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Impact of Tonsillectomy on Quality-of-life in

Children: Our Experience
Neelima Gupta*, Lakshmi Vaid**, PP Singh†

Abstract
An important requirement of contemporary medicine is the assessment of patient benefit or change in health status resulting
from medical or surgical intervention. Tonsillectomy is a commonly performed surgery in children. Its indications and benefits
have been documented in the literature but to the best of our knowledge, there have been no Indian studies to measure
the quality-of-life (QOL), post-tonsillectomy, in children. Objective: To assess QOL of children after tonsillectomy, with or
without adenoidectomy. Study design and setting: Retrospective study in a tertiary referral center. Methodology: The sample
consisted of 136 children who had undergone tonsillectomy with or without adenoidectomy over a period of two years. The
parents of these children were sent a questionnaire to assess their QOL six months after the surgery. The questionnaire used
was a modified version of Glasgow Children’s Benefit Inventory (GCBI), a post-intervention, health-related benefit measure.
Results: Forty-four questionnaires were returned (32.2% response rate). Four questionnaires were declared invalid. Two parents
reported worsening of a few symptoms, resulting in a negative score. In the remainder, the total score ranged from 2.08 to 91.6.
Conclusions: Sixty-eight percent of the parents were extremely satisfied after the surgery. Overall, the parents reported change
for the better in various observed aspects of the life of their children as reflected in the positive scores after intervention. Most
of them reported decreased number of visits to the doctor and decreased need for antibiotic prescription, that is, there was an
improvement in the ‘physical health’ aspect of the life of children. But there was no change observed in the ‘emotional and
psychosocial’ aspect of behavior in children.
Keywords: Quality-of-life, tonsillectomy, children

T
onsillectomy and adenotonsillectomy are
common surgical procedures performed in
children. But their indications are still variable
and differ from center to center. In the past, the
most frequent indication for surgery was recurrent
tonsillitis. There has been a rise in obstructive sleep
apnea (OSA) as a significant indication from 0% in
1978 to 19% in 1986.1
Various studies have evaluated the effect of
tonsillectomy in children suffering from upper airway
obstruction. This study was designed to evaluate the
effect of tonsillectomy on the quality-of-life (QOL)
of children, with the idea that the beneficial effects of
tonsillectomy could be ascertained and more pertinent
recommendations for surgery may be formulated.
*Associate Professor
**Professor
†Professor and Head
Dept. of ENT
University College of Medical Sciences and GTB Hospital, Delhi
Address for correspondence
Dr Neelima Gupta
A-304, Abhyant Apartments, 2, Vasundhara Enclave, Delhi - 96
E-mail: write2drneelima@yahoo.com
As far as our knowledge goes, there are very few Indian
studies that have studied the effect of tonsillectomy on
the QOL of children.
Methodology
Study design: Retrospective study.
Study area: Children operated for tonsillectomy or
adenotonsillectomy in a hospital setting.
Case selection: One hundred and thirty-six children
consecutively operated over a period of two years were
selected from records. Twelve years was taken as the
upper age limit. Questionnaires were mailed to all of
them with a self-addressed envelope. Only 44 parents
returned questionnaires (response rate of 32%). Out of
the respondents, the age group of children ranged from
4 to 12 years with the mean being 8.45 years. The male-
female ratio was 1.2:1.
We adapted the questionnaire from the Glasgow
Children’s Benefit Inventory (GCBI), which has
24 questions on the consequences of a specified
intervention on various aspects of the child’s day-to-day
life, without reference to any specific symptoms.2 The
questionnaire was modified and translated into Hindi

Indian Journal of Clinical Practice, Vol. 24, No. 6, November 2013 543
ENT
(mother tongue) and was pretested among a group of
parents prior to its administration. It was also tested
for its consistency and internal validity. We also added
one question (Question number 25), which asked for
the parents, overall satisfaction with the intervention.
The questionnaire was self-administered and was filled
up by either parent of the operated child.
The questions were worded to apply to child of any age.
The pattern of responses assesses the child’s QOL in
terms of emotion, physical health, learning and vitality.
For each question, a response was given on a 5-point
Likert-type rating scale, with the central point being
‘no change’ and the extremes representing ‘much better’
and ‘much worse’.
Assigning the individual responses, a numerical value
from –2 to +2, adding the total score and dividing by
24, calculated a summary score for the questionnaire.
The score was multiplied by 50 to produce a result on
a scale from –100 (maximum harm) to +100 (maximum
benefit).
Observation and Results
Forty-four questionnaires were returned out of 136.
Four were declared invalid since a few questions were
unanswered in these forms. On calculating the scores,
two questionnaires had a negative score of –8.33 and
–20.83. The rest had positive scores ranging from 2.08
to 91.6.
Responses related to questions pertaining to
self-consciousness, embarrassment, easy distraction,
self-esteem, confidence and self-care addressing the
factor of ‘emotion’ were mostly responded to as ‘no
change’. Similarly, the questions assessing change in
learning, concentration, liveliness, fun with friends and
leisure activities addressing the factors of ‘learning’ and
‘vitality’ were responded to as ‘no change’. Questions
relating to overall life, absences from school, colds,
visit to the doctor and need for antibiotic prescriptions,
addressing the factor of ‘physical health’ were uniformly
answered with ‘much better’ as shown in Table 1 that
shows the number of parents who gave a particular
response. The figures in bold indicate that this is the
response ticked by the maximum number of parents.
No statistically significant difference was observed
in responses regarding change in food habits, sleep
pattern, learning and progress of the child, as they were
either answered with ‘little better’ or ‘no change’.
Limitations of the study: Ideally, a pre post comparison
on QOL of the patients should have been done, but due
to logistic constraints a comparative study could not
be undertaken. Similarly, no matched control group of
544 Indian Journal of Clinical Practice, Vol. 24, No. 6, November 2013
unoperated children was available. The attrition rate was
very high, as only 32% respondents returned the filled
up questionnaire, may be because of the socioeconomic
background, lack of permanent addresses and literacy
level constraints of our population. But considering that
there are few Indian studies in this area, our findings
add substantively to the existing knowledge regarding
impact of tonsillectomy on the QOL of the children.
Discussion
As decisions concerning resource allocation become
increasingly stringent, it is important to understand
the personal impact of diseases and their treatment
beyond the standard medical morbidity or functional
limitations so that this can be incorporated into the
decision-making process. This has led to studies
pertaining to outcome measures and effect of disease
and management on QOL.
On review of literature, we encountered various studies
that assessed the QOL before and after an intervention.
We used a retrospective measure of assessment of QOL
after tonsillectomy. The advantages of the retrospective
approach are that it halves the burden of questionnaires
for the parents, it is much more sensitive to change and
it can be used in conditions for which a sizeable cohort
of patients can take years to build up.2
It has been shown in a few studies that trials
commonly use serial measurements by the patients at
two points in time, while clinicians use the patient’s
retrospective assessment of change made at one point
in time. Retrospective measures were found to be more
sensitive to change than serial measures and correlated
more strongly with patient’s satisfaction with change.3
Therefore, we chose to use a retrospective measure.
Paradise et al4 studied the efficacy of tonsillectomy for
recurrent throat infection in 187 children in randomized
as well as nonrandomized trials. They found that
tonsillectomy with or without adenoidectomy was
unequivocally effective for two years and probably for
one more year in reducing the frequency and severity
of episodes of throat infection. Differences between
the treatment groups in regard to secondary outcome
measures such as number of visits on which isolated
cervical lymphadenopathy was found, number of
parent reported sore-throat days and school absent days
due to sore-throat, were less clear cut and of uncertain
clinical importance. In our study, majority of parents
reported decrease in visits to the doctor, improvement
in school attendance and decrease in episodes of cold.
Our study has a follow-up of only six months, so we
have not studied infection rate following tonsillectomy.
 ENT

Table 1. Number of Responses to the Questions Assessing Various Aspects of QOL

S. No. Question Much better Little better No change Little worse Much worse
1 Overall life 8 17 14 1 0
2 Things they do 5 12 23 0 0
3 Behavior 7 12 20 1 0
4 Progress and development 8 15 16 1 0
5 Liveliness 2 19 15 3 1
6 Sleep 8 17 11 3 1
7 Food 10 14 16 0 0
8 Self-consciousness 4 4 29 2 1
9 Family harmony 7 4 27 2 0
10 Fun with friends 5 7 27 1 0
11 Embarrassment 4 5 31 0 0
12 Distractibility 3 3 31 2 1
13 Learning 6 14 17 3 0
14 Absences from school 18 8 13 0 1
15 Concentration 2 6 27 5 0
16 Irritability 5 6 24 3 2
17 Self-esteem 8 10 22 0 0
18 Happiness 4 16 19 0 1
19 Confidence 6 9 24 0 0
20 Self-care 5 7 28 0 0
21 Leisure 6 12 22 0 0
22 Colds 20 15 4 0 1
23 Visits to doctor 26 10 2 2 0
24 Need for medication 29 7 2 2 0
25 Overall satisfaction 27 9 1 2 1
The figures in bold indicate the response given by maximum number of parents.

In a study comprising of 138 children, compared with
children who had not undergone adenotonsillectomy,
parents of the adenotonsillectomy group more
frequently reported improvement in breathing, snoring,
excessive daytime sleepiness and QOL, postoperatively.
Parental reporting of asthma, bedwetting, concentration,
school performance and intellectual or developmental
progress were not statistically different between the two
groups.5 In our analysis, 67.5% of the parents observed
‘no change’ in level of concentration or intellectual
progress of the child after intervention.
Ali and his group6 concluded from their study on
33 children, that following surgery relief of mild-
to-moderate sleep-disordered breathing improves
behavior and functioning. In our study, 50% of the
parents said they had observed no change in behavior
of the child after surgery, while 30% said that the
behavior had changed for the better. Pediatricians
and otolaryngologists should advice parents that
adenotonsillectomy most likely results in improvement
in breathing, sleep and QOL but should be guarded in
promising improvement in behavior and development.
Some studies have shown improvement in all aspects
of the life of children. Goldstein,7 in a pilot study,
demonstrated a high prevalence (28%) of abnormal
behavior in children undergoing tonsillectomy and
adenoidectomy (T&A) for chronic upper airway
obstruction. The Child Behavior Checklist (CBCL)
scores significantly improved following T&A.
Subclasses that showed improvement were withdrawn
behavior, somatic complaints, attention problems and
thought problems. Similarly, De Serres et al,8 in their
study of 101 children found large, moderate and
small improvements in QOL in 74.5%, 6.1% and 7.1%

Indian Journal of Clinical Practice, Vol. 24, No. 6, November 2013 545
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of children, respectively. Sleep disturbance, caregiver
concern and physical suffering were the most improved
domains, although significant changes also occurred
for speech and swallowing problems, emotional
disturbance and activity limitations. However, in our
study, 57.5% and 67.5% parents observed no change in
the child’s activities and his interaction with friends,
respectively as shown in Table 1.
In their study on 64 children who underwent
tonsillectomy, Goldstein et al9 found that behavioral
and emotional difficulties were found in children
with sleep-disordered breathing before treatment and
improved after intervention. They used the CBCL total
problem T scores as their outcome measure.
Flanary10 studied both short-term and long-term
effect of adenotonsillectomy on general and disease
specific QOL in children suffering from upper airway
obstruction secondary to adenotonsillar hypertrophy.
This study used both Children’s Health Questionnaire
Parent Form-28 and OSA-18 QOL measures and found
that CHQPF-28 psychosocial summary scores did
not show significant improvement in the short-term
or long-term results. Mitchell11 also confirmed that
caregiver concerns were reduced after tonsillectomy
and the domain with the most significant improvement
was sleep disturbance, while least improvement was
seen in emotional distress. We observed in our study
that 42.5% parents reported ‘a little better’ sleep pattern
in their children, while 27.5% parents observed no
change in sleep pattern.
Conclusion
Tonsillectomy definitely leads to an improvement in
the QOL in children and 68% of parents were extremely
satisfied with the surgical outcome. Almost all the
parents reported decrease in visits to the doctor and
in antibiotic prescription but there were no significant
changes observed in the emotional aspects and
personality of the children. The low response rate led
to a small sample size so we could not apply any tests
of statistical significance. A control group of children
who are followed up with no surgical intervention will
help in concluding that improvement is because of the
surgical intervention. Also our results can only give
insight into short-term QOL improvements because we
thought that if we send the questionnaires any later it
will lead to further reduction in response rate. However,
these limitations notwithstanding we conclude that
tonsillectomy has a positive impact on QOL of children.
■■■■
546 Indian Journal of Clinical Practice, Vol. 24, No. 6, November 2013
What we know: There are studies available about the
effects of tonsillectomy on child behavior and QOL, in
western literature.
What this study adds: Tonsillectomy is a frequently
performed surgery in India, but very few outcome
evaluation studies are available. Our study adds to the
knowledge that tonsillectomy has a positive impact on
the physical health of the child, while there are none or
little changes observed in the emotional and behavioral
aspects of the child’s life.
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3. Fischer D, Stewart AL, Bloch DA, Lorig K, Laurent D,
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