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Efficacy and Quality-of-Life Impact of Adult Tonsillectomy
Neil Bhattacharyya, MD;
Lynn J. Kepnes, RNP;
Jo Shapiro, MD
Arch Otolaryngol Head Neck Surg. 2001;127:1347-1350.
ABSTRACT
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Objective To determine the quality-of-life impact and overall efficacy of adult
tonsillectomy for chronic tonsillitis.
Design Cross-sectional survey analysis of patients at least 1 year after undergoing
adult tonsillectomy.
Interventions and Outcome Measures The Glasgow Benefit Inventory was used to quantify the health benefit
of tonsillectomy. Data were collected for demographics and antibiotic use,
physician visits, and workdays missed due to chronic tonsillitis for the 12
months before and after tonsillectomy.
Results Sixty-five patients returned completed surveys. Mean age was 27.3 years,
and mean follow-up was 42.6 months. The improvements in the total score (+27.1),
general health subscore (+34.7), social functioning subscore subscore (+14.4),
and physical functioning subscore (+9.5) of the Glasgow Benefit Inventory
were each statistically significant (P<.001),
indicating a significant health benefit of tonsillectomy. Statistically significant
decreases in mean weeks receiving antibiotics (-7.8 weeks), mean physician
visits (-5.4), and mean workdays missed (-6.3 days) were noted
after tonsillectomy (P<.001).
Conclusions Adult tonsillectomy provides a significant quality-of-life improvement
for patients with chronic tonsillitis. Tonsillectomy also affords decreases
in medical resource utilization and missed workdays after tonsillectomy. Such
factors should be incorporated into decision making when considering tonsillectomy.
INTRODUCTION
TONSILLECTOMY with or without adenoidectomy is one of the most commonly
performed surgical procedures in the United States.1
Traditionally, recommendation for tonsillectomy in adults has depended primarily
on the frequency of the acute episodes of tonsillitis in the setting of recurrent
(chronic) disease. Recent American Academy of Otolaryngology clinical indicators
specify that patients with 3 or more infections of the tonsils and/or adenoids
per year, despite adequate medical therapy, may be considered candidates for
tonsillectomy.2 In addition, chronic or recurrent
tonsillitis associated with the streptococcal carrier state and nonresponsiveness
to ß-lactamase antibiotics may be considered an appropriate indication
for tonsillectomy. In reality, however, quality-of-life assessments and patient
preferences often influence or temper traditional guidelines in deciding whether
to recommend tonsillectomy for adult patients with chronic tonsillitis. For
example, patients with fewer than 3 episodes of tonsillitis per year, but
in whom each episode results in protracted absences from work, might be deemed
candidates for tonsillectomy. Such decision making is often considered the
art of medicine. The efficacy of tonsillectomy for chronic tonsillitis in
children has been well studied, but similar data are lacking for adults.3 Accurate quality-of-life data would assist in patient
counseling about treatment options for chronic tonsillitis.
The goal of this study was to determine the quality-of-life benefit
derived from adult tonsillectomy and the specific impact of tonsillectomy
on antibiotic use, frequency of physician visits, and workdays missed. It
is hoped that with adequate quality-of-life and disease-impact data, more
pertinent recommendations for tonsillectomy might be formulated.
SUBJECTS AND METHODS
This study was approved by our institutional human studies committee.
We searched the procedural database of a large academic general otolaryngology
practice retrospectively for patients who had undergone tonsillectomy alone
between January 1, 1994, and December 31, 1998. Patients who met the following
criteria were extracted from the database: age greater than 16 years, tonsillectomy
performed for chronic infectious tonsillitis, and minimum follow-up of 1 year.
Patients who simultaneously underwent adenoidectomy or uvulopalatopharyngoplasty
were excluded, as were patients who underwent tonsillectomy to rule out malignant
neoplasm.
The extracted cohort underwent evaluation by means of medical chart
review and mail survey. Components of the survey included patient-reported
data for disease severity variables. These variables included the number of
weeks during which the patient was taking antibiotics specifically for tonsillitis,
the number of workdays missed due to sore throat, and the number of physician
visits specifically for sore throat during the 12 months before tonsillectomy.
Analogous data were collected for the 12 months after tonsillectomy (excluding
the immediate postoperative period). Each patient was asked to complete the
Glasgow Benefit Inventory (GBI), which was modified accordingly to measure
the change in health status and quality of life due to the tonsillectomy intervention.4 The GBI scores were scaled in standard fashion to
range from -100 to +100, with positive scores implying an improvement
in quality of life due to tonsillectomy.
Statistical analysis was conducted using commercially available software
(SPSS, Version 10.0; SPSS Inc, Chicago, Ill). Descriptive statistics were
calculated for patient demographics and mean follow-up. Statistical comparison
between disease variables before and after tonsillectomy was conducted using
paired t test. The significance of scores on the
GBI was assessed using the t test for population
examining for scores that differed from a population mean of 0 (a score of
0 on the GBI or its subscales implies no positive or negative benefit). Correlation
analysis was conducted between GBI scores and disease severity variables using
the Pearson correlation coefficient.
RESULTS
A total of 247 patients met inclusion criteria for this study. Sixty-five
patients returned completed surveys (response rate, 26.3%). Most patients
who failed to respond to the survey had moved out of the geographic area with
no available forwarding address. At least 2 US postal mailings were attempted
for each potential study patient. To check for potential response biases,
we conducted demographic comparisons between responders and nonresponders.
Statistical analysis disclosed no significant differences in sex (75.4% [49/65]
vs 71.3% [129/181] female, respectively; P = .63,
Pearson  2 exact significance) or age (27.3 vs 27.1 years,
respectively; P = .86, Student t test). Similarly, no significant differences in rates of response
according to year of surgery (P = .28, Pearson 2 exact significance) were identified.
The mean age was 27.3 years (range, 16-60 years), and mean follow-up
was 42.6 months (range, 15.9-76.2 months). Data for the mean number of weeks
receiving antibiotics, mean workdays missed, and mean number of physician
visits before and after tonsillectomy are presented in Table 1. Decreases in all 3 measurements were statistically significant
(paired t test).
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Table 1. Impact of Chronic Tonsillitis Before and After Tonsillectomy
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The summary of scores for the GBI is presented in Table 2. Patients derived statistically significant benefit on the
total score as well as on the individual subscales of general health, social
functioning, and physical functioning from the tonsillectomy intervention
(t test). No correlation was found between GBI scores
and length of follow-up (all P>.05, Pearson correlation
coefficient). To test for potential recall bias among patients, we divided
the cohort into equal populations above and below the median follow-up. The
groups were compared for differences in GBI scores, physician visits, antibiotic
use, and workdays missed. No statistically significant difference between
groups was identified, suggesting a minimal recollection bias. Results of
correlation analysis between GBI scores and decreased antibiotic use, physician
visits, and workdays missed are presented in Table 3.
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Table 2. Quality-of-Life Impact of Adult Tonsillectomy Measured Using
the Glasgow Benefit Inventory
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Table 3. Correlation Between Glasgow Benefit Inventory Scores and Disease
Severity Variables in Chronic Tonsillitis After Adult Tonsillectomy*
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COMMENT
Tonsillectomy with or without adenoidectomy is one of the most commonly
performed surgical procedures in the United States, with most performed in
the pediatric patient population. Traditionally, adult tonsillectomy has been
recommended for recurrent tonsillitis, chronic tonsillitis, or the streptococcal
carrier state.5 To some degree, these indications
have been extrapolated from children. In addition, varying criteria for a
diagnosis of chronic tonsillitis have been used, depending on frequency and
severity of episodes. Other less common indications for adult tonsillectomy
include halitosis, chronic cryptic debris, and obstructive sleep apnea syndrome
(as an adjunct to uvulopalatopharyngoplasty). Despite the prevalence of chronic
tonsillitis and tonsillectomy, relatively few studies have examined the impact
of the diagnosis and treatment of this disorder on health and quality of life.
Even fewer such data exist for chronic tonsillitis in adults and adult tonsillectomy.
In a recent study by Mui et al,6 the efficacy
of tonsillectomy for recurrent tonsillitis in an adult population was examined.
The authors found that the mean number of clinic visits for throat infection
and the mean number of oral antibiotic prescriptions for throat infection
exhibited statistically significant decreases after tonsillectomy. These declines
were evident in patients with and without the streptococcal carrier state.
A follow-up telephone survey indicated that more than 87% of patients would
recommend the operation for chronic tonsillitis. Other studies on tonsillectomy
have uncovered similar results, but none of these studies attempted to examine
more rigorously quality-of-life issues and the impact of health care resource
utilization surrounding tonsillectomy.7-9
Such data are important for patient counseling and formulation of clinical
guidelines to recommend tonsillectomy.
The GBI is a well-studied and -validated outcomes instrument that was
developed specifically to study outcomes after otolaryngologic interventions.
It has been used to examine clinical outcomes for acoustic neuroma, middle
ear surgery, and botulinum toxin treatments for head and neck dystonias.10-11 The GBI is very sensitive to the
impact of the otolaryngologic intervention on the patient's quality of life.
We found that patients who underwent adult tonsillectomy had a dramatic improvement
in GBI scores, indicating a solid beneficial impact of tonsillectomy on their
quality of life. This benefit was significantly more pronounced in the total
score and general health subscore than in the social and physical functioning
subscores. This finding suggests that tonsillectomy has more impact in other
facets of the patient's life beyond improving health from a purely medical
standpoint. These other areas of beneficial impact are likely to involve decreases
in work absences, physician visits, and medication requirements. We found
no correlation between scores on the GBI and the duration of follow-up. This
suggests that the benefit from tonsillectomy is durable and long-term. Furthermore,
the mean follow-up approximating 3.5 years underscores the durable value of
tonsillectomy in these patients.
Aside from patient-reported scores on outcome measurement tools, several
other variables may be used to assess the overall health benefit of tonsillectomy.
One common assessment method for a single surgical intervention is to examine
health care resource utilization before and after the proposed intervention.
We measured health care resource utilization for chronic tonsillitis by the
frequency of physician visits and antibiotic use specifically for sore throats,
as in other studies on chronic tonsillitis.6
We found a similar number of physician visits before and after tonsillectomy,
similar to the results of Mui et al.6 However,
our antibiotic utilization rate before tonsillectomy was notably higher, exceeding
1.5 months receiving antibiotics in the 12 months before tonsillectomy. The
number of days of antibiotic treatment for sore throat after tonsillectomy
dropped dramatically, suggesting that patients had fewer infections, or their
infections were not severe enough to warrant antibiotic use. Both decreases
reflect a substantial decrease in utilization of health care resources after
tonsillectomy.
When considering the impact of chronic tonsillitis on patients' quality
of life, physicians should consider the number of the workdays missed due
to the tonsillitis episodes. Excessive absences from work may have a significant
impact on the patient's productivity, promotion status, and even employability.
We were somewhat surprised by the relatively high number of mean workdays
missed during the 12 months before tonsillectomy. Some patients reported up
to 30 days of work absence due to chronic tonsillitis. Again, the dramatic
decrease in the number of workdays missed further emphasizes the potential
impact of tonsillectomy on the quality of life of patients with chronic tonsillitis.
We identified a statistically significant correlation between the GBI
total score (and the general health subscore) and the decrease in number of
workdays missed before and after tonsillectomy. This indicates that the benefit
from tonsillectomy perceived by patients may actually be related more to workdays
missed due to tonsillitis than to the need to take antibiotics or visit physicians
for treatment. This correlation also highlights work absence due to exacerbations
of tonsillitis as an important factor that should probably be considered when
recommending tonsillectomy for adult patients.
This study possesses several potential limitations. First, our data
collection regarding medication use, physician visits, and workdays missed
depended heavily on patient recollection and self-reporting. However, the
consistency in reported variables between both subgroups above and below the
median follow-up argues that patients retain an accurate representation of
the impact of chronic tonsillitis in these areas. In addition, we encountered
a relatively poor response rate. This was not surprising given that most of
our patients undergoing adult tonsillectomy are in their third decade of life,
often in secondary school or college, and are therefore highly likely to relocate
within a few years after tonsillectomy. We found that this group of patients
often changed mailing addresses and insurance information on a yearly basis,
making subsequent follow-up very difficult. In fact, because of the geographic
mobility of this patient group, we were unable to complete a prospective study
on tonsillectomy, and therefore adopted the present study method. This factor
also likely contributed to our relatively long mean follow-up period, because
patients who responded were often permanent residents in our catchment area.
We also asked patients to assess the impact of the chronic tonsillitis in
the 2 years surrounding the tonsillectomy. This potentially neglects the variation
in disease severity that may occur before and after tonsillectomy. Some patients
may have had only 1 year of very severe tonsillitis leading to tonsillectomy,
whereas other patients may have had years or decades of persistent but less
severe problems as the indication for their tonsillectomy. In many cases,
the combination of the number of acute episodes of tonsillitis per year and
the number of years for which the patient has been ill serves as the indication
for tonsillectomy. Finally, we did not assess for the presence or absence
of streptococcal pharyngitis or tonsillitis in these patients. Although this
may have added some information in terms of disease severity, we find that
fewer and fewer patients undergo culture or testing using the rapid streptococcal
antigen test by their primary care physicians when a diagnosis of acute tonsillitis
or pharyngitis is given. We believed that this inconsistency in practice preferences
may lead to more bias than helpful information, and therefore did not include
it as part of the data to be considered.
As this was a retrospective analysis, 2 other items merit mention. First,
we asked patients to evaluate their perceived change in quality of life due
to the tonsillectomy. Capturing the patient's view of change as a clinical
outcome measure may not be as accurate as prospective before-and-after measurements
of quality of life. In fact, when asked to rate retrospectively the change
in quality of life after medical interventions, patients often ascribe higher
values for such change than would be realized from serial measures of quality
of life before and after the intervention. However, retrospective measures
of change in quality of life have been found to be more sensitive to change
than have serial measurements and may correlate more strongly with patients'
overall satisfaction with the intervention.12
Second, it is possible that some percentage of the improvement in quality
of life may in fact be due to the natural history of the chronic tonsillitis.
That is, even if tonsillectomy were not an effective treatment for chronic
tonsillitis, some patients may report improvement in quality of life because,
due to the natural history of their disease, the frequency and severity of
tonsillitis episodes may have diminished. The potential contribution to quality-of-life
improvement from the natural history of the disease could only be assessed
by simultaneously studying patients who did not undergo tonsillectomy with
long-term follow-up. However, since we found no positive correlation between
quality-of-life improvement and duration of follow-up, the potential impact
of spontaneous clinical improvement in chronic tonsillitis (which would theoretically
take >1 year to manifest) is less likely to be a contributing factor in the
patient's overall improvement.
CONCLUSIONS
Even in an era of broad-spectrum antibiotics, tonsillectomy provides
significant symptom relief and quality-of-life improvement for properly selected
adult patients with chronic tonsillitis. Our data suggest that tonsillectomy
significantly decreases use of antibiotics, physician visits, and workdays
missed due to chronic tonsillitis. Such factors may be as important as the
absolute frequency of tonsillitis episodes in determining the appropriateness
of tonsillectomy. Despite the solitary nature of tonsillectomy as a surgical
intervention, the perceived benefit of tonsillectomy persists with long-term
follow-up.
AUTHOR INFORMATION
Accepted for publication July 11, 2001.
Corresponding author: Neil Bhattacharyya, MD, Division of Otolaryngology,
333 Longwood Ave, Boston, MA 02115.
From the Division of Otolaryngology, Brigham and Women's Hospital,
(Drs Bhattacharyya and Shapiro and Ms Kepnes), and the Department of Otology
and Laryngology, Harvard Medical School (Drs Bhattacharyya and Shapiro), Boston,
Mass.
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