Background/Rationale
The current outbreak of coronavirus (COVID-19) has forced a significant change in the delivery of services throughout the National Health Service (NHS) in the United Kingdom (UK). The majority of elective operations have been deferred to allow increased inpatient capacity for patients with COVID-19, allow surgeons to support critical care delivery and to reduce the risk of cross-infection to protect elective patients, staff and visitors. Postponing elective surgery has led to longer waiting lists in England with the median waiting time to elective treatment in April 2020 at 12.2 weeks compared with 7.2 weeks in April 2019(1). This is likely to continue to worsen causing a decrease in the quality of life (QoL) of our patients and an increase in the incidence of associated disease sequelae.
Tonsillectomy is the most common elective procedure undertaken in the field of Ear, Nose and Throat (ENT) surgery within the UK. It makes up 17% of the elective workload and costs £68 million per year. The most common indications for tonsillectomy or tonsillotomy are recurrent tonsillitis and Obstructive Sleep Apnoea (OSA).
It has previously been demonstrated that a proportion of the paediatric population with recurrent tonsillitis will recover whilst on the waiting list for surgery. Prim et al found that 18.6% of their patients on their waiting list no longer fulfilled the criteria for tonsillectomy; the average waiting time was 10.8 months. Woolford et al contacted patients who had been on their waiting list for longer than 9 months and found that 27% of their paediatric population no longer required tonsillectomy . As such it can be deduced that a proportion of children, with recurrent tonsillitis, will spontaneously resolve over time. It is not known however how to identify this subset of the waiting list accurately.
The pathophysiology of recurrent tonsillitis in children has focussed on the microbiome of the pharynx. Cultivation studies have demonstrated numerous pathogenic bacteria in the pharynx in asymptomatic children and in those with recurrent tonsillitis. Similar studies have demonstrated latent viral reservoirs which also may play a role. It has been shown the Epstein Barr Virus (EBV) is reactivated in astronauts as a result of the stressors of spaceflight and it is understood that the virus’ life cycle is regulated by both cellular and viral factors. There is a lack of research surrounding the role that viral load, within the patient’s surroundings and how social distancing may affect the pathophysiology of recurrent tonsillitis. The recent COVID-19 outbreak, within the UK, has led to numerous public health measures to reduce human contact. Schools have been shut to the majority of pupils and the population has been advised to keep a distance of 2 metres apart unless residing in the same household .