Tonsillectomy in Children

Tonsillectomy is the second-most common surgical procedure in children, with more than 500,000 tonsillectomies performed annually in the United States. The two most common indications are recurrent throat infections and sleep disordered breathing, both of which can decrease a child’s quality of life.

A new evidence-based guideline published earlier this year provides recommendations on appropriate indications for referral for tonsillectomy. The guideline is important because the procedure is so common. In addition, there are wide practice and geographic variations in the use of tonsillectomy, a procedure that carries the risk of significant expense, morbidity, and rare mortality with its use.

Benefits of Tonsillectomy

Recurrent throat infections can be a common occurrence in children, and parents may be quick to request a tonsillectomy. However, there is evidence that tonsillectomy has limited benefits for most children, because the natural history of recurrent sore throats is that they frequently resolve without tonsillectomy.

Tonsillectomy for recurrent throat infections in severely affected children reduces the frequency and severity of infections for 2 years following surgery and delivers improvements in quality of life. Children with less severe infections have not been shown to benefit from the procedure. For children with sleep-disordered breathing (SDB), tonsillectomy appears to be effective in resolving SDB, improving behavioral parameters, school performance, and quality of life.

Downsides of Tonsillectomy

In addition to cost, the adverse consequences of tonsillectomy include hemorrhage (in 0.2%-2% of patients) that may require repeat surgery or admission to hospital, trauma to teeth, aspiration, and rare respiratory compromise, along with common postoperative complications of nausea, vomiting, pain, and dehydration. Approximately 4% of patients have postoperative complications that are severe enough to require readmission to the hospital, most commonly because of pain, vomiting, fever, or tonsillar hemorrhage. Other rare complications can occur, and the mortality rate is estimated at 1 in 35,000 procedures.

Recommendations

Consideration of tonsillectomy is recommended for children who meet the Paradise criteria, which have four aspects. First, there must be a minimum frequency of sore throat episodes: either seven episodes in the past year, five episodes per year for the past 2 years, or three episodes per year for the past 3 years. Second, clinical features must consist of a sore throat plus either a fever, tonsillar exudates, cervical lymphadenopathy, or a positive strep culture. Third, each qualifying episode must have been treated with antibiotics given in the conventional dose and for the appropriate time. Fourth, each episode must have been documented in the medical record.

Those children who do not meet the Paradise criteria should receive watchful waiting. They should continue to be followed closely and observed for any decline in quality of life or further incidents of recurrent throat infection. The natural history of recurrent throat infections follows a decline in occurrences without intervention.

Tonsillectomy

The guideline emphasizes the importance of appropriate documentation. An observational study showed only 17% of cases had appropriate supporting documentation. In addition, all children should be followed for at least 1 year prior to referral to a surgeon, because there is a high rate of resolution of symptoms in 12 months.

There are instances in which the evidence suggests tonsillectomy in children who did not fit the Paradise criteria. These include children who have episodes that require hospitalization, complications including peritonsillar abscess, or a family history of rheumatic fever, all of whom should be considered for referral.

Also, when a child does not meet the Paradise criteria but has significant modifying risk factors – including allergies to multiple antibiotics, a history of peritonsillar abscess, or a clinical syndrome such as PFAFA (periodic fevers, aphthous stomatitis, pharyngitis, and adenitis) – a tonsillectomy can be considered, because the benefits to these children likely outweigh the risk of recurrent infections.

Sleep-Disordered Breathing

Sleep-disordered breathing is a syndrome that causes recurrent partial or total upper airway obstruction during sleep and can lead to diverse symptoms such as behavioral problems, problems with memory and attention, poor school performance, decreased quality of life, failure to thrive, and enuresis.

Tonsillar and adenoid hypertrophy is the most common cause of SDB in children. The diagnosis of SDB can be made by history and physical examination. Adjuvant diagnostics that are helpful include polysomnography, nocturnal pulse oximetry, and video sleep studies.