Abstract
Background
Tonsillectomy is performed more than 400 000 times in the European Union each year, making it one of the most common operations. Nonetheless, there have been only a few long-term studies of quality of life after tonsillectomy.
Methods
In 2004, data on the quality of life after tonsillectomy were obtained from adult German-speaking tonsillectomy patients by means of the Glasgow Benefit Inventory and a questionnaire specifically designed for that study. The present study concerns the further follow-up of these patients, sometimes many years later. 114 patients with recurrent tonsillitis were included in this descriptive study.
Results
Of the 114 patients, 97 (85%) provided further data at 14 months, and 71 (62%) at ca. 7 years. The Glasgow Benefit Inventory revealed postoperative improvement of quality of life at 14 months and at 7 years, with median values of 16.67 points (quartile 11.11/25) and 13.89 points (quartile 8.33/25) (p = 0.168). The mean number of annual episodes of sore throat fell from 10 preoperatively to 2 postoperatively (p = 0.0001). The number of visits to the doctor, the intake of analgesic drugs and antibiotics, and the number of medical absences from work also declined significantly over the period of observation.
Conclusion
Tonsillectomy was associated with a long-lasting improvement of health and quality of life, and with lower utilization of medical resources. The 62% response rate at 7 years leaves the question open whether patients with a favorable postoperative course may have been more likely than others to participate in the study.
Tonsillectomy is one of the most common surgical interventions overall (1). However, the number of studies on the subjective success for the patient is significantly lower than those on the economic and clinical data. As demonstrated by recent examples, both tonsillectomy itself as well as the frequency of its implementation—particularly in Germany—are sources of extensive discussions and criticism, which has also been expressed in the public media (2– 4). The large increase in publications is indicative of this trend. For instance, a MEDLINE search we carried out in 2008 for the terms “life quality AND tonsillectomy,” “benefit AND tonsillectomy,” and “economic AND tonsillectomy” resulted in only 11 relevant published studies that addressed the quality of life after tonsillectomy. Our same searches in 2014 resulted in more than 30 relevant publications, although most of those studies addressed the clinical results, as measured by objective postoperative results (5– 10). In the meantime, however, more studies are available in which the patient’s subjective assessment has also been taken into account (11– 14). Another aspect that has also been discussed in the literature concerns the short follow-up period: so far, statements about the postoperative success can only be made in terms of months to a few years. Studies in which a longer follow-up period was used are uncommon (14).
As we had previously published a study on this subject in 2010 (15), we decided to interview the same patient collective again to examine whether the newly-obtained results were consistent. Thus, the aim of this descriptive study was to evaluate both the perceived changes in the quality of life after tonsillectomy as well as objective parameters, such as the number of physician visits and the use of resources, over a long term.
Methods
An exploratory analysis was performed. A total of 114 consecutive patients were interviewed preoperatively, who then underwent elective tonsillectomy in the Marienhospital Gelsenkirchen in 2004. Inclusion criteria were:
Adult (≥ 18 years old)
Good knowledge of German
At least three episodes of acute tonsillitis in the previous 12 months.
Patients were referred to us for surgery by a specialist or primary care physician. Exclusion criteria were:
Abscess tonsillectomy
Tonsillectomy with neoplasia (suspected or proven)
Exclusively tonsillar hyperplasia
Tonsillectomy à chaud.
Patients were first informed about the procedures, and their written consent for both the operation and participation in the study was obtained. A day prior to the operation, each patient was evaluated with a structured interview developed by the authors, which—in contrast to the Glasgow Benefit Inventory (GBI)—allows a controlled before-and-after comparison.
The study participants were asked the same questions 14 months later, and—taking the arithmetic mean—once again seven years after surgery (in 2004 or 2005), using a—likewise standardized—telephone interview. In each case, the evaluation was based on the previous 12 months. Up to three telephone attempts were initially made to reach each subject. If this was unsuccessful, a letter was first sent to the address given during their interviews and then, after contacting the Einwohnermeldeamt (Residents’ Registration Office), up to two further letters were sent to their current addresses. Only then were the patients who had not been reached (n = 43) classified as nonresponders. Patients were also additionally interviewed with the GBI at 14 months and at the second time of contact. The GBI was developed in 1996 to measure the benefits after otorhinolaryngologic interventions and can be used for various interventions (16, 17). The GBI can measure changes in health and quality of life after a surgical intervention; the survey tool has been validated for this purpose (18).
Surgeries were performed under general anesthesia by surgeons with varying degrees of qualification, using the so-called “cold steel” technique (19, 20). In this technique, a relieving mucosal incision is made with scissors, and then the tonsils are removed from the tonsillar fossa with a periosteal elevator. The main complications and side effects of tonsillectomy (bleeding and pain) (21) were the subject of a separate study that has been partially published (22). This study was approved by the Ethics Committee of the Medical Association of Westfalen-Lippe.
Statistical methods
Patient characteristics were represented by descriptive measures (median, quartiles) and frequency tables and, where necessary, were compared using simple univariate tests (Wilcoxon rank sum test and Fisher’s exact test). All resulting p values were indicated descriptively (without further adjustment). To test the pre- and postoperative differences (analgesics, antibiotics, sore throat episodes, physician visits, and work absences), the Wilcoxon signed rank test was used. In a multivariate analysis using the linear mixed model for longitudinal data, the effects of time, age, and sex on the number of sore throat episodes per year was examined. To analyze the robustness, the linear mixed model was used with different covariance structures for random effects (diagonal, unstructured, and compound symmetry with heterogeneous variances).
For the pre/post comparison, the effect sizes were ≥ 0.25 with a sample size of N = 114, and ≥ 0.33 for n = 71. Effect sizes of ≥ 0.5 are commonly assessed as a medium effect.
Results
In 2004, 467 patients who had undergone tonsillectomy were excluded from this study based on the criteria given above. However, 114 patients met the inclusion criteria. Of these, n = 97 (85%) were interviewed again at 14 months postoperatively, and n = 71 (62%), at 7 years (2004–2011).
Of the participants interviewed postoperatively, 73 or 53 (75%) were women, and 24 or 18 (25%) were men, for n = 97 or n = 71, respectively. In comparison, the gender distribution among all adult patients operated on in 2004 was 59% women to 41% men. The youngest study participant at the time of surgery was 18 years old, and the oldest participant was 62 years old. The median age of the study participants in 2004 was 26 years (mean 28 years), which did not change in the two interviewed groups once corrected for the time past (i.e., 14 months or seven years). The average age at baseline did not differ between men (28.2 years) and women (27.9 years).
Before surgery, the median number of tonsillitis or sore throat episodes was 6 per year (mean: 10); postoperatively, it dropped to 1 (mean: 2), as shown in Table 1. The lower number of postoperative sore throat episodes differed significantly from that of preoperative episodes (p = 0.0001).
Table 1. Sore throat episodes. physician visits. and work absences in the year previous to survey.
| Preoperative (N = 114) | Postoperative at 14 months (n = 97) | Postoperative at 7 years (n = 71) | |||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Number of results (subgroup) | None | 1–3 | 4–6 | 7–10 | >10 | None | 1–3 | 4–6 | 7–10 | >10 | None | 1–3 | 4–6 | 7–10 | >10 | ||||
| Sore throat episodes | |||||||||||||||||||
| Sex | |||||||||||||||||||
| – Male | n (%) | 0 | 7 (23%) | 16 (51%) | 5 (16%) | 3 (10%) | 12 (50%) | 8 (33%) | 1 (4%) | 3 (13%) | 0 | 9 (50%) | 7 (39%) | 1 (6%) | 1(6%) | 0 | |||
| – Female | n (%) | 0 | 14 (25%) | 32 (39%) | 27 (32%) | 10 (12%) | 25 (34%) | 33 (45%) | 9 (12%) | 3 (4%) | 3 (4%) | 18 (34%) | 24 (45%) | 9 (17%) | 2(4%) | 0 | |||
| – Total | N | 0 | 21 | 48 | 32 | 13 | 37 | 41 | 10 | 6 | 3 | 27 | 31 | 10 | 3 | 0 | |||
| Mean ± SD (total) | 9.7 ± 33 (max. 365) | 2 ± 2.9 | 1.8 ± 2.3 | ||||||||||||||||
| Unpaired Wilcoxon test for sex differences | p = 0.32 | p = 0.10 | p=0.16 | ||||||||||||||||
| Wilcoxon signed rank test | Pre- to postoperative at 14 months: p < 0.0001 | Postoperative at 14 months to 7 years: p < 0.56 | |||||||||||||||||
| Pre- to postoperative at 7 years: p < 0.0001 | |||||||||||||||||||
| Physician Visits | |||||||||||||||||||
| Sex | |||||||||||||||||||
| – Male | n (%) | 0 (0%) | 12 (42%) | 14 (46%) | 4 (12%) | 1 (0%) | 20 (84%) | 4 (16%) | 0 (0%) | 0 (0%) | 0 (0%) | 15 (94%) | 2 (13%) | 1 (6%) | 0 (0%) | 0 (0%) | |||
| – Female | n (%) | 1 (1%) | 20 (24%) | 42 (51%) | 17 (20%) | 3 (4%) | 51 (69%) | 15 (21%) | 5 (7%) | 2 (3%) | 0 (0%) | 35 (70%) | 14 (28%) | 4 (8%) | 0 (0%) | 0 (0%) | |||
| – Total | N | 1 | 32 | 56 | 21 | 4 | 71 | 19 | 5 | 2 | 0 | 50 | 16 | 5 | 0 | 0 | |||
| Mean ± SD | 5 ± 2.7 | 0.7 ± 1.6 | 0.7 ± 1.4 | ||||||||||||||||
| Unpaired Wilcoxon test for sex differences | p = 0.16 | p = 0.68 | p = 0.22 | ||||||||||||||||
| Wilcoxon signed rank test | Pre- to postoperative at 14 months: p < 0.001 | Postoperative at 14 months to 7 years: p < 0.6045 | |||||||||||||||||
| Pre- to postoperative at 7 years: p < 0.001 | |||||||||||||||||||
| Work absences | |||||||||||||||||||
| Sex | |||||||||||||||||||
| – Male | n (%) | 4 (13%) | 7 (23%) | 2 (6%) | 4 (13%) | 14 (45%) | 22 (92%) | 1 (4%) | 0 (0%) | 1 (4%) | 0 (0%) | 16 (88%) | 1 (5%) | 0 (0%) | 0 (0%) | 1 (5%) | |||
| – Female | n (%) | 22 (26%) | 8 (10%) | 7 (8%) | 11 (13%) | 35 (42%) | 60 (84%) | 1 (1%) | 2 (3%) | 4 (5%) | 5 (7%) | 45 (85%) | 1 (2%) | 2 (4%) | 1 (2%) | 4 (8%) | |||
| – Total | N | 26 | 15 | 9 | 15 | 49 | 82 | 2 | 2 | 5 | 5 | 61 | 2 | 20 | 13 | 4 | |||
| Mean ± SD (total) | 11.9 ± 13.2 | 1.4 ± 4.0 | 1.8 ± 5.5 | ||||||||||||||||
| Unpaired Wilcoxon test for sex differences | p = 0.51 | p = 0.19 | p = 0.62 | ||||||||||||||||
| Wilcoxon signed rank test | Pre- to postoperative at 14 months: p < 0.001 | Postoperative at 14 months to 7 years: p = 0.8396 | |||||||||||||||||
| Pre- to postoperative at 7 years: p < 0.001 | |||||||||||||||||||
The multivariate analyses with the mixed model confirmed the decrease observed for the sore throat episodes per year over time (p<0.0001). Significant effects of age or sex could not be detected, nor on the timing of the number of sore throat episodes per year. Sensitivity analysis with different covariance structures for random effects showed robust results.
Preoperatively, 58 (51%) of the 114 participants required analgesics for throat infections (Table 2). On average, these patients took analgesics 1.6 times in the year prior to the operation. At 7 years postoperatively, 16 (23%) of the surveyed 71 participants used an analgesic. Likewise, the use of antibiotics for sore throat was reduced postoperatively (Table 2). Preoperatively, the participants who had used antibiotics used them on average 4 times a year; at 14 months or 7 years postoperatively, they used them 2.5 times per year.
Table 2. Number of participants who took analgesics or antibiotics. per year and in comparison.
| Preoperative (N=114) | Postoperative 14 months (n=97) | Postoperative 7 years (n=71) | |||||||
|---|---|---|---|---|---|---|---|---|---|
| Number of participants who took analgesics | |||||||||
| Sex | |||||||||
| – Male | n (%) | 14 (45%) | 1 (4%) | 4 (22%) | |||||
| – Female | n (%) | 44 (53%) | 6 (8%) | 12 (23%) | |||||
| – Total | N | 58 | 7 | 16 | |||||
| Fisher’s exact test | p = 0.24 | p = 0.67 | p = 1 | ||||||
| Wilcoxon signed rank test | Pre- to postoperative at 14 months: P< 0.001 | Postoperative at 14 months to 7 years: p = 0.0127 | |||||||
| Pre- to postoperative 7 years: P< 0.001 | |||||||||
| Number of participants who took antibiotics | |||||||||
| Sex | |||||||||
| – Male | n (%) | 30 (97%) | 3 (13%) | 2 (11%) | |||||
| – Female | n (%) | 80 (96%) | 18 (25%) | 15 (29%) | |||||
| – Total | N | 110 | 21 | 17 | |||||
| Fisher’s exact test | p = 1 | p = 0.26 | p = 0.20 | ||||||
| Wilcoxon signed rank test | Pre- to postoperative at 14 months: p < 0.001 | Postoperative at 14 months to 7 years: p = 0.8318 | |||||||
| Pre- to postoperative 7 years: p < 0.001 | |||||||||
The median number of physician visits preoperatively was 4 (mean: 5), but at 14 months and at 7 years postoperatively, this was reduced to 0 (mean: 0.7). At the 14-month or 7-year time point, 71 (73%) or 50 (70%) of the participants, respectively, did not consult a primary care or ENT physician due to a sore throat (Table 1).
The median number of lost work days related to tonsillitis or sore throat decreased from 10 days (mean: 11.9) preoperatively to 0 days (mean: 1.4/1.8) postoperatively (p<0.001) (Table 1).
The detailed results of the GBI survey are shown in the eTable. A postoperative change in the subscale “Social support” (e.g., help from family and friends) as compared to the preoperative conditions was noted by only 7 of the 97 respondents at 14 months, but by 17 of the 71 respondents at 7 years. However, this picture is complex, as it comprises participants who detected changes at the later time point as well as participants who detected changes originally but did not later on (Figure).
eTable. Comparison of Glasgow Benefit Inventory (GBI) postoperative scores at 14 months and 7 years.
| GBI | Total. 14 months/ 7 years | p value* | General perception of well-being. 14 months/7 years | p value* | Social support. 14 months/7 years | p value* | Overall physical health. 14 months/7 years | |
|---|---|---|---|---|---|---|---|---|
| Total | Minimum | −25.00/−52.78 | 0.1682 | −29.17/–54.17 | 0.1227 | −66.67/–33.33 | 0.4994 | −50.00 /–83.33 |
| Lower quartile | 11.11/8.33 | 8.33/4.17 | 0/0 | 33.33/0 | ||||
| Median | 16.67/13.89 | 12.5/12.5 | 0/0 | 33.33/50.00 | ||||
| Arithm. Mean | 18.66/15.22 | 18.02/13.97 | 0.23/1.17 | 39.67/34.27 | ||||
| Upper quartile | 25.00/25.00 | 25.00/20.83 | 0/0 | 50.00/66.67 | ||||
| Maximum | 55.56/50.00 | 70.83/62.50 | 50/33.33 | 83.33/100.00 | ||||
| Male | Minimum | −22.22/–2.78 | 0.7759 | −29.17/0 | 0.3384 | −16.67/0 | 0.089 | -33.33/–50 |
| Lower quartile | 11.11/9.03 | 8.33/4.17 | 0/0 | 33.33/16.67 | ||||
| Median | 18.06/13.89 | 14.58/8.33 | 0/0 | 33.33/50 | ||||
| Arithm. Mean | 15.59/15.28 | 14.35/12.04 | 0/4.63 | 36.11/38.89 | ||||
| Upper quartile | 24.30/21.52 | 25.00/16.67 | 0/0 | 50.00/62.50 | ||||
| Maximum | 33.33/38.89 | 45.83/33.33 | 16.67/33.33 | 66.67/83.33 | ||||
| Female | Minimum | −25.00/–52.78 | 0.1614 | −25.00/–54.17 | 0.1968 | −66.67/–33.33 | 0.9576 | −50.00/–83.33 |
| Lower quartile | 11.11/2.78 | 8.33/4.17 | 0/0 | 33.33/0 | ||||
| Median | 16.67/13.89 | 12.50/12.50 | 0/0 | 33.33/33.33 | ||||
| Arithm. mean | 19.71/15.20 | 19.26/14.62 | 0.31/0 | 40.88/32.70 | ||||
| Upper quartile | 25.00/27.78 | 29.17/25.00 | 0/0 | 66.67/66.67 | ||||
| Maximum | 55.56/50.00 | 70.83/62.50 | 50.00/33.33 | 83.33/100.00 |
Values from –100 to +100: positive values indicate an improvement in quality of life
*Wilcoxon signed rank test for before–after comparison (14 months compared to 7 years)
Arithm. mean. arithmatic mean
Figure.
Box plots
showing the comparison of the Glasgow Benefit Inventory (GBI) scores postoperatively and after 7 years, for the scales “General perception of well-being,” “Social support,” and “Overall physical health”
Discussion
Until now, almost no studies have addressed the subjective long-term results of tonsillectomy. The observation periods have rarely been longer than one year (7, 8, 13, 23), with very few studies including a time period of longer than five years (14, 24). Indeed, to the best of our knowledge, the observation of seven years presented here is the longest one to date.
None of these studies (including this one) used a control group with conservative treatment (Table 3).
Table 3. Previously available long-term studies (follow-up >12 months) worldwide. published in English or German.
| N Start | n End | Follow-up (months) | Age (mean) | Survey | Results | |
|---|---|---|---|---|---|---|
| Bhattacharyya 2002 (7) | 293 | 83 | 37.7 | 27.3 | GBI | Improvement in quality of life |
| Mui 1998 (8) | 147 | 60 | 24 | ND | Own survey | Improvement in quality of life |
| Wireklint 2012 (14) | 75 | 68 | 72 | 25 | SF 36 | Improvement in quality of life |
| Schwentner 2007 (24) | 600 | 227 | 38 | 30.1 | GBI | Improvement in quality of life |
| Ovesen 2013 (12) | 614 | 386 | 36 | ND | Own survey | Improvement in quality of life |
| Our present study | 114 | 71 | 84 | 26 | GBI | Improvement in quality of life |
GBI. Glasgow Benefit Inventory; ND. not determined
The average age of patients at the time of surgery in this study is similar to that given in other studies of adult patients (7, 13, 14, 24, 25).
The striking gender distribution in our collective at the time of surgery in favor of women (3.5:1) did not change over the years of follow up. This trend is also observed in comparable studies (of up to 3:1) (14, 24, 25), with a high variability across studies.
In the present study, we were able to re-survey 62% of the participants in the collective after a 7-year time span. By comparison, other studies were able to re-contact from 26% to 91% of their participants (14, 25). It can not be excluded that the partial loss of participants led to a distortion of our results. However, based on other collected parameters (average age, gender distribution), we think that any systematic error due to loss of participants is minimal.
For the following comparisons, it should be noted that only one other study had a similar follow-up period (14). This characteristic of the present study thus makes it difficult to correlate these results with those of other publications.
Surgery was associated with a reduced number of episodes of sore throat at 14 months postoperatively (p = 0.0001). This reduction remained stable over the further study period of six years. The same or very similar results were obtained by Nikakhlagh et al. (9) and Wolfensberger and Mund (26). This was accompanied by a lower frequency of the use of analgesics for a sore throat. These results are consistent with those of other studies (7, 8, 27). Despite an overall decrease, we saw a slight increase in analgesic use between the time points of 14 months and 7 years. As far as we know, only one other study monitored patients after tonsillectomy over a long period (14). While the main objective of that study (reduction of snoring) was different, Wireklint and Ericsson (14) also observed that a small part of the collective developed ENT-related problems over time.
Despite a reduction in use, almost every fourth patient still used antibiotics for sore throat, albeit at a significantly lesser frequency.
Consistent with Mui et al. (8), Bhattacharyya and Kepnes (7), Nikakhlagh et al. (9), and Wikstén et al. (23), we observed in the present study a significant decrease in the number of physician visits. Preoperatively, there were between 4 (Mui et al. [8] and this collective) and 6 physician visits (Nikakhlagh [9] and Bhattacharyya and Kepnes [7]). This trend did not change in our patient collective after 7 years. In 2002, Bhattacharyya and Kepnes (7) used a cost–effectiveness analysis to determine a break even point for tonsillectomy at 2.7 years. Our present results indicate that this assumption is not reversed over time, assuming that the indications for tonsillectomy were correct.
To capture the subjective assessment of quality of life after tonsillectomy, we used the Glasgow Benefit Inventory (GBI) (16). High GBI scores were observed in all similar studies for the overall score and for the score for the subscale “General perception of well-being.” The evaluation of the answers to the questions in this subscale showed that especially the perception of well-being or of satisfaction, as well as contacts and relationships in the social environment (for example, professional and in public) had improved. One explanation could be that social ties are more intense due to less illness-related absences.
Likewise, Schwentner et al. (24) and Baumann et al. (28), with follow-up periods of 5 years and 2.2 years, respectively, observed the highest GBI values for “General perception of well-being” and “Overall physical health,” whereas the relationship with family and friends did not change. This coincides with the most current study, from Koskenkorva et al. (11), which revealed a significant improvement in the above-mentioned points but hardly any change in the subscale „Relationship with family and friends“ after six months. Although Powell et al. (13) and Wireklint and Ericsson (14) used a different questionnaire, they also saw increased values for responses to questions of physical and psychological well-being.
In contrast, in 2001, Bhattacharyya et al. (27) found only a slight improvement (+9.5) in physical functioning after a period of 3.5 years, which was surprising when compared to those for the subscales “General perception of well-being” (+35) and “Relationships with family and friends” (+14). We did not find a conclusive explanation for this difference.
Our study differs from others mainly in our long follow-up period. Differences from the previous studies also arise from the response rate of 62% (at 7 years), and the additional parameters collected: frequency of lost work days, physician consultations, sore throat episodes, and medication use.
We and others (7, 11, 12, 25, 28) decided for a retrospective approach for a survey measuring quality of life after tonsillectomy, implemented here using the already-established GBI. The strength of this study lies in the direct comparison of two follow-up periods as well as in the long follow-up time. The study design is prospective, employing retrospective follow-up questionnaires. The retrospective approach principally bears the risk of recall bias, although it is standard in this form worldwide.
Limitations
Even with a response rate of 62%, we can not exclude that only those who had experienced a positive postoperative course participated. However, that was not the impression that was made during the interviews; indeed, some of the participants expressed their disappointment. Another limiting point is the study’s inherent lack of randomization. Finally, fewer men than women were in the surveyed groups; however, we did not notice a difference due to gender when analyzing the results.
Conclusion
The present study shows that adults who suffer a recurrent sore throat as a form of tonsillitis—as occurred within the patient collective in this study at least three times per year—experience a significant improvement in quality of life after tonsillectomy. Furthermore, we identified economic benefits due to reduced medication consumption as well as fewer work absences and visits to the physician. These effects remained constant for years.
We cannot determine whether or not switching to a payment system for hospitals based on diagnosis-related groups (DRG) had an impact on patient care and thus on the results of this investigation.
Key Messages.
Tonsillectomy seems to improve the long-term quality of life for patients.
Tonsillectomy can reduce medication consumption due to a sore throat for years postoperatively.
Operated patients miss fewer work days due to a sore throat.
Tonsillectomy may lead to reduced use of medical resources due to a sore throat.
The limitations of the study are that only 114 patients were enrolled, one of the two questionnaires used has not been validated, and participant memory gaps may have affected the survey.
Acknowledgments
Translated from the original German by Veronica A. Raker, PhD.
Footnotes
Conflict of interest statement
The authors declare that no conflict of interests exists.
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