To Evaluate the Indications for Adenotonsillectomy Surgery and the Quality-of-Life Post-Surgery- A Descriptive, Cross-Sectional Study

Abstract

Aim

To determine the indications of adenotonsillectomy and to evaluate the quality-of-life post-adenotonsillectomy surgery.

Materials and Methods

This is a descriptive cross-sectional study done in the department of ENT, Indira Gandhi Medical College and Research Institute (IGMCRI), Puducherry among patients who underwent adenotonsillectomy surgery from the year 2015 to 2022. The data regarding their clinical profile and indications for surgery were collected from the medical case records and these patients were contacted through telephone to know their quality of life using a standardized questionnaire.

Results

A total of 98 patients were included in the study, 43 males and 55 females, between the age of 4 to 48 years. Adenotonsillitis (infection) was the indication for adenotonsillectomy in 69 out of 98 patients (70.4%), and Adenotonsillar hypertrophy (Obstruction) in 29 out of 98 patients (29.5%). Postoperatively, the symptoms like frequency of episodes of throat pain had decreased from 6.162.08 to 1.240.44 (p<0.001), snoring (72–1%), mouth breathing (70.4–3.1%), average number of doctor visits due to throat pain (3.911.44 to 1) and average number of days absent to school/ work (3.81 1.26 to nil) had decreased significantly.

Conclusion

Adenotonsillitis (Infection) as an indication is more common than adenotonsillar hypertrophy (Obstruction) for performing adenotonsillectomy in our study. Majority of the patient’s symptoms had markedly decreased post-surgery and hence a significant improvement in overall quality of life, both physical and general well-being.

Supplementary Information

The online version contains supplementary material available at 10.1007/s12070-023-04113-5.

Introduction

Adenotonsillectomy is one of the commonest surgical procedures performed by Otorhinolaryngologists world over and the most common indications being recurrent tonsillitis and obstructive sleep apnea syndrome [1]. The surgical management of diseases involving adenoids and tonsils, i.e., adenotonsillectomy is indicated only when they interfere with the patient’s quality of life.

Acute, chronic or recurrent tonsillitis not only affects the patient’s physical well-being but also increases the healthcare visits leading to absenteeism from school or work, and thus affecting the quality of life [2]. Similarly, sleep-disordered breathing causes excessive daytime sleepiness and altered circadian rhythms may affect education, employment, and interpersonal relations, thus significantly impairing the quality of life, especially in relation to functional capacity, health, and sensation of well-being [3].

However, these surgical indications have changed over the years in different parts of the world; infection was once the predominant indication for adenotonsillectomy, whereas now obstruction secondary to adenotonsillar hypertrophy is the primary indication [4]. Thus, when adenotonsillectomy is performed for the appropriate indications, it contributes to the improvement in quality of life [5].

Although adenotonsillectomy is a very common surgery, there are very few studies in the literature on the indications of the surgery and the quality-of-life post-surgery in India, especially in the southern part of India. With this background, we aim to determine the indications of adenotonsillectomy and to evaluate the quality-of-life post-adenotonsillectomy surgery.

Methods

This is a descriptive cross-sectional study done in the department of ENT, Indira Gandhi Medical College and Research Institute (IGMCRI), Puducherry from September 2021 to August 2022 after obtaining institute ethics committee approval. All the patients who underwent adenotonsillectomy surgery from the year 2015 to 2020 in IGMC&RI were recruited into the study after obtaining voluntary informed consent.

Their demographic data, contact details, indications for surgery, questions pertaining to the quality of life, and findings were collected from the medical case records.

The patients were contacted through telephone, and they were interviewed after obtaining their consent. They were asked questions about their quality-of-life post-adenotonsillectomy using a standardized questionnaire adapted from the Centre for disease control and Prevention Health-Related Quality of Life (CDC HRQOL4) measures. The questions were modified according to the specific nature of our study & were validated by the experts in the field of Otorhinolaryngology.

Inclusion Criteria:

All the patients who underwent adenotonsillectomy from the year 2015 to 2022 in IGMCRI were recruited into the study.

Exclusion Criteria:

Patients who couldn’t be contacted for more than 3 calls and who were not willing to participate in the study were excluded from the study.

Statistical Analysis

Data entry was done in MS Excel 2010. The data analysis was done using SPSS version 16. Results are presented in the form of descriptive and inferential statistics. The continuous variables were represented in the form of mean and standard deviation. The categorical variables were summarized in percentages and proportions. Shapiro Wilk test and normal Q-Q plots was applied to check for normality. The findings between the groups were compared using the Chi-square test and Mann-Whitney U test. A P-value of less than 0.05 was considered statistically significant.

Results

A total of 98 medical case records of patients who underwent adenotonsillectomy /tonsillectomy in our Institute between 2015 and 2020 were reviewed, and their details were collected and analyzed.

Clinical Profile

Demographic Results

There was a total of 43 males and 55 females (Fig. 1), and the age ranged between 4 years to 48 years, with a median age of 7 for males and 13 for females.

Fig. 1.

Pie chart showing gender distribution

In our study, we divided the study participants broadly into 2 groups based on age:

Group 1 comprising of Age 12 years (children) and

Group 2 comprising of Age > 12 years, i.e., from 13 and above (adolescents and adults).

In group 1, there were 34 males and 26 females; in group 2, there were 9 males and 29 females (Fig. 2).

Fig. 2.

Age and Gender distribution

Symptoms (summarized in Table 1):

1. Throat Pain:69 out of 98 (70.4%) patients had throat pain, among which 41(59.4%) were from group 1 (children) and 28 (40.6%) were from group 2 (adults and adolescents) and the average number of episodes per year were 6.162 0.08.

2. History of frequent URTI was present only in 22 out of 98(22.4%) patients, among which 14(63.6%) were from group 1, and 8 (36.4%) were from group 2.

3. History of mouth breathing was present in 69 out of 98(70.4%) patients, 56 (81.2%) from group 1 and 13 (18.8%) from group 2. History of snoring was present in 72 out of 98(73.4%) patients, 58 (80.6%) from group 1 and 14 (19.4%) from group 2 and there was a significant association between the two age groups and the above-mentioned symptoms (P < 0.001).

4. History of dysphagia was seen only among 30 patients (30.6%), 22(73.3%) from group 1 and 8(26.7%) from group 2.

5. History of hearing loss was seen only among a smaller number of patients, 3 out of 98 patients (1 from group 1 and 2 from group 2).

6. History of inattentiveness was noticed by the parents at home only among 2 out of 98 patients (1 from group 1 and 1 from group 2).

7. 70 out of 98 patients, 41(58.6%) from group 1 and 29(41.4%) from group 2 had history of hospital visits pertaining to tonsil and the average number of visits were 3.91 1.44.

8. History of absenteeism to school and work was seen among 44 patients, 33(75%) from group 1 and 11(25.0%) from group 2 for a duration of 3–5 days with average number of days absent to work/ school were 3.81 1.26), and there was a strong association between the age groups 1 and 2, i.e., it was observed higher among group 1 when compared to group 2.

9. History of hospitalization prior to pre-op admission concerning tonsils was seen only among 17 out of 98 patients and predominantly among group 2, 13(76.5%) from group 2 and 4(23.5%) from group 1.

Table 1.

Clinical profile of patients who underwent adenotonsillectomy/ tonsillectomy surgery in our study

History and symptoms	Number of patients based on age groups (n = 98)			P value
	Total (Out of 98)	Age 12 years (n = 60)	Age > 12 years (n = 38)
Throat pain	69 (70.4%)	41 (59.4%)	28(40.6%)	0.320
Frequent URTI	22 (22.4%)	14 (63.6%)	8(36.4%)	0.070
Snoring	72 (73.4%)	58 (80.6%)	14 (19.4%)	< 0.001
Mouth breathing	69 (70.4%)	56 (81.2%)	13(18.8%)	< 0.001
Dysphagia	30 (30.6%)	22 (73.3%)	8(26.7%)	0.102
Hearing loss	3 (3.06%)	1 (33.3%)	2(66.7%)	0.314
History of inattentiveness at home	2 (2.04%)	1(50.0%)	1(50.0%)	1.000(Fisher’s exact test)
Hospital visits pertaining to tonsil	70 (71.4%)	41(58.6%)	19(67.9%)	0.394
Hospitalization prior to pre-op admission	17 (17.3%)	2(23.5%)	13(76.5%)	< 0.001
History of absenteeism to school and work	44 (44.8%)	33(75.0%)	11(25.0%)	0.012

Indications for Adenotonsillectomy

In our study, we came across two main groups of indications for adenotonsillectomy, which were Group A: adenotonsillitis (Infection) and Group B: adenotonsillar tonsillar hypertrophy (Obstructive symptoms). Adenotonsillitis as an indication for adenotonsillectomy was seen among 69 out of 98 patients (70.4%), and adenotonsillar hypertrophy was seen among 29 out of 98 patients (29.5%) (Fig. 3).

Fig. 3.

Pie chart showing indications for adenotonsillectomy

Quality of Life Post Adenotonsillectomy: (Summarized in Table 2)

1. 90 out of 98 (91%) patients had improvement in overall general health after adenotonsillectomy surgery.

2. After adenotonsillectomy surgery, there was a marked reduction in the history of throat pain from 70.4% (69 out of 98) before surgery to 21.4% (21 out of 98) after surgery, both among group 1(children) from 68.3% (41 out of 98) to 20.0% (12 out of 98) and among the group 2 (adolescent and adult) from 73.7% (28 out of 98) to 23.7% (9 out 98). The average number of episodes of acute infection of the tonsils had also markedly decreased from 6.162.08 to 1.240.44.

3. History of frequent URTI episodes had also comparatively reduced from 22 out of 98 patients (22.4%),14(23.3%) from group 1 and 8(21.1%) from group 2 patients before surgery to 9 out of 98 (9.2%) with 6(10.0%) group 1 and 3(7.9%) group 2 patients after adenotonsillectomy.

4. History of hospital visits pertaining to tonsil had also evidently decreased from 71.4% (70 out of 98) before surgery with 41(68.3%) from group 1 and 29(76.3%) from group 2 patients to 13.2% (13 out of 98) after surgery with 7(11.7%) from group 1 and 5(13.1%) from group 2. Similarly, the average number of doctor visits had evidently reduced from 3.911.44 to 1 after adenotonsillectomy.

5. History of snoring had remarkably reduced post-surgery, i.e., 72 out of 98 patients (72%), 58(94.9%) from group 1 and 14(36.8%) from group 2 had history of snoring before surgery, whereas only 1(1%) out of 98 patients from group 1 had snoring post adenotonsillectomy.

6. Similarly, 69 out of 98 patients (70.4%) with 56(94.9%) group 1 and 13(34.2%) group 2 patients had history of mouth breathing before adenotonsillectomy which has markedly reduced to 3 out 98 patients (3.1%) with 1(1.7%) group 1 and 2(2%) group 2 patients’ post-surgery.

7. Patients with history of absenteeism to school had markedly decreased from 44.9% (44 out of 98) before surgery with 33(55.0%) group 1 and 11(28.9%) group 2 patients to 2% (2 out of 98) with 1(1.7%) group 1 and 1(2.0%) group 2 after adenotonsillectomy surgery.

Table 2.

Quality of life post adenotonsillectomy

History and symptoms	Number of patients with Frequency(n = 98)
	Before surgery		After surgery
Throat pain	69 (70.4%)		21(21.4%)
	Group1: 41(68.3%)	Group2: 28(73.7%)	Group1: 12(20.0%)	Group2: 9(23.7%)
Frequent URTI	22(22.4%)		9(9.2%)
	Group1: 14(23.3%)	Group2: 8(21.1%)	Group1: 6(10.0%)	Group2: 3(7.9%)
Hospital visits due to throat pain	70(71.4%)		13(13.2%)
	Group1: 41(68.3%)	Group2: 29(76.3%)	Group1: 7(11.7%)	Group2: 5(13.1%)
Snoring	72(72%)		1(1%)
	Group1: 58(94.9%)	Group2: 14(36.8%)	Group1: 1(1%)	Group2: Nil
Mouth breathing	69(70.4%)		3(3.1%)
	Group1: 33(55.0%)	Group2: 13(34.2%)	Group1: 1(1.7%)	Group2: 2(2%)
Absenteeism to school/work	44(44.9%)		2(2%)
	Group1: 33(55.0%)	Group2: 11(28.9%)	Group1: 1(1.7%)	Group2: 1(2.0%)

Quality of life post adenotonsillectomy between Group A (adenotonsillitis) and Group B (adenotonsillar hypertrophy) (Summarized in Table 3):

1. Among group A, 64 out of 68 patients (92.7%), and among group B, 26 out of 29 patients (90%) had improvement in overall general health, i.e., both the groups had improvement in overall general health post adenotonsillectomy, and there is no much difference among the 2 groups.

2. 17 out of 69 patients (24.6%) among group A and 4 out of 29 patients (13.7%) among group B had history of throat pain post adenotonsillectomy. i.e., History of throat pain was seen comparatively more among group A than group B post adenotonsillectomy.

3. 11 out of 69 (15.9%) from group A and 1 out of 29 (3.4%) from group B had visited a doctor due to throat pain post adenotonsillectomy surgery, i.e., history of doctor visits due to throat pain post adenotonsillectomy was comparatively more among group A.

4. Only 1 out of 69 patients (1.4%) from group A had history of snoring post adenotonsillectomy, and there was no history of snoring among group B post adenotonsillectomy.

5. 1 out of 69 (1.4%) from group A and 1 out of 29 (3.4%) from group B had history of mouth breathing post adenotonsillectomy, and it is very negligible among the 2 groups.

6. Only 2 out of 69 patients (2.8%) from group A had history of absenteeism to school post adenotonsillectomy, and there was no such history among group B post adenotonsillectomy.

Table 3.

Quality of life post adenotonsillectomy between chronic group A and group B

History and symptoms	Number of patients with Frequency(n = 98)
	Before Surgery		After Surgery
	Adenotonsillitis (n = 69) Group A	Adenotonsillar hypertrophy (n = 29) Group B	Adenotonsillitis (n = 69) Group A	Adenotonsillar hypertrophy (n = 29) Group B
Overall general health	Nil	Nil	64(92.7%)	26(90%)
Throat pain	69(100%)	Nil	17(24.6%)	4(13.7%)
Frequent URTI	18(26%)	4(13.7%)	7(10.1%)	2(6.8%)
Hospital visits concerning throat symptoms	68(98.5%)	2(6.8%)	11(15.9%)	1(3.4%)
Snoring	45(65.2%)	27(93.1%)	1(1.4%)	Nil
Mouth breathing	44(63.7%)	25(86.2%)	1(1.4%)	1(3.4%)
Absenteeism to school/work	44(63.7%)	Nil	2(2.8%)	Nil

Discussion

Infections involving tonsils have been known to mankind since the Hippocratic era (460 − 370 BC), and the literature is abundant with a variety of treatments for the same that includes both medical and surgical [6].

Medical treatment of adenotonsillitis involves mainly supportive care, including hydration, analgesics like NSAIDs for pain relief, and antibiotic therapy is preferred only for bacterial tonsillitis [7].

The two most common indications for adenotonsillectomy include infection (e.g., recurrent tonsillitis, peritonsillar abscess, tonsillolithiasis, and pharyngotonsillitis) and sleep-disordered breathing (a continuum from primary snoring to obstructive sleep apnoea syndrome) [8, 9].

There have been many trials since early the 1970s for improved understanding of the appropriate indications for adenotonsillectomy and have better defined the candidacy for adenotonsillectomy; one of the landmark trials is by Paradise et al. who defined an evidence-based criteria (Paradise criteria) with a primary purpose of determining the candidate populations for tonsillectomy [10].

The paradise criteria have been adopted worldwide by otolaryngologists and they optimized their own guidelines for the indications of adenotonsillectomy, e.g., The American Association of Otolaryngology and Head and Neck Surgery and The Scottish Intercollegiate Guidelines Network [11, 12].

Although there are many guidelines and criteria available worldwide for determining the appropriate indications and hence the good candidate for adenotonsillectomy; when it comes to a developing country like India, whether these criteria are being followed which can lead to improvement in quality of life is a big concern, and there are very few studies available in the literature from India. Hence, we chose to do this study.

In our study, Among the 98 patients, the age ranged from 4 to 42 years (55 females and 43 females) with 2 groups in our study, group 1 comprised of ages 12(Children), and group 2 comprised of age>12 (adolescents and adults) and this age limit has been derived from American academy of pediatrics [13].

Among the total 98 patients in our study, history of throat pain (70.4%), snoring (73.4%), and mouth breathing (70.4%) were the most prevalent symptoms, out of which snoring and mouth breathing were predominant among group 1 (Age 12 years) which is in accordance with the study done by K. Shamboul et al., 2001 [13] where among their 120 patients, the most prevalent symptom was recurrent sore throat (96%) and snoring (51.7%) however, the distribution among different age groups weren’t mentioned in the same.

In a study done by Mohd Nazir Othman et al., [15] 2016 among 29 children aged 3–12 years and Juliana Alves Sousa et al., 2020 [16] among 51 children between 3 and 13 years, snoring was the most prevalent primary symptom (32% and 100% respectively) which is in accordance with our study where snoring and mouth breathing were the predominant symptoms among group 1, i.e., age 12 years (80.6% & 81.2%).

Our study had history of hospital visits concerning tonsils between group 1 (58.6%) and 2 (67.9%) was almost the same, with an average number of hospital visits were 3.91 ± 1.44 days which is similar to the Indian studies done by Santosh Kumar Swain et al., 2020 [17] and Soheila et al., 2011 [18] where average number of hospital visits were 5.10 and 5.6 respectively. Similarly, the average number of days absent from school or work in our study was 3.81 1.26, which is almost similar to the previously done studies by Santosh Kumar Swain et al., 2020 and Soheila et al., 2011 [17, 18].

In our study, history of hospitalization prior to preoperative hospital admission concerning tonsils was present among 17 out of 98 patients and was seen predominantly among group 2, age > 12 years (76.5%), and group 1, age 12 years (23.5%). However, this aspect has to be studied further to come to a conclusion as to why adults and adolescent age groups have more history of hospitalization than children, as this hasn’t been dealt with in any of the studies.

Indications of Adenotonsillectomy

In our study, infection involving the adenoids and tonsils (70.4%) as an indication was more than obstructive symptoms (29.4%) as an indication for adenotonsillectomy which was seen in other studies as K. Shamboul et al., 2001 [14] in Sudan among 120 patients aged 3–50 years where exudative tonsillitis (3 or more in one year) (72.5%) was more than upper airway obstruction (16.7%) as an indication for adenotonsillectomy.

In a study done by Jeng-Wen Chen et al., 2018 [19] in Taiwan recurrent tonsillitis remained the most common indication in all ages from 1997 to 2010 (83.3–57.0%) followed by upper airway obstruction (46–24%), which is in accordance with our study.

In a study done by Farah L. Lokman et al., 2020 [20] in Malaysia recurrent tonsillitis (60%) was the main indication, followed by sleep-disordered breathing (36%), which is in accordance with our study.

However, There are Other Studies from Other Parts of the World that Had Results Different from Our Studies Which Include

A cross-sectional survey done by Britt K. Erickson et al., 2009 [21] in Minnesota showed upper airway obstruction as an indication has increased over the years from 12% in 1970 to 77% in 2005, a study done by Noah P. Parker et al., 2010 [22] in Chicago, USA, among 302 patients aged 5 months to 18 years had Obstruction as an indication more common in both children, aged 4–10 years (91.9%) and Adolescents, aged 11–18 years (84.6%) than infection which were only 13.4% (children) and 33.3% (Adolescents) respectively and a study done by AO Ahmed et al., 2013 [4] in Nigeria showed that a total of 68.7% had obstruction as an indication while infection accounted only 31.3% of the indications for surgery which were not the case in our study.

Another study done by Dini Atiyah et al., 2015 [5] in Indonesia among 207 patients ranged 2 to 53 years had infection as an indication in 51.2% and obstruction as an indication in 48.3% for adenotonsillectomy, although infection was more compared to obstruction as an indication both are almost equal whereas it is not the same with our study.

The indications of adenotonsillectomy vary in different parts of the world may be because of 2 reasons:

1. There may be a change in trend over the years but we need more studies to follow it up.

2. The eastern part of the world and the western part of the world may have different distribution, i.e., recurrent infections of the adenoids and tonsils remain the most common indication for adenotonsillectomy and these results are probably due to either lack of awareness among pediatricians and otolaryngologists of the symptoms of SDB or the difficulty in diagnosing OSA in the pediatric population, especially in the developing countries.

Quality of Life Post Adenotonsillectomy Surgery

Any surgical interventional procedure has to be evaluated by assessing the quality of life of the patients who underwent the procedure to know the outcome and Adenotonsillectomy, when performed for appropriate indications, is believed to cause improvement in quality of life.

Various Studies Done Across the World Which had Significant Improvement in Quality-of-Life Post Adenotonsillectomy, Which is in Accordance with Our Study Include

A study done by O.A. Aflolabi et al., 2009 [23] in Nigeria, which assessed parental satisfaction post adenotonsillectomy showed almost 96.6% of the parents were satisfied, i.e., the preoperative symptoms had improved postoperatively, whereas only 3.4% weren’t satisfied which is in accordance with our study.

Similarly, a study done by Soheila et al., 2011 [18] in Iran had significant improvement in overall quality of life, i.e., the frequency of tonsillitis per year had decreased from 8.33 to 1.41, Days off work/ school had decreased from 8.78 to 0.61, doctor visits had decreased from 5.6 to 0.4 and feelings of well-being had improved from 0.5 to 8.09 which were in accordance with our study.

Another study done by Mohd Nazir Othman et al., 2016 [15] in Malaysia using OSA-18 scores showed that there was a significant improvement in quality-of-life post-surgery, i.e., the total OSA-18 scores significantly decreased from 57.5 preoperatively to 28.5 postoperatively, and both the results are in accordance with our study in terms of improvement in quality of life, although we didn’t evaluate the severity of OSA.

Various Studies Done Across Different Parts of India Which had Significant Improvement in Quality-of-Life Post Adenotonsillectomy, Which is in Accordance with Our Study Include

A study done by Uptal Sharma et al., 2018 [24] in New Delhi, India using OSA 18 scores and Rutter children’s behavior questionnaire showed that the mean score of OSA 18 and total RCBQ decreased significantly 6 months post-surgery (mean score of OSA decreased from 4.2 ± 1.4 to 1.19 ± 0.12 and RCBQ decreased from 20.5 ± 2 to 7.4 ± 2.55) and this result is in accordance with our study.

Similarly, a study done by B. Ramya et al., 2016 [25] in Bangalore using 3 of the 6 features of tonsil and adenoid health status instruments showed that there was a statistically significant reduction in the total symptom score of children post adenotonsillectomy in terms of recurrent tonsillitis, airway/sleep and eating/swallowing disturbances which is in accordance with our study.

Another study done by Santosh kumar Swain et al., 2020 [17] in Odisha showed a significant improvement in quality-of-life post-adenotonsillectomy, i.e., the mean score of frequency of throat pain per year had decreased from 7.45 to 1.35, Absent from work/ school had decreased from 8.50 to 0.58, doctor visits had decreased from 5.10 to 0.32, sleep apnea per night had decreased from 3.02 to 0.01 and feelings of well-being had improved from 0.51 to 8.08 which were in accordance with our study.

Comparison of Quality-of-Life Post Adenotonsillectomy Between Chronic Adenotonsillitis (Group A) and Chronic Adenotonsillar Hypertrophy (Group B)

In our study, we went ahead and compared the quality-of-life post-adenotonsillectomy surgery between the 2 groups, group A and group B. Among the 2 groups, we found that history of throat pain was seen comparatively more among group A (24.6%) than Group B (13.7%), history of hospital visits was seen more among group A (15.9%) compared to group B (3.4%) whereas the percentage of patients who had other history & symptoms like frequent URTI, snoring, mouth breathing and absenteeism to school/work were either negligible or absent and so cannot be compared. Hence, we need further studies with a larger population to be able to compare the 2 groups and see whether there is any difference in quality-of-life post adenotonsillectomy between patients who were operated for chronic adenotonsillitis and chronic adenotonsillar hypertrophy.

Conclusion

Our descriptive study on patients who underwent adenotonsillectomy surgery showed that adenotonsillectomy surgery is being done more commonly among children, i.e., age 12 years, than adults and adolescents. Infection involving adenoids and tonsils (chronic adenotonsillitis) as an indication is more common than obstructive symptoms (Chronic adenotonsillar hypertrophy) for performing adenotonsillectomy in our study. Majority of the patient’s symptoms, like frequency of throat pain episodes, snoring, mouth breathing, average number of doctor visits due to throat pain and average number of days absent to school/ work, had decreased postoperatively and an improvement in overall general health resulting in significant improvement in overall quality of life, both physical and general well-being.

Electronic Supplementary Material

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Authors Contribution

All authors contributed to the study conception and design. Material preparation, data collection and analysis were performed by [Abinaya Rajendiran], [Sophia Amalanathan]. The first draft of the manuscript was written by [Abinaya Rajendiran] and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript.

Conceptualization: [Abinaya Rajendiran], [Sophia Amalanathan]; Methodology: [Abinaya Rajendiran], [Sophia Amalanathan] [Kumaran Alias Ramesh Colbert]; Formal analysis and investigation: [Abinaya Rajendiran], [Sophia Amalanathan] [Kumaran Alias Ramesh Colbert] [Satish Kumar]; Writing - original draft preparation: [Abinaya Rajendiran]; Writing - review and editing: [Abinaya Rajendiran], [Sophia Amalanathan] [Kumaran Alias Ramesh Colbert] [Satish Kumar].

Declarations

The authors have no relevant financial or non-financial interests to disclose.

Competing Interests

The authors have no competing interests to declare that are relevant to the content of this article.

All authors certify that they have no affiliations with or involvement in any organization or entity with any financial interest or non-financial interest in the subject matter or materials discussed in this manuscript.

The authors have no financial or proprietary interests in any material discussed in this article.

Ethical Approval

Ethical clearance for the study was obtained from the Institute Ethical committee.

Consent to Participate

Informed written consent was obtained from all the participants/ parents included in the study.

Consent to Publish

Patients have consented regarding publishing their data.