Discussion

SDB and RT, both have significant impacts to the health and QoL of children, their families, and the healthcare system (4, 5). Tonsillectomy is a surgical treatment with reported efficacy for improving the symptom burden of children with SDB and/or RT.(2) However, tonsillectomy is generally considered a non-urgent elective procedure resulting in a large discrepancy in waiting times for paediatric tonsillectomy between the patients of the Australian public and private healthcare systems.(1) This observational study demonstrates that a child’s QoL remains adversely impacted whilst waiting for elective tonsillectomy, which was often 6 months or longer, for the majority of patients undergoing treatment in a public hospital.
Children’s QoL, adversely impacted whilst waiting for paediatric tonsillectomy, demonstrated minimal improvement in T-14 scores in those that met the indications for surgery.(2, 16) However, surgery significantly improved QoL by 6 weeks post-operatively and this improved QoL was maintained at 6 months post-operatively.(13) Analysis of the T-14 infection and obstruction sub-scores showed similar results with no improvement while waiting for surgery. The group of children waiting for surgery could represent a ‘watchful waiting’ group, who ultimately had improved T-14 scores after surgery and importantly, the improvement was sustained at 6 months post-operatively. These findings highlight the health benefit of paediatric tonsillectomy to the child’s QoL and raises the importance of reducing wait times for elective surgery in the Australian public healthcare system.
These study outcomes are supported by other investigations using the T-14 questionnaire. The present study is supported by Hopkins et al (13) demonstrating, in a UK population, little change to QoL while awaiting tonsillectomy and a large improvement in QoL post-operatively that is sustained in the longer term. These findings are reinforced by Konieczny et al who used the T-14 questionnaire to demonstrate the continued benefits of tonsillectomy at follow-up after 5 years.(17) Similar findings showing substantial improvements to QoL post-operatively were reported in the Childhood Adenotonsillectomy Trial (CHAT) and other randomised clinical trials (RCTs).(18-21)
The Karolinska Adenotonsillectomy (KATE) study was an RCT comparing adenotonsillectomy with 6 months watchful waiting for management of non-severe obstructive sleep apnoea (OSA) in 53 children aged 2 - 4 years.(16) The KATE study used the Obstructive Sleep Apnea-18 (OSA-18) questionnaire as the tool to measure QoL.(22) A sub-group analysis consisting of children of similar age, SDB and wait duration showed no improvement in QoL using the T-14 scores whilst waiting for surgery and we infer our study’s findings strongly support the KATE study findings and recommendations for treatment with paediatric tonsillectomy in these patients.
The strengths of this study include its pragmatic observational design, highlighting the effectiveness of paediatric tonsillectomy on patient’s QoL in routine real-life clinical practice.(23) Each participant served as their own control and were followed longitudinally to determine changes in their QoL. We have previously reported that the T-14 questionnaire has high compliance with parents and is suitable for Australian patients undergoing tonsillectomy, as well as its use in assessing clinical efficacy of the BiZact tonsillectomy device.(14, 24) This study has demonstrated that parents perceive their child’s symptoms do not significantly change while waiting for elective surgery. However, parents perceive a significant improvement in their child’s symptoms following tonsillectomy and that this benefit is sustained even at 6 months post-operatively. We can also infer that QoL while waiting for elective surgery in children who meet criteria for tonsillectomy does not improve and therefore shortening waiting times for tonsillectomy in an Australian public hospital system would benefit a child’s QoL. There are limitations in this study. Patients with SDB and/or RT are typically referred by the general practitioner to either a public hospital clinic or a private clinic. The waiting time for the public pathway to be seen in clinic is predictably longer, for example 9 months median waiting time for an appointment in an ENT clinic in our institution or 14 months at the state’s children’s hospital(25); whereas the estimated time for a patient to be seen in a private clinic is generally shorter. The reasons for and number of parents requesting removal of their child from the elective waiting list for tonsillectomy could not be determined, though common anecdotal reasons include improvement of symptoms, relocation to another public hospital catchment area, or undergoing tonsillectomy at a private institution. This may be a confounding factor for interpretation of this data if this occurred in large numbers.