Comia, Ralph Joseph B.

Medicine III

June 24, 2011 ENT

Current Indications for Tonsillectomy

Tonsillectomy

Although a long-practiced procedure, tonsillectomy is still a common operation and considered one of the most common major surgical procedure performed in children. This procedure is still surrounded by controversy, especially regarding indications for surgery and details of surgical technique.

Tonsils are clumps of tissue on both sides of the throat that help fight infections.

Tonsils may swell when they become infected (tonsillitis). If you look down your child's throat with a flashlight, the tonsils may be red and swollen or have a white or yellow coating on them. Other symptoms of tonsillitis can include:

sore throat pain or discomfort when swallowing fever swollen glands (lymph nodes) in the neck

Enlarged tonsils without any symptoms are common among kids. Left alone, enlarged tonsils may eventually shrink on their own over the course of several years. The tonsils are 3 masses of tissue: the lingual tonsil, the pharyngeal (adenoid) tonsil, and the palatine or fascial tonsil. The tonsils are lymphoid tissue covered by respiratory epithelium, which is invaginated and which causes crypts.

In addition to producing lymphocytes, the tonsils are active in the synthesis of immunoglobulins. Because they are the first lymphoid aggregates in the aerodigestive tract, the tonsils are thought to play a role in immunity. Although healthy tonsils offer immune protection, diseased tonsils are less effective at serving their immune functions. Diseased tonsils are associated with decreased antigen transport, decreased antibody production above baseline levels, and chronic bacterial infection. Medical Therapy Adjunctive intraoperative medical therapy may include the following: Rectal acetaminophen in children Intravenous antiemetics Intravenous narcotics (except if a history of airway obstruction is present) Intravenous steroids (controversial, probably a small benefit) Local anesthetic

Preoperative Details Careful history taking is needed to evaluate for the following: Bleeding disorders or wish to avoid transfusion Anesthesia intolerance Obstructive sleep apnea

In patients with Down syndrome, order cervical spine images to evaluate for C1-C2 subluxation. Also, be aware of possible underlying cardiac disease.

Sleep studies are recommended if the severity of the patient's symptoms is uncertain. Regarding admission planning, insurance plans are increasingly disallowing inpatient admission for tonsillectomy or

adenoidectomy. Children who should be admitted are those with obstructive sleep apnea, those with significant comorbid disease such as hypotonia or neuromotor delays, and those younger than 3 years.

Postoperative Details The patient should eat an adequate diet. No evidence suggests that a special diet is required; however, soft foods are more easily swallowed than hard foods. Administer antibiotics. Oral antibiotic use for the week after tonsillectomy is associated with improved outcomes in children. Instruct the patient to avoid: o o Smoking. Heavy lifting and exertion for 10 days.

Warn patients that pain will abate during the first 3-5 days then increase for 1-2 days before completely disappearing.

Most often, tonsillectomy is safely performed on an outpatient basis. Individuals who should not receive tonsillectomy as outpatients are those younger than 3 years, those with obstructive sleep apnea, those who live far away from the outpatient facility, those with Down syndrome, or those who have difficulty in complying with instructions.

Indications
Tonsillectomy, the removal of the palatine tonsils, has three principal indications.

1. Recurrent attacks of tonsillitis (typically Streptococcal). 2. Enlarged tonsils causing obstruction of the airway, which may be the cause of Obstructive Sleep Apnoea recurrent airway obstruction at night and this has serious effects on health and wellbeing. 3. Possible malignant disease in the tonsils typically squamous carcinoma or lymphoma.

Patients should meet all of the following criteria: sore throats are due to tonsillitis five or more episodes of sore throat per year symptoms for at least a year episodes of sore throat are disabling and prevent normal functioning

Otolaryngology textbooks list a variety of indications for tonsillectomy. The American Academy of OtolaryngologyHead and Neck Surgery (AAO-HNS) publishes clinical indicators for surgical procedures. Paraphrased, these clinical indicators are as follows:

Absolute indications

Enlarged tonsils that cause upper airway obstruction, severe dysphagia, sleep disorders, or cardiopulmonary complications

Peritonsillar abscess that is unresponsive to medical management and drainage documented

by surgeon, unless surgery is performed during acute stage Tonsillitis resulting in febrile convulsions Tonsils requiring biopsy to define tissue pathology

Relative indications

Three or more tonsil infections per year despite adequate medical therapy

Persistent foul taste or breath due to chronic tonsillitis that is not responsive to medical therapy
Chronic or recurrent tonsillitis in a streptococcal carrier not responding to beta-lactamaseresistant antibiotics Unilateral tonsil hypertrophy that is presumed to be neoplastic