Koltai PJ, Solares CA, Koempel JA, et al. Otolaryngol Head Neck Surg. 2003;129:532–538
Purpose of the Study.
To compare the safety and efficacy of intracapsular tonsillar reduction (partial tonsillectomy) with those of conventional tonsillectomy for treating obstructive sleep-disordered breathing among children.
The authors reviewed the medical records for a total of 350 children who underwent either partial (243 children) or standard (107 children) tonsillectomy for treatment of obstructive sleep-disordered breathing. The diagnosis of sleep-related obstruction was made on the basis of history findings.
This was a retrospective chart review of patient records for all children with obstructive sleep-disordered breathing who underwent either partial or standard tonsillectomy, performed by 1 of 3 primary surgeons. The choice of surgical technique was made by the parents, who were told that the new partial tonsillectomy might be associated with less postoperative discomfort but might have a greater chance of recurrence, compared with standard tonsillectomy. Subjective assessments of outcomes and quality of life, recorded in a telephone survey of parents, included postoperative pain assessment, measurement of the days to return to a normal diet, measurement of analgesic use, and assessment of relief of sleep-related obstructive symptoms. Analyses of patient records included measurements of operative time, estimated blood loss, and incidence of delayed postoperative complications, such as bleeding and tonsil regrowth. Partial tonsillectomy was performed by using a microdébrider to remove the bulk of the tonsil tissue while leaving the surrounding capsule intact. Standard tonsillectomy was performed by using electrocautery to remove the palatine tonsils and their capsules in their entirety.
The children who underwent partial tonsillectomy were younger than those who underwent standard tonsillectomy (mean age: 6.1 years vs 9.1 years; P < .001). The children who were treated with the new technique experienced significantly less postoperative pain, fewer days to normal activity and diet, and less analgesic use, compared with the children who underwent standard tonsillectomy. Partial tonsillectomy was associated with small but significantly greater intraoperative blood loss, after adjustment for patient age, and the new procedure required a slightly longer time to perform (an average of 3 minutes longer for experienced surgeons). The microdébrider instrumentation was more expensive than that used for conventional tonsillectomy. The frequency of delayed postoperative bleeding appeared lower with partial tonsillectomy (4.7% and 1.7% for standard and partial tonsillectomy, respectively), but this difference was not statistically significant. Quality of life measurements showed similar rates of improvement for children treated with the 2 procedures, with >93% of the parents in both groups reporting marked improvements after surgery. Tonsillar regrowth after partial tonsillectomy was not observed for any patient during the 2-year follow-up period.
Partial tonsillectomy is a safe reliable technique that results in less postoperative pain, more rapid return to normal function, and equivalent improvements in sleep-related airway obstruction and quality of life, compared with standard tonsillectomy, among children.
The most common indication for adenotonsillectomy among children is an obstructive sleep disorder. Tonsillectomy is associated with considerable postoperative discomfort and a small but finite risk of perioperative bleeding. The authors support the concept that subtotal tonsil removal (usually combined with adenoidectomy) may be curative, with less postoperative pain and other morbidities. This study has the limitations of all retrospective analyses. The study groups may not be directly comparable, because of selection biases. Additional bias may occur with telephone surveys of patients and families after a surgical procedure. Finally, the diagnosis of obstructive sleep-disordered breathing on the basis of history findings, with similar assessments of improvement after surgery, does not have the quantitative accuracy of preoperative and postoperative polysomnographic evaluations. Despite these limitations, this study succeeded in showing that intracapsular tonsillar reduction (partial tonsillectomy) shows great promise as a safe effective treatment for children with obstructive sleep-disordered breathing and appears to cause less morbidity than standard tonsillectomy. Additional studies with more long-term follow-up monitoring are required to assess the recurrence rates for both obstructive and infectious tonsillar disease, after this procedure is performed among young children.