Tonsils and Sleep-Disordered Breathing: An Analysis of Symptom Screening and Tonsillar Inflammation as Performed by Dental Providers
The purpose of the research presented in this article is to determine the effectiveness of this surgical procedure and compare it to children that have not had such surgery
April 1, 2025
Volume 46
,
Issue 4
,
April 2025
ABSTRACT
Tonsillectomies traditionally have been used as the first line of treatment for children with sleep-disordered breathing. The purpose of the research presented in this article is to determine the effectiveness of this surgical procedure and compare it to children that have not had such surgery. A sample comprised 9,317 subjects, of which 537 had tonsillectomies and 8,780 did not have tonsillectomies. The study analyzed: (1) the effectiveness of the tonsillectomies regarding the elimination of swollen tissues; (2) six symptoms of sleep-disordered breathing that remained following surgery; (3) the estimation of post-surgery improvement achieved through the use of a preformed removable appliance; and (4) the total expected outcome for both surgery and use of the post-surgery appliance. The authors concluded thatsignificant removal of lymphoidal tissue resulted from tonsillectomies. Significant improvement was observed in two of the six evaluated symptoms that remained after surgery-interrupted snoring and nighttime mouth breathing. Significant improvement resulted in all six symptoms when the tonsillectomies were combined with post-surgical use of a preformed removable sleep appliance.
Sleep-related breathing disorders (SRBDs) include clinical conditions in which patients present with abnormal or difficult respiration during sleep. Clinical symptoms and poor oral habits have been associated with SRBD in pediatric patients and include but are not limited to snoring, mouth breathing both during the day and at night, tonsillar inflammation, and speech issues. It is estimated that 1% to 3% of pediatric patients are diagnosed with obstructive sleep apnea (OSA),1 but the prevalence of pediatric patients who experience symptoms associated with SRBD is estimated to be as high as 90%.2
Depending on the severity of symptoms presented, current standard of care for pediatric patients who present with SRBD includes evaluation by a sleep physician with a polysomnogram and other diagnostics as determined by a treating doctor, and referral to an otorhinolaryngologist for evaluation and treatment as needed. The American Academy of Otolaryngology Head and Neck Surgery Foundation updated the clinical practice guidelines for tonsillectomies in children in 2019 with the purpose of supporting a multidisciplinary approach to improve patient outcomes.3
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When a patient presents with moderate to severe tonsillar hypertrophy and/or recurrent tonsillitis, the typical recommendation includes tonsillectomy and/or tonsil and adenoidectomy, pending any additional diagnostic data and evaluation that is ordered prior to finalizing a treatment plan. A historical review and meta-analysis of tonsillectomy and tonsillotomy summarized that regrowth of tonsil tissue occurred in 3% to 16% of cases, requiring revision surgeries in 0.46% to 3.24% of cases. Variability in findings included the age at which the patient underwent the surgical procedure, the postoperative follow-up timeline, history of recurrent tonsillitis, and primary diagnosis.4
Methodology
The present study was aimed at determining the effectiveness of tonsillectomy surgery and comparing it to cases in which children did not have the surgery. Baseline data on 9,317 patients was evaluated. Patients were seen in HealthyStart® (HS) (thehealthystart.com) offices for a comprehensive examination and screening for SRBD. An HS office is defined as one with a dental provider (general dentist, pediatric dentist, or orthodontist) who has 16 hours of continuing education and advanced training in sleep-disordered breathing, airway issues, and early interceptive orthodontics as taught by HealthyStart. Male and female patients were pooled and all included up to 16 years of age, as a result of no gender significant differences.
The screening process for SRBD by an oral healthcare provider included a health history review, a comprehensive dental examination, and the collection of data as prompted by the HS screening protocols (Figure 1). In addition to this patient information, the initial screening appointment may have also included imaging (eg, panoramic x-ray, intraoral radiographs, CBCT scans, cephalometric analysis), orthodontic photographs, study models, sleep analysis, and discussion with a collaborative healthcare provider (eg, otolaryngologist, pediatrician, speech therapist, or myofunctional therapist). Collection of this additional patient information would depend on parent consent, patient compliance, and the discretion of the treating doctor.
Based on the data provided, the 9,317 patients were then subdivided into two categories: history of tonsillectomy or no history of tonsillectomy. There was no further division and/or subsequent analysis based on the type of tonsillectomy performed (or specifics related to the surgical procedure), age at which the procedure was completed, presence of complications, or other potentially contributing factors to recovery and long-term prognosis. Both patient groups were then evaluated for the prevalence of six symptoms or oral habits: (1) snoring, (2) interrupted snoring, (3) mouth breathing during the day, (4) mouth breathing while sleeping, (5) nasal breathing difficulty, and (6) speech problems. Some patients may experience more than one of these symptoms. The presence and severity of these symptoms are based on questionnaire data (Figure 1) as indicated by the patient's parent or guardian. Additionally, all 9,317 patients were evaluated in the clinical examination for the presence and/or inflammation of tonsils using the standardized tonsillar hypertrophy grading scale (Figure 2).5
A further analysis of a separate sample (N = 220) was used to determine the potential benefit of using a preformed removable sleep modifying appliance (HealthyStart® Habit Corrector®, Ortho-Tain, Inc., orthotain.com) to possibly improve the post-surgical SRDB results.
Beyond the primary 9,317 patient population being analyzed for the purposes of this research, a separate analysis was performed on a different patient population of 1,034 cases for the sole purpose of determining if there was a statistical difference between males and females, of which there was none. Because there were no gender differences, the sexes were pooled for the analysis of data. Statistical determinations used t-tests and chi-square depending on the data available.
Findings
Clinical screening data was reviewed for a total of 9,317 patients. Of these, 537 were reported as having a history of tonsillectomy (ie, health history as reported by the patient, parent, or guardian revealing that the patient previously had tonsils removed); 8,780 patients reported having no history of tonsillectomy (ie, still have their tonsils) (Table 1).
Discussion
As seen in Table 2, for patients who had previously undergone a tonsillectomy, 90.6% were found to have no evidence of tissue or tissue swelling, 6.4% presented with minor tonsil swelling, 1.9% had major swelling, and in 1.1% tonsils were touching. For the latter two groups, this 3% (1.9% + 1.1%) falls within the regrowth rate as confirmed in the meta-analysis previously cited.4 With only 3% of the tonsillectomy patients experiencing a regrowth rate that would qualify for consideration for a revision procedure, it is reasonable to conclude that the procedure was successful at removing lymphoid tissue without relapse.
Based on the symptom findings in these same patients, the tonsillectomy procedure did not appear to provide predictable resolution of the symptoms and habits associated with SRBD (Table 1). There was still prevalence of snoring (48.4%), interrupted snoring (11.9%), daytime mouth breathing (41.5%), mouth breathing while sleeping (50.5%), difficulty with nasal breathing (19.6%), and speech problems (19%). These symptom findings indicate that snoring remained uncorrected following a tonsillectomy and was significantly greater (P = .001) in these patients than in those with no history of a tonsillectomy. Two symptoms, interrupted snoring and nighttime mouth breathing, had less residual presence in patients following a tonsillectomy than in those without surgery. The other three symptoms favored those without surgery. A possible deficiency of this study is that the analysis focuses on a binary evaluation of symptoms (present versus not present), whereas it may be that patients who had a tonsillectomy experienced a greater initial severity of swelling than those who did not have surgery.
The aforementioned 2019 updated clinical practice guidelines for tonsillectomies in children do not include recommendations for referral to oral healthcare providers (general dentists, pediatric dentists, and orthodontists) for evaluation and potential adjunctive treatment to tonsillectomy.3 Such adjunctive treatment may include, for example, the use of removable preformed sleep and oral habit appliances, which have demonstrated efficacy in the reduction of SRBD symptoms (Table 3, column C).6 Table 3 indicates that significant positive changes in post-surgical results might be attainable with the use of such removable appliances, as a mean improvement of 20% following the surgical result was shown.
It is hypothesized that the prevalence of certain symptoms and/or clinical conditions is higher in HS offices than in the general population because there is potential for a positive correlation between the patient's chief complaint and the referral to a provider who treats this chief complaint-that is, patients with sleep and airway issues will likely seek out a provider who has expertise in addressing these issues. This could present a confirmation bias, which should be accounted for in future research. The author (Bergersen) investigated this type of bias in unpublished research and found a 20% difference between those seeking sleep issues and those only interested in their dental issues (the dental issue group being 20% less in mean symptoms present per patient).
Limitations of This Analysis
The following data was not included in this investigation: tonsillectomy technique used (intracapsular, extracapsular) and whether it was tonsillectomy only or included adenoidectomy in the same procedure; reason for tonsillectomy; evaluation of change in severity of SRBD symptoms in tonsillectomy patients; clinical interventions employed (or not) prior to surgery to alleviate symptoms (ie, use of nasal spray to improve nasal breathing); age of patient at the time of procedure (follow-up timeline could also contribute to variability in symptoms); pre- and postoperative patient compliance with doctor recommendations; other contributing factors to medical history, including prescription and over-the-counter medication, systemic health issues, nutrition, etc. The data was dependent on an accurate history taken and the examination performed by the various providers.
Conclusion
Many pediatric patients who present with a history of tonsillectomy experience ongoing symptoms of sleep-related breathing disorders, including but not limited to snoring, interrupted snoring, mouth breathing during the day, mouth breathing while sleeping, difficulty with nasal breathing, and speech issues. As a result of this research, the following conclusions can be made:
· For pediatric patients who had a tonsillectomy, interrupted snoring and mouth breathing while sleeping showed significant improvement over patients who did not have tonsillectomies.
· Tonsillectomies reduced the various degrees of swelling.
· The use of a preformed intraoral appliance was effective in reducing symptoms associated with SRBD.
· Tonsillar surgery improved the outcome of these six symptoms by 20%, and these surgical outcomes may increase with the use of an oral appliance for 6 months following the procedure.
· Oral healthcare providers (specifically those trained in pediatric SRBD) see patients on average two times per year and could be a vital source of patient education, screening, referral, and/or cross-disciplinary therapy management to address SRBD symptoms, oral habits, and root causes of this condition.
More collaborative research is needed in the following areas: screening and referral efficacy of pediatric SRBD patients by oral healthcare providers; patient family preference and/or optimization related to multidisciplinary care management and referral pathway; otorhinolaryngologist-dental provider collaborations for optimal upper airway management, including but not limited to screening and diagnostic protocols, referral patterns, and pre- and postoperative education and instructions; studies designed to account for the limitations of the current analysis (as listed above).
DISCLOSURE
Dr. Bergersen is the innovator of the appliance used for treatment in this study. He is an advisor on the board of Ortho-Tain, Inc., which manufactures and distributes the appliance, volunteering his time and taking no compensation for his role. Neither Drs. Bergersen nor Stevens-Green have any commercial interest in the ownership of the company; both share a family relationship with the owners and chief executive officer of the company. Dr. Rosellini is a research associate and clinical advisor for HealthyStart®.
ABOUT THE AUTHORS
Elizabeth Rosellini, DDS
Private Practice, Dorado, Puerto Rico
Earl O. Bergersen, DDS, MSD
Former Assistant Professor for 25 years, Northwestern University Dental School, Graduate Orthodontic Department, Chicago, Illinois; Private Practice in Orthodontics (ret.), Winnetka, Illinois
Brooke Stevens-Green, BS, DDS
Private Practice, Farmington Hills, Michigan
