Clinical Practice Guideline: Tonsillectomy in Children

From Medscape Pediatrics
An Expert Interview With Ellen E. Wald, MD
by Laurie Scudder, DNP, NP

Editor's Note: The American Academy of Otolaryngology -- Head and Neck Surgery recently issued Clinical Practice Guideline: Tonsillectomy in Children .
The new guideline, which is intended for all providers who care for children 1-18 years old in whom tonsillectomy is being considered, offers evidence-based recommendations on identifying children who are the best candidates for tonsillectomy, operative care, and management.
Laurie Scudder, Clinical Editor, Medscape, recently discussed the guideline with Ellen Wald, MD, a member of the guideline committee and Professor and Chair, Department of Pediatrics, University of Wisconsin School of Medicine and Public Health, to expand on the significance of the document for pediatric primary care providers.

Medscape: One of the most relevant recommendations in the guideline for primary care providers is the first statement, which recommends watchful waiting for recurrent throat infections if there have been fewer than 7 episodes in the previous 12 months or fewer than 5 episodes per year in the previous 2 years or fewer than 3 episodes per year in the past 3 years.
So bottom line, children should be observed for at least 1 year before a referral to a surgeon to consider tonsillectomy.
Is this number of episodes irrespective of the severity of the episodes?
Is the intent that these episodes will have all been of sufficient intensity to warrant a visit to a healthcare provider?

Dr. Wald: To put this in perspective, and this is stated clearly in the document, the purpose of the guideline is to avoid unnecessary intervention in children who have recurrent throat infection who are very likely to have a favorable natural history and improve on their own and therefore will be benefited by avoiding surgery. There may be exceptions occasionally on the basis of either very severe or very complicated infections. But in general, I think this is a good outline and the idea is that, yes, these episodes would have been seen by a clinician and the infection would be adequately documented.
A lot of this work dates back to a study that was done by Jack Paradise in the late 1970s. His research used very stringent criteria that described what were termed "counting episodes."
A child was considered to have had a counting episode that contributed to the number of episodes if they had, in addition to their sore throat, at least 1 of the following 4 criteria:

* A fever > 38.3° Celsius;
* Cervical adenopathy, which was defined as a lymph node in the neck that measured > 1 cm and was tender;
* Tonsillar exudates; or
* A positive test for group A streptococci.

Medscape: In a concluding discussion of implementation considerations, the guideline emphasizes the importance of appropriate documentation to support treatment decisions.

Dr. Wald: Absolutely. I think that is one of the important messages for the practitioner. When evaluating a child with sore throat, it is important to specifically note the presence or absence of fever, the presence or absence of swollen lymph nodes, and the appearance of the throat including any swelling of the tonsils, size of the tonsils, and presence or absence of exudates. When group A strep is suspected, there should be an attempt at microbiologic confirmation in the form of a rapid streptococcal antigen detection test or a positive culture for group A strep.
In addition to documenting the specific characteristics of the episode of sore throat, it is also important to specifically ask about absences from school and quality-of-life issues like being able to pay attention and being in a good frame of mind for learning. Growth, also, should always be monitored and documented.

Medscape: Even for those children who meet these stringent criteria over a period of 1-2 years, the guideline indicates that monitoring without surgery is still an option.
Can you discuss some of the children who might reasonably be monitored for a longer period in whom you would expect a spontaneous reduction in episodes?

Dr. Wald: One of the reasons for continued observation is again based on the Paradise studies. Children who met the criteria described earlier were randomly assigned to receive tonsillectomy or continued observation. For the group that was observed, the mean number of episodes of sore throat in the next year prospectively was about 1.
Even children who have a very compelling previous history of sore throat will often improve and would not in subsequent years qualify for surgery. And of course you would rather not do a tonsillectomy in a child who wasn't going to have a lot more trouble.
Another factor that influences a decision about management is the severity of the infection. For example, a child with 5 mild infections in a year might be followed a little bit longer. On the other hand, severe episodes, especially if they involve something like a peritonsillar abscess, might be considered for tonsillectomy a little bit earlier.
Another potential modifying factor is the presence of periodic fever, aphthous stomatitis, pharyngitis, and adenitis (PFAPA). There is some indication that children with PFAPA who do not fit those very stringent criteria may benefit from tonsillectomy.
This tends to be a self-limiting syndrome, usually lasting several years, and so the degree of morbidity a child is experiencing should be considered before recommending surgery.

The availability of medical care for a given child should also be considered. Does the child live in an urban area where the healthcare provider is down the street or within a short car ride, or does he or she live in a rural area where the ability to get medical care for severe sore throat may be much more difficult? Another important issue is the impact of missing school due to multiple infections. The good student with a mild infection who misses school for a day might reasonably continue to be observed.

In sum, the things that should be considered are the severity of the individual episodes, the proximity of good medical care, and the impact on school performance for any given child. Always keep in mind that even a child who has had a bad season of recurrent streptococcal infections very often will not have that same experience the following year.

Medscape: The guideline does not make a distinction based on a child's age.
A child of 5 years or 15 years should be observed until the criteria described are met. Is that correct?
Are there modifying factors that should be considered in children of varying ages?

Dr. Wald: Age really is not, in general, an important variable, recognizing that sore throat is not a common problem until children are at least 4 or 5 years of age. The peak age for strep pharyngitis as well as other viral causes of pharyngitis or sore throat is usually between 5 and 15 years of age. Precise age isn't important.

Medscape: The guideline strongly supports the consideration of tonsillectomy for sleep disordered breathing (SDB), a diagnosis that may be made clinically.
The guideline clearly notes the range of comorbid conditions that may occur in the child with SDB but does not appear to weight any particular factor more strongly than others.
Can you provide some guidance for primary care providers in determining children with SDB who should more seriously be considered for tonsillectomy?

Dr. Wald: SDB is characterized by recurrent partial or complete upper airway obstruction during sleep that results in disruption of the normal breathing and sleep pattern.
The diagnosis is usually based on history and physical exam, though sometimes more sophisticated testing is necessary. Tonsillar and adenoid hypertrophy is the most common cause of SDB.
While a lot of kids have this problem, there are accompanying factors that persuade us that we want to do something about it.
One issue is growth retardation.
Others include poor school performance or behavioral problems. Behavior seems to be related to poor sleep, and things like aggression, hyperactivity, or depression may be associated with disordered breathing.
Another issue that, interestingly, has some association with SDB is enuresis or bed wetting.
A parent's report of a history in their child of noisy respirations at night associated with a brief cessation of breathing and a very noisy restart of respirations should prompt additional questioning.
You would inquire specifically about their growth, school performance, bed wetting, and any associated behavioral problems. If that history suggests ongoing issues, you might be more interested in referring them for a tonsillectomy.

Medscape: Dr. Wald, any concluding recommendations for primary care providers?

Dr. Wald: I think the bottom line is that while these are very good guidelines and will serve the best interests of children most of the time, we should individualize our approach to patients. It is important to look at each patient, consider these criteria, and then ask the question of benefit vs risk. There are very rare complications of tonsillectomy, including anesthetic accidents and hemorrhage post-tonsillectomy. Accordingly, there should be pretty good indications to justify the risk, even though the risk is small.