By Belinda A Mantle, MD
Inova Fairfax Hospital for Children
Tonsillectomy is the third most commonly performed pediatric surgery in the United States. Most often, physicians consider tonsillectomy as an option in patients with recurrent sore throat or sleep-disordered breathing (SDB).
The first evidence-based national clinical guideline for the treatment of tonsillectomy in pediatric patients was recently published. Members of the panel that drafted the guideline included pediatricians, family medicine doctors, otolaryngologists, anesthesiologists, sleep medicine specialists, infectious disease physicians and nurses. Of note, Richard Schwartz, MD, an active member of IFHC’s educational faculty and a partner at Advance Pediatrics in Vienna, was part of this select committee.
The primary objective of the guideline is to help practitioners appropriately identify patients between the ages of 1 and 18 years who require tonsillectomy. It recommends a period of “watchful waiting” without surgical intervention for patients with fewer than seven episodes of pharyngitis in one year, fewer than five episodes per year for two years, or fewer than three episodes per year for three years. Modifying factors that favor tonsillectomy even if the above criteria have not been met include multiple antibiotic allergies/intolerances; PFAPA (periodic fever, adenopathy, pharyngitis, aphthous ulcers) syndrome; recurrent, severe infections requiring hospitalization; complications from tonsillitis (a history of peritonsillar abscess, for example); or numerous repeated infections within a single household. The panel stated that physicians should document the severity of episodes of sore throat by noting the presence of fever; tonsillar size, erythema or exudates; cervical adenopathy; and group A ß-hemolytic streptococcus test results. The panel also encouraged counseling caregivers about the benefits of tonsillectomy versus the natural history of the disease, the risks of surgery and post-operative pain management.
Other recommendations for tonsillectomy centered on SBD. A thorough history and physical exam, audio/video taping and sometimes polysomnography are appropriate tools used in the diagnosis of SDB. Tonsil and adenoid hypertrophy are the most common causes of SDB in children. However, tonsil size alone does not correlate with severity of SDB. Snoring, or its absence, does not define SDB. Polysomnography is not required, but is the best test to establish the diagnosis of SDB. SDB may persist after tonsillectomy and require further management, especially in patients with obesity, craniofacial anomalies or neuromuscular disorders. Other conditions that might improve after tonsillectomy include growth retardation, poor school performance, enuresis and other behavior problems. It is important to review all these issues with caregivers prior to surgery.
The new tonsillectomy guideline provides useful information for clinicians to discuss the option of surgical intervention with patients and families.
Clinical Practice Guideline: Tonsillectomy in Children, Otolaryngol Head Neck Surg. Jan 2011; Vol. 14a 4 (1): suppl S1-S30
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