The American Academy of Otolaryngology–Head and Neck Surgery Foundation recently updated the guideline for tonsillectomy in children. The guideline addresses indications for tonsillectomy based on obstructive and infectious causes in children aged 1 to 18 years.

Tonsillectomy is one of the most common surgical procedures performed in children <15 years of age. Indications for surgery include recurrent throat infections and obstructive sleep-disordered breathing (oSDB), both of which can substantially affect child health status and quality of life (QoL).

The American Academy of Otolaryngology–Head and Neck Surgery Foundation recently updated the guideline for tonsillectomy in children. The guideline was updated keeping in view the frequency of tonsillectomy, the associated morbidity, and the availability of new randomised clinical trials.

Key action statements from the guideline are discussed below.

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Statement 1. Watchful waiting for recurrent throat infection

Watchful waiting for recurrent throat infection is recommended in the following cases:

• <7 episodes in the past year
• <5 episodes per year in the past 2 years
• <3 episodes per year in the past 3 years

The panel emphasises on avoiding harm related to unnecessary surgery; the potential complications of vomiting, bleeding, pain, infection, or anesthesia problems is also considered.

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Statement 2. Recurrent throat infection with documentation

Tonsillectomy is recommended for recurrent throat infection with a frequency of:

• At least 7 episodes in the past year
• At least 5 episodes per year for 2 years
• At least 3 episodes per year for 3 years

The above scenario should be supported with documentation in the medical record for each episode of sore throat and ≥1 of the following:

• Temperature >38.3°C (101°F)
• Cervical adenopathy
• Tonsillar exudate, or positive test for group A beta-hemolytic Streptococcus

Patients who opt for tonsillectomy will achieve a modest reduction in the frequency and severity of recurrent throat infection for 1 year after surgery and a modest reduction in frequency of group A streptococcal infection for 1 year after surgery.

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Statement 3. Tonsillectomy for recurrent infection with modifying factors

In children with recurrent throat infection who do not meet the criteria mentioned in key action statement 2, clinicians should look out for modifying factors which may favor tonsillectomy. Identifying these factors (which might otherwise be overlooked), may aid the decision to perform tonsillectomy and ultimately improve patient outcomes.

The modifying factors may include (but are not limited to):

• Multiple antibiotic allergies/intolerance
• PFAPA (periodic fever, aphthous stomatitis, pharyngitis, and adenitis)
• History of >1 peritonsillar abscess

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Statement 4. Tonsillectomy for obstructive sleep-disordered breathing

To improve decision making in children with obstructive sleep-disordered breathing (oSDB), clinicians should ask caregivers of children with oSDB and tonsillar hypertrophy about comorbid conditions (which may be otherwise overlooked) which shows improvement after tonsillectomy.

The comorbid conditions may include growth retardation, poor school performance, enuresis, asthma, and behavioral problems.

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Statement 5. Indications for polysomnography

Before tonsillectomy is conducted, polysomnography (PSG) is recommended in children with obstructive sleep-disordered breathing (oSDB). PSG confirms indications and appropriateness of tonsillectomy, helps plan perioperative management, provides a baseline for postoperative PSG, and defines severity of obstructive sleep apnea (OSA).

PSG should be performed in the following cases:

• If they are <2 years of age

Or

• If they exhibit (any one) - obesity, Down syndrome, craniofacial abnormalities, neuromuscular disorders, sickle cell disease, or mucopolysaccharidoses.

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Statement 6. Additional recommendations for polysomnography

Polysomnography (PSG) prior to tonsillectomy for obstructive sleep-disordered breathing (oSDB) is recommended in children without any of the comorbidities listed in key action statement 5 for whom the need for tonsillectomy is uncertain or when there is discordance between the physical examination and the reported severity of oSDB. This approach is suggested for selecting the most appropriate candidates for tonsillectomy and avoiding surgery for those where it is not indicated.

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Statement 7. Tonsillectomy for obstructive sleep apnea

Clinicians should recommend tonsillectomy for children with obstructive sleep apnea (OSA) documented by overnight polysomnography (PSG). The panel suggest that this would lead to improved awareness (for the caregiver) of how tonsillectomy may benefit children when they have OSA. It may also prevent or improve comorbid conditions.

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Statement 8. Education regarding persistent or recurrent obstructive sleep-disordered breathing

The patients and caregivers should be counselled (by clinician) and educated that obstructive sleep-disordered breathing (oSDB) may persist or recur after tonsillectomy and may require further management.

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Statement 9. Perioperative pain counseling

As part of the perioperative education process, the clinician should counsel patients and caregivers regarding the importance of managing posttonsillectomy pain. At the time of surgery, this counselling should be reinforced with reminders regarding the need to anticipate, reassess, and adequately treat pain after surgery.

Proper counselling at the appropriate time may help in pain relief, improved and faster recovery; it may also help to avoid the complications from dehydration, inadequate food intake.

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Statement 10. Perioperative antibiotics

Due to the increased risk of adverse effects, administration or prescription of perioperative antibiotics is not recommended in children undergoing tonsillectomy.

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Statement 11. Intraoperative steroids

A single intraoperative dose of intravenous dexamethasone should be administered to children undergoing tonsillectomy. This is for preventing postoperative nausea and vomiting (PONV) for up to 24 hours posttonsillectomy. This may, in turn, lead to decreased time to first oral intake, and decreased pain and longer latency times to analgesic administration.

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Statement 12. Inpatient monitoring for children after tonsillectomy

Overnight, inpatient monitoring is advised in children after tonsillectomy in the following cases:

• <3 years old

Or

• Have severe obstructive sleep apnea (OSA; apnea-hypopnea index [AHI] ≥10 obstructive events/hour, oxygen saturation nadir <80%, or both)

Inpatient monitoring is recommended to improve patient safety and patient satisfaction after tonsillectomy. This would allow prompt detection and management of respiratory complications among high-risk children.

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Statement 13. Postoperative ibuprofen and acetaminophen

Ibuprofen, acetaminophen, or both are recommended for pain control after tonsillectomy. This approach would avoid the use of opioids for pain control.

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Statement 14. Postoperative codeine

In children younger than 12 years, codeine, or any medication containing codeine, is not recommended after tonsillectomy. This is to avoid the risk of severe or life-threatening complications of codeine in children who are ultra-rapid metabolizers of codeine (It might even be their first exposure to the medication).

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Statement 15a. Outcome assessment for bleeding

The presence or absence of bleeding within 24 hours of surgery (primary bleeding) and bleeding occurring later than 24 hours after surgery (secondary bleeding) should be followed up with the patient (or caregiver) and documented in the medical record.

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Statement 15b. Posttonsillectomy bleeding rate

The rate of primary and secondary posttonsillectomy bleeding should be assessed at least once a year.

Outcome assessment for bleeding may help improve self-awareness of outcomes for the surgeon and improve the confidence of patients and referring physicians, the ability to compare personal outcomes with national metrics and encourage quality improvement efforts. This may also reflect the perceived heterogeneity among clinicians regarding knowledge of their own bleeding rates after tonsillectomy and help the clinicians reassess their process of care and improve quality.

 

Read more on management of tonsils- crypts and Tonsilloliths in our expert article by Dr. Vijay Chourdia. Click Treatment protocol for Tonsillar Crypts, Tonsilloliths.