Clinical Practice Guideline Issued for Tonsillectomy in Children

From Medscape Medical News
Laurie Barclay, MD

January 3, 2011 — The prevalence of tonsillectomy, the associated morbidity, and the availability of hundreds of randomized clinical trials evaluating associated interventions create a pressing need for evidence-based guidance to aid clinicians, according to the multidisciplinary Clinical Practice Guideline: Tonsillectomy in Children, published online January 3, 2011, in Otolaryngology–Head and Neck Surgery.

"Over half a million tonsillectomies are done every year in the United States," said guideline coauthor Richard M. Rosenfeld, MD, MPH, from SUNY Downstate Medical Center and Long Island College Hospital in Brooklyn, New York, in a news release. "The tonsillectomy guideline will empower doctors and parents to make the best decisions, resulting in safer surgery and improved quality of life for children who suffer from large or infected tonsils."

The new guideline, which is intended for all clinicians in any setting who care for children 1 to 18 years old in whom tonsillectomy is being considered, offers evidence-based recommendations on identifying children who are the best candidates for tonsillectomy, and on preoperative, intraoperative, and postoperative care and management. Other objectives of this guideline include highlighting the need for evaluation and intervention in special populations, improving counseling and education for families, describing management options for patients with modifying factors, reducing inappropriate or unnecessary variations in care, and discussing the significant public health implications of tonsillectomy.

The definition of tonsillectomy is a surgical procedure in which the peritonsillar space between the tonsil capsule and the muscular wall is dissected to completely remove the tonsil, including its capsule. The term often refers to tonsillectomy with adenoidectomy, especially in relationship to sleep-disordered breathing (SDB) or other contexts where adenoidectomy is appropriate.

SDB refers to a continuum of obstructive disorders ranging in severity from primary snoring to obstructive sleep apnea (OSA). SDB is characterized by abnormalities of respiratory pattern or of the adequacy of ventilation during sleep, as well as by associated daytime symptoms such as excessive sleepiness, inattention, poor concentration, and hyperactivity.

Indications for tonsillectomy include recurrent throat infections and SDB, both of which can significantly impair childhood health and quality of life (QoL). Throat infection, which includes strep throat and acute tonsillitis, pharyngitis, adenotonsillitis, or tonsillopharyngitis, is defined as sore throat caused by viral or bacterial infection of the pharynx, palatine tonsils, or both, which may or may not be culture positive for group A streptococcus.

"The importance of tonsillectomy as an intervention relates to its documented benefit on child QoL," the guidelines authors write. "For example, when compared with healthy children, children with recurrent throat infections have more bodily pain and poorer general health and physical functioning. Tonsillectomy may improve QoL by reducing throat infections, health care provider visits, and the need for antibiotic therapy."

SDB in children is also associated with cognitive and behavioral impairment that usually improves after tonsillectomy, as do QoL, sleep disturbance, and vocal quality. The potential benefits of tonsillectomy must be weighed against possible surgical complications, including throat pain; postoperative nausea and vomiting; delayed feeding; voice changes; hemorrhage; and, rarely, death.

Guideline Recommendations

Specific recommendations included in the clinical practice guideline are as follows:

* Watchful waiting for recurrent throat infection is recommended if there have been fewer than 7 episodes in the previous year, fewer than 5 episodes per year in the previous 2 years, or fewer than 3 episodes per year in the previous 3 years (statement 1).
* Tonsillectomy may be an option for recurrent throat infection with a frequency of at least 7 episodes in the previous year, at least 5 episodes per year for 2 years, or at least 3 episodes per year for 3 years, provided that the medical record documents each episode of sore throat and the presence of at least one of the following: temperature of more than 38.3°C, cervical adenopathy, tonsillar exudate, or positive test result for group A β-hemolytic streptococcus (statement 2).
* Children with recurrent throat infection who do not meet the criteria in statement 2 may have modifying factors favoring tonsillectomy, including but not limited to multiple antibiotic allergy/intolerance, periodic fever, aphthous stomatitis, pharyngitis and adenitis, or a history of peritonsillar abscess (statement 3).
* Clinicians should ask caregivers of children with SDB and tonsillar hypertrophy about comorbid conditions that might improve after tonsillectomy, such as growth retardation, poor school performance, enuresis, and behavioral problems (statement 4).
* Caregivers of children with abnormal polysomnography results who also have tonsillar hypertrophy and SDB should be counseled about tonsillectomy as a means to improve health issues related to SDB (statement 5).
* Caregivers should be informed that SDB may persist or recur after tonsillectomy and may require further management (statement 6).
* A single, intraoperative dose of intravenous dexamethasone should be given to children undergoing tonsillectomy (statement 7; strong recommendation).
* Clinicians should not routinely administer or prescribe perioperative antibiotics to children undergoing tonsillectomy (statement 8; strong recommendation).
* Clinicians should advocate for pain management after tonsillectomy and should educate caregivers about the need to manage and reevaluate pain (statement 9).
* At least annually, clinicians who perform tonsillectomy should determine their rate of primary and secondary posttonsillectomy hemorrhage (statement 10).

Otolaryngol Head Neck Surg. Published online January 3, 2011.