Tonsillectomy is one of the most common surgeries in the United States, with more than 11,400 procedures performed on children and adults in hospital settings in 2009, according to the National Center for Health Statistics, and an increasing number being performed in outpatient clinics as well.
Explore this issue:December 2012
For most of the thousands of children and adults who undergo tonsillectomy each year, post-operative pain, bleeding, swelling and discomfort last a few days, or a few weeks at most. But, for a slim minority of patients, the complication of post-tonsillectomy taste disorder can linger much longer. New research findings about the prevalence and duration of post-tonsillectomy taste disorder may point to a need to rethink pre- and post-operative practices for both pediatric and adult patients.
Taste Disorders Rare, but Present
In the initial study, published in 2010, researchers followed over the course of four years 223 adult patients who used a self-assessing questionnaire to report taste disorders after their tonsillectomy surgeries (Laryngoscope. 2010;120(10):2119-2124). “We wanted to look at qualitative taste disorders: the sensation of having a bitter, salty, sweet or metallic taste in your mouth,” said lead author Clemens Heiser, MD, with the department of otorhinolaryngology-head and neck surgery at Technical University in Munich, Germany. “And, we wanted to figure out how long the sensation lasted.” (see “Patient Taste Questionnaire,” below).
Of those 223 patients, 32 percent reported suffering dysgeusia for two weeks following the surgery, and 8 percent (15 patients) reported dysgeusia at the six-month mark. Additionally, almost 30 percent of the original 223 patients reported post-operative bleeding, 10 percent reported long-lasting post-operative pain and 20 percent reported foreign body sensation.
“A few studies about taste disorder after tonsillectomy can be found in the literature…but most of the clinical trials report that taste disorders are a very rare complication or something that disappears quickly,” said Dr. Heiser. Knowing this, the results surprised him, particularly the fact that 8 percent of patients reported taste disturbance after six months. “That’s almost one in 10 patients, and that’s a pretty high number,” Dr. Heiser said. “That is something that can really lower one’s quality of life.”
Indeed, most research describes transient post-tonsillectomy dysgeusia lasting a few weeks as an occasional patient complaint (J Fam Practice. 2010;59(10):E4-E9; Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2010;109(1):e11-e14). And, at least two studies report the incidence of long-term taste disturbance complications as rare (Ear Nose and Throat J. 1990;69:155-160; Head Neck Surg. 1999;121:303-304).
Because dysgeusia lasting several months or longer is rarely seen following tonsillectomy, the condition is seldom discussed with patients. “I think it’s an important study of adult data and the conclusions seem valid that we should be aware of that risk,” said Kaalan Johnson, MD, assistant professor in the department of otolaryngology-head and neck surgery at the University of Cincinnati College of Medicine and division of pediatric otolaryngology-head and neck surgery at Cincinnati Children’s Hospital Medical Center in Ohio. “Consideration should be given to discussing that risk with patients—both adult and pediatric—pre-operatively.”
Recently, in a follow-up study of those 15 patients who experienced taste disturbances after six months, Dr. Heiser and his team of researchers found two who reported taste disturbance that lasted more than a year post-surgery (Laryngoscope. 2012;122(6):1265-1266). One of those two had diabetes and reported suffering “permanent” dysgeusia. While these results showed that about 1 percent of the original group of patients reported long-lasting and possibly permanent taste disorders after tonsillectomy, Dr. Heiser and his co-authors said that their data should be taken into consideration when patients are informed about complications after surgery.
Is It Really a Taste Disorder?
Richard Doty, PhD, professor of psychology in otorhinolaryngology-head and neck surgery and director of the Smell and Taste Center at the University of Pennsylvania’s Perelman School of Medicine in Philadelphia, said he’s found that true, isolated taste disorder following tonsillectomy is “extremely rare,” given his research and the analysis in numerous studies published on the topic. He contends that most patients who complain of problems with their taste are really experiencing a temporary loss of their sense of smell.
Indeed, in a study of 750 patients from the University of Pennsylvania Smell and Taste Center who complained of taste disturbance, fewer than 5 percent had true taste dysfunction, and 68 percent exhibited only olfactory dysfunction. Additionally, fewer than 1 percent of those patients who complained of dysgeusia could attribute their condition to a previous tonsillectomy procedure (Arch Otolaryngol Head Neck Surg. 1991;117:519-528).
A similar study, which surveyed patients who claimed that taste disturbance was affecting their ability to sense bitterness, sweetness, sourness and saltiness in different foods, concluded that “difficulty in detecting true taste problems…likely reflects…the relatively low prevalence of taste deficits in the general population and the tendency of patients to confuse loss of olfaction-related flavor sensations with taste bud-mediated deficits” (Laryngoscope. 2008;118(4):611-617).
“One of the things that happens, particularly with an adult tonsillectomy, is that it’s a rather traumatic experience for some patients, producing considerable post-operative pain during swallowing and eating, said Dr. Doty. “During this time, the flavor of foods can be greatly diminished, and airflow needed to stimulate the olfactory receptors is reduced from lack of normal swallowing or mastication.”
Rare in Pediatric Patients
Despite the fact that the majority of tonsillectomies are performed on pediatric patients, assessment of post-surgery dysgeusia in pediatric patients seldom occurs. The complication of post-tonsillectomy taste dysgeusia among pediatric patients hasn’t been studied and documented as frequently as it has been in adults. Otolaryngologists attribute this lack of information to difficulty in getting valid responses from young children about taste dysfunction.
“How do you ask a 5-year-old, ‘So, do you have a metallic taste in your mouth?” said Laura J. Orvidas, MD, FACS, associate professor of otorhinolaryngology at the Mayo Clinic in Rochester, Minn. “[Taste disturbance] could be more prevalent than we see or are hearing about, but kids just don’t know what to say, or it doesn’t bother them enough.”
“I’ve never had a kid come back and complain that their taste was off, nor a teenager for that matter,” said Dr. Orvidas. “Young people tend to tolerate things better; they recover better; they’re better healers; they have better blood supply. That could be part of the reason that they don’t experience [dysgeusia], or if they do, it goes away fast enough that they don’t ever think about it again.”
Most follow-up questions for post-tonsillectomy patients revolve around bleeding, pain, swallowing and voice changes. However, given the latest research findings about the prevalence and persistence of taste disorder, Dr. Orvidas suggests it might be time to ask about it, and to counsel patients pre-surgery.
“We have a post-op tonsillectomy survey that we do about four to six weeks after the operation,” said Dr. Orvidas. “We ask them standard questions: Is there any bleeding, are there voice issues, things like that. But, we don’t specifically ask about taste distortion. Unless a child said to mom, ‘Boy, my food tastes funny’ or ‘This doesn’t taste right,’ you wouldn’t know,” she added. “I’ve never heard a parent say that to me, and usually they’re on top of things. But, [the study] does make me think we should ask.”
If handled properly, interviewing children about post-tonsillectomy taste disorder can provide valuable information. “The trend for pediatric tonsillectomies is that more and more clinicians are doing outpatient surgery and telephone follow-ups for routine tonsillectomy cases,” said Dr. Johnson. “That follow-up could be an opportunity for parents to voice a taste disturbance concern, and is something we are currently exploring in our department. More extensive evaluation of post-tonsillectomy taste disturbance in the pediatric populations is clearly indicated.”Multi-Page