Predictive Pediatric Characteristics for Revision Tonsillectomy After Intracapsular Tonsillectomy

Abstract

Objectives

There is little research on the rate and risk factors for revision tonsillectomy after primary intracapsular tonsillectomy. Our study aimed to determine the revision rate following intracapsular tonsillectomy, identify patient characteristics that may increase the probability of revision surgery, and report the tonsillar hemorrhage rate after revision.

Study Design

Level III, retrospective case-control study.

Setting

A tertiary care pediatric center (Alfred I. duPont Hospital for Children, Wilmington, Delaware).

Methods

A case-control study of pediatric patients who underwent intracapsular tonsillectomy between January 1, 2004, and December 31, 2018, was performed. Patients aged 2 to 20 years were analyzed and compared with matched controls who underwent intracapsular tonsillectomy within 7 days of the same surgeon’s case. In total, 169 revision procedures were included with 169 matched controls.

Results

A 1.39% revision rate was observed among a total of 12,145 intracapsular tonsillectomies. Among the 169 patients who underwent a revision procedure, the mean time between cases was 3.5 years. Tonsillitis was the most common diagnosis prompting revision tonsillectomy. Four (2.4%) patients underwent operative control of a postoperative tonsillar hemorrhage after revision surgery. Younger patients (P < .001) and patients with a history of gastroesophageal reflux disease (P = .006) were more likely to undergo revision tonsillectomy.

Conclusion

Patients below age 4 years and patients with gastroesophageal reflux disease may be at increased risk of undergoing revision tonsillectomy after primary intracapsular tonsillectomy. These factors should be considered when selecting an intracapsular technique for primary tonsillectomy in pediatric patients.

Keywords

intracapsular tonsillectomy tonsillotomy tonsil regrowth revision tonsillectomy

Tonsillectomy is a standard surgical procedure performed in the United States, with 289,000 completed in 2017 in children younger than 15 years.¹ Many techniques and instruments have been introduced to remove tonsil tissue. The most common indications for tonsillectomy are tonsillar hypertrophy, sleep-disordered breathing (SDB), obstructive sleep apnea (OSA), and recurrent or chronic tonsillitis.² In the present day, intracapsular tonsillectomy (IT), also known as a partial tonsillectomy or tonsillotomy, and total tonsillectomy (TT), also known as an extracapsular tonsillectomy, are acceptable techniques for tonsil tissue removal. In TT, the tonsil is dissected from the tonsillar fossa and underlying superior constrictor muscle. This procedure has well-documented risks of bleeding, postoperative pain, dehydration, and delays in return to regular activity.^3-5

Intracapsular tonsillectomy reduces some of these risks. A systematic review by Zhang et al⁶ found reduced postoperative bleeding, pain, and complications in children who underwent IT compared with TT. Since the tonsil is not entirely removed in IT, there is a risk of recurrent tonsillitis and regrowth after the initial surgery. However, a meta-analysis performed by Kim et al⁷ describes no significant difference in recurrent tonsillitis after IT compared with traditional TT. Current literature describes revision tonsillectomy rates after IT to be between 0% and 1.4%,^8,9 except for 1 study that used radiofrequency ablation, which saw a 16.6% rate.¹⁰ Children younger than 5 years at the time of IT reportedly have a higher regrowth rate.¹¹ Although there is a regrowth risk, IT offers reduced postoperative pain, analgesic use, recovery time, bleed rate, and infection rate, as well as improved time to a regular diet.^12-14

While TT hemorrhage rates have typically been reported as approximately 5%, IT bleeding rates have been reported as less than 0.5%.^15-17 One meta-analysis found a significant relative risk reduction in bleeding rates between IT and TT of 0.44.⁷ Another systematic review of randomized clinical trials demonstrated significantly lower rates of secondary hemorrhage in the IT group (0.7%) compared with the TT group (2%).¹² We aimed to identify factors that may increase the likelihood of revision surgery, such as age, medical comorbidities, body mass index (BMI), initial indication for surgery, and tonsil size.

Materials and Methods

This study was performed at a tertiary care pediatric referral center. Institutional review board (IRB) approval was obtained through the Nemours IRB, Wilmington, Delaware. The electronic medical record (EMR) was queried to identify patients who underwent tonsillectomy with or without adenoidectomy between January 1, 2004, and December 31, 2018, within the Nemours enterprise. These cases were identified using the Current Procedural Terminology (CPT) codes 42820, 42821, 42825, and 42826. Patients with 1 or more of these CPT codes entered at 2 different time points in the medical record were identified as possible revision cases. Among these patients, operative notes were reviewed for surgical technique and to confirm the presence of a revision procedure. All patients who first underwent an intracapsular tonsillectomy followed by a revision tonsillectomy of any method were selected for inclusion in the revision cohort. In patients who underwent a single procedure, operative notes were similarly reviewed to identify control patients who had IT without revision.

Study Design

A retrospective case-control study was performed by coupling all patients in the revision cohort to controls who did not undergo revision after IT. Cases were paired in a 1:1 fashion using attending surgeon and week of surgery as matching criteria. We did not match using other demographic variables to study these as potential risk factors. Control cases were not excluded if bleeding occurred in the second case.

Patients were determined to be candidates for tonsillectomy or revision tonsillectomy based on published American Academy of Otolaryngology (AAO) guidelines. Relaxed criteria were not used in the decision to perform revision tonsillectomies. Patient- and procedure-specific data were collected from the medical record, including age at the time of surgery, sex, race, ethnicity, surgical indication, tonsil size, surgical technique, BMI percentile, posttonsillectomy bleeding occurrences, Down syndrome diagnosis, and history of gastroesophageal reflux disease (GERD). History of GERD was determined by either a GERD diagnosis or prescription of proton-pump inhibitors within 2 years of surgery. Surgical indications were derived from the preoperative and operative notes. BMI percentiles were calculated for all children between ages 2 and 20 years using the sex-appropriate Centers for Disease Control and Prevention (CDC) chart. Patients were classified as either underweight (<5th percentile), normal weight (5th to <85th percentile), overweight (85th to <95th percentile), or obese (≥95th percentile) following CDC definitions. Hemorrhage following tonsillectomy was identified using the International Classification of Diseases, Ninth Revision (ICD-9) code 998.11 in patients who required return to the operating room for control of bleeding.

Surgical Technique

All primary or first tonsillectomies were performed in an intracapsular plane using the microdebrider (Straightshot M4 microdebrider; Medtronic). Thirteen fellowship-trained pediatric otolaryngologists performed the procedures, using the same technique, with or without otolaryngology residents under direct supervision. The attending physician completed any inadequate intracapsular tonsillectomies. A near-total intracapsular procedure was used, which includes removing all tissue until the fibrous strands of the tonsillar capsule are identified. Once positioned, the tonsil was injected with 1% lidocaine with 1:100,000 epinephrine. Microdebrider tonsillectomy was performed at 1500 revolutions per minute (rpm). Next, fulguration was performed, and hemostasis was achieved with suction electrocautery at 25 to 35 watts. Secondary or revision tonsillectomies were performed using either an intracapsular microdebrider technique as above or an extracapsular approach using pencil electrocautery at a setting of 15 watts or coblation at 7 watts.

Statistical Analysis

Analyses were performed using SPSS version 27 (SPSS, Inc). Baseline descriptive characteristics of the case and control groups were calculated and compared using bivariate statistics. For cases with missing values, the matched value in the case/control population was omitted from the analysis, and the valid percent is presented for each cohort. Categorical variables were compared using χ² and Fisher exact tests where appropriate. Independent samples t tests were used for comparison of categorical variables. Binary logistic regression was used to assess the risk independently associated with each patient- and procedure-related characteristic in predicting the need for revision tonsillectomy. All variables evaluated in Table 1 were included in the regression model. Descriptive statistics are provided to further characterize the revision cohort at the time of the revision case. A P value of <.05 was considered statistically significant.

Table 1.

Bivariate Statistics: Comparison of Case and Control Group Characteristics.^a

Characteristic	Revision cohort (n = 169)	Control (n = 169)	P value
Age, mean (SD), y	5.0 (3.6)	7.5 (4.0)	<.001
Sex
Male	77 (45.6)	73 (43.2)	.661
Female	92 (54.4)	96 (56.8)	.661
Race
White	118 (70.7)	119 (71.3)	.205
Black	36 (21.6)	27 (16.2)
Other	13 (7.8)	21 (12.6)
Ethnicity
Hispanic	12 (7.2)	25 (15.0)	.023
Non-Hispanic	155 (92.8)	142 (85.0)	.023
Diagnosis
OSA/SDB	124 (73.4)	125 (74.4)	.360
Tonsillitis	36 (21.3)	39 (23.2)
OSA/SDB + tonsillitis	9 (5.3)	4 (2.4)
Tonsil size
1/2+	25 (16.1)	24 (15.5)	.122
3+	76 (49.0)	60 (38.7)
4+	54 (34.8)	71 (45.8)
BMI class
Underweight (<5th percentile)	10 (6.3)	5 (3.2)	.368
Normal weight (5th-85th percentile)	92 (58.2)	89 (56.3)
Overweight (85th-95th percentile)	24 (15.2)	22 (13.9)
Obese (>95th percentile)	32 (20.3)	42 (26.6)
Trisomy 21
Yes	2 (1.2)	1 (0.6)	.562
No	167 (98.8)	168 (99.4)
History of GERD
Yes	54 (32.0)	32 (18.9)	.006
No	115 (68.0)	137 (81.1)	.006

Abbreviations: BMI, body mass index; GERD, gastroesophageal reflux disease; OSA, obstructive sleep apnea; SDB, sleep-disordered breathing.

Values are presented as number (%) unless otherwise indicated. Bold values indicate statistical significance.

Results

During the 15-year study period, 12,145 IT procedures were performed. A total of 183 patients were identified as having undergone tonsillectomy at 2 different time points. Fourteen patients who could not be matched with an adequate control were excluded from the analysis ( Figure 1 ), leaving 169 revision cases analyzed and compared with 169 controls. The revision rate for tonsillectomy after IT was 1.39%.

Age

Children who underwent revision tonsillectomy were significantly younger than the control group (mean 5.0 vs 7.5 years, P < .001). On multivariable regression analysis, younger age remained a significant predictor of the need for revision tonsillectomy. Compared with patients greater than 12 years old, children under 2 years of age were 18.4 times more likely to undergo revision tonsillectomy (95% CI, 5.3-63.3, P < .001), and children aged 2 to 4 years were 6.5 times more likely (95% CI, 2.1-19.6, P = .001).

Ethnicity, Race, and Sex

The revision cohort had a significantly larger percentage of non-Hispanic patients than the control group (92.8% vs 85%, P = .023). Following regression analysis, non-Hispanic ethnicity was not independently associated with the need for revision tonsillectomy (odds ratio [OR], 2.3; 95% CI, 0.6-9.6; P = .240). Sex and race did not differ significantly between groups ( Table 1 and Table 2 ).

Table 2.

Binary Logistic Regression: Patient Characteristics Predictive of Revision Tonsillectomy and Associated Odds Ratios.^a

Characteristic	OR (95% CI)	P value
Age, y
>12	1.0 (reference)	—
8-12	1.5 (0.6-4.1)	.424
5-7	1.4 (0.5-4.4)	.549
2-4	6.5 (2.1-19.6)	.001
<2	18.4 (5.3-63.3)	<.001
Sex
Male	1.0 (reference)	—
Female	1.4 (0.8-2.4)	.295
Race
White	1.0 (reference)	—
Black	1.4 (0.7-2.9)	.378
Other	1.0 (0.3-4.1)	.974
Ethnicity
Hispanic	1.0 (reference)	—
Non-Hispanic	2.3 (0.6-9.6)	.240
Diagnosis
OSA/SDB	1.0 (reference)	—
Tonsillitis	2.7 (1.2-5.9)	.014
OSA/SDB + tonsillitis	8.4 (1.9-37.6)	.006
Tonsil size
1/2+	1.0 (reference)	—
3+	1.4 (0.6-3.2)	.476
4+	0.9 (0.4-2.1)	.788
BMI
Normal weight	1.0 (reference)	—
Underweight	4.0 (0.9-17.7)	.066
Overweight	2.1 (0.9-4.7)	.075
Obese	1.5 (0.7-3.3)	.263
Trisomy 21
No	1.0 (reference)	—
Yes	NA	~1.000
History of GERD
No	1.0 (reference)	—
Yes	2.0 (1.1-3.8)	.028

Abbreviations: BMI, body mass index; GERD, gastroesophageal reflux disease; NA, not applicable, unable to calculate; OR, odds ratio; OSA, obstructive sleep apnea; SDB, sleep-disordered breathing; —, reference value, statistical analysis not performed. ^aBold values indicate statistical significance.

Preoperative Diagnosis

The indication for primary tonsillectomy did not differ significantly between groups. Overall, 73.7% of cases were performed for OSA/SDB and 22.2% for tonsillitis. The remaining 3.8% of patients carried both surgical indications. After accounting for all other patient characteristics in the multivariable analysis, patients with a surgical indication of tonsillitis alone were at significantly higher risk for revision tonsillectomy than those with a diagnosis of OSA/SDB alone (OR, 2.7; P = .014). Patients who underwent primary tonsillectomy for concurrent diagnoses of OSA/SDB and tonsillitis had the highest probability of revision tonsillectomy with an OR of 8.4 relative to OSA/SDB alone (P = .006).

Gastroesophageal Reflux

Patients in the revision cohort were significantly more likely to have been diagnosed with GERD than those in the control group (32.0 vs 18.9%, P = .006). History of GERD was also independently predictive of the need for revision tonsillectomy on regression analysis with an OR of 2.0 (P = .028).

Characteristics of the Revision Tonsillectomy Cohort

Additional characteristics of the revision cohort are shown in Table 3 . The mean time between revision cases was 3.5 ± 2.6 years, while the mean age at revision intervention was 8.4 ± 4.0 years. At the time of the revision, the mean BMI percentile was 69.5 ± 29.6, with a 7.5 ± 23.9 percentile increase in BMI between the primary and revision surgeries.

Table 3.

Revision Tonsillectomy Cohort Characteristics.

Characteristic	Mean (SD), Range
Years between cases	3.5 (2.6), 0.3-12.4
Age at time of revision	8.4 (4.0), 1.8-18.8
Change in BMI percentile between cases	+7.5 (23.9)
BMI percentile at time of revision	69.5 (29.6)

Abbreviation: BMI, body mass index.

Recurrent or chronic tonsillitis was the most common diagnosis prompting revision surgery (50%), followed by a diagnosis of OSA or SDB (38.7%). In total, 111 patients underwent primary intracapsular tonsillectomy and revision tonsillectomy for the same indication (79 for obstructive and 32 for infectious indications). Fifty-three patients with a primary obstructive indication went on to have a revision tonsillectomy for an infectious indication. Five patients with an initial infectious indication went on to have revision surgery for an obstructive indication.

The median number of documented pharyngitis episodes in those diagnosed with recurrent tonsilitis was 5 (range, 2-12), at a median frequency of 7 episodes over 12 months. Of those with a diagnosis of OSA or SDB, 29 had polysomnogram (PSG) results before the revision procedure. The median apnea-hypopnea index (AHI) was 20.4 (range, 2.5-142.7) with a median O₂ nadir of 84% (range, 32%-96%). Eight patients underwent drug-induced sleep endoscopy (DISE) before the procedure, 5 of whom also had a PSG. In total, 146 (86.4%) revision cases were TT. Twelve included a revision adenoidectomy, and none were noted to be the significant factor for surgery. Most tonsils were size 1 or 2+ (58.4%) at the time of revision tonsillectomy. However, for those patients undergoing revision surgery for OSA or SDB, 73.7% had 3 or 4+ tonsils ( Table 4 ). Postoperative bleeding requiring a return to the operating room was seen in 4 patients (2.4%) after revision tonsillectomy compared with zero patients following initial IT (P = .044). All 4 cases occurred after revision TT.

Table 4.

Revision Tonsillectomy Surgical Case Characteristics.

Characteristic	No. (%)
Diagnosis
OSA/SDB	82 (48.5)
Tonsillitis	78 (46.2)
Tonsillitis with tonsilloliths	6 (3.6)
OSA/SDB + tonsillitis	3 (1.8)
Procedure
Total tonsillectomy	146 (86.4)
Intracapsular tonsillectomy	23 (13.6)
Tonsillitis + tonsilloliths tonsil size
1/2+	77 (85.6)
3+	10 (11.1)
4+	3 (3.33)
OSA/SDB + adenotonsillar hypertrophy tonsil size
1/2+	20 (26.3)
3+	45 (59.2)
4+	11 (14.5)

Abbreviations: OSA, obstructive sleep apnea; SDB, sleep-disordered breathing.

Discussion

Examination of this case-control matched population revealed a revision rate after IT of 1.39% and identified several patient characteristics independently associated with an increased risk for revision tonsillectomy: younger age, history of GERD, and a surgical indication of tonsillitis relative to OSA/SDB. No other patient variables were shown to be significant, including sex, race, tonsil size, BMI percentile, and history of trisomy 21.

Although there may be an understandable amount of parental anxiety regarding a visit to an otolaryngologist for renewed tonsil problems after one’s child had previously undergone IT, the literature indicates a 6-fold higher risk of residual tonsillar tissue after IT when compared with TT.⁷ Therefore, we strongly encourage practitioners to follow objective criteria when recommending additional tonsil surgery. For recurrent tonsil infections, this includes reviewing the infectious indications for tonsillectomy as enumerated in the AAO’s clinical practice guidelines with the caregivers and trying to avoid deviating from them unless modifying factors are also present.¹ Similarly, children with recurrent sleep symptoms after IT and moderate or less tonsil regrowth should be referred for PSG.¹⁸ If the PSG reveals significant SDB, DISE should be used to assess for other areas of obstruction prior to proceeding with revision tonsillectomy.¹⁹ Drug-induced sleep endoscopy may be performed under the same anesthetic as the revision tonsillectomy.

Younger age at the time of initial IT appears to be a risk factor for revision surgery. Tonsils undergo more rapid growth in younger children with a peak in size between 4 and 8 years of age.²⁰ It is logical to conclude that younger children will undergo more rapid growth and have more time for regrowth than older children. In addition, our study found that revision tonsillectomy had a more extensive distribution of smaller tonsil sizes than the primary IT cohort, suggesting that fulminant regrowth is much less common than mild regrowth, even in younger children.

Little is known about ethnic and racial differences when performing tonsillectomy in pediatric patients. Our results suggest race is not a significant variable for revision tonsillectomy. Bhattacharyya and Shapiro²¹ showed Hispanic and black children were more likely to have hospital revisits and acute pain at the revisit after tonsillectomy. Intracapsular tonsillectomy may be one way to help mitigate this increased morbidity.

History of GERD was demonstrated as a significant risk factor for revision surgery. Patients with GERD undergoing tonsillectomy have been known to have higher rates of complications, such as desaturations requiring supplemental oxygen or reintubation, pulmonary edema, posttonsillectomy bleed, and dehydration.²² Other studies have claimed significantly more extended hospital stays, higher pain measures, and increased bleeding rates after tonsillectomy.^23,24 Gastroesophageal reflux may contribute to lymphoid hyperplasia, as 1 study saw an association between lymphoid hypertrophy of the base of the tongue and GERD.²⁵ An in vitro study concluded that pepsin likely aggravates tonsil hypertrophy in the context of GERD, although there is no direct evidence of this association.²⁶ Further research is required to determine the strength and cause of the GERD association with revision surgery risk.

Recurrent or chronic tonsillitis was the most common diagnosis prompting revision surgery in our cohort. A recent IT study for recurrent tonsillitis concluded that it is a safe and effective treatment for recurrent tonsillitis.²⁷ However, with a short mean follow-up period of 13 months, the long-term revision tonsillectomy rate is unknown. Another study of IT in adults for chronic or recurrent tonsillitis similarly demonstrated improved symptoms at 6 months postsurgery.²⁸ Further research into the long-term efficacy of IT for chronic or recurrent tonsillitis would be beneficial.

Our results reveal an increased risk for bleeding following revision tonsillectomy compared with initial tonsillectomy. The bleed rate following revision surgery was found to be 2.4%, which is most likely attributable to the tonsillectomy technique. Most revision procedures (86.4%) were TT. This rate is similar to that reported in a recent meta-analysis for TT using electrocautery (2.6%) or coblation (2.5%).²⁹ This same meta-analysis demonstrated a 1.5% overall risk of bleeding after IT, with operative intervention in 0.64% of children.²⁹ This is similar to the incidence of bleeding after IT previously reported by this institution.⁹ The cumulative risk of revision surgery (1.4%) and operative control of hemorrhage (<1%) after IT still compare favorably with the accepted risk of operative control of hemorrhage after TT. Moreover, a recent study found that emergency as opposed to elective surgery was correlated with increased emotional distress in younger children, and increased parental stress at the time of surgery was correlated with increased emotional distress in all ages of children 3 to 5 months after surgery.³⁰ Thus, an insignificant difference between techniques for the need for an additional surgery and the presumed additional stress associated with emergency surgery when compared with elective surgery make IT an attractive choice.

The present study has several limitations, some inherent to a retrospective chart review. The case data generated by the EMR were found to be subject to coding errors, requiring record review to ensure the validity of all data. The primary indication for surgery, and its effect in the need for reoperation if required, could not be clearly identified among the total studied population. The individual attending surgeons decided to perform a revision tonsillectomy; although all surgeons in the practice use the AAO guidelines as part of their decision-making process, there will undoubtedly be variability among providers in deciding to perform revision surgery just as there would be for primary surgery.

Case-control matching was employed to reduce variance associated with the week of surgery and attending surgeon; however, the possibility of selection bias cannot be excluded. The current inquiry may underestimate or overestimate each variable’s effect as we could not account for patients who had subsequent revision tonsillectomies at outside facilities. In addition, since patients were included up to December 31, 2018, there may be additional cases in the future, as some patients may not have had sufficient time for substantial regrowth. One source of confounding may have been the presence of residents as surgeons, although the same resident typically worked with each surgeon throughout their rotation, limiting the influence of any possible variability in surgical technique.

Conclusion

Our revision rate for tonsillectomy after IT was 1.39%. Positive predictors of revision tonsillectomy after IT in the pediatric population include younger age, GERD, and a surgical indication of tonsillitis relative to OSA/SDB. Clinicians should consider these factors when counseling in the shared decision-making process between selecting intracapsular vs extracapsular techniques.

Footnotes

Author Contributions

S. Hamad Sagheer, data collection, data analysis, manuscript writing; Caroline M. Kolb, study design, data collection, data analysis, manuscript writing; Meghan M. Crippen, data analysis, manuscript writing; Andrew Tawfik, data collection, manuscript writing; Nathan D. Vandjelovic, study design, manuscript editing; Heather C. Nardone, study design, manuscript editing; Richard J. Schmidt, study design, manuscript editing.

Disclosures

Competing interests: None.

Sponsorships: None.

Funding source: None.

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