The aim of this study is to measure the distance from the midline of the upper incisors to the lower pole of the tonsils in paediatric patients of varying ages. This will enable the design of accurately sized tonsil tie simulators.

Two hundred patients between 1 year and 16 years old were recruited in this prospective observational study. The patient's age and the mean distance from the midline of the upper incisors to the lower pole of the tonsils were plotted into a scatter plot and the line of best fit was calculated.

The equation for the line of best fit was: distance (mm) = 1.9604 × age (digitalised years) + 72.436.

This is the first study to measure the anatomical distance from the upper incisor teeth to the inferior tonsillar pole in a paediatric population. This can be used to accurately size tonsil tie simulators and enhance their fidelity.

Post-tonsillectomy haemorrhage is an increasingly common cause of morbidity following tonsillectomy. Secondary post-tonsillectomy haemorrhage occurring more than 24 hours after an operation has long been attributed to post-operative infection; however, there is little evidence to support this hypothesis and the associated use of antibiotics in the current literature.

This study looked at the aetiology and evidence-based management of post-tonsillectomy haemorrhage, and investigated the impact of bacterial infection and antimicrobials on the pathogenesis and clinical course of this complication.

A number of peri-operative risk factors for post-tonsillectomy haemorrhage exist, and infective pathologies, including recurrent or chronic tonsillitis and group A streptococcus on blood cultures, may predispose to bleeding. Very few studies have shown a link between post-tonsillectomy haemorrhage and objective markers of infection such as pyrexia, raised inflammatory markers or positive microbiology cultures. The role of antibiotics in secondary post-tonsillectomy haemorrhage remains controversial, and numerous randomised, controlled trials of peri-operative antibiotics have shown no significant difference in bleeding rates between antibiotics and controls.

Further trials investigating the role of antibiotics and more robust studies investigating the presence of bacterial infection at the time of bleeding may be required to determine the true role of infection in post-tonsillectomy haemorrhage.

Tonsillectomy is one of the commonest operations in children. Routinely collected national data were used to assess variations in the paediatric tonsillectomy rate across Scotland, and to determine if socio-economic deprivation is the cause.

The Scottish Morbidity Records were reviewed for all children (0–16 years) undergoing tonsillectomy from 2001 to 2018.

The mean annual tonsillectomy rate was 2.64 per 1000 children. Rates in each health board area varied from 1.24 to 3.9 per 1000. Half of this variation resulted from transfers between regions. There was a 1.75-fold difference between tonsillectomy rates in the most and least deprived population quintiles, but this did not account for the geographical variation.

Half the variance in paediatric tonsillectomy rates is associated with children being transferred between regions for treatment. After accounting for this, there is a 1.5-fold difference in rate between health board areas, which is not related to socio-economic deprivation and is currently unexplained.

The junior otolaryngologist is responsible for recognition and drainage of the peritonsillar abscess. Although other simulators have been proposed, there is still a need for an accessible, educationally useful, low-cost peritonsillar abscess simulator to build skills and confidence in the novice.

The peritonsillar abscess simulator was constructed from basic disposable healthcare equipment and a party balloon. Evaluation of this Newport Quinsy Simulator was performed by expert and novice clinicians, who provided feedback in the form of Likert scales and free-text qualitative responses.

Overall, 24 clinicians evaluated the simulator. All felt the simulator was useful for the novice otolaryngologist, and represented the key anatomy and motor skills needed to drain a peritonsillar abscess. Qualitative evaluation highlighted the educational usefulness of the simulator as a peritonsillar abscess training device.

The Newport Quinsy Simulator is affordable, accessible, easy to use and educationally valuable to the novice otolaryngologist.

To assess parent or guardian satisfaction with a newly instituted day-case tonsillectomy programme at a tertiary paediatric institution.

After receiving ethical approval, an anonymous questionnaire was sent to the parent or guardian of every patient who underwent day-case tonsillectomy between July 2018 and December 2020.

A total of 135 patients were included. The parent or guardian of each patient was sent a questionnaire to be filled in and returned. Ninety-two completed surveys were returned. There were high satisfaction levels, with 91.3 per cent of parents or guardians feeling comfortable bringing their child home, and 92.4 per cent of parents or guardians would recommend day-case tonsillectomy to another parent or guardian. Of the parents or guardians, 10.9 per cent needed to contact healthcare services in the 24 hours following surgery.

Day-case tonsillectomy has proven to be a safe, efficient service at our institution, with high satisfaction levels from patients and parents or guardians. Areas for improvement focused on communication at the time of discharge regarding follow up and analgesia.

The clinical value of tonsillectomy continues to cause much debate, despite tonsil disease representing a significant burden to patients, caregivers and healthcare systems. This study assessed the long-term effect of adenotonsillectomy or tonsillectomy on the Paediatric Throat Disorders Outcome Test (‘T-14’), a validated tool used to objectively assess obstructive and infective symptoms in paediatric throat disorders.

Patients aged under 16 years undergoing adenotonsillectomy or tonsillectomy were recruited consecutively from 2018 into our prospective observational study. The Paediatric Throat Disorders Outcome Test questionnaire was completed by the children's caregivers pre-operatively (n = 80), and at 21 days (n = 68) and 2 years (n = 66) post-operatively.

Significant reductions were noted in mean total Paediatric Throat Disorders Outcome Test scores at 21 days and 2 years post-operatively (p ≤ 0.003).

Our results provide supporting evidence that paediatric adenotonsillectomy or tonsillectomy significantly improves quality of life up to two years post-operatively, and therefore remains a valuable use of healthcare resources.

Post-tonsillectomy haemorrhage remains a significant complication despite modifications of technique and instrumentation. Intracapsular tonsillectomy spares the capsule as a protective barrier for underlying blood vessels and musculature. Its efficacy in children with sleep-disordered breathing has been established, along with lowered rates of haemorrhage and pain, but research pertaining to adults and for recurrent infections has been limited.

This retrospective study, encompassing 730 patients, compared post-operative haemorrhage rates between extracapsular (n = 379) and intracapsular tonsillectomy (n = 351) across all ages and indications using CoblationTM technology.

A significant difference in post-operative haemorrhage rate was observed between extracapsular and intracapsular tonsillectomy techniques (2.1 vs 0.3 per cent; p = 0.025). In addition, an age of 18 years or older was also found to be an independent risk factor for post-operative haemorrhage (p = 0.01).

CoblationTM intracapsular tonsillectomy was shown to be safe and effective across all ages and indications, with a low risk of bleeding and revision surgery.

More young children are undergoing tonsillectomy, driven by sleep-disordered breathing concerns. Their specific risks are not well described.

A retrospective review was conducted of children aged 1–23 months undergoing tonsillectomy at one institution between 2014 and 2018.

A total of 157 children were identified (3.9 per cent of all tonsillectomies in those aged 0–16 years). Sixty-seven per cent were male. The youngest child was six months old; the smallest weighed 6.9 kg. Sixty-eight (43.3 per cent) had co-morbidities. The indication for tonsillectomy was sleep-disordered breathing in 94 per cent; 29.9 per cent had co-existing airway lesions, mostly laryngomalacia and tracheobronchomalacia. Of the children, 83.4 per cent were managed post-operatively on the surgical ward, and 63.7 per cent stayed 1 night. Emergency paediatric intensive care unit admission occurred in 3.8 per cent. Early respiratory complications and emergency paediatric intensive care unit admission were more common if the patient was medically complex, aged less than 18 months or weighed less than 12 kg. Re-operation for bleeding occurred in 1.9 per cent.

Most children stay 1 night on a general ward, with an uneventful course. Complications are occasionally severe, mostly in the very young and medically complex.

The impact of coronavirus disease 2019 on healthcare has led to rapid changes in otolaryngology service provisions. As such, new standard operating procedures for the management of suspected tonsillitis or quinsy were implemented in our centre.

A retrospective audit was performed of acute referrals to ENT of patients with suspected tonsillitis, peritonsillar cellulitis or quinsy, during the 10 weeks before (group 1) and 10 weeks after (group 2) implementation of the new standard operating procedures.

Group 2 received fewer referrals. Fewer nasendoscopies were performed and corticosteroid use was reduced. The frequency of quinsy drainage performed under local anaesthetic increased, although the difference was not statistically significant. Hospital admission rates decreased from 56.1 to 20.4 per cent, and mean length of stay increased from 1.13 to 1.5 days. Face-to-face follow up decreased from 15.0 to 8.2 per cent, whilst virtual follow up increased from 4.7 to 16.3 per cent. There were no significant differences in re-presentation or re-admission rates.

Management of suspected tonsillitis or quinsy using the new standard operating procedures appears to be safe and effective. This management should now be applied to an out-patient setting in otherwise systemically well patients.

This study examined the uptake of ENT UK coronavirus disease 2019 adult tonsillitis and quinsy guidelines at our tertiary centre, and assessed perceived barriers to uptake.

A retrospective case series of tonsillitis and quinsy patients was analysed in two arms: before and after the introduction of new ENT UK management guidelines. A survey assessed perceptions and practice differences between ENT and emergency department doctors.

Each study arm examined 82 patients. Following the introduction of new ENT UK guidelines, ENT clinicians demonstrated significant changes in practice, unlike their emergency department counterparts. Survey results from emergency department doctors highlighted a lack of appreciation of guideline change and identified barriers to guideline uptake.

The introduction of new management guidelines for tonsillitis and quinsy patients during the pandemic resulted in disparate uptake within ENT and emergency department departments at the tertiary centre. Clearer dissemination to all affected clinicians is paramount for future rapidly introduced changes to practice, to ensure clinician safety.

The global pandemic of coronavirus disease 2019 has necessitated changes to ‘usual’ ways of practice in otolaryngology, with a view towards out-patient or ambulatory management of appropriate conditions. This paper reviews the available evidence for out-patient management of three of the most common causes for emergency referral to the otolaryngology team: tonsillitis, peri-tonsillar abscess and epistaxis.

A literature review was performed, searching all available online databases and resources. The Medical Subject Headings ‘tonsillitis’, ‘pharyngotonsillitis’, ‘quinsy’, ‘peritonsillar abscess’ and ‘epistaxis’ were used. Papers discussing out-patient management were reviewed by the authors.

Out-patient and ambulatory pathways for tonsillitis and peritonsillar abscess are well described for patients meeting appropriate criteria. Safe discharge of select patients is safe and should be encouraged in the current clinical climate. Safe discharge of patients with epistaxis who have bleeding controlled is also well described.

In select cases, tonsillitis, quinsy and epistaxis patients can be safely managed out of hospital, with low re-admission rates.

Acute tonsillitis represents a significant proportion of admissions to ENT departments nationally. Given current hospital pressures, it is vital to look for safe alternatives to admission. This study explores the safe management of patients in an ambulatory medical unit, without the need for admission.

A retrospective review of 48 patients’ notes was carried out. Following the development and implementation of a guideline for acute tonsillitis, a prospective re-audit of 41 patients was carried out, measuring length of stay, overnight admissions and re-admissions.

The rate of overnight admission following implementation of the guideline fell from 0.75 to 0.29, and average length of stay dropped from 19.2 to 9.5 hours. There were two re-admissions in each cycle of the audit, which represents a non-significant increase.

The tonsillitis guideline has significantly reduced admissions and length of stay. Re-admissions remain low, demonstrating that this is a safe and cost-effective intervention.

The incidence of deep neck space abscesses, which can result in significant morbidity and mortality, is rising. The aetiology is thought to be dental. However, this study suggests a reduction in tonsillectomies may be associated with the rise.

In a retrospective cohort study, patients were identified by a clinical code within one hospital over 10 years. Evidence of preceding infection source, management, lifestyle risks, comorbidities and demographics were extracted.

Fifty-two patients were included: 23 (44 per cent) had concurrent or recent tonsillitis; 11 (21 per cent) had poor dental hygiene; 22 (42 per cent) were smokers; and 9 (17 per cent) had diabetes. The incidence of deep neck space abscess cases increased from 1 in 2006, to 15 in 2015 (correlation value 0.9; p = 0.00019).

The incidence of deep neck space abscess cases is increasing. Risk factors include tonsillitis, smoking and dental infection. This paper adds to the growing evidence that deep neck space abscesses are increasingly related to tonsillitis, and questions whether the threshold for tonsillectomy has been raised too high.

Smoking is purported to increase the risk of peritonsillar abscess formation, but prospective data are needed to confirm this hypothesis. This prospective study aimed to identify this correlation.

Fifty-four patients with peritonsillar abscess were prospectively asked about their smoking behaviour using a questionnaire that was designed and approved by the Robert Koch Institute (Berlin, Germany) to analyse smoking behaviour in epidemiological studies. Afterwards, a consecutive control group (without peritonsillar abscess), matched in terms of age and gender, was surveyed using the same questionnaire. A classification of smoker, former smoker and non-smoker was made, and the numbers of pack-years were calculated and compared.

Statistical analysis of both groups revealed a significant correlation between peritonsillar abscess and smoking experience (p = 0.025). Moreover, there were significantly fewer non-smokers in the non-peritonsillar abscess group (p = 0.04). The number of pack-years was higher in the peritonsillar abscess group (p = 0.037).

There is a statistically significant association between peritonsillar abscess and smoking.

To assess the diagnostic role of mean platelet volume in tonsillitis with and without peritonsillar abscess.

Mean platelet volume and other laboratory data were retrospectively investigated.

Mean platelet volume was significantly lower in the tonsillitis group (7.8 per cent ± 0.7 per cent) than in the control group (8.7 per cent ± 0.6 per cent; p < 0.0001), and it was significantly lower in the abscess group (7.5 per cent ± 0.6 per cent) than in the no abscess group (8.0 per cent ± 0.7 per cent; p = 0.0277). White blood cell counts and C-reactive protein levels were not significantly different between patients with an abscess and those without. The mean platelet volume cut-off values for the diagnosis of tonsillitis and peritonsillar abscess were 7.95 fl and 7.75 fl, respectively.

Our results suggest that a decreased mean platelet volume is associated with the development and severity of tonsillitis. This finding provides useful diagnostic information for physicians treating patients with tonsillitis.

Throat swabs are neither specific nor sensitive for micro-bacteria causing sore throat symptoms; however, current guidelines suggest they are still useful in some cases.

Retrospective and prospective analyses were conducted of throat swabs requested within the months of January 2016 and August 2016, respectively.

The study comprised 247 patients. Fifty-nine (24 per cent) had a positive culture. Forty-six grew group A beta-haemolytic streptococci, with the remainder growing candida (n = 10), coliform (n = 1) and klebsiella (n = 2). There was no significant difference in culture rates between primary or secondary care sources (χ2 = 0.56, p = 0.45). None of the swabs influenced a variation in patient management from local antimicrobial policies. Current practice has an estimated annual financial impact of £3 434 340 on the National Health Service.

Throat swabs do not influence the antimicrobial treatment for patients with sore throats, even under current guidelines, and incur unnecessary cost. Current clinical guidelines could be reviewed to reduce the number of throat swabs being conducted unnecessarily.

Peritonsillar abscess is the most common deep infection of the head and neck in young adults. It is considered a purulent complication of acute tonsillitis, but other mechanisms have been proposed. There is no consensus as to whether seasonality affects peritonsillar abscess incidence.

This observational, descriptive, retrospective study explored the epidemiology of peritonsillar abscess and its relationship with seasonality. The cases were selected from the emergency otolaryngology service of a tertiary hospital.

The sample comprised 528 patients (42.61 per cent males, mean age = 26.63 years). A moderate positive correlation was found between peritonsillar abscess incidence and monthly average temperature. No associations were found with insolation, precipitation or humidity.

In this sample, peritonsillar abscess was more likely to occur in warmer months. The findings corroborate the theory that peritonsillar abscess is not a direct complication of acute tonsillitis and may improve understanding of peritonsillar abscess aetiology.

To identify Helicobacter pylori infection in tonsillar tissue samples from patients undergoing tonsillectomy for chronic tonsillitis versus tonsillar hypertrophy, and to assess the possible relationships between H pylori and patients’ sociodemographic data and laryngopharyngeal reflux.

In this prospective study, 97 patients who underwent tonsillectomy were divided into the following 2 groups: patients with chronic tonsillitis (n = 62) and patients with tonsillar hypertrophy (control group; n = 35). H pylori infection in the tonsillar biopsy samples was identified using histochemical and rapid urease tests.

The incidence of H pylori infection was significantly higher in the chronic tonsillitis group (56.5 per cent) compared to the control group (31.4 per cent). Similar findings were obtained for both subgroups of adults (68.6 vs 42.3 per cent) and children (40.7 vs 0.0 per cent). Significant relationships between a positive H pylori finding and laryngopharyngeal reflux related signs of vocal fold oedema, diffuse laryngeal oedema and hypertrophy of the posterior commissure were revealed.

H pylori infection may be related to chronic tonsillitis and laryngopharyngeal reflux.

To assess cardiac functions in adenotonsillar or tonsillar hypertrophy.

A prospective, interventional, academic centre based study was conducted on 25 children with adenotonsillar or tonsillar hypertrophy. All patients underwent pulsed 2-dimensional Doppler echocardiography, pulse oximetry and 12-lead electrocardiography. These assessments were repeated three months later to determine the impact of adenotonsillectomy.

There were significant differences in mean arterial oxygen saturation, pulmonary flow acceleration time and mean pulmonary artery pressure post-operatively. Adenotonsillectomy led to significant improvements in pulmonary flow acceleration time and pulmonary flow velocity time index, while tonsillectomy resulted in right ventricular early and late diastolic velocity index improvement.

Upper airway obstruction in children affects cardiac functioning and this can subsequently lead to morbidity and delayed growth. Hence, revision of surgical indications is advocated in adenotonsillar hypertrophy to avoid irreversible damage to cardiopulmonary functions.

Adenoidectomy and tonsillectomy are the oldest surgical procedures. The neutrophil-to-lymphocyte ratio is an inflammatory marker. This study aimed to investigate neutrophil-to-lymphocyte ratios in chronic tonsillitis patients and to determine whether this ratio reflects the pre- and post-operative inflammatory status in these patients.

Patients and healthy individuals were assigned to four groups: the adenoid hypertrophy, adenotonsillar hypertrophy, chronic tonsillitis and control groups. The neutrophil-to-lymphocyte ratio was calculated for each patient before surgery and one month post-surgery. Pre- and post-operative white blood cell, neutrophil and lymphocyte counts and neutrophil-to-lymphocyte ratios were compared both within and between groups.

Pre- and post-operative neutrophil-to-lymphocyte ratios were significantly higher in the chronic tonsillitis group than in the adenoid hypertrophy and adenotonsillar hypertrophy groups (p < 0.01 and p < 0.05, respectively). In the chronic tonsillitis group, post-operative neutrophil-to-lymphocyte ratios were significantly lower than pre-operative ratios (p = 0.045). The pre-operative neutrophil-to-lymphocyte ratio was significantly higher in the chronic tonsillitis group than in the adenoid hypertrophy, adenotonsillar hypertrophy and control groups (p = 0.000). In contrast, there was no significant difference in post-operative neutrophil-to-lymphocyte ratios among all groups (p = 0.584).

The neutrophil-to-lymphocyte ratio measurement can be used in chronic tonsillitis patients as an effective auxiliary method for determining the necessity and timing of tonsillectomy and post-operative follow up, thereby helping prevent complications due to delayed or inadequate treatment.