New Tonsillectomy Guidelines: Information for the Primary Care Provider
From The Child's Doctor, Spring 2012
- Stephen R. Hoff, MD
- Attending Physician, Otolaryngology, Ann & Robert H. Lurie Children's Hospital of Chicago; Assistant Professor of Otolaryngology - Head and Neck Surgery, Northwestern University Feinberg School of Medicine
- Disclosure: Dr. Hoff has no industry relationships to disclose and does not refer to products that are still investigational or not labeled for the use in discussion.
Other Disclosure Information
At the conclusion of this activity, participants will be able to:
Describe the indications for tonsillectomy, including recurrent tonsillitis and sleep-disordered breathing
Identify which patients should have a sleep study prior to surgery
Help manage the postoperative care of tonsillectomy patients
Tonsillectomy is one of the most common surgical procedures performed in the pediatric population, but there remains a wide variation on the indications for the procedure and management in the perioperative period. In 2011, the American Academy of Otolaryngology published new tonsillectomy guidelines, including 10 position statements on the workup and care of these patients. The guidelines emphasize careful documentation of tonsillitis episodes, and generally encourage a watchful waiting approach until patients have met strict numbers criteria for surgery for recurrent tonsillitis. Sleep disordered breathing (SDB) and sleep apnea can have significant negative effects on a patient’s life, and tonsillectomy may relieve these symptoms. Sleep studies are not necessary prior to tonsillectomy, but should be obtained in certain circumstances. Antibiotics should not be given for tonsillectomy patients, and encouragement of pain control in the postoperative period is paramount to improved recovery.
Tonsillectomy with or without adenoidectomy is frequently done for recurrent tonsillitis or sleep disordered breathing, but controversy over the indications for surgery continues to fuel studies and debate within the primary care and otolaryngology fields. Historically, the justifications for surgery have changed over the years, from whole families getting tonsillectomies on the same day (largely just because the tonsils were there), to a more recent shift in which more tonsillectomies are done for sleep disturbances than recurrent infection. In the US, more than 530,000 patients under 15 years of age had a tonsillectomy procedure in 2006, which represents 16% of all ambulatory surgeries in this age group.
Although tonsillectomy is common, there has been a wide variation as to who should be offered the surgery. Are 3 infections in the last year enough? Should a sleep study be done first? What about antibiotics during recovery? There have been previous recommendations, but the “threshold” for surgery has remained largely subjective and dependent on the primary care physician and otolaryngologist. There was a need for an updated literature review and establishment of recommendations for this frequently performed procedure.
To this end, the American Academy of Otolaryngology put together a task force and in 2011 published statement guidelines on tonsillectomy. The final paper involved 17 authors from the fields of otolaryngology, pediatrics, sleep medicine, infectious disease, advanced practice nursing, family medicine, anesthesiology, and consumers. An exhaustive literature search was followed by development of specific practice guidelines, with a final report that is over 30 pages with 229 references. The authors based their recommendations on the quality of published trials, and produced 10 “Evidence-Based Statements” on the care of patients with tonsillar disease and tonsillectomy. Based on the strength of evidence, the final statements had following criteria:
Strong Recommendation – benefits clearly exceed the harm, quality of evidence is excellent
Recommendation – benefits exceed the harm, quality of evidence is not as strong
Option – quality of evidence is suspect or well-done studies show little clear advantage to one approach vs. another
No Recommendation – lack of evidence, unclear balance between benefits and harms
For clarity, I have grouped the statements by topic, and will go through each section starting with the Academy guideline statements and followed by my interpretation and the implications for primary care and ENT physicians. For the statements regarding snoring and sleep apnea, I have also added the new guidelines on polysomnography prior to tonsillectomy that were published several months after the overall guidelines. Tonsillectomy is performed with or without adenoidectomy.
TONSILLECTOMY FOR RECURRENT TONSILLITIS
Statement 1: Watchful waiting for recurrent throat infections
“Clinicians should recommend watchful waiting for recurrent throat infection if there have been fewer than 7 episodes in the past year, or fewer than 5 episodes per year in the past 2 years or fewer than 3 episodes per year in the past 3 years.”
Episode criteria: sore throat, plus:
- Temp > 38.3 OR
- Positive culture for group A beta-hemolytic streptococcus OR
- Tender cervical lymph nodes > 2 cm OR
- Tonsillar exudate
Statement 2: Recurrent throat infection with documentation
“Clinicians may recommend tonsillectomy for recurrent throat infection with a frequency of at least 7 episodes in the past year, 5 episodes per year in the past 2 years, or 3 episodes per year in the past 3 years.”
Statement 3: Tonsillectomy for recurrent infection with modifying factors
“Clinicians should assess the child with recurrent throat infection who does not meet criteria in Statement 2 for modifying factors that may nonetheless favor tonsillectomy, which may include but are not limited to multiple antibiotic allergy/intolerance, PFAPA (periodic fever, aphthous ulcers, pharyngitis, and adenitis), or history of peritonsillar abscess.”
Most children with recurrent throat infections will improve with time and antibiotics, and watchful waiting is recommended. The first 3 guidelines reinforce the stringent numbers criteria for tonsillectomy originally set forth by Paradise et al. in 1984 and verified since then. The threshold for surgery should be set high, with each episode carefully documented by the primary care physician (and not just by parent report) to include the above factors such as temperature and cultures. If the numbers threshold is reached, the child should be considered for a tonsillectomy. Removing the tonsils in patients with fewer episodes of tonsillitis may not offer any benefit for the patient, yet puts them through the risk, expense, and recovery of the procedure. While the decision for surgery is still up to the patient, primary care provider, and otolaryngologist, all attempts should be made to use documented episodes of tonsillitis during the decision-making process.
Of course, common sense needs to be applied, and patients with modifying factors such as PFAPA, IgA nephropathy, and antibiotic intolerance may benefit from a tonsillectomy even if they do not meet the strict numbers criteria. PFAPA is characterized by high fevers, oral ulcers, pharyngitis, and usually neck adenopathy that occurs cyclically, “like clockwork,” every few weeks with complete recovery between episodes. Tonsillectomy has been shown to be beneficial for these patients. Clinicians should be aware of and inquire about the modifying factors that may be present and help make the decision for watchful waiting or tonsillectomy.
TONSILLECTOMY FOR SLEEP-DISORDERED BREATHING AND OBSTRUCTIVE SLEEP APNEA
Statement 4: Tonsillectomy for sleep-disordered breathing (SDB)
“Clinicians should ask caregivers of children with SDB and tonsil hypertrophy about comorbid conditions that might improve after tonsillectomy, including growth retardation, poor school performance, enuresis, and behavioral problems.”
Statement 5: Tonsillectomy and polysomnography
“Clinicians should counsel caregivers about tonsillectomy as a means to improve health in children with abnormal polysomnography who also have tonsil hypertrophy and sleep-disordered breathing.”
Statement 6: Outcome assessment for sleep-disordered breathing
“Clinicians should counsel caregivers and explain that SDB may persist or recur after tonsillectomy and may require further management.”
When a parent describes snoring and apneas, it is important to elicit a history about potential effects of SDB, including growth restriction, attention difficulties, and behavioral problems. Tonsillectomy is indicated for SDB in children, and is usually considered first-line treatment (as opposed to adults, who typically start with CPAP). A sleep study is usually not needed and does not establish the effects of the sleep disorder on the child’s wellbeing. Sleep studies should be obtained for patients with complex medical conditions and syndromes, and should be considered for patients with obesity as well. When there is discordance between the symptoms and the exam (reports of loud snoring and apneas with small tonsils) or there is a question whether the surgery is really necessary, a sleep study can help determine whether the child will benefit from a tonsillectomy or if watchful waiting is more reasonable.
It should also be noted that the guidelines only refer to total tonsillectomy (traditional tonsillectomy in which all of the tonsillar tissue is removed from the tonsillar fossa) and do not address partial intracapsular tonsillectomy (in which most of the tonsil is removed, but an outer shell of tonsillar tissue is left behind). When used for patients with SDB, there is a growing body of research that intracapsular tonsillectomy has less postoperative pain and increased oral intake than total tonsillectomy, with equivalent sleep improvements.
Although tonsillectomy and adenoidectomy is effective for 80%-90% of children with obstructive sleep apnea, some patients will have persistent obstructive symptoms after surgery. For these patients, there are some options prior to BiPAP/CPAP, and a full office evaluation with office laryngoscopy is indicated. Allergies, obesity, orthodontics, and hypotonia should be considered. A “sleep endoscopy” can be done in which a sleep state is induced in the operating room, and the site of collapse and obstruction during sleep can be identified. Sites may include adenoid regrowth, lingual tonsillar hypertrophy, “occult laryngomalacia” (no stridor during the day but laryngeal collapse and obstruction with sleeping, which tends to be more common in older patients than typical laryngomalacia), micrognathia, and nasal turbinate hypertrophy. Based on the sleep endoscopy, the child may benefit from further surgical procedures, such as lingual tonsillectomy or supraglottoplasty, which will improve the sleep apnea. Repeat polysomnography after intervention helps guide the decision for further procedures or CPAP. It is also important to note that tonsillectomy produces resolution of SDB in only 10%-25% of obese children.
PERIOPERATIVE CARE OF TONSILLECTOMY PATIENTS
Statement 7: Intraoperative steroids
“Clinicians should administer a single, intraoperative dose of intravenous dexamethasone to children undergoing tonsillectomy.”
Strength: Strong Recommendation
Statement 8: Perioperative antibiotics
“Clinicians should not routinely administer or prescribe perioperative antibiotics to children undergoing tonsillectomy.”
Strength: Strong Recommendation
Statement 9: Postoperative pain control
“Clinicians should advocate for pain management after tonsillectomy and educate caregivers about the importance of managing and reassessing pain.”
Statement 10: Post-tonsillectomy hemorrhage
“Clinicians who perform tonsillectomy should determine their rate of primary and secondary post-tonsillectomy hemorrhage at least annually.”
The only 2 Strong Recommendation statements deal with the perioperative management of patients undergoing tonsillectomy – that patients should not get antibiotics in the operating room or postoperatively, and should get a single dose of steroids in the operating room. The strong recommendation against antibiotics is based on evidence that antibiotics do not offer any benefit, and cumulatively cost millions of dollars per year for an unnecessary medication. For many practicing otolaryngologists, not giving intraoperative or postoperative antibiotics represents a major change in management. A single dose of dexamethasone given in the operating room has been shown to decrease nausea, vomiting, and pain, leading to increased oral intake and a lesser likelihood of overnight admission.
Another key component to the guidelines is the education and encouragement for pain control. Parents are often hesitant to give their children pain medication for fear that it will make them drowsy or for other reasons, which leads to the children getting “behind” in their pain management. Pain leads to less fluid intake, which leads to more pain and prolongs recovery. Parents and caregivers should be given clear instructions prior to surgery on pain control, which is then reinforced in the recovery room. They should be taught how to assess for pain and encouraged to keep ahead of the pain curve. Parents should also be informed to expect their child to complain more about pain in the morning. I encourage parents to give pain medication (acetaminophen and ibuprofen) for the first 2 days on a scheduled basis, whether the child asks for it or not. Each medication is given every 6 hours, but staggered so that the child is getting a dose of pain medicine every 3 hours. This is converted to as needed after 2 days, and children will typically need intermittent doses for the first week. It should be noted that scheduled administration has not been proven to be more effective than PRN dosing.
The authors also summarized the literature on non-steroidal anti-inflammatory drugs (NSAIDs) for tonsillectomy patients, and found them to be safe (with the exception of ketorolac). Previously, there has been some hesitation to using ibuprofen for fear of impaired platelet function and bleeding, but the literature shows no significant difference in hemorrhage rates. Narcotics may cause increased nausea, vomiting, and sedation, and caution is advised for post-tonsillectomy patients. Acetaminophen with codeine has not been shown to be more effective than acetaminophen alone.
SUMMARY FOR THE PRIMARY CARE PHYSICIAN
- Clinicians should document and adhere to the Paradise criteria for tonsillitis, except when modifying factors are present.
- Sleep apnea may have a major impact on a child’s life, and tonsillectomy should be considered for patients with sleep apnea symptoms.
- Tonsillectomy should improve but may not resolve sleep apnea – obesity is a major factor.
- Sleep studies are not required prior to tonsillectomy, but should be done in the following circumstances: complex medical history or syndromes, discrepancy between history and exam, persistent sleep symptoms after tonsillectomy.
- Antibiotics should not be given intraoperatively or postoperatively.
- Pain control is paramount for the postoperative recovery of tonsillectomy patients. Education on pain control, with encouragement for administration of pain medication by the parents should be provided.
- NSAIDs are safe, except ketorolac, and codeine should be avoided if possible.
For further reading
[1.] Baugh RF, et al. Clinical Practice Guideline: Tonsillectomy in children. Otolaryngol Head Neck Surg 2011 Jan;144(1 Suppl):S1-S30.
[2.] Roland PS, et al. Clinical Practice Guideline: Polysomnography for sleep-disordered breathing prior to tonsillectomy in children. Otolaryngol Head Neck Surg 2011 Jul;145(1 Suppl):S1-S15.