European Archives of Oto-Rhino-Laryngology

, Volume 275, Issue 6, pp 1353–1363 | Cite as

Systematic review of tonsil surgery quality registers and introduction of the Nordic Tonsil Surgery Register Collaboration

  • Johanna Ruohoalho
  • Eirik Østvoll
  • Mette Bratt
  • Vegard Bugten
  • Leif Bäck
  • Antti Mäkitie
  • Therese Ovesen
  • Joacim Stalfors
Review Article



Surgical quality registers provide tools to measure and improve the outcome of surgery. International register collaboration creates an opportunity to assess and critically evaluate national practices, and increases the size of available datasets. Even though millions of yearly tonsillectomies and tonsillotomies are performed worldwide, clinical practices are variable and inconsistency of evidence regarding the best clinical practice exists. The need for quality improvement actions is evident. We aimed to systematically investigate the existing tonsil surgery quality registers found in the literature, and to provide a thorough presentation of the planned Nordic Tonsil Surgery Register Collaboration.


A systematic literature search of MEDLINE and EMBASE databases (from January 1990 to December 2016) was conducted to identify registers, databases, quality improvement programs or comprehensive audit programs addressing tonsil surgery.


We identified two active registers and three completed audit programs focusing on tonsil surgery quality registration. Recorded variables were fairly similar, but considerable variation in coverage, number of operations included and length of time period for inclusion was discovered.


Considering tonsillectomies and tonsillotomies being among the most commonly performed surgical procedures in otorhinolaryngology, it is surprising that only two active registers could be identified. We present a Nordic Tonsil Surgery Register Collaboration—an international tonsil surgery quality register project aiming to provide accurate benchmarks and enhance the quality of tonsil surgery in Denmark, Finland, Norway and Sweden.


Quality assurance Surgical quality Tonsillectomy Tonsillotomy Registry Database 



This study was funded by NordForsk foundation (Grant no. 971274255).

Compliance with ethical standards

Conflict of interest

The authors declare that they have no conflict of interest.

Ethical approval

This article does not contain any studies with human participants or animals performed by any of the authors.


Data from the Norwegian Patient Register has been used in this publication. The interpretation and reporting of these data are the sole responsibility of the authors, and no endorsement by the Norwegian patient register is intended nor should be inferred.


  1. 1.
    Official webpage of Swedish National Quality Registries. Accessed 12 Apr 2017
  2. 2.
    National Institute of Health and Welfare, Finland (2017). Accessed 24 Jul 2017
  3. 3.
    Official webpage of Norwegian national quality register (2017). Accessed 20 Sep 2017
  4. 4.
    Statens Serum Institute, Denmark (2017). Accessed 24 Jul 2017
  5. 5.
    Hessen Soderman AC, Ericsson E, Hemlin C, Hultcrantz E, Mansson I, Roos K, Stalfors J (2011) Reduced risk of primary postoperative hemorrhage after tonsil surgery in Sweden: results from the National Tonsil Surgery Register in Sweden covering more than 10 years and 54,696 operations. Laryngoscope 121(11):2322–2326CrossRefPubMedGoogle Scholar
  6. 6.
    Hultcrantz E, Ericsson E (2013) Factors influencing the indication for tonsillectomy: a historical overview and current concepts. ORL J Otorhinolaryngol Relat Spec 75(3):184–191CrossRefPubMedGoogle Scholar
  7. 7.
    Windfuhr JP, Toepfner N, Steffen G, Waldfahrer F, Berner R (2016) Clinical practice guideline: tonsillitis II. Surgical management. Eur Arch Oto-Rhino-Laryngol 273(4):989–1009CrossRefGoogle Scholar
  8. 8.
    Burton MJ, Glasziou PP, Chong LY, Venekamp RP (2014) Tonsillectomy or adenotonsillectomy versus non-surgical treatment for chronic/recurrent acute tonsillitis. Cochrane Database Syst Rev 11:CD001802Google Scholar
  9. 9.
    Hollis LJ, Burton MJ, Millar JM (2000) Perioperative local anaesthesia for reducing pain following tonsillectomy. Cochrane Database Syst Rev 2(2):CD001874Google Scholar
  10. 10.
    Lim J, McKean MC (2009) Adenotonsillectomy for obstructive sleep apnoea in children. Cochrane Database Syst Rev 2:CD003136Google Scholar
  11. 11.
    Pinder DK, Wilson H, Hilton MP (2011) Dissection versus diathermy for tonsillectomy. Cochrane Database Syst Rev 3:CD002211Google Scholar
  12. 12.
    Croft P, Malmivaara A, van Tulder M (2011) The pros and cons of evidence-based medicine. Spine (Phila Pa 1976) 36(17):E1121–E1125CrossRefGoogle Scholar
  13. 13.
    Malmivaara A (2013) Real-effectiveness medicine-pursuing the best effectiveness in the ordinary care of patients. Ann Med 45(2):103–106CrossRefPubMedGoogle Scholar
  14. 14.
    Moher D, Liberati A, Tetzlaff J, Altman DG, PRISMA Group (2009) Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. J Clin Epidemiol 62(10):1006–1012CrossRefPubMedGoogle Scholar
  15. 15.
    Drolet BC, Johnson KB (2008) Categorizing the world of registries. J Biomed Inform 41(6):1009–1020CrossRefPubMedGoogle Scholar
  16. 16.
    Stalfors J, Ericsson E, Hemlin C, Hultcrantz E, Mansson I, Roos K, Hessen Soderman AC (2012) Tonsil surgery efficiently relieves symptoms: analysis of 54 696 patients in the National Tonsil Surgery Register in Sweden. Acta Otolaryngol 132(5):533–539CrossRefPubMedGoogle Scholar
  17. 17.
    Soderman AC, Odhagen E, Ericsson E, Hemlin C, Hultcrantz E, Sunnergren O, Stalfors J (2015) Post-tonsillectomy haemorrhage rates are related to technique for dissection and for haemostasis. An analysis of 15734 patients in the National Tonsil Surgery Register in Sweden. Clin Otolaryngol 40(3):248–254CrossRefPubMedGoogle Scholar
  18. 18.
    Sunnergren O, Hemlin C, Ericsson E, Hessen-Soderman AC, Hultcrantz E, Odhagen E, Stalfors J (2014) Radiofrequency tonsillotomy in Sweden 2009–2012. Eur Arch Otorhinolaryngol 271(6):1823–1827CrossRefPubMedGoogle Scholar
  19. 19.
    Hultcrantz E, Ericsson E, Hemlin C, Hessen-Soderman AC, Roos K, Sunnergren O, Stalfors J (2013) Paradigm shift in Sweden from tonsillectomy to tonsillotomy for children with upper airway obstructive symptoms due to tonsillar hypertrophy. Eur Arch Otorhinolaryngol 270(9):2531–2536CrossRefPubMedGoogle Scholar
  20. 20.
    Ericsson E, Brattwall M, Lundeberg S (2015) Swedish guidelines for the treatment of pain in tonsil surgery in pediatric patients up to 18 years. Int J Pediatr Otorhinolaryngol 79(4):443–450CrossRefPubMedGoogle Scholar
  21. 21.
    Elinder K, Soderman AC, Stalfors J, Knutsson J (2016) Factors influencing morbidity after paediatric tonsillectomy: a study of 18,712 patients in the National Tonsil Surgery Register in Sweden. Eur Arch Otorhinolaryngol 273(8):2249–2256CrossRefPubMedGoogle Scholar
  22. 22.
    Ostvoll E, Sunnergren O, Ericsson E, Hemlin C, Hultcrantz E, Odhagen E, Stalfors J (2015) Mortality after tonsil surgery, a population study, covering eight years and 82,527 operations in Sweden. Eur Arch Otorhinolaryngol 272(3):737–743CrossRefPubMedGoogle Scholar
  23. 23.
    Tomkinson A, Harrison W, Owens D, Harris S, McClure V, Temple M (2011) Risk factors for postoperative hemorrhage following tonsillectomy. Laryngoscope 121(2):279–288CrossRefPubMedGoogle Scholar
  24. 24.
    Public Health Wales annual report 2015: Tonsillectomy and adenoidectomy single-use instrument surveillance (2016). Accessed 20 Feb 2018
  25. 25.
    Sarny S, Ossimitz G, Habermann W, Stammberger H (2012) The Austrian tonsil study 2010–part 1: statistical overview. Laryngorhinootologie 91(1):16–21CrossRefPubMedGoogle Scholar
  26. 26.
    Sarny S, Habermann W, Ossimitz G, Stammberger H (2012) The Austrian Tonsil Study 2010—Part 2: postoperative haemorrhage. Laryngorhinootologie 91(2):98–102CrossRefPubMedGoogle Scholar
  27. 27.
    Sarny S, Ossimitz G, Habermann W, Stammberger H (2013) Austrian tonsil study part 3: surgical technique and postoperative haemorrhage after tonsillectomy. Laryngorhinootologie 92(2):92–96PubMedGoogle Scholar
  28. 28.
    Sarny S, Habermann W, Ossimitz G, Stammberger H (2013) What lessons can be learned from the Austrian events? ORL J Otorhinolaryngol Relat Spec 75(3):175–181CrossRefPubMedGoogle Scholar
  29. 29.
    The Royal College of Surgeons of England, England (2005) National Prospective Tonsillectomy Audit final report. The Royal College of Surgeons of EnglandGoogle Scholar
  30. 30.
    Lowe D, van der Meulen J, Cromwell D et al (2007) Key messages from the national prospective tonsillectomy audit. Laryngoscope 117(4):717–724CrossRefPubMedGoogle Scholar
  31. 31.
    Audit NP (2008) Impact of NICE guidance on rates of haemorrhage after tonsillectomy: an evaluation of guidance issued during an ongoing national tonsillectomy audit. Qual Saf Health Care 17(4):264–268CrossRefPubMedGoogle Scholar
  32. 32.
    Blanchford H, Lowe D (2013) Cold versus hot tonsillectomy: state of the art and recommendations. ORL J Otorhinolaryngol Relat Spec 75(3):136–141CrossRefPubMedGoogle Scholar
  33. 33.
    Lowe D, van der Meulen J, National Prospective Tonsillectomy Audit (2004) Tonsillectomy technique as a risk factor for postoperative haemorrhage. Lancet 364(9435):697–702CrossRefPubMedGoogle Scholar
  34. 34.
    Scotland Scottish Otolaryngology Society (2008) A Scottish prospective audit of tonsil and adenoid surgery with disposable surgical instruments—Final reportGoogle Scholar
  35. 35.
    Blair RL, McKerrow WS, Carter NW, Fenton A (1996) The Scottish tonsillectomy audit. Audit Sub-Committee of the Scottish Otolaryngological Society. J Laryngol Otol 110(Suppl 20):1–25PubMedGoogle Scholar
  36. 36.
    Officiel webpages for tonsil surgery register of Sweden (2017) Accessed 20 Feb 2018
  37. 37.
    Department of Health. Risk assessment for transmission of vCJD via surgical instruments: a modelling approach and numerical scenarios (2001). Accessed 20 Feb 2018
  38. 38.
    Public Health Wales Clinical Instrument Surveillance Program webpage (2015). Accessed 23 Mar 2018
  39. 39.
    Bergqvist D, Bjorck M, Lees T, Menyhei G (2014) Validation of the VASCUNET registry—pilot study. Vasa 43(2):141–144CrossRefPubMedGoogle Scholar
  40. 40.
    de By TM, Mohacsi P, Gummert J et al (2015) The European Registry for Patients with Mechanical Circulatory Support (EUROMACS): first annual report. Eur J Cardiothorac Surg 47(5):770–776CrossRefPubMedGoogle Scholar
  41. 41.
    Elefteriades JA, Ziganshin BA (2015) Gratitude to the international registry of acute aortic dissection from the aortic community. J Am Coll Cardiol 66(4):359–362CrossRefPubMedGoogle Scholar
  42. 42.
    Havelin LI, Fenstad AM, Salomonsson R et al (2009) The Nordic Arthroplasty Register Association: a unique collaboration between 3 national hip arthroplasty registries with 280,201 THRs. Acta Orthop 80(4):393–401CrossRefPubMedPubMedCentralGoogle Scholar
  43. 43.
    Marks W, Bailey L, Sanger TD (2017) PEDiDBS: the pediatric international deep brain stimulation registry project. Eur J Paediatr Neurol 21(1):218–222CrossRefPubMedGoogle Scholar
  44. 44.
    Petruzzo P, Lanzetta M, Dubernard JM et al (2010) The international registry on hand and composite tissue transplantation. Transplantation 90(12):1590–1594CrossRefPubMedGoogle Scholar
  45. 45.
    Stehlik J, Hosenpud JD, Edwards LB, Hertz MI, Mehra MR, International Society for Heart and Lung Transplantation (2013) ISHLT international registry for heart and lung transplantation—into the fourth decade, from strength to strength. J Heart Lung Transplant 32(10):941–950CrossRefPubMedGoogle Scholar
  46. 46.
    Vallabhaneni SR, Harris PL (2001) Lessons learnt from the EUROSTAR registry on endovascular repair of abdominal aortic aneurysm repair. Eur J Radiol 39(1):34–41CrossRefPubMedGoogle Scholar
  47. 47.
    Levine MN, Julian JA (2008) Registries that show efficacy: good, but not good enough. J Clin Oncol 26(33):5316–5319CrossRefPubMedGoogle Scholar
  48. 48.
    Porter M, Teisberg E (2006) Redefining health care: creating value-based competition on results. Harvard Business Press, BostonGoogle Scholar
  49. 49.
    The International Consortium for Health Outcomes Measurement (2015) What matters most: patient outcomes and the transformation of health care. Accessed 13 Sep 2017
  50. 50.
    Stalfors J, Ericsson E, Hemlin C, Hessen Soderman AC, Odhagen E, Sunnergren O (2014) Annual report for the National Tonsil Surgery Register in Sweden 2013. Karolinska University Hospital. Stockholm, SwedenGoogle Scholar
  51. 51.
    Officiel webpage of The National Tonsil Surgery Register of Sweden. Accessed 12 Sep 2017
  52. 52.
    Ludvigsson JF, Andersson E, Ekbom A et al (2011) External review and validation of the Swedish national inpatient register. BMC Public Health 11:450-2458-11-450CrossRefGoogle Scholar
  53. 53.
    Organization for Economic Co-operation and Development, OECD. Statistics of surgical procedures 2014. Accessed 20 Feb 2018
  54. 54.
    National Institute of Health and Welfare, Finland. Specialised Health Care - Database of Annual Number of Preocedures (in Finnish). Accessed 23 Mar 2018
  55. 55.
    Norwegian Patient Register (2017) Annual number of tonsil surgery procedures in 2014. 
  56. 56.
    Månsson I (ed) (2009) Report on indications for tonsil surgery in Sweden (in Swedish). Sveriges Kommuner och Landsting, Stockholm, SwedenGoogle Scholar
  57. 57.
    Ministry of Social Affairs and Health (2010) Uniform criteria for access to non-emergency treatment 2010. 2nd edn. (in Finnish). Helsinki, FinlandGoogle Scholar
  58. 58.
    National clinical guideline for the removal of tonsils (tonsillectomy) (2016) Danish Health Authority. Accessed 23 Mar 2018
  59. 59.
    Wiksten J, Blomgren K, Eriksson T, Guldfred L, Bratt M, Pitkaranta A (2014) Variations in treatment of peritonsillar abscess in four Nordic countries. Acta Otolaryngol 134(8):813–817CrossRefPubMedGoogle Scholar

Copyright information

© Springer-Verlag GmbH Germany, part of Springer Nature 2018

Authors and Affiliations

  1. 1.Department of Otorhinolaryngology, Head and Neck SurgeryUniversity of Helsinki and Helsinki University HospitalHelsinkiFinland
  2. 2.Department of Otorhinolaryngology, Head and Neck SurgerySahlgrenska University HospitalGöteborgSweden
  3. 3.Institute of Clinical SciencesSahlgrenska Academy at the University of GothenburgGöteborgSweden
  4. 4.Department of Otorhinolaryngology, Head and Neck SurgerySt Olav’s University HospitalTrondheimNorway
  5. 5.Department of Neuromedicine and Movement ScienceNorwegian University of Science and TechnologyTrondheimNorway
  6. 6.Department of Otorhinolaryngology, Region Hospital Holstebro, Institute of Clinical MedicineAarhus UniversityÅrhus CDenmark
  7. 7.Sheikh Khalifa Medical CityAjmanUnited Arab Emirates

Personalised recommendations