in Forlı`, Italy Department of Otolaryngology, Head-Neck Surgery, University of Zagazig, Zagazig, Egypt c King Fahd Armed Forces Hospital, Jeddah, Saudi Arabia b
A R T I C L E I N F O
A B S T R A C T
Article history: Received 8 February 2015 Received in revised form 26 April 2015 Accepted 27 April 2015 Available online xxx
Objectives: To compare the results of powered intracapsular tonsillectomy and adenoidectomy (PITA) with that of conventional extracapsular tonsillectomy and adenoidectomy (ECTA) in treatment of pediatric obstructive sleep apnea (OSA) as regard efficacy, complications including postoperative pain and bleeding, and quality of life. Methods: Four hundred fifty children with adenotonsillar hyperplasia (with age range from 3 to 14 years) underwent tonsillectomy adenoidectomy (251 PITA and 199 ECTA) from January 2012 till October 2014 for OSA. Outcome measures included Obstructive Sleep Apnea Survey (OSA-18), the number of cases treated for post tonsillectomy bleeding with particular regard to the number of cases that needed readmission, the need for analgesics, the visual analog scale (VAS) for post-operative pain, the perceived satisfaction assessed by post tonsillectomy quality of life questionnaire (QOL). Results: OSA-18 scores proved that both PITA and ECTA were equally effective in curing upper airway obstructive symptoms as reflected by the targeted questionnaire. Postoperative bleeding was significantly lower in the PITA group (P < 0.01). Postoperative pain and number of needed analgesic doses were significantly lower in the PITA group (P = 0.01, P < 0.01, respectively). Satisfaction and quality of life were significantly higher in the PITA group (P < 0.01). Conclusion: PITA is proved to be effective in treating pediatric OSA with less morbidity, less complications in terms of postoperative bleeding mainly with better satisfaction and lower incidence of regrowth. ß 2015 Elsevier Ireland Ltd. All rights reserved.
Keywords: Tonsillotomy Tonsillectomy Microdebrider
1. Introduction Tonsillectomy has been practiced for many years, with varying degree of popularity over the centuries. Tonsillectomy can be performed by dissecting the tonsil from its surrounding capsule, a so-called extra-capsular tonsillectomy. Post-operative problems of this technique including significant pain and frequent bleeding led to a recent interest in what is called sub-total tonsillectomy or ‘intra capsular tonsillectomy’ in order to reduce these complications. Changes in philosophy about the need for complete removal of the tonsils by subtotal removal without violation of the capsule
* Corresponding author. Tel.: +39 3209583691. E-mail address: [email protected] (M. Eesa).
has been introduced over the past decades as a mean of reducing peri-operative morbidity while treating the sleep-related airway obstruction caused by tonsillar mass effect [1]. Many techniques were used for intracapsular tonsillectomy; however, the use of the powered microdebrider to remove the bulk of the tonsils was first reported by Koltai et al. [2]. In this procedure, the microdebrider shaves away most of the tonsil, leaving a thin rim of lymphoid tissue overlying the capsule. This ‘‘biological dressing’’ protects the pharyngeal muscles. Blood vessels are thought to be cut distal to arborization; thus, the exposed stumps are from smaller-caliber vessels producing a minimal volume bleeding [2]. On the other hand the obstructing effect of the residual tissue is negligible, even in case of possible partial regrowth. In this study, we tried to represent our experience about the use of microdebrider in intracapsular tonsillectomy in a large series of
http://dx.doi.org/10.1016/j.ijporl.2015.04.041 0165-5876/ß 2015 Elsevier Ireland Ltd. All rights reserved.
Please cite this article in press as: C. Vicini, et al., Powered intracapsular tonsillotomy vs. conventional extracapsular tonsillectomy for pediatric OSA: A retrospective study about efficacy, complications and quality of life, Int. J. Pediatr. Otorhinolaryngol. (2015), http:// dx.doi.org/10.1016/j.ijporl.2015.04.041
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PEDOT-7571; No. of Pages 5 C. Vicini et al. / International Journal of Pediatric Otorhinolaryngology xxx (2015) xxx–xxx
2
patients through the last 3 years. We believed that targeted intracapsular resection strategy is all what we need for managing benign tonsillar hypertrophy obstruction rather than radical extracapsular strategy (similar to the oncological strategy) needed only for recurrent tonsillitis cases. We aim that our results provide additional data to those previously published in the literature about powered intracapsular tonsillectomy and adenoidectomy (PITA) as a really effective, safe and painless surgery for obstructive sleep apnea (OSA) in children.
using diathermy supplied in the same hand piece. All the steps were carried out under loupe magnification 2.5. In the other group of ECTA, dissection was done by cold instruments under loupe magnification 2.5, then hemostasis was done at the end of the procedure by bipolar forceps for cauterization of the few small points of bleeding, selective bipolar coagulation was devised in order to minimize the thermal injury in the surrounding muscles and mucosa. 2.3. Outcome assessment
2. Patients and methods Outcome measures included: 2.1. Patients A retrospective study was conducted after its approval by the Institutional Review Board at G.B. Morgagni L. Pierantoni hospital, Forli. Between January 2012 and October 2014, 450 children with age range from 3 to 14 years underwent adenotonsillectomy for OSA related to adenotonsillar hypertrophy (251 in the PITA and 199 in the extracapsular tonsillectomy and adenoidectomy (ECTA) group). The choice of intracapsular vs. extracapsular was influenced by the number of episodes of acute tonsillitis. Irrespective to the obstruction degree, children with a clear cut history of recurrent tonsillitis i.e. 7 episodes/year over 1 year; 5 episodes/year for 2 years or 3 episodes/year over 3 years underwent extracapsular tonsillectomy [3], while those with mainly respiratory obstruction during sleep and no clear cut history of recurrent tonsillitis underwent intracapsular tonsillectomy. Children with tonsillar grade 1 or 2 and those with craniofacial syndromes or neurological deficits were excluded from the study. All children underwent preoperative pulseoximetry for diagnosis of OSA. Brouillette et al. [4] criteria were used for diagnosis in which (1) a desaturation was defined as a decrease in Sao2 of 4% or more; (2) a cluster of desaturations was defined as five or more desaturations occurring in a 10- to 30-min period; (3) on the oximetry trend graphs, periods of relative tachycardia, usually 10–25 beats per minute, at the beginning and end of nocturnal pulse oximetry, and periods of relative tachycardia and increased heart rate variability exceeding 30 min were regarded as wakeful time and not considered; (4) a positive oximetry trend graph had three or more desaturation clusters and at least three desaturations to 90%. We offered pulse oximetry (MirOxi, MIR-Medical International Research USA, Inc.) for the parents to perform it at home for three consecutive nights and then we calculated the average number for more accuracy. 2.2. Surgical technique All children underwent adenotonsillar surgery under general anesthesia. Boyle-Davis mouth gag and cheek retractors were used to provide good exposure. PITA was performed in patients using an Olympus microdebrider (Gyrus ACMI, Inc., USA) with an angled 4-mm-diameter blade provided with mono or bipolar cautery. The device was adjusted on the variable oscillating mode with a speed between 1000 and 3000 rpm for intracapsular tonsil removal, with different velocity according to the different surgical steps (slow velocity/more aggressive inside the tonsil vs. high velocity/less aggressive close to the capsule). Careful attention was paid to avoid trauma to the uvula (palate and uvula retraction by rubber tubes), tonsillar pillars (protected by Hurd-dissector and pillar-retractor) and tonsillar capsule (keeping the cutting window at 908 preventing any capsule suction inside the debrider). Dissection was performed till the internal capsule plane and then hemostasis was achieved only at the end of the procedure by a piece of gauze soaked with 10% hydrogen peroxide and bipolar diathermy or by
(1) Measure for efficacy by using survey of pediatric obstructive sleep apnea with OSA-18 [5] presented to the parents before and 1 month after surgery (the maximum score equals 126 and the higher the score the higher the probability for OSA and the low score means relief of symptoms). (2) Number of cases presented with post tonsillectomy bleeding. (3) How many of these cases needed readmission for observation and/or re-intervention. (4) Post-operative pain represented by the need for analgesics and also by visual analog scale (VAS) presented to the parents to fill in the first 3 days after surgery then the average was calculated. (5) Detection of tonsillar regrowth by regular follow up done at 6th month and 1 year interval postoperative. (6) Finally, Satisfaction by post tonsillectomy quality of life questionnaire (QOL) [6], as a measure of discomfort in posttonsillectomy children based on non-verbal behavior, even in very young children (the maximum score for that questionnaire equals 39, and the lowest score equals 9 which means the maximum pain and the worst quality of life).
3. Results The total number of patients included in the study is 450 with tonsillar size ranging from 3 to 4, no size 1 or 2 was included. Demographic characteristics of patients (age, sex) according to surgical technique are shown in Table 1 and showed that both groups of children were not statistically different for age and gender distribution. The severity of OSA was expressed by the impact of OSA on quality of life as shown by the results of preoperative questionnaire and it was as follow; in PITA group 44% had moderate impact, 23% had severe impact and 33% had mild impact on quality of life, in ECTA group 53% had mild impact, 30% had moderate impact and 15% had severe impact on quality of life. Efficacy on reduction of upper airway obstructive symptoms were determined by using survey of pediatric obstructive sleep apnea with OSA-18 presented to the parents before and one month after surgery, In both groups of children underwent PITA and ECTA, there was significant reduction of symptoms when comparing pre and post OSA-18 scores (P < 0.01, P < 0.01 respectively; Fig. 1). For post-operative bleeding as one of the main concerns after tonsillectomy, there was significantly lower number of cases presented by hemorrhage after tonsillectomy either mild or severe in the group of PITA (three cases over 3 years in PITA group vs. 31
Table 1 Demographic characteristics of patients (age, sex) according to surgical technique.
Mean age standard deviation (min–max) Sex (% of males)
PITA
ECTA
P-value
5.3 2.1 (2–12)
5.5 1.5 (4–9)
0.3
53%
46%
1.0
Please cite this article in press as: C. Vicini, et al., Powered intracapsular tonsillotomy vs. conventional extracapsular tonsillectomy for pediatric OSA: A retrospective study about efficacy, complications and quality of life, Int. J. Pediatr. Otorhinolaryngol. (2015), http:// dx.doi.org/10.1016/j.ijporl.2015.04.041
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Fig. 1. Pre-operative and post-operative OSA-18 scores in PITA and ECTA.
cases over 3 years in ECTA group, P < 0.01). Moreover, only one case of the PITA bleeding group needed readmission compared to 29 cases of the ECTA bleeding group. Table 2 showed the details over the 3 studied years. In our study, it was not possible to evaluate post-operative pain in all subjects, instead, we could do that for a sample group of subjects in which the data about analgesic doses and VAS questionnaire were fully available (59 PITA and 13 ECTA). Two main parameters were used for pain evaluation:
scores in the PITA group (25.4 in PITA group vs. 20.45 in ECTA group, P < 0.01) which means better quality of life and also, less perception of discomfort in this group (Fig. 3). As regard the tonsillar regrowth rate, the results of regular postoperative follow up at 6th month and 1 year interval has shown 50% persistence of small remnant of lymphoid tissue without any clinical impact, and up till now no one case of our PITA group needed revision tonsillectomy for obstructive manifestations.
- First, by using VAS presented to the parents to fill in during the first three days post operatively then the average number was calculated, and the results showed significantly lower score in the group of PITA when compared with the group of ECTA (4.1 in PITA group vs. 6.3 in ECTA group, P = 0.01; Fig. 2). - Second, by calculating the average number of analgesic doses needed in both groups during the first post-operative week, it was observed that this number was significantly lower in the group of PITA (3.5 doses in PITA group vs. 15.7 doses in ECTA group, P < 0.01).
4. Discussion
Satisfaction after tonsillectomy by QOL questionnaire presented to the parents before discharge showed significantly better
Table 2 Post-tonsillectomy bleeding cases in 3 years 2012, 2013, 2014.
No. of cases No. of post-tonsillectomy bleeding No. of cases needed readmission
Total
ECTA
PITA
450 34 (7.5%) 30 (6.6%)
199 (44%) 31 (6.8%) 29 (6.4%)
251 (56%) 3 (0.7%) 1 (0.2%)
Adenotonsillectomy is the first choice for otherwise healthy children diagnosed with adenotonsillar hypertrophy related OSAS. Such surgery can be expected to relieve sleep-related airway obstruction in the great majority of children, and it remains the mainstay of treatment for childhood OSAS [7]. Different resection tools with different technologies were used ranging from cold to hot instruments but the never ending dilemma from the past remains how to combine the need for a really effective procedure and the need for a safe and painless surgery and that was the reason for changing the philosophy with the introduction of the term of intracapsular tonsillectomy. The introduction of powered microdebrider to remove the bulk of the tonsils (PITA) was first reported by Koltai et al. [2] with its efficacy in relieving OSA symptoms already well established in Ref. [8]. Our results show that irrespective of the technique of tonsillectomy either intracapsular or extracapsular, there is evident and significant reduction of upper airway obstructive symptoms as reflected by OSA-18 [5]. However, it was more crucial for us when we studied carefully the impact of surgical
Please cite this article in press as: C. Vicini, et al., Powered intracapsular tonsillotomy vs. conventional extracapsular tonsillectomy for pediatric OSA: A retrospective study about efficacy, complications and quality of life, Int. J. Pediatr. Otorhinolaryngol. (2015), http:// dx.doi.org/10.1016/j.ijporl.2015.04.041
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Fig. 2. VAS for pain after PITA and ECTA.
Fig. 3. Satisfaction by post-tonsillectomy quality of life questionnaire after PITA and ECTA.
Please cite this article in press as: C. Vicini, et al., Powered intracapsular tonsillotomy vs. conventional extracapsular tonsillectomy for pediatric OSA: A retrospective study about efficacy, complications and quality of life, Int. J. Pediatr. Otorhinolaryngol. (2015), http:// dx.doi.org/10.1016/j.ijporl.2015.04.041
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intervention on different aspects including pain, bleeding and quality of life, as we could demonstrate that intracapsular technique had the upper hand regarding all these different parameters. We could notice that there is a gradual reduction in the incidence of post tonsillectomy bleeding over the last three years (only 5 cases in 2014 compared to 20 cases in 2012), and that was in conjunction with the introduction and the use of microdebrider in our hospital for performing intracapsular tonsillectomy rather than conventional extracapsular tonsillectomy. Although pain parameters were studied in a smaller group of children but it showed also significant difference in the favor of PITA group with less VAS and less need for analgesics (P = 0.01, P < 0.01, respectively) which had a clear impact on earlier return to normal diet. The overall satisfaction and quality of life of children as determined by post tonsillectomy QOL questionnaire proved that children underwent PITA had better perception of discomfort and better quality of life after surgery (P < 0.01). We usually use the term intracapsular ‘‘tonsillectomy’’ rather than ‘‘tonsillotomy’’ because we believe that by using microdebrider, we were able to remove most of tonsillar lymphatic tissue leaving only a really thin rim of lymphoid tissue over the capsule which was difficult to achieve by using different tools other than microdebrider. It seems to prevent massive and significant regrowth of lymphoid tissue in the future, as we could assess in the short term follow up of our patients. 5. Limitation of the study Our study is just a retrospective one in a couple group of patients who underwent two different kinds of tonsillectomy techniques for obstructive or infectious problems. It is worth to be mentioned that this preliminary report pay a basic bias in terms of patient selections. So far, we did not include in PITA group patients
5
suffering from significant recurrence of tonsillitis; this group of patients is basically treated by ECTA this means that we cannot exclude that some post-operative bleeding in ECTA group may be induced by higher degree of inflammation of tonsillar parenchyma. In the future in a subsequent study we will randomize in a prospective way for any kind of tonsillar pathology.
6. Conclusion PITA is proved to be effective in treating pediatric OSA with less morbidity, less complications in terms of postoperative bleeding mainly with better satisfaction and lower incidence of regrowth until 1 year follow up. Further studies in a larger group of patients for longer time are mandatory and under evaluation in our Institution.
References [1] D.E. Tunkel, K.S. Hotchkiss, K.A. Carson, L.M. Sterni, Efficacy of powered intracapsular tonsillectomy and adenoidectomy, Laryngoscope 118 (7) (2008) 1295–1302. [2] P.J. Koltai, C.A. Solares, E.J. Mascha, M. Xu, Intracapsular partial tonsillectomy for tonsillar hypertrophy in children, Laryngoscope 1112 (2002) 17–19. [3] M.A. Bitar, C. Rameh, Microdebrider-assisted partial tonsillectomy: short- and long-term outcomes, Eur. Arch. Otorhinolaryngol. 265 (2008) 459–463. [4] R.T. Brouillette, A. Morielli, A. Leimanis, A.K. Waters, R. Luciano, F.M. Ducharme, Nocturnal pulse oximetry as an abbreviated testing modality for pediatric obstructive sleep apnea, Pediatrics 105 (2000) 405–411. [5] R.A. Franco Jr., R.M. Rosenfeld, M. Rao, Quality of life for children with obstructive sleep apnea, Otolaryngol. Head Neck Surg. 123 (2000) 9–16. [6] H.M. Myatt, R.A. Myatt, The development of a paediatric quality of life questionnaire to measure post-operative pain following tonsillectomy, Int. J. Pediatr. Otorhinolaryngol. 44 (1998) 115–123. [7] J. Suen, J. Arnold, L. Brooks, Adenotonsillectomy for treatment of obstructive sleep apnea in children, Arch. Otolaryngol. Head Neck Surg. 121 (1995) 525–530. [8] P.J. Koltai, C.A. Solares, J.A. Koempel, K. Hirose, T.I. Abelson, P.R. Krakovitz, et al., Intracapsular tonsillar reduction (partial tonsillectomy): reviving a historical procedure for obstructive sleep disordered breathing in children, Otolaryngol. Head Neck Surg. 129 (5) (2003) 532–538.
Please cite this article in press as: C. Vicini, et al., Powered intracapsular tonsillotomy vs. conventional extracapsular tonsillectomy for pediatric OSA: A retrospective study about efficacy, complications and quality of life, Int. J. Pediatr. Otorhinolaryngol. (2015), http:// dx.doi.org/10.1016/j.ijporl.2015.04.041
PEDOT-7571; No. of Pages 5 International Journal of Pediatric Otorhinolaryngology xxx (2015) xxx–xxx
Contents lists available at ScienceDirect
International Journal of Pediatric Otorhinolaryngology journal homepage: www.elsevier.com/locate/ijporl
Powered intracapsular tonsillotomy vs. conventional extracapsular tonsillectomy for pediatric OSA: A retrospective study about efficacy, complications and quality of life Claudio Vicini a, Mohamed Eesa b,*, Ehsan Hendawy b, Milena Pari a, Giovanni D’Agostino a, Saleh AlGhamdi c, Giuseppe Meccariello a a
Department of Special Surgery, ENT and Oral Surgery Unit, G.B. Morgagni – L. Pierantoni Hospital, University of Pavia in Forlı`, Italy Department of Otolaryngology, Head-Neck Surgery, University of Zagazig, Zagazig, Egypt c King Fahd Armed Forces Hospital, Jeddah, Saudi Arabia b
A R T I C L E I N F O
A B S T R A C T
Article history: Received 8 February 2015 Received in revised form 26 April 2015 Accepted 27 April 2015 Available online xxx
Objectives: To compare the results of powered intracapsular tonsillectomy and adenoidectomy (PITA) with that of conventional extracapsular tonsillectomy and adenoidectomy (ECTA) in treatment of pediatric obstructive sleep apnea (OSA) as regard efficacy, complications including postoperative pain and bleeding, and quality of life. Methods: Four hundred fifty children with adenotonsillar hyperplasia (with age range from 3 to 14 years) underwent tonsillectomy adenoidectomy (251 PITA and 199 ECTA) from January 2012 till October 2014 for OSA. Outcome measures included Obstructive Sleep Apnea Survey (OSA-18), the number of cases treated for post tonsillectomy bleeding with particular regard to the number of cases that needed readmission, the need for analgesics, the visual analog scale (VAS) for post-operative pain, the perceived satisfaction assessed by post tonsillectomy quality of life questionnaire (QOL). Results: OSA-18 scores proved that both PITA and ECTA were equally effective in curing upper airway obstructive symptoms as reflected by the targeted questionnaire. Postoperative bleeding was significantly lower in the PITA group (P < 0.01). Postoperative pain and number of needed analgesic doses were significantly lower in the PITA group (P = 0.01, P < 0.01, respectively). Satisfaction and quality of life were significantly higher in the PITA group (P < 0.01). Conclusion: PITA is proved to be effective in treating pediatric OSA with less morbidity, less complications in terms of postoperative bleeding mainly with better satisfaction and lower incidence of regrowth. ß 2015 Elsevier Ireland Ltd. All rights reserved.
Keywords: Tonsillotomy Tonsillectomy Microdebrider
1. Introduction Tonsillectomy has been practiced for many years, with varying degree of popularity over the centuries. Tonsillectomy can be performed by dissecting the tonsil from its surrounding capsule, a so-called extra-capsular tonsillectomy. Post-operative problems of this technique including significant pain and frequent bleeding led to a recent interest in what is called sub-total tonsillectomy or ‘intra capsular tonsillectomy’ in order to reduce these complications. Changes in philosophy about the need for complete removal of the tonsils by subtotal removal without violation of the capsule
* Corresponding author. Tel.: +39 3209583691. E-mail address: [email protected] (M. Eesa).
has been introduced over the past decades as a mean of reducing peri-operative morbidity while treating the sleep-related airway obstruction caused by tonsillar mass effect [1]. Many techniques were used for intracapsular tonsillectomy; however, the use of the powered microdebrider to remove the bulk of the tonsils was first reported by Koltai et al. [2]. In this procedure, the microdebrider shaves away most of the tonsil, leaving a thin rim of lymphoid tissue overlying the capsule. This ‘‘biological dressing’’ protects the pharyngeal muscles. Blood vessels are thought to be cut distal to arborization; thus, the exposed stumps are from smaller-caliber vessels producing a minimal volume bleeding [2]. On the other hand the obstructing effect of the residual tissue is negligible, even in case of possible partial regrowth. In this study, we tried to represent our experience about the use of microdebrider in intracapsular tonsillectomy in a large series of
http://dx.doi.org/10.1016/j.ijporl.2015.04.041 0165-5876/ß 2015 Elsevier Ireland Ltd. All rights reserved.
Please cite this article in press as: C. Vicini, et al., Powered intracapsular tonsillotomy vs. conventional extracapsular tonsillectomy for pediatric OSA: A retrospective study about efficacy, complications and quality of life, Int. J. Pediatr. Otorhinolaryngol. (2015), http:// dx.doi.org/10.1016/j.ijporl.2015.04.041
G Model
PEDOT-7571; No. of Pages 5 C. Vicini et al. / International Journal of Pediatric Otorhinolaryngology xxx (2015) xxx–xxx
2
patients through the last 3 years. We believed that targeted intracapsular resection strategy is all what we need for managing benign tonsillar hypertrophy obstruction rather than radical extracapsular strategy (similar to the oncological strategy) needed only for recurrent tonsillitis cases. We aim that our results provide additional data to those previously published in the literature about powered intracapsular tonsillectomy and adenoidectomy (PITA) as a really effective, safe and painless surgery for obstructive sleep apnea (OSA) in children.
using diathermy supplied in the same hand piece. All the steps were carried out under loupe magnification 2.5. In the other group of ECTA, dissection was done by cold instruments under loupe magnification 2.5, then hemostasis was done at the end of the procedure by bipolar forceps for cauterization of the few small points of bleeding, selective bipolar coagulation was devised in order to minimize the thermal injury in the surrounding muscles and mucosa. 2.3. Outcome assessment
2. Patients and methods Outcome measures included: 2.1. Patients A retrospective study was conducted after its approval by the Institutional Review Board at G.B. Morgagni L. Pierantoni hospital, Forli. Between January 2012 and October 2014, 450 children with age range from 3 to 14 years underwent adenotonsillectomy for OSA related to adenotonsillar hypertrophy (251 in the PITA and 199 in the extracapsular tonsillectomy and adenoidectomy (ECTA) group). The choice of intracapsular vs. extracapsular was influenced by the number of episodes of acute tonsillitis. Irrespective to the obstruction degree, children with a clear cut history of recurrent tonsillitis i.e. 7 episodes/year over 1 year; 5 episodes/year for 2 years or 3 episodes/year over 3 years underwent extracapsular tonsillectomy [3], while those with mainly respiratory obstruction during sleep and no clear cut history of recurrent tonsillitis underwent intracapsular tonsillectomy. Children with tonsillar grade 1 or 2 and those with craniofacial syndromes or neurological deficits were excluded from the study. All children underwent preoperative pulseoximetry for diagnosis of OSA. Brouillette et al. [4] criteria were used for diagnosis in which (1) a desaturation was defined as a decrease in Sao2 of 4% or more; (2) a cluster of desaturations was defined as five or more desaturations occurring in a 10- to 30-min period; (3) on the oximetry trend graphs, periods of relative tachycardia, usually 10–25 beats per minute, at the beginning and end of nocturnal pulse oximetry, and periods of relative tachycardia and increased heart rate variability exceeding 30 min were regarded as wakeful time and not considered; (4) a positive oximetry trend graph had three or more desaturation clusters and at least three desaturations to 90%. We offered pulse oximetry (MirOxi, MIR-Medical International Research USA, Inc.) for the parents to perform it at home for three consecutive nights and then we calculated the average number for more accuracy. 2.2. Surgical technique All children underwent adenotonsillar surgery under general anesthesia. Boyle-Davis mouth gag and cheek retractors were used to provide good exposure. PITA was performed in patients using an Olympus microdebrider (Gyrus ACMI, Inc., USA) with an angled 4-mm-diameter blade provided with mono or bipolar cautery. The device was adjusted on the variable oscillating mode with a speed between 1000 and 3000 rpm for intracapsular tonsil removal, with different velocity according to the different surgical steps (slow velocity/more aggressive inside the tonsil vs. high velocity/less aggressive close to the capsule). Careful attention was paid to avoid trauma to the uvula (palate and uvula retraction by rubber tubes), tonsillar pillars (protected by Hurd-dissector and pillar-retractor) and tonsillar capsule (keeping the cutting window at 908 preventing any capsule suction inside the debrider). Dissection was performed till the internal capsule plane and then hemostasis was achieved only at the end of the procedure by a piece of gauze soaked with 10% hydrogen peroxide and bipolar diathermy or by
(1) Measure for efficacy by using survey of pediatric obstructive sleep apnea with OSA-18 [5] presented to the parents before and 1 month after surgery (the maximum score equals 126 and the higher the score the higher the probability for OSA and the low score means relief of symptoms). (2) Number of cases presented with post tonsillectomy bleeding. (3) How many of these cases needed readmission for observation and/or re-intervention. (4) Post-operative pain represented by the need for analgesics and also by visual analog scale (VAS) presented to the parents to fill in the first 3 days after surgery then the average was calculated. (5) Detection of tonsillar regrowth by regular follow up done at 6th month and 1 year interval postoperative. (6) Finally, Satisfaction by post tonsillectomy quality of life questionnaire (QOL) [6], as a measure of discomfort in posttonsillectomy children based on non-verbal behavior, even in very young children (the maximum score for that questionnaire equals 39, and the lowest score equals 9 which means the maximum pain and the worst quality of life).
3. Results The total number of patients included in the study is 450 with tonsillar size ranging from 3 to 4, no size 1 or 2 was included. Demographic characteristics of patients (age, sex) according to surgical technique are shown in Table 1 and showed that both groups of children were not statistically different for age and gender distribution. The severity of OSA was expressed by the impact of OSA on quality of life as shown by the results of preoperative questionnaire and it was as follow; in PITA group 44% had moderate impact, 23% had severe impact and 33% had mild impact on quality of life, in ECTA group 53% had mild impact, 30% had moderate impact and 15% had severe impact on quality of life. Efficacy on reduction of upper airway obstructive symptoms were determined by using survey of pediatric obstructive sleep apnea with OSA-18 presented to the parents before and one month after surgery, In both groups of children underwent PITA and ECTA, there was significant reduction of symptoms when comparing pre and post OSA-18 scores (P < 0.01, P < 0.01 respectively; Fig. 1). For post-operative bleeding as one of the main concerns after tonsillectomy, there was significantly lower number of cases presented by hemorrhage after tonsillectomy either mild or severe in the group of PITA (three cases over 3 years in PITA group vs. 31
Table 1 Demographic characteristics of patients (age, sex) according to surgical technique.
Mean age standard deviation (min–max) Sex (% of males)
PITA
ECTA
P-value
5.3 2.1 (2–12)
5.5 1.5 (4–9)
0.3
53%
46%
1.0
Please cite this article in press as: C. Vicini, et al., Powered intracapsular tonsillotomy vs. conventional extracapsular tonsillectomy for pediatric OSA: A retrospective study about efficacy, complications and quality of life, Int. J. Pediatr. Otorhinolaryngol. (2015), http:// dx.doi.org/10.1016/j.ijporl.2015.04.041
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Fig. 1. Pre-operative and post-operative OSA-18 scores in PITA and ECTA.
cases over 3 years in ECTA group, P < 0.01). Moreover, only one case of the PITA bleeding group needed readmission compared to 29 cases of the ECTA bleeding group. Table 2 showed the details over the 3 studied years. In our study, it was not possible to evaluate post-operative pain in all subjects, instead, we could do that for a sample group of subjects in which the data about analgesic doses and VAS questionnaire were fully available (59 PITA and 13 ECTA). Two main parameters were used for pain evaluation:
scores in the PITA group (25.4 in PITA group vs. 20.45 in ECTA group, P < 0.01) which means better quality of life and also, less perception of discomfort in this group (Fig. 3). As regard the tonsillar regrowth rate, the results of regular postoperative follow up at 6th month and 1 year interval has shown 50% persistence of small remnant of lymphoid tissue without any clinical impact, and up till now no one case of our PITA group needed revision tonsillectomy for obstructive manifestations.
- First, by using VAS presented to the parents to fill in during the first three days post operatively then the average number was calculated, and the results showed significantly lower score in the group of PITA when compared with the group of ECTA (4.1 in PITA group vs. 6.3 in ECTA group, P = 0.01; Fig. 2). - Second, by calculating the average number of analgesic doses needed in both groups during the first post-operative week, it was observed that this number was significantly lower in the group of PITA (3.5 doses in PITA group vs. 15.7 doses in ECTA group, P < 0.01).
4. Discussion
Satisfaction after tonsillectomy by QOL questionnaire presented to the parents before discharge showed significantly better
Table 2 Post-tonsillectomy bleeding cases in 3 years 2012, 2013, 2014.
No. of cases No. of post-tonsillectomy bleeding No. of cases needed readmission
Total
ECTA
PITA
450 34 (7.5%) 30 (6.6%)
199 (44%) 31 (6.8%) 29 (6.4%)
251 (56%) 3 (0.7%) 1 (0.2%)
Adenotonsillectomy is the first choice for otherwise healthy children diagnosed with adenotonsillar hypertrophy related OSAS. Such surgery can be expected to relieve sleep-related airway obstruction in the great majority of children, and it remains the mainstay of treatment for childhood OSAS [7]. Different resection tools with different technologies were used ranging from cold to hot instruments but the never ending dilemma from the past remains how to combine the need for a really effective procedure and the need for a safe and painless surgery and that was the reason for changing the philosophy with the introduction of the term of intracapsular tonsillectomy. The introduction of powered microdebrider to remove the bulk of the tonsils (PITA) was first reported by Koltai et al. [2] with its efficacy in relieving OSA symptoms already well established in Ref. [8]. Our results show that irrespective of the technique of tonsillectomy either intracapsular or extracapsular, there is evident and significant reduction of upper airway obstructive symptoms as reflected by OSA-18 [5]. However, it was more crucial for us when we studied carefully the impact of surgical
Please cite this article in press as: C. Vicini, et al., Powered intracapsular tonsillotomy vs. conventional extracapsular tonsillectomy for pediatric OSA: A retrospective study about efficacy, complications and quality of life, Int. J. Pediatr. Otorhinolaryngol. (2015), http:// dx.doi.org/10.1016/j.ijporl.2015.04.041
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Fig. 2. VAS for pain after PITA and ECTA.
Fig. 3. Satisfaction by post-tonsillectomy quality of life questionnaire after PITA and ECTA.
Please cite this article in press as: C. Vicini, et al., Powered intracapsular tonsillotomy vs. conventional extracapsular tonsillectomy for pediatric OSA: A retrospective study about efficacy, complications and quality of life, Int. J. Pediatr. Otorhinolaryngol. (2015), http:// dx.doi.org/10.1016/j.ijporl.2015.04.041
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PEDOT-7571; No. of Pages 5 C. Vicini et al. / International Journal of Pediatric Otorhinolaryngology xxx (2015) xxx–xxx
intervention on different aspects including pain, bleeding and quality of life, as we could demonstrate that intracapsular technique had the upper hand regarding all these different parameters. We could notice that there is a gradual reduction in the incidence of post tonsillectomy bleeding over the last three years (only 5 cases in 2014 compared to 20 cases in 2012), and that was in conjunction with the introduction and the use of microdebrider in our hospital for performing intracapsular tonsillectomy rather than conventional extracapsular tonsillectomy. Although pain parameters were studied in a smaller group of children but it showed also significant difference in the favor of PITA group with less VAS and less need for analgesics (P = 0.01, P < 0.01, respectively) which had a clear impact on earlier return to normal diet. The overall satisfaction and quality of life of children as determined by post tonsillectomy QOL questionnaire proved that children underwent PITA had better perception of discomfort and better quality of life after surgery (P < 0.01). We usually use the term intracapsular ‘‘tonsillectomy’’ rather than ‘‘tonsillotomy’’ because we believe that by using microdebrider, we were able to remove most of tonsillar lymphatic tissue leaving only a really thin rim of lymphoid tissue over the capsule which was difficult to achieve by using different tools other than microdebrider. It seems to prevent massive and significant regrowth of lymphoid tissue in the future, as we could assess in the short term follow up of our patients. 5. Limitation of the study Our study is just a retrospective one in a couple group of patients who underwent two different kinds of tonsillectomy techniques for obstructive or infectious problems. It is worth to be mentioned that this preliminary report pay a basic bias in terms of patient selections. So far, we did not include in PITA group patients
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suffering from significant recurrence of tonsillitis; this group of patients is basically treated by ECTA this means that we cannot exclude that some post-operative bleeding in ECTA group may be induced by higher degree of inflammation of tonsillar parenchyma. In the future in a subsequent study we will randomize in a prospective way for any kind of tonsillar pathology.
6. Conclusion PITA is proved to be effective in treating pediatric OSA with less morbidity, less complications in terms of postoperative bleeding mainly with better satisfaction and lower incidence of regrowth until 1 year follow up. Further studies in a larger group of patients for longer time are mandatory and under evaluation in our Institution.
References [1] D.E. Tunkel, K.S. Hotchkiss, K.A. Carson, L.M. Sterni, Efficacy of powered intracapsular tonsillectomy and adenoidectomy, Laryngoscope 118 (7) (2008) 1295–1302. [2] P.J. Koltai, C.A. Solares, E.J. Mascha, M. Xu, Intracapsular partial tonsillectomy for tonsillar hypertrophy in children, Laryngoscope 1112 (2002) 17–19. [3] M.A. Bitar, C. Rameh, Microdebrider-assisted partial tonsillectomy: short- and long-term outcomes, Eur. Arch. Otorhinolaryngol. 265 (2008) 459–463. [4] R.T. Brouillette, A. Morielli, A. Leimanis, A.K. Waters, R. Luciano, F.M. Ducharme, Nocturnal pulse oximetry as an abbreviated testing modality for pediatric obstructive sleep apnea, Pediatrics 105 (2000) 405–411. [5] R.A. Franco Jr., R.M. Rosenfeld, M. Rao, Quality of life for children with obstructive sleep apnea, Otolaryngol. Head Neck Surg. 123 (2000) 9–16. [6] H.M. Myatt, R.A. Myatt, The development of a paediatric quality of life questionnaire to measure post-operative pain following tonsillectomy, Int. J. Pediatr. Otorhinolaryngol. 44 (1998) 115–123. [7] J. Suen, J. Arnold, L. Brooks, Adenotonsillectomy for treatment of obstructive sleep apnea in children, Arch. Otolaryngol. Head Neck Surg. 121 (1995) 525–530. [8] P.J. Koltai, C.A. Solares, J.A. Koempel, K. Hirose, T.I. Abelson, P.R. Krakovitz, et al., Intracapsular tonsillar reduction (partial tonsillectomy): reviving a historical procedure for obstructive sleep disordered breathing in children, Otolaryngol. Head Neck Surg. 129 (5) (2003) 532–538.
Please cite this article in press as: C. Vicini, et al., Powered intracapsular tonsillotomy vs. conventional extracapsular tonsillectomy for pediatric OSA: A retrospective study about efficacy, complications and quality of life, Int. J. Pediatr. Otorhinolaryngol. (2015), http:// dx.doi.org/10.1016/j.ijporl.2015.04.041