Acta Oto-Laryngologica

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The effect of tonsillotomy on chronic recurrent

tonsillitis in children

Elisabeth Foki, Rudolf Seemann, Klaus Stelter & Claudia Lill

To cite this article: Elisabeth Foki, Rudolf Seemann, Klaus Stelter & Claudia Lill (2017): The
effect of tonsillotomy on chronic recurrent tonsillitis in children, Acta Oto-Laryngologica, DOI:
10.1080/00016489.2017.1322712

To link to this article: http://dx.doi.org/10.1080/00016489.2017.1322712

Published online: 04 May 2017.

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ACTA OTO-LARYNGOLOGICA, 2017
https://doi.org/10.1080/00016489.2017.1322712

RESEARCH ARTICLE

The effect of tonsillotomy on chronic recurrent tonsillitis in children

Elisabeth Fokia, Rudolf Seemannb, Klaus Stelterc and Claudia Lilla
a
Department of Otorhinolaryngology, Head and Neck Surgery, Medical University of Vienna, Vienna, Austria; bDepartment of Oral and
Maxillofacial Surgery, Medical University of Vienna, Vienna, Austria; cDepartment of Head and Neck Surgery, ENT Centre Mangfall-Inn,
RoMed Clinic Bad Aibling, Rosenheim, Germany

ABSTRACT ARTICLE HISTORY

Objectives: The objective of this study is to determine whether partial tonsillectomy (tonsillotomy) Received 7 March 2017
impacts the occurrence of acute or recurrent tonsillitis in children. Revised 6 April 2017
Methods: One hundred and eighty patients (114 years) were retrospectively surveyed by a question- Accepted 11 April 2017
naire or by data analysis of a regional database. Subjects who suffered from severe systemic diseases
or immunodeficiency syndromes were excluded. Episodes of acute tonsillitis before and after surgery, KEYWORDS
rate of antibiotic treatment, postoperative hemorrhage, and re-operation were obtained. Tonsil surgery; throat
Results: Fifty-one patients suffered from preoperative tonsillitis. The rate of reinfection was 9.8%. The infections; inflammation;
frequency of tonsillitis was significantly reduced in children after tonsillotomy (p < .001). Further, tonsil- post-tonsillectomy
lotomy led to a significant reduction of antibiotic treatment (p < .001). The rate of definitive tonsillec- complications
tomy was 1.1% and thus effectiveness was very high. About 1.7% of all children suffered from
postoperative bleeding, of which one (0.6%) required surgical revision. None of the bleedings was life
threatening.
Conclusions: Tonsillotomy is beneficial for patients with recurrent tonsillitis and carries less risk of
postoperative complications than tonsillectomy.

Introduction causes a shorter recovery period [7]. The major indication

for tonsillotomy is obstructive sleep disordered breathing
Acute bacterial tonsillitis accounts for estimated 5% of all
and hyperplasia of the Waldeyer ring [7,8]. Due to the
medical consultations [1] and tonsil surgery is often the first
occurrence of lethal bleeding events in children, tonsillotomy
operation during childhood. The main pathogen in bacterial
is recommended rather than tonsillectomy in children of
tonsillitis during childhood is streptococcus pyogenes or A
this age [9]. An analysis of 54,696 patients undergoing either
-hemolytic streptococci [1]. When antibiotic treatment is
tonsillotomy or tonsillectomy in Sweden showed that both
insufficient to resolve recurrent infections, surgical therapy
surgeries efficiently relieved symptoms in patients, with a
is indicated. Unfortunately, the rate of post-tonsillectomy
benefit for patients undergoing tonsillectomy. However, this
hemorrhage lies within the range of 0.13% [2,3]. Lethal
study did not analyze the effect dependent on the indication
postoperative bleeding events occurred frequently in the
[10]. Ericson et al. [11] showed equal effectiveness for TO
years 20062007 in Austria and, therefore, tonsillectomy
and TE in patients of every age concerning reduction of
(TE) has been indicated with more qualms [4].
snoring, reduction of recurrent infections as well as postop-
Tonsil surgery is often combined with adenoidectomy
erative health-related quality of life. Another randomized
when obstructive sleep disordered breathing or chronic otitis
study evaluating the effect of TO performed with radiofre-
media are the indication for surgery.
quency technique, which included children from 5 to 15
Conventional tonsillectomy is performed by dissection of
years showed beneficial long-term effects for TO concerning
the complete tonsil of the superior constrictor muscle in
snoring and recurrent throat infections and thus recom-
order to keep its capsule intact. With the aim of minimizing
mended TO as standard tonsil surgery [12].
the risk of post-tonsillectomy hemorrhage, some surgeons
However, data concerning the effect of tonsillotomy on
perform an intracapsular tonsillectomy or tonsillotomy (TO)
recurrent antibiotic treatment requiring tonsillitis is still
by dissecting the tonsil sub-totally under maintenance of a
insufficient.
rim of tonsillar tissue with the objective of leaving the
muscle intact [5]. Thus, the aim of the present study was to determine the
However, during the last years, focus was put on tonsil- effect of tonsillotomy on recurrent tonsillitis in patients under
lotomy with the objective to reduce the risk of postoperative 15 years in order to potentially adapt surgical treatment in
morbidity [6]. Tonsillotomy (TO) is a less traumatic inter- patients undergoing tonsillectomy for recurrent tonsillitis of
vention, carrying less risk for severe bleeding events and any age.

CONTACT Claudia Lill claudia.lill@meduniwien.ac.at Department of Otorhinolaryngology, Head and Neck Surgery, Medical University of Vienna,
Waehringer Guertel 18-20, A-1090 Vienna, Austria
2017 Acta Oto-Laryngologica AB (Ltd)
2 E. FOKI ET AL.
Materials and methods
One hundred and eighty patients from 1.1 to 14.34 years
undergoing tonsillotomy or adeno-tonsillotomy due to snor-
ing or acute recurrent tonsillitis were retrospectively included
in this study. All patients underwent tonsillotomy at the
Department of Otorhinolaryngology, Head and Neck
Surgery, Medical University of Vienna, Austria. Children suf-
fering from immunodeficiency syndromes or systemic dis-
eases were excluded from the study. Follow-up was obtained
by a questionnaire surveyed by a telephone interview with the
parents of the former patient (Figure 1). In the case of loss of
contact, patient data were obtained from our regional data-
base, if accurate data was available. Indication for surgery
(upper airway obstruction or recurrent acute tonsillitis),
number of acute infections, and pre- and postoperative anti-
biotic treatment, as well as postoperative hemorrhage and the
rate of re-operation due to symptomatic remnants of tonsillar
tissue, was obtained. Data of post-operative tonsillitis as well
as definitive-tonsillectomy due to symptoms causing tonsillar
remnants were registered and analyzed using descriptive sta-
tistics (Table 1). Postoperative hemorrhage was defined as
bleeding of any severity (self-limiting minor bleeding to lethal
bleeding).
Follow-up was obtained after 2.8 years mean value ( 1.4,
range 0.329.18 years). All patients underwent tonsillotomy
with a Colorado needle. Adenoidectomy was performed
using a ring knife on the same occasion. The study was
approved by the institutional research ethics board, Medical
University of Vienna (#Number 1791/2016).
Statistical analysis
Data were analyzed using descriptive statistics. Thus, fre-
quency data were measured in percent and absolute num-
bers, age, and follow-up time were reported as
mean standard deviation and the range (minimum, max-
imum). To analyze the impact of tonsillotomy, frequencies
Figure 1. Questionnaire of the telephone survey.
of (1) acute tonsillitis and (2) intake of antibiotics before
and after the surgery were compared using paired Wilcoxon
rank sum and signed rank tests. A p value <.05 (2-sided)
was considered statistically significant. Since multiple testing
(two tests) were performed, a Bonferroni adjustment of the
p values was computed. Data were analyzed using the
open source statistical program R (version 3.2.3, http://
www.r-project.org).
Results
One hundred and eighty patients, 127 male (70.56%) and 53
female (29.44%), were retrospectively surveyed, of whom 51
(28.33%) suffered from chronic recurrent tonsillitis and
resulting antibiotic treatment preoperatively. All patients
presented a tonsillar hyperplasia. One hundred and twenty-
nine (71.67%) patients suffered from consecutive problems
such as snoring, recurrent otitis media with effusion, or
chronic obstructive upper airway problems. In 177 patients
(98.33%), additional adenoidectomy and, in 89 (49.44%)
patients, a paracentesis was performed due to chronic otitis
media on the same occasion.
Mean age was 5 years ( 2.13 years, range 1.114.34
years) for all patients. Patients who underwent tonsillotomy
due to recurrent tonsillitis had a mean age of 5.4 years
( 2.5 years, range 2.0614.34 years) and patients undergoing
tonsillotomy due to upper airway obstruction had a mean
age of 4.8 years ( 1.9 years, range 1.112.69), respectively.
Follow-up was conducted after 2.8 years ( 1.4 years, range
0.329.18 years).
Three (1.67%) children suffered from postoperative hem-
orrhage, none of whom had lethal complications. One of
those patients had to undergo surgical revision due to the
bleeding (0.6%), the other cases were self-limiting bleeding
episodes. Two (1.11%) patients had to undergo definitive
tonsillectomy due to tonsillar remnants causing obstructive
symptoms (18 and 34 months after tonsillotomy). All
patients had a follow up visit at least once after the surgery
 ACTA OTO-LARYNGOLOGICA 3

Table 1. Demographic data of 180 patients undergoing

tonsillotomy.
Characteristics Value (%)
Patients 180
Sex
Female 127 (70.6)
Male 53 (29.4)
Age, years
Mean 5
Median 4.7
Range 114
Indication
Hyperplasia 129 (71.7)
Recurrent acute tonsillitis 51 (28.3)
Simultaneous adenoidectomy 177 (98.3)
Simulataneous paracentesis 89 (49.4)
Hemorrhage
Surgical revision 1 (0.6)
Self limiting 2 (1.1) Figure 2. Descriptive data of patients with preoperative recurrent tonsillitis and
Definitive tonsillectomy 2 (1.1) frequency of acute tonsillitis after tonsillotomy. The bars on the left side repre-
sent preoperative data, whereas the bars at the right side represent postopera-
Values represent number of patients (%).
tive data.

for a routine check at the Department of
Otorhinolaryngology, Head and Neck Surgery, Medical
University of Vienna.
Fifty-one patients suffered from recurrent infections with
a range of 124 episodes of recurrent tonsillitis per year
(28.33%). Only five patients suffered from postoperative
reinfection, all of those patients suffered from chronic recur-
rent tonsillitis before the surgery. The rate of postoperative
reinfection was 9.8%.
Thirty-nine patients (21.67%) suffered from minimum
four episodes of recurrent tonsillitis before the surgery per
year. Except of one patient, all of the patients suffering from
recurrent tonsillitis required antibiotic treatment. Mean fre-
quency of antibiotic treatment was 2.97 (range 024).
Five of those patients suffered from tonsillitis after the
surgery (12.82%), all of them required antibiotic treatment
(Figure 2). Remarkably, each of them had only one postop-
erative infection (two patients 9 months after the surgery,
one patient 4 months, and two patients 3 months postopera-
tively). Mean follow-up period was 2.09 years ( 1.09 years,
range 1.183.82 years). Interestingly, all of those patients
had had more than four episodes per year of recurrent ton-
sillitis before the surgery.
Patients had significantly fewer tonsil infections after sur-
gery (Wilcoxon signed rank test: W 1326, p < .001, adjusted
p < .001). Further, patients took significantly fewer antibiotics
after surgery (Wilcoxon signed rank test: W 1081, p < .001,
adjusted p < .001).
Discussion
Tonsil surgery is one of the most commonly performed sur-
geries in children accounting for 20% of all operative inter-
ventions performed by an otolaryngologist [13]. The tonsils
as well as the adenoids are part of the Waldeyer ring and
consist of mucosa associated lymphoid tissue with a high
rate of T-cells [14]. Respiratory antigens primarily affect
immune-competent organs in the nose, mouth, and pharynx,
and thus involve the organs of the Waldeyer ring primarily.
As a consequence, those organs play a major role in
immune defense and thus many children suffer from recur-
rent infections or hyperplasia. Recurrent infections and
resulting health care visits, antibiotic treatments as well as
problems associated with upper airway obstruction causing
snoring and day-time-sleepiness, are associated with a severe
impairment of health-related quality of life in children [11].
Complete extracapsular tonsillectomy has always been the
method of choice in tonsil surgery indicated due to obstruct-
ive airway symptoms and recurrent tonsillitis [15]. The main
complications after surgery include predominantly hemor-
rhage and pain for at least 2 weeks postoperatively. In 2006
and 2007, five children below the age of six died due to
severe postoperative bleeding after tonsillectomy in Austria
[9]. As tonsillotomy harbors a lower risk of postoperative
bleeding (2.3% versus 12.3%), a complete reduction of ton-
sillectomy rate in patients aged under six has taken place in
Austria and tonsillotomy has become the gold-standard in
patients suffering from hyperplasia of the tonsils [9].
The common surgery technique in our study was to
remove the protruding parts of the tonsils medial to the pal-
atal arch with a monopolar electro-knife. In our patients col-
lective, only three patients reported of postoperative
hemorrhage (1.67%) of any intensity. One patient required
surgical revision due to severe but not life-threatening bleed-
ing, while the other two patients suffered from self-limiting
minor bleedings. Windfuhr et al. [16] reported in a literature
review a risk of 0.2% (range 02.5%) of post-tonsillotomy
hemorrhage seeking operative intervention. However, as these
two bleeding events in our patients did not require medical
intervention they probably would have not been documented
in most studies. None of these bleeding events were fatal. The
bleeding rate we observed constitutes a low risk of bleeding
in comparison with tonsillectomy that lies within the range of
previous study results [4,16].
Still, the benefit of TO for patients suffering from chronic
tonsillitis is still unclear. Ericsson et al. compared TE and
TO in previous studies. The group showed, despite a lower
sample size, equal benefits concerning health-related quality
of life, recurrent infections, snoring, and behavior [11,12].
Not only health-related but also socio-economic benefits
favor TO. Stelter et al. showed a significant benefit for
4 E. FOKI ET AL.
children concerning physical health, learning, and vitality
after laser- and radiofrequency tonsillotomy [6]. In this pro-
spective, double-blind trial, one patient of 26 (3.9%) had to
undergo definitive tonsillectomy after primary tonsillotomy
[6]. A recent retrospective register-based study of Odhagen
et al. in over 27,000 patients showed a seven-times higher
risk for a second tonsil-surgery for patients who had under-
gone tonsillotomy than for patients who had had tonsillec-
tomy before (0.6% versus 3.9%). However, the only
significant reason for re-operation was recurrent upper air-
way obstruction. In cases of recurrent tonsillitis, no signifi-
cant difference between the two groups could be detected
[17]. In a recent literature review, Windfuhr et al. calculated
a rate of re-operation of 1.7% in 6106 patients undergoing
previous tonsillotomy [16]. In our study, 1.11% of the chil-
dren had to be treated by definitive tonsillectomy. This dif-
ference might be due to the differing patient numbers;
however, it indicates that the effectiveness of tonsillotomy is
very high.
In our study population, patients with recurrent tonsillitis
benefit substantially from tonsillotomy. Only 9.8% of the
patients with chronic recurrent tonsillitis suffered from an
infection after tonsillotomy (mean follow-up period: 2.10
years). Interestingly, all of those patients had more than four
episodes of acute tonsillitis per year before the surgery (five,
six, eight, nine, and 12 episodes per year), indicating that
the risk of re-infection increases with the frequency of pre-
operative episodes of acute infections. In the present study,
39 (21.67%) patients suffered from minimum four episodes
of acute tonsillitis per year before the surgery. Nevertheless,
using those 39 patients for calculation, the re-infection risk
was 12.82%.
Burton et al. published a meta-analysis about the existing
evidence of surgical versus non-surgical treatment of chronic
tonsillitis. They concluded that more severely affected
patients benefit from tonsillectomy in contrast to less
affected patients, in whom the spontaneous healing rate
equals the effect of tonsillectomy [18]. In our study, the rate
of infections decreased substantially in patients, showing
that those patients with a high frequency of acute tonsillitis
profit equally from surgery than those with a lower fre-
quency of recurrent infections.
Children undergoing tonsillotomy due to obstructive
symptoms did not suffer from an increased rate of tonsillar
infections after surgery, which is consistent with a prospect-
ive study of Reichel et al. [19] in 113 children undergoing
TO or TE.
In our retrospective analysis, the follow-up period was
2.8 years ( 1.4 years, range 0.329.18 years), which provides
sufficient evidence for the effect of tonsillotomy on symp-
tom relief. This theory is supported by a study of Burton
et al., which showed that the beneficial effect of tonsillotomy
started immediately after the surgery [18].
Interestingly, all children suffering from recurrent throat
infections regularly receive antibiotic treatment. However,
this could be a bias due to the retrospective nature of this
study resulting in an inaccuracy considering treatment of
recurrent throat infections. Prospective, randomized trials of
established routines are difficult to conduct for practical
reasons, as it was shown in the study from the group of
Van Staaj [20] in 2004.
Another possible cause could be that retrospective differ-
entiation between severe throat infections and acute tonsil-
litis is challenging for parents. However, all parents could
clearly specify that the surgery was beneficial for their
children.
Conclusions
In this retrospective survey, we could show that children
with recurrent antibiotic-requiring tonsillitis benefit substan-
tially from tonsillotomy, which might be explained by a
reduction of MALT-tissue. The rate of re-infection, anti-
biotic intake, and risk of postoperative hemorrhage were
very low. Taking into concern that tonsillotomy harbors
much less postoperative risks than tonsillectomy, it should
be considered tonsil surgery of choice for recurrent infec-
tions of the tonsils.
Disclosure statement
No potential conflict of interest was reported by the authors.
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