EFFECT OF TONSILLECTOMY ON ASO-TITRE

N. Viswanathan ~, S. S a s i k u m a r a n Nair 2, S. T h u l s e e d h a r a n 3,

INTRODUCTION
A raised A S O titre level is one of the m o s t relevant
retrospective serological indices of antecedent Group A
Beta hemolytic streptococcal(GABHS) infection. Group
A Beta h e m o l y t i c streptococci are the m o s t c o m m o n
bacteria that cause acute tonsillitis. Streptococcal infection
can lead to rheumatic fever. The incidence of rheumatic
fever in untreated case's of tonsillitis is 3% and in treated
cases the incidence falls to 0.3%. It has been estimated
that rheumatic heart disease constitute 25 to 40% of all
cardiovascular disease in third world countries.
The A S O titre is the m o s t widely used and the best
standardized serological test of a recent streptococcal
infection. A single titre of more than 200 iu/ml is considered
as a raised value. A c c o r d i n g to Read SE and Zabrinskie
an increase in A S O titre warn of the possible development
of rheumatic fever. It is known that each episode of
rheumatic fever is associated with an elevated ASO titre.
A raised level of ASO titre is mandatory for the diagnosis
of r h e u m a t i c f e v e r according to the m o d i f i e d Johnes
criteria. There is often a preceding history of tonsillitis in
a s i g n i f i c a n t p e r c e n t a g e o f r h e u m a t i c f e v e r and
reactivation. So it was decided to conduct a stt~dy of the
effect of tonsillectomy on ASO titrc of patients suffcring
from chronic tonsillitis, since as mentioned earlier, a raised
A S O titre is an indication of antecedent streptococcal
infection. The effect of tonsillectomy on the incidence of
sore throat was also assessed.

age of 15 years were screened. 50patients who showed

raised ASO titre above 200 iu/ml were included in this
study. This consisted of 28 males and 22 females.The
youngest patient was 3V2 years and the oldest was 15
years the mean age was 8.13 _+ 2.8 years.
Clinical p a r a m e t e r s used for the diagnosis o f chronic
tonsillitis were as follows:
1. Minimum of 6 attacks of sore throat per year for not
less than 2 years.
2. Tender, atrophic or hypertrophied tonsils wth persistent
sore throat.
3. Presence of congestion of the anterior pillar.
4. Palpable jugulodigastric lymph node.
5. Expression of cheesy material from crypts on applying
pressure on the tonsils.
A thorough clinical examination of all the patients was
followed by routine blood and urine examination. Blood
examination included total white cell count differential
count, ESR, hemoglobin, bleeding time and clotting time.
Urine was e x a m i n e d for sugar, albumin and deposits.
Throat swab was sent for culture and sensitivity. Blood
was examined for A S O titre on the day before surgery-.
2ml of fresh clean s e r u m was used. H a e m o l y s e d , and
c o n t a m i n a t e d s a m p l e s w e r e e x c l u d e d . P o s i t i v e and
negative controls were used to check the quality. All the
tests were done with immunostat ASO titre kit by Ranbaxy
Laboratories to eliminate bias.

STUDY D E S I G N
In this prospective, case control study, conducted in the
ENT Department of Trivandrum Medical College for a
period o f one year (January 1996 to D e c e m b e r 1997),
136 children suffering from chronic tonsillitis below the

All the patients underwent tonsillectomy under general

anesthesia by dissection method. A course o f injection
ampicillin was given postoperatively for seven days to all
patients.

1Associate Professor, 2Professor, ENT Medical College, Trivandrum, 3Lecturer, ENT Medical College Alleppy.

330

Efect o f Tonsillectomy on Aso-titre

ASO titre estimation was done after 1 month, 3 months,

6 months a n d lyear postoperatively. Statistical analysis
was done using Chi square method.

RESULTS
Table I
ASO titre after tonsillectomy
ASO Titre

1 months

3 months

6 months

1 year

Negative

11 (22%)

31(62%)

39(78%)

44(88%)

(p>0.10 N.S) (p<0.001)

(p<0.001) (p<0.001)

Table -II
Number of episodes of sore throat after tonsillectomy
during 1 year follow up period.
Number of attacks
of sore throat

Number of
patients

One
Two
Nil

11
2
37

Percentage

22
4
74
(p<0.001)

DISCUSSION
Chronic tonsillitis is one of the common clinical problems
in ENT practice. Streptococcus is the main organism
r e s p o n s i b l e for this. R h e u m a t i c f e v e r is one o f the
complications of streptococcal tonsillitis. Rheumatic fever
constitutes 25 t o 40% of cardiovascular diseases in third
world countries. This underscores the importance of early
detection of streptococcal throat infection and effective
intervention. Throat swabs culture is positive in 80% of
streptococcal infections. But most often it is negative in
chronic tbnsillitis. Antigen detection test is very sensitive;
but it is very costly and not available in all the centers.
ASO titre test is the most widely used test. It is more
popular because of its availability in our country, less cost
and reasonable sensitivity.
T h o u g h medical treatment with peneillin is effective,
repeated attacks of tonsillitis leads to incomplete resolution
and ends in chronic tonsillitis, for which surgery remains

the treatment of choice. Very few studies have been

reported regarding the effect of tonsillectomy on ASO
titre. So a comparative discussion is limited. In this study
136 cases were screened. 50 cases were ASO positive.
This reveals 41% prevalence of streptococcal infection in
our community. Bell & Smith et al in a study reported that
30% of pharyngitis with or without tonsillitis is caused by
Group-A streptococcus. Read & Zabrinskie et al showed
that among the population at great risk of rheumatic fever;
up to 50% o f sore t h r o a t s are due to G r o u p - A
streptococcus.
Denny 2 & Wannamarker et al found that incidence of acute
rheumatic fever following streptococcal tonsillitis declined
from 3% to 0.3% after pencillin treatment. Tile incidence
of a second attack of rheumatic fever is approximately
60% and reduced to 4% in long term prophylaxis with
pencillin. In our study there was no case of rheumatic
fever. So we could not study the effect of surgery on
rheumatic fever.
T h i s study, which was a i m e d at the e f f i c a c y of
tonsillectomy, showed a significant reduction in ASO titre
after tonsillectomy. One m o n t h a f t e r t o n s i l l e c t o m y
11(22%) cases were negative for ASO titre. However this
was not statistically significant (p=>0.1)
3 months after surgery 31 patients (62%) became negative
for ASO titre. This observation was statistically significant
(p=<0.001). After 6 months 39 patients (78%) (p=<0.001)
became ASO titre negative. One year after tonsillectomy
44 p a t i e n t s ( 8 8 % ) b e c a m e n e g a t i v e for ASO titre
(p=<0.001).
Thus there was a marked reduction in the ASO titre level
from third month onwards after tonsillectomy and ASO
continued to remain negative at six months and one year
in a statistically significant level, in 88% of patients.
Rheumatic fever and r h e u m a t i c f e v e r reactivation is
associated with raised ASO titre. Raised ASO titre is
suggestive of recent streptococcal infection. In the present
study, since in more than 88% of patients the ASO titre
remained negative during the one year after tonsillectomy;
it can be a s s u m e d that t h e r e had not been any
streptococcal throat infection in these patients during the
period. This may be because the tonsils had been removed.
This is supported by the observation that 37(74%) of

Indian Journal o f Otolaryngology and Head and Neck Surgery Vol. 52 No. 4, October - December 2000

patients had no episodes of sore throat after tonsillectomy

(p=<0.001). 4% had only 2 episodes of sore throat and
22% had only one episode of sore throat. MatanoskP et al
showed that patients who had under gone surgery have
lower infection rate with GABHS. Paradise 4 et al, also
found that throat infection were markedly reduced in the
first 2 years after tonsillectomy. Our study also strongly
supports the fact that tonsillectomy has a significant role
in preventing or reducing recurrent streptococcal throat
infections. This observation is very important since
incidence of rheumatic fever and rheumatic reactivation
can be reduced by preventing streptococcal infection.
However the role of tonsillectomy in preventing rheumatic

fever or its reactivation needs further elucidation in

randomised clinical trials.

REFERENCES
1.

Read SE & Zabriskie : Streptococcal disease and immune

response, New York, Academic press 1980.

2.

D e n n y et al : P r e v e n t i o n o f rheumatic f e v e r - t r e a t m e n t o f
preceding streptococcal infection, J A M M A 143: 151, 1950.

3.

Matanoski G M et al : Epidemiology o f streptococcal infections

in rheumatic and non rheumatic families Am. J. Epidemiol. 87
: 226, 1968.

4.

Paradise et al - efficacy o f tonsillectomy for recurrent throat

infection in severly affected children: results o f parallel and
nonrandomized clinical trial N. Engl.J.Med. 310( 11 ) ;674, 1984.

ARYTENOID ADDUCTION TECHNIQUE

FOR CORRECTION OF PARALYTIC DYSPHONIA
Vo P h a n i e n d r a

K u m a r 1, S.Rama C h a n d r a R e d d y 2, M.H. Das ~, D. C. S. Srinivas 4,

Key Words : Laryngoplasty, Vocal Cord Paralysis, Dysphonia, Arytenoid Adduction.

INTRODUCTION
Phonosurgery for correction of paralytic dysphonia was
started as early as 1915 .by Payr who first reported
medialization procedure through the anteriorly based
cartilage flap. Since then several methods were described
for medialization of paralysed vocal cord. Professor Isshiki
of Japan who popularised the Silastic implant in
medialization also had the credit of introducing fojr the
first time the technique of arytenoid adductlon for
correction of paralytic dysphonia.
Selection of phonosurgical procedures in cases of paralytic
dysphonia depends on the severity of patient's symptoms,
glottic configuration, the tone of the paralysed cord, and
status of paralysis (Temporary or Permanent). Since
arytenoid adduction (AA) is an irreversible procedure, it

is adapted only in long standing, uncompensated, unilateral

vocal cord paralysis with breathy dysphonia and also in
cases where it is ascertained that the neuronal function of
the affected vocal cord will not return to normal as shown
by Laryngeal EMG. AA is also indicated in high vagal
lesions with a triangular glottic defect of more than 2 mm
and also in cases where the paraiysed vocal cord is at a
much lower level when compared to normal cord, as
observed by fiberoptic laryngoscopy. In these cases AA
is done as a primary procedure along with medialization
laryngoplasty. Secondary AA is done sometimes when
the previous thyroplasty Type I has failed to give sufficient
voice improvement due to posterior glottic gap.

MATERIAL & METHODS

15 patients with paralytic dysphonia attending a private

~Prof.of E.N.T, 2Asst. Prof.of ENT., Guntur Medical College, 3ENT Specialist., Guntur (A.P), 4Speach Therapist, Guntur