Tonsil Regrowth After Intracapsular Tonsillectomy

[Dr. Kevin Huoh]
It is interesting you bring up your experience as a resident because Dr. Riley was one of the first ones to adopt the intracapsular approach that Dr. Peter Kotai wrote about. He was one of the early proponents along with Dr. Kotai, so it's interesting you had that experience as a resident.

[Dr. Gopi Shah]
Yes, so the DuPont Group, they published papers as well. Because I think the big concern is tonsil regrowth. What is the percentage of tonsil regrowth? They looked at their data and they also looked at the other factors such as pain and time to PO and bleeding. I think the tonsil regrowth rate, it's like less than 1%, maybe 1%-2% at most. In terms of some people would say, "Well, regrowth is my big concern," especially the one people-- for those of us that are still doing traditional, is there an age where you're like, "Hey, this child is three. If I do an intracap for sleep-disordered breeding, are they going to have like a little bit of regrowth that could cause issues when they're six?" Is that a silly concern or how-

[Dr. Kevin Huoh]
No, I just-

[Dr. Gopi Shah]
Because we think that it proliferates, the tonsil tissue. The lymphoid tissue will proliferate between age two to six, right?

[Dr. Kevin Huoh]
Yes, absolutely. You're absolutely right, Gopi. We have data on that. The early data for intracapsular tonsillectomy alignment was from Europe, was from Sweden, and they had really varied regrowth rates, anywhere from 1% to like 12% I saw one paper. One difference about that data over from Europe is a lot of those countries, when they do intracapsular tonsillectomy, they're just doing up to the pillars. They're not going all the way to the capsular. As you would expect, those populations might have more regrowth. In our group, we've seen a regrowth rate that's around less than 1%, but the data does show that the younger you are, the more likely you are to have regrowth. Because of what you said, it proliferates at that age.
When I counsel parents of children, usually under the age of four, three or four, I will tell them there's a little higher rate of tonsil regrowth. I'll quote them, actually, a 3% rate of regrowth. My other patients, I'll say 1% or less. It's a similar rate of regrowth to risk of bleeding for total or extracap, so you kind of weigh those two different risks. I would much rather do a revision tonsillectomy at 8:00 AM in the morning, than a bleeding tonsil at 2:00 AM trying to get an airway and having a three year old bleeding in my ER. I'll take that any day of the week, you know?

[Dr. Gopi Shah]
Yes. Well, we consider two questions for you. One is if you do have a child that you did intracap on, that you have to go back for some regrowth, are you doing intracap again or do you switch techniques at that point? Then the second question is I wanted to get a little bit more into like the pain and recovery after an intracap.

[Dr. Kevin Huoh]
You asked great questions, Gopi. No wonder you're the host of the podcast.

[Dr. Gopi Shah]
Because I'm sitting here like-- no, one of my partners came on, not came on, one of my partners a couple years younger than me started-- an old partners when I was in Dallas. Stephen Chorney, he trained at CHOP and he's so brilliant. He's wonderful. Came in was like, "No, I'm going to do intracap." He's such a scientific, evidence-based mind. He saw in practice, he knows the data, and that's what he was doing. Yet the rest of us were still doing extracap. I remember getting out of fellowship being like, "Well, this is what we do here, so this is what I'm going to do because this is how we know how to handle. This is our algorithm." These are just the questions. Because I'm like, "Do I need to like-- am I a dinosaur now? What do I need to do?" That's why I have these questions for you.

[Dr. Kevin Huoh]
There's so much unpacked there.

[Dr. Gopi Shah]
[laughs].

[Dr. Kevin Huoh]
We'll, start with you-

[Dr. Gopi Shah]
About the being a dinosaur. What are we unpacking, Kevin? [laughs]

[Dr. Kevin Huoh]
There's so much to unpack about data, about surgeons following data. Let's go back to your original question, which is what do you do if you have to revise intracapsular tonsillectomy. I've done probably around 5 to 10 of these. Our rate is about less than 1%, but when I had my first regrowth, this was early in my career, and I was like, "Oh my gosh, am I doing the right thing?" Right?

[Dr. Gopi Shah]
Right.

[Dr. Kevin Huoh]
For those patients, I did a bovie tonsillectomy, I did a traditional extracapsular tonsillectomy. Then my partner, Nguyen Pham, said to me once, she like, "Kevin, why don't we just do this again? Do another intracapsular." I'm like, "Huh, okay." That's what we do now. I just do another intracapsular tonsillectomy. Now, your colleague, Stephen Chorney, he's absolutely right about following data.

There's very few things in surgery in otolaryngology where we have data. There's actually randomized control trials. Actually, one of my old attendings Dr. Kay Kane, at Lucile Packard, he did a randomized control trial on extra versus intracapsular using Coblator, so we have good data, we've got meta-analysis on this that show improved recovery, decreased post-op morbidity, et cetera. I think you're not a dinosaur, but-

[Dr. Gopi Shah]
Thank you. Yes. There is time to keep up with the data-

[Dr. Kevin Huoh]
Time's are a-changin'.

[Dr. Gopi Shah]
Yes, times are a-changin'. I guess, if you are doing a revision intracapsular tonsillectomy, it makes sense because the kids are usually a bit older, so that sort of tonsil regrowth period that we worried about isn't maybe as much. I think there was a point where I think an intracap, I would think about it for my young kids, the under two that have really bad OSA, that 15 month old for some reason that, you know what I mean? Then I'm like, "Well, is this going to regrow or my cardiac kids on the aspirin?" It's just like, "Well, why am I not just switching over completely," but when you explain, tell me about the post-op recovery, because on the other hand, and again, this is where I'm so excited you're here, because it's like, "Well, do you want your kid to have a potential for a tonsillectomy all over again?"

[Dr. Gopi Shah]
Yes. You said that, at the conferences, we're not talking about tonsillar intracap as much right now.

[Dr. Kevin Huoh]
Yes, I think at the last academy meeting in Philadelphia, there was a panel on how to manage pain after pediatric tonsillectomy. The elephant in the room is intracapsular. They're talking about all these other ways of reduce pain, Tylenol/Motrin alternating, but they failed to talk about intracapsular. I always raised my hand to talk about it.

Then when you look at the latest clinical practice guidelines from our academy, they didn't mention intracapsular tonsillectomy once in the guidelines, but they did have an addendum this time saying that intracapsular is around, like you can try it, we need "more data". If you look at the guidelines in England and the UK, if you look at guidelines in France, it's on their national guidelines. Actually the National Health Service in the UK, they recommend intracapsular tonsillectomy because they have the data, they've looked at the data.

[Dr. Gopi Shah]
Well, it sounds like we have data too, because we have randomized control trials and meta-analysis. It's just hasn't quite taken off I guess. Would you agree with that?

[Dr. Kevin Huoh]
Yes. I would. I think some of it has to do with the free-thinking, independent spirit of Americans in general. I think it takes a little time for any new innovation to spread. I did my survey five years ago of ASPO members, American Society of Pediatric Otolaryngology members. I think only 20% were doing intracaps. That was 2017, thereabouts. My guess is that it's higher than that now. I think probably 40%, I would hope by now. If we look at Malcolm Gladwell's book, The Tipping Point, he talks about the 20% being the tipping point or the point at which diffusion increases at exponential rate. After seeing that number, I felt encouraged.