Abstract
Background and Objectives
Although adenotonsillectomy (ATE) is widely accepted for obstructive sleep apnea and recurrent tonsillitis, its effectiveness in reducing respiratory tract infections (RTIs) remains a topic of debate. This nationwide population-based cohort study evaluated the association between ATE and the incidence of upper and lower RTIs in pediatric patients.
Methods
Data were obtained from the Korean National Health Insurance Service sample cohort for 2010–2017. Children who underwent ATE were identified and matched with nonsurgical controls at a 1:5 ratio by age and sex. Hospital visits due to RTIs—including acute upper RTIs, influenza or pneumonia, and acute lower RTIs—were assessed from 1 year before surgery through 3 years after surgery. The odds of hospital visits were estimated using multivariable logistic regression, with odds ratios and 95% confidence intervals.
Results
A total of 6,848 children who underwent ATE and 34,240 matched controls were included. Compared with the matched nonsurgical control group, the ATE group had higher odds of hospital visits due to upper and lower RTIs, whereas no significant difference was observed for pneumonia. Age-stratified analyses showed that lower RTIs increased first in younger children and later in older age groups during follow-up. Sex-stratified analyses showed increased lower RTIs in boys during postoperative years 1–2 and increased influenza or pneumonia in girls during postoperative years 2–3. Postoperative increases in RTIs were more pronounced among children without preoperative infection histories.
Conclusion
ATE was not associated with fewer RTIs in pediatric patients. Instead, certain subgroups had a higher incidence of upper and lower RTIs after surgery. These findings suggest that ATE may have limited effectiveness in preventing RTIs and should not be performed solely for this purpose.
Keywords: Adenotonsillectomy, Respiratory tract infection, Pediatric, National cohort study
INTRODUCTION
Acute upper and lower respiratory tract infections (RTIs) are among the most common diagnoses in pediatric primary care [1,2]. Children aged 0–6 years frequently experience recurrent episodes of the common cold and pharyngitis throughout the year [3]. Most acute RTIs resolve spontaneously with conservative medical management. However, when infections are unusually frequent or recurrent, surgical interventions such as adenotonsillectomy (ATE) may be considered.
Because recurrent acute RTIs are associated with greater healthcare utilization and socioeconomic burden, clinicians have long questioned whether removing the tonsils and adenoids—key components of mucosal immunity involved in early pathogen recognition and initiation of immune responses—can reduce RTI frequency [4]. Although ATE is one of the most commonly performed pediatric surgical procedures worldwide [5], its clinical effectiveness in reducing acute RTI incidence remains unclear. Long-term follow-up data on postoperative acute RTI occurrence are also limited, and this question remains unresolved.
A previous retrospective cohort study reported fewer outpatient visits due to upper RTIs among children who underwent ATE than among controls [6]. In contrast, a randomized controlled trial of children aged 1–6 years with recurrent upper RTIs compared ATE with conservative management over 24 months and found no significant differences in RTI frequency or quality of life between the groups [7]. Moreover, a long-term follow-up study suggested that removal of immune-related lymphoid tissues, such as the adenoids or tonsils, during childhood may increase the long-term risk of upper respiratory infections and allergic diseases [8].
Accordingly, the 2019 clinical practice guidelines from the American Academy of Otolaryngology-Head and Neck Surgery define the primary indications for ATE as sleep-disordered breathing and moderate-to-severe recurrent tonsillitis, whereas recurrent RTIs alone are not considered a principal indication for surgery [9]. Previous nationwide cohort studies using the Korean National Health Insurance Service (NHIS) database have primarily focused on upper RTIs or asthma-related outcomes after ATE [10,11]. However, the effects of ATE on both upper and lower RTIs, as well as potential differences according to age, sex, and preoperative infection history, remain incompletely understood. Therefore, the present study aimed to provide a more comprehensive evaluation of postoperative respiratory infection risk using a nationwide population-based cohort.
METHODS
Data source and study population
This study used the NHIS sample cohort database, a nationwide population-based database. Pediatric participants were randomly selected from the cohort between 2010 and 2017. Children who underwent ATE were identified and compared with children who did not undergo tonsillectomy or adenoidectomy.
Children in the ATE group were matched with controls at a 1:5 ratio by age and sex. For subgroup analyses, participants were further stratified into three age groups: 0–4, 5–9, and 10–14 years. The study followed the Declaration of Helsinki and was approved by the Institutional Review Board (IRB No. SCHCA 2019-12-007). The requirement for informed consent was waived because the study used anonymized secondary data from a national administrative database.
Outcome measures
To compare upper and lower RTI occurrence between the surgical and control groups, hospital visits related to RTIs were assessed during the 1-year period before the index date and during each of the 3 postoperative years. Diagnoses were classified according to the International Classification of Diseases, 10th Revision, and categorized as acute upper RTIs (J01–J06, including acute sinusitis, acute pharyngitis, acute tonsillitis, acute laryngitis and tracheitis, acute epiglottitis and croup, and unspecified upper respiratory infections), influenza or pneumonia (J09–J18), and acute lower RTIs (J20–J22, including acute bronchitis, acute bronchiolitis, and unspecified lower respiratory infections).
Statistical analyses
Baseline characteristics were compared between the ATE and control groups using Student’s t-test for continuous variables and the chi-square test for categorical variables. Multivariable logistic regression analyses were performed to compare hospital visits due to RTIs before and after surgery between the ATE group and the matched nonsurgical control group. Using the nonsurgical group as the reference, odds ratios (ORs) and 95% confidence intervals (CIs) were calculated. Covariates included age, sex, insurance premium quintile, and prior healthcare utilization for each respiratory condition during the 1-year period before the index date. Additional subgroup analyses were performed according to age group, sex, and preoperative infection history. All statistical analyses were performed using SAS software version 9.4 (SAS Institute). A two-sided p-value <0.05 was considered statistically significant.
RESULTS
Baseline characteristics
Table 1 summarizes the demographic characteristics of pediatric patients who underwent ATE between 2010 and 2017 and those of the control group. A total of 6,848 children were included in the ATE group, and 34,240 children were selected for the control group through 1:5 matching by age and sex. The distributions of sex, age, and insurance premium quintiles were comparable between the ATE and control groups.
Table 1.
Demographic characteristics of control and adenotonsillectomy patients
| Variables | Control (n=34,240) | ATE (n=6,848) | p-value |
|---|---|---|---|
| Age (yr) | >0.9999 | ||
| 0–4 | 4,250 (12.41) | 850 (12.41) | |
| 5–9 | 22,070 (64.46) | 4,414 (64.46) | |
| 10–14 | 7,920 (23.13) | 1,584 (23.13) | |
| Male sex | 20,775 (60.67) | 4,155 (60.67) | >0.9999 |
| Household income, ≤20% | 4,269 (12.47) | 833 (12.16) | 0.4866 |
| Clinic visit, 1 year before surgery | |||
| Acute upper respiratory infection | 24,244 (70.81) | 5,380 (78.56) | <0.0001 |
| Influenza and pneumonia | 3,488 (10.19) | 870 (12.70) | <0.0001 |
| Acute lower respiratory infection | 23,468 (68.54) | 4,948 (72.25) | <0.0001 |
Data are presented as n (%).
Comparison of hospital visits before and after surgery
Compared with matched nonsurgical controls, children in the ATE group had higher odds of hospital visits due to both upper and lower RTIs (Fig. 1). Children who underwent ATE had significantly higher odds of acute upper RTIs at 1–2 years (OR: 1.063; 95% CI: 1.004–1.125) and 2–3 years (OR: 1.061; 95% CI: 1.005–1.120) after surgery. The odds of acute lower RTIs were also significantly higher throughout follow-up, including within 1 year (OR: 1.072; 95% CI: 1.007–1.140), 1–2 years (OR: 1.104; 95% CI: 1.042–1.171), and 2–3 years (OR: 1.078; 95% CI: 1.002–1.160) after surgery. No significant association was observed for influenza or pneumonia.
Fig. 1.
Forest plot of odds ratios (ORs) and 95% confidence intervals (CIs) for RTIs after adenotonsillectomy compared with matched nonsurgical controls. RTI, respiratory tract infection.
In the age-stratified analysis (Table 2), higher odds of lower RTI-related hospital visits were observed in the 0–4-year age group during the first and second postoperative years. During postoperative years 1–2, higher odds of lower RTIs persisted in the 5–9-year age group. During postoperative years 2–3, significantly higher odds of lower RTIs were observed in the 10–14-year age group.
Table 2.
Odds ratios and 95% confidence intervals for acute upper respiratory infection, influenza and pneumonia, and acute lower respiratory tract infection within 3 years after adenotonsillectomy according to age groups
| Age | Disease group | Post-surgery, within 1 year | Post-surgery, 1–2 year | Post-surgery, 2–3 year |
|---|---|---|---|---|
| 0–4 years | Acute upper respiratory infection | 1.066 (0.866–1.311) | 1.200 (0.996–1.444) | 1.123 (0.954–1.322) |
| Influenza and pneumonia | 1.106 (0.904–1.353) | 1.046 (0.838–1.305) | 1.048 (0.809–1.357) | |
| Acute lower respiratory infection | 1.308 (1.033–1.656)* | 1.337 (1.081–1.654)* | 1.193 (0.997–1.426) | |
| 5–9 years | Acute upper respiratory infection | 1.038 (0.962–1.119) | 1.078 (1.005–1.158)* | 1.048 (0.980–1.121) |
| Influenza and pneumonia | 1.060 (0.940–1.197) | 1.007 (0.876–1.156) | 1.111 (0.953–1.295) | |
| Acute lower respiratory infection | 1.061 (0.983–1.146) | 1.083 (1.008–1.164)* | 1.047 (0.978–1.120) | |
| 10–14 years | Acute upper respiratory infection | 1.001 (0.892–1.123) | 0.979 (0.875–1.096) | 1.069 (0.956–1.195) |
| Influenza and pneumonia | 1.005 (0.715–1.414) | 0.844 (0.571–1.247) | 1.074 (0.689–1.674) | |
| Acute lower respiratory infection | 1.040 (0.926–1.168) | 1.093 (0.976–1.225) | 1.122 (1.002–1.257)* |
p<0.05.
Sex-stratified analysis
In the sex-stratified analysis (Table 3), higher odds of lower RTIs were observed in boys during postoperative years 1–2. In contrast, higher odds of influenza or pneumonia were observed in girls during postoperative years 2–3.
Table 3.
Odds ratios and 95% confidence intervals for acute upper respiratory infection, influenza and pneumonia, and acute lower respiratory tract infection within 3 years after adenotonsillectomy stratified by sex
| Sex | Disease group | Post-surgery, within 1 year | Post-surgery, 1–2 year | Post-surgery, 2–3 year |
|---|---|---|---|---|
| Male | Acute upper respiratory infection | 1.037 (0.960–1.120) | 1.056 (0.982–1.136) | 1.051 (0.981–1.126) |
| Influenza and pneumonia | 1.046 (0.922–1.187) | 0.942 (0.815–1.088) | 1.001 (0.848–1.182) | |
| Acute lower respiratory infection | 1.083 (1.000–1.173) | 1.151 (1.068–1.241)* | 1.126 (1.048–1.210) | |
| Female | Acute upper respiratory infection | 1.015 (0.921–1.118) | 1.072 (0.978–1.174) | 1.075 (0.986–1.172) |
| Influenza and pneumonia | 1.099 (0.937–1.289) | 1.111 (0.929–1.329) | 1.244 (1.023–1.512)* | |
| Acute lower respiratory infection | 1.055 (0.957–1.164) | 1.038 (0.946–1.138) | 1.010 (0.926–1.103) |
p<0.05.
Analysis according to preoperative infection history
In the analysis stratified by preoperative infection history (Table 4), children without a prior history of pneumonia or lower RTIs had higher odds of new hospital visits for pneumonia and lower RTIs within the first postoperative year. Among children without a history of pneumonia before surgery, the incidence of both upper and lower RTIs increased during postoperative years 1–2, whereas only lower RTIs showed a significant increase during postoperative years 2–3. Similarly, among children without a prior history of lower RTIs, both upper and lower RTIs increased during postoperative years 2–3.
Table 4.
Odds ratios and 95% confidence intervals for acute upper respiratory infection, influenza and pneumonia, and acute lower respiratory tract infection within 3 years after adenotonsillectomy according to preoperative infection status
| Preoperative infection status | Disease group | Post-surgery, within 1 year | Post-surgery, 1–2 years | Post-surgery, 2–3 years |
|---|---|---|---|---|
| Acute upper respiratory infection | ||||
| No | Acute upper respiratory infection | 1.022 (0.913–1.144) | 0.985 (0.879–1.105) | 1.119 (0.989–1.254) |
| Influenza and pneumonia | 1.085 (0.833–1.414) | 1.119 (0.837–1.496) | 1.204 (0.877–1.654) | |
| Acute lower respiratory infection | 1.038 (0.915–1.176) | 1.124 (0.996–1.268) | 1.094 (0.972–1.230) | |
| Yes | Acute upper respiratory infection | 1.034 (0.962–1.111) | 1.091 (1.021–1.165)* | 1.046 (0.984–1.112) |
| Influenza and pneumonia | 1.046 (0.940–1.165) | 0.969 (0.858–1.095) | 1.061 (0.924–1.218) | |
| Acute lower respiratory infection | 1.053 (0.981–1.131) | 1.066 (0.997–1.140) | 1.045 (0.981–1.113) | |
| Influenza and pneumonia | ||||
| No | Acute upper respiratory infection | 1.019 (0.956–1.087) | 1.068 (1.006–1.135)* | 1.058 (0.999–1.121) |
| Influenza and pneumonia | 1.099 (0.974–1.240) | 1.001 (0.873–1.146) | 1.089 (0.934–1.271) | |
| Acute lower respiratory infection | 1.075 (1.007–1.147)* | 1.093 (1.028–1.163)* | 1.074 (1.013–1.139) | |
| Yes | Acute upper respiratory infection | 1.079 (0.889–1.310) | 0.976 (0.822–1.160) | 1.052 (0.899–1.232) |
| Influenza and pneumonia | 0.999 (0.842–1.186) | 1.008 (0.827–1.229) | 1.097 (0.879–1.369) | |
| Acute lower respiratory infection | 0.951 (0.773–1.170) | 1.132 (0.938–1.367) | 1.046 (0.883–1.239) | |
| Acute lower respiratory infection | ||||
| No | Acute upper respiratory infection | 1.030 (0.925–1.146) | 1.025 (0.924–1.137) | 1.123 (1.015–1.243)* |
| Influenza and pneumonia | 0.931 (0.716–1.210) | 1.008 (0.763–1.333) | 0.778 (0.545–1.111) | |
| Acute lower respiratory infection | 1.186 (1.071–1.313)* | 1.108 (1.000–1.228) | 1.192 (1.076–1.320)* | |
| Yes | Acute upper respiratory infection | 1.014 (0.942–1.091) | 1.065 (0.995–1.141) | 1.027 (0.963–1.094) |
| Influenza and pneumonia | 1.077 (0.967–1.198) | 0.991 (0.877–1.121) | 1.138 (0.994–1.304) | |
| Acute lower respiratory infection | 1.012 (0.938–1.093) | 1.102 (1.027–1.184)* | 1.035 (0.971–1.105) | |
p<0.05.
In contrast, among children with a preoperative history of infection, higher odds were observed only for the corresponding infection category—upper or lower RTIs—during postoperative years 1–2.
DISCUSSION
ATE is one of the most frequently performed surgical procedures in children; however, its indications for preventing RTIs remain uncertain. Although obstructive sleep apnea and recurrent infections of the tonsils or adenoids are widely accepted indications, the effectiveness of ATE for controlling upper and lower RTIs has not been sufficiently established.
Several large-scale cohort studies have evaluated the association between pediatric ATE and respiratory diseases, including asthma and RTIs. Bhattacharjee et al. [12] analyzed a cohort of 13,506 pediatric patients with asthma in the United States and evaluated the incidence of acute asthma exacerbations and acute severe asthma attacks during the first year after ATE. They reported significant reductions in both acute asthma exacerbations and acute severe asthma attacks after surgery. Prescriptions for asthma-related medications, including bronchodilators and inhaled corticosteroids, were also significantly reduced, suggesting that ATE may contribute to improved asthma control. In contrast, a nationwide cohort study reported that tonsillectomy did not reduce the frequency of asthma treatment or asthma-related hospitalizations in children when the control group was matched for preoperative asthma history, suggesting that apparent benefits in earlier studies may have been influenced by baseline differences in disease severity [13].
Bae et al. [14] analyzed Korean NHIS data, comparing more than 240,000 children who underwent ATE with approximately 730,000 controls. They reported significant reductions in outpatient visits and hospitalizations related to upper RTIs, rhinitis, and asthma after surgery. Prescriptions for medications associated with these conditions—including antihistamines, leukotriene receptor antagonists, oral antibiotics, and systemic corticosteroids—were also significantly reduced.
In contrast, Kim et al. [10] conducted a long-term follow-up study using the Korean NHIS database that compared 1,039 children who underwent ATE with matched controls over an observation period of up to 11 years. They reported a significantly increased risk of asthma development in the surgical group, whereas no significant long-term reduction in upper RTIs was observed.
Given these conflicting findings, the present study evaluated both the short-term and longer-term postoperative associations of ATE with upper and lower RTIs. In this retrospective analysis, RTI-related hospital visits did not significantly decrease after ATE in pediatric patients, a finding largely consistent with previous retrospective cohort studies and randomized controlled trials. In addition, children without a preoperative history of respiratory infections had increased RTI-related hospital visits after surgery. To address the potential influence of increased healthcare utilization immediately before surgery, as noted by Tsou et al. [6] and Bae et al. [14], we included the presence of each respiratory infection during the preoperative period as a covariate in the multivariable models. By adjusting for preoperative infection history, we aimed to account for baseline disease burden and reduce potential bias related to regression to the mean. In the age- and sex-stratified analyses, no consistent differences were observed for acute upper RTIs. However, increases in acute lower RTIs, influenza, and pneumonia were observed in certain age and sex subgroups. These findings should be interpreted with caution because the subgroup analyses were exploratory and may have been influenced by temporal variation in circulating respiratory pathogens and other unmeasured factors. Taken together with previous studies of ATE and upper respiratory infections, our findings suggest that surgical strategies targeting acute RTIs do not show clear clinical superiority over the natural course of the disease. Therefore, the expectation that ATE will reduce RTI frequency alone appears insufficient to justify ATE as a primary surgical indication.
Several explanations may account for the lack of reduction in RTI incidence after ATE. First, the natural course of pediatric RTIs should be considered. As children grow, their immune systems mature, and RTI frequency tends to decrease spontaneously over time [11]. Previous randomized controlled trials have shown that both surgically treated and conservatively managed groups have a gradual decline in RTI prevalence over time [7]. Kim et al. [10] evaluated the annual number of upper respiratory infection-related visits using an equivalence-testing approach over a long-term follow-up period of up to 11 years. Upper respiratory infection-related visits gradually decreased in both the ATE and control groups, with no significant difference between groups. This finding suggests that the natural decline in respiratory infections with age may substantially influence long-term outcomes. In contrast, our study focused on the first 3 postoperative years to better evaluate the potential association with ATE itself while minimizing the influence of longer-term age-related changes in infection patterns.
Second, RTIs may continue to occur through alternative pathways because mucosal immunity is distributed across multiple anatomical sites [15]. The increased risk of RTIs observed in some subgroups may also reflect biological changes after ATE. Removal of adenotonsillar lymphoid tissue may alter local mucosal immune responses and the composition of the nasopharyngeal microbiota [16,17], potentially affecting susceptibility to subsequent respiratory infections. Although the underlying mechanisms remain unclear, these factors may partly explain the increased RTI risk observed after surgery and warrant further investigation.
Third, regression to the mean and related selection bias may also have contributed to these findings. In many cases, patients are referred for ATE when symptoms are at their most severe. Subsequent natural improvement may then occur regardless of surgical intervention, which can lead to overestimation or underestimation of the true surgical effect. This phenomenon may also explain why some studies involving patients with relatively mild symptoms report small statistical reductions that do not translate into clinically meaningful benefits.
For these reasons, ATE performed solely to reduce RTI frequency is difficult to recommend. Although ATE is generally considered safe, postoperative bleeding and respiratory adverse events can occur, even if they are uncommon. Furthermore, several observational studies, together with the findings of the present study, suggest that ATE during childhood may be associated with an increased long-term risk of respiratory, allergic, and infectious diseases.
This study has several limitations. First, because the analysis was based on a national health insurance claims database, diagnoses were identified using administrative codes rather than direct clinical assessment, which may have resulted in misclassification. Analyses by surgical indication could not be performed because information on the primary indication for ATE was not consistently available in the claims database. Second, detailed clinical information, such as symptom severity, laboratory findings, and environmental factors, was not available in the dataset. Third, surveillance bias may have influenced the findings because children undergoing ATE are likely to have more frequent healthcare encounters than nonsurgical controls, increasing the opportunity for RTI diagnosis and coding. Conversely, healthcare utilization was used as a proxy for infection occurrence, and infections that did not lead to hospital visits may not have been captured. In addition, increased RTI-related hospital visits after ATE do not necessarily indicate a true increase in infection incidence, because differences in healthcare utilization and postoperative follow-up may have influenced the observed associations. Fourth, potential confounders such as asthma, allergic rhinitis, atopic dermatitis, and chronic rhinosinusitis were not included in the analysis. Because these conditions may affect susceptibility to RTIs, residual confounding cannot be excluded. Finally, although follow-up was conducted for up to 3 years after surgery, longer-term outcomes could not be evaluated. Despite these limitations, the use of a large nationwide cohort and matched comparison design strengthens the reliability of our findings.
Conclusion
In this cohort study, ATE was associated with higher odds of both upper and lower RTI-related hospital visits compared with the matched nonsurgical control group, and infection patterns varied by age and sex. In some cases, new respiratory infections were observed even among children without a prior infection history. These findings suggest that ATE may have limited effectiveness in preventing long-term respiratory infections. Therefore, clinicians should carefully weigh the potential benefits and risks when considering ATE in pediatric patients.
Footnotes
Availability of Data and Material
The datasets analyzed during the current study are not publicly available because they were obtained from the Korean National Health Insurance Service (NHIS) under a data use agreement. The data cannot be shared or redistributed, and access to the dataset expired after completion of the approved study period.
Conflicts of Interest
The authors have no potential conflicts of interest to disclose.
Author Contributions
Conceptualization: Gwanghui Ryu, Hyo Yeol Kim. Data curation: Jun Young Kim, Gwanghui Ryu. Formal analysis: Jun Young Kim, Sang Duk Hong, Gwanghui Ryu. Funding acquisition: Gwanghui Ryu. Methodology: Jun Young Kim, Gwanghui Ryu. Supervision: Sang Duk Hong, Yong Gi Jung. Validation: Gwanghui Ryu. Visualization: Jun Young Kim. Writing—original draft: Jun Young Kim, Gwanghui Ryu. Writing—review and editing: all authors.
Funding Statement
This work was supported by grants from the Korean Society of Otorhinolaryngology-Head and Neck Surgery, 2019 and the Korean Rhinologic Society.
Acknowledgments
None
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