Review Article
Tonsillectomy or tonsillotomy? A systematic review for paediatric sleep-disordered breathing

https://doi.org/10.1016/j.ijporl.2017.10.008Get rights and content

Abstract

Background

Recent evidence has challenged the practice of tonsillectomy in children with sleep-disordered breathing. Tonsillotomy (subtotal/partial/intracapsular tonsillectomy) has been proposed as an alternative with equivalent effectiveness and decreased post-operative morbidity, thus improving cost-effectiveness.

Objective

To systematically review the literature comparing clinical efficacy, post-operative morbidity, and cost-effectiveness of tonsillotomy and tonsillectomy in paediatric (<16yo) patients with sleep-disordered breathing.

Data sources

A systematic search of MEDLINE, EMBASE, and CENTRAL (1984–July 2014) was conducted. Papers in English directly comparing post-operative outcomes in tonsillectomy and tonsillotomy in children undergoing surgery for sleep-disordered breathing were included.

Review methods

Two authors independently assessed abstracts for relevance, with disagreements resolved by a third author. Selected studies were independently assessed regarding inclusion and exclusion criteria.

Results

Thirty-two studies satisfied inclusion and exclusion criteria (19 randomised, 13 non-randomised). Patient satisfaction, quality-of-life, and polysomnographic improvement post-surgery did not vary between tonsillotomy and tonsillectomy. Tonsillotomy reduced the odds of a secondary haemorrhage by 79% (OR 0.21, 95% CI 0.17–0.27, p < 0.01), decreased post-operative pain and reduced return to normal oral intake by 2.8 days (95% CI 1.08–4.52, p < 0.01). The odds of readmission were decreased by 62% (OR 0.38, 95% CI 0.23–0.60, p < 0.01). Tonsillotomy had a slightly higher rate of symptom recurrence (4.51%) than tonsillectomy (2.55%), the long-term impact of which was unclear.

Conclusion

Current evidence supports tonsillotomy in children with obstructive surgical indications. It is likely to reduce post-operative haemorrhage, pain, and facilitate a faster return to normal diet and activity. Healthcare burden is decreased due to fewer post-operative complications and reduced need for medical re-contact. More research is necessary to assess the risk of recurrence, and further classification of secondary haemorrhage severity is required to fully clarify the clinical benefit of tonsillotomy.

Introduction

Tonsillectomy (tonsillectomy) is currently the mainstay of surgical treatment for paediatric sleep-disordered breathing due to tonsillar hypertrophy. It involves the complete removal of the tonsils, including the tonsillar capsule, leaving the underlying pharyngeal muscles exposed to heal by secondary intention. In contrast, tonsillotomy (tonsillotomy, or partial/intracapsular tonsillectomy) avoids capsular disruption by only removing the obstructive tonsillar segment.

While tonsillectomy is the preferred procedure in recurrent tonsillar infection [1], [2], studies have suggested that tonsillectomy and tonsillotomy have similar effectiveness in treating isolated sleep-disordered breathing, both clinically and on polysomnographic testing [3], [4], [5]. There is evidence that tonsillotomy has less post-operative morbidity, as larger-calibre blood vessels near the capsule and pharyngeal muscles remain intact [6], [7], [8]. This in turn may decrease post-operative pain, minimising analgesia use and allowing patients a faster return to normal diet and activity. It may also decrease the risk of both primary and secondary haemorrhage, the latter of which may sometimes result in life-threatening hypovolemia necessitating a return to theatre. All of these factors raise the possibility that tonsillotomy may be more cost-effective than tonsillectomy, with lower rates of readmission and medical re-contact for complications; the potentially faster recovery times observed in tonsillotomy may also decrease the time caregivers are required to take off work.

However, there is concern that the tonsillar remnant in tonsillotomy may predispose to post-operative infection [7]. Tonsillar remnants may also re-hypertrophy, with possible recurrence of sleep-disordered breathing which may require a revision tonsillectomy if severe [9], thus exposing the patient to additional operative morbidity and increasing healthcare cost. It is therefore important to determine whether these risks outweigh the potential improved post-operative morbidity and cost-effectiveness offered by tonsillotomy.

Previous systematic reviews comparing the two techniques have either included non-target populations or excluded data from large non-randomised studies. Both Acevedo et al. [10] and Kim et al. [11] incorporated adult patient populations within their analyses, while Walton et al. [12] conducted a meta-analysis of randomised controlled trials only. Our study aims to systematically review the literature comparing clinical efficacy, post-operative morbidity, and cost-effectiveness of tonsillectomy and tonsillotomy, performed in the paediatric population for sleep-disordered breathing. Based on findings from both randomised trials and non-randomised real-world patient registers, this review hopes to make a recommendation on the best procedure for this patient population.

Section snippets

Study selection

MEDLINE, EMBASE, and CENTRAL were systematically searched (1948–July 2014) using the key words “tonsillectomy”, “adenotonsillectomy”, “tonsillotomy”, “intracapsular”, “subtotal”, “partial”, “subcapsular”, “supracapsular”, and “reduction” in combinations. Both randomised and non-randomised articles in English were included if they studied paediatric patients (<16yo) without comorbidities (obesity, craniofacial abnormalities, etc.) undergoing tonsillar surgery of any technique for obstructive

Results

In total, 453 articles were identified via search strategy from the three databases (Fig. 1). Thirty studies complied with criteria and were included in the final review. Sixty-six additional studies were identified in the reference lists of included studies, with one study meeting eligibility criteria. Another study, in-press, was identified by the leading author via the journal's mailing list. Three studies originally considered for inclusion were excluded as authors were not contactable. The

Summary and significance of main findings

This systematic review of 32 randomised and non-randomised studies comparing tonsillectomy with tonsillotomy found equal long-term effectiveness, with similar patient satisfaction and quality-of-life end-points. Polysomnographic improvement was also similar. These results suggest that tonsillotomy and tonsillectomy are both equally effective in treating paediatric sleep-disordered breathing.

It has been well established that haemorrhage, especially secondary haemorrhage, is one of the most

Conclusions

Paediatric sleep-disordered breathing can occur secondary to tonsillar enlargement. Tonsillotomy has demonstrated similar effectiveness compared to tonsillectomy in treating tonsillar hypertrophy. However, tonsillotomy decreases the odds of secondary haemorrhage by 79%, reduces intensity of post-operative pain, and allows a 3 day earlier return to normal diet and activity. A 62% reduction in the odds of readmission was also found. While further clarification regarding the severity of secondary

Financial support/funding

None.

Conflict of interest

None.

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