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.