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Tonsillectomy in Children
Boris A. Stuck, Jochen P. Windfuhr, Harald Genzwrker,
Horst Schroten, Tobias Tenenbaum, Karl Gtte
SUMMARY
Introduction: Tonsillectomy is one of the most frequently T onsillectomy is one of the more common surgical
procedures in childhood, yet the proper determi-
nation of its indications requires extensive clinical expe-
performed surgical interventions in children. In the
following, indications, preoperative evaluation, surgical rience and is often complicated by difficulties in inter-
techniques and postoperative complications will be preting the child's complaints, combined with parental
discussed. expectations and the recommendations of the physicians
Methods: Literature search in PubMed (National Library of who have already been taking care of the child. More-
Medicine) focusing on publications in German or English over, physicians from the various medical specialties
up to June 2008. dealing with such patients tend to base their recommen-
dations about surgery on highly divergent clinical expe-
Results: Indications are selected infectious diseases, upper
riences and points of view.
airway obstruction for example due to tonsillar hypertrophy,
Tonsillar surgery, particularly for children, has evolved
and a suspected malignancy. Viral infections of the tonsils
to some extent in recent years. Time-tested or innovative
without upper airway obstruction are not an indication for
techniques of partial tonsillar resection are now being
surgery; in the case of acute bacterial tonsillitis,
tonsillectomy is no longer recommended. In recurrent
used more frequently (again). Not only scientific journals,
tonsillitis, tonsillectomy is only effective in specific and but also the popular press, continue to report case after
narrow indications. The indication for tonsillectomy in case of fatal complications after tonsillectomy, usually
sleep-disordered breathing due to adenotonsillar hypertrophy involving postoperative hemorrhage. Operative mortality
has to be based on clinical assessment, medical history, in childhood, though rare, is of particular concern. This
and a sleep history. The most relevant risk factors are prospect creates a special challenge not just for surgeons
obstructive sleep apnea and coagulation disorders. and for the hospitals where these operations are per-
A standardized history regarding hemostasis and bleeding formed, but also for the physician initially determining
is mandatory, and is superior to routine coagulation tests. the indication for surgery.
Postoperative bleeding is still the most relevant complication In view of these facts, this review article will contain
of tonsillectomy and is always an emergency situation. a discussion of the current state of knowledge regarding
the indications, preoperative risk assessment, operative
Conclusion: Tonsillectomy is one of the most frequently
performed interventions in children but should be considered techniques, and postoperative complications of ton-
with care, as life-threatening complications can occur. sillectomy in children, with particular attention to the
current national and international guidelines and con-
Dtsch Arztebl Int 2008; 105(49): 85261 sensus statements.
DOI: 10.3238/arztebl.2008.0852
After reading this article, the reader should be able to
Key words: tonsillectomy, sleep apnea, coagulation > understand the indications for tonsillectomy in
disorders, complications, bleeding childhood in an interdisciplinary context,
> know what preoperative tests are needed to assess
surgical risks according to the current recommen-
dations, and implement this knowledge in practice,
Prevalence
Tonsillectomy is one of the more commonly
Universitts-HNO-Klinik Mannheim: Prof. Dr. med. Stuck, Gtte performed operations in childhood.
HNO-Klinik, Malteserkrankenhaus St. Anna, Duisburg: Dr. med. Windfuhr
Klinik fr Ansthesiologie und Intensivmedizin Neckar-Odenwald-Klinik gGmbH
Buchen und Mosbach: Dr. med. Genzwrker
Universittsklinikum Mannheim, Klinik fr Kinder- und Jugendmedizin:
Prof. Dr. med. Schroten, Dr. med. Tenenbaum
understand the basics of surgical technique and post- through the presence, not only of odynophagia and ton-
operative management in order to initiate the sillar swelling, but also of symptoms and signs typically
necessary steps in case of postoperative hemorrhage. absent in bacterial tonsillitis, such as rhinorrhea, cough-
ing, a mucosal efflorescence, or generalized lymph-
Methods adenopathy. Isolated cervical lymphadenopathy, however,
The authors selectively searched the PubMed database is a common finding in acute bacterial tonsillitis. Viral
for articles in English or German appearing up to June tonsillitis without airway obstruction is not an indication
2008, and also made use of personally collected data. for surgery. There is only weak evidence to support the
The articles were chosen on the basis of the authors' sub- hypothesis that tonsillectomy can lower the frequency
jective assessment and extensive clinical experience. of viral pharyngitis or improve the clinical course of
No formal meta-analysis or structured assessment of all mononucleosis (1).
publications was performed; in view of the vast size of In Central Europe, streptococcal pharyngitis and
the available literature, this hardly seems to be practically scarlet fever are practically the only bacterial infections
feasible in any case. Furthermore, special attention was of the tonsils that are of any clinical importance. Since
paid to national and international guidelines and the advent of antibiotics, tonsillectomy is no longer con-
consensus statements, as well as to review articles sidered to be indicated in the acute stage of these condi-
previously written by the authors. tions. Although some other typical bacterial pathogens
The technique of surgery on hyperplastic tonsils has in the head and neck area, such as Haemophilus influenzae,
undergone a certain amount of change in recent years, Moraxella catarrhalis, Staphylococcus aureus, and
not only for adult patients, but for children as well. anaerobic bacteria, can be cultured from a high percen-
Nonetheless, the indications for tonsillectomy, the pre- tage of tonsillectomy specimens, their pathophysiological
operative assessment of risk factors, and the management significance in tonsillitis remains unclear, as they can
of postoperative complications are largely independent often be found in the oropharyngeal area in normal
of technical aspects. Thus, only the term "tonsillectomy" persons as well. The identification of these types of bac-
will be used in what follows, without any narrower teria in tonsillectomy specimens does, however, provide
specification. The discussion, however, will be applicable a possible explanation for the low effectiveness of peni-
by analogy to all alternative surgical methods as well, cillins (even though Streptococcus pyogenes remains
except where the contrary is explicitly stated. fully sensitive to penicillin) compared to second- and
third-generation cephalosporins and aminopenicillins
Indications combined with a beta-lactamase inhibitor (e1). A positive
Tonsillectomy or tonsillotomy is indicated culture for any of these organisms is not, of course, an
in certain infectious diseases of the tonsils or the indication for tonsillectomy. Moreover, there are no
peritonsillar space, published studies to provide scientific support for the
in airway obstruction due (e.g.) to tonsillar hyper- hypothesis that so-called focus elimination in any way
plasia, or improves the course of any type of allergic, autoimmu-
if a malignant disease is suspected. ne, dermatological, or rheumatological disease. A positive
Tumors of the tonsils of epithelial origin do not occur effect has only been demonstrated in "PFAPA syndrome"
in childhood. Lymphoma rarely affects the tonsils in (periodic fever, aphthous stomatitis, pharyngitis, and
childhood; if it is suspected (because of tonsillar asym- adenitis) (e2).
metry or unilateral tonsillar hyperplasia), the diagnosis The term "chronic tonsillitis" has no valid definition
requires histological confirmation. of any kind, neither with respect to the history and
manifestations of the condition nor with respect to its
Infectious diseases clinical, histological, and microbiological findings. In
Tonsillar infections are not necessarily an indication for the German-speaking countries, this putative entity is
tonsillectomy. Viral infections that can involve the tonsils considered to be an indication for tonsillectomy, yet it is
include influenza, the common cold, herpangina, never mentioned in the Anglo-Saxon world. "Recurrent
infectious mononucleosis, and, less commonly, herpes tonsillitis," on the other hand, has a definition that is
zoster, measles, and acute HIV infection. Viral tonsillitis both simple and clear. As a matter of definition, only
can be distinguished clinically from bacterial tonsillitis clinically manifest, purulent tonsillitis that has been
shown by culture or rapid antigen assay to be caused by > even after tonsillectomy, the patient might still
beta-hemolytic Group A streptococci (GAS) is considered develop a parapharyngeal abscess.
to count as a recurrence of tonsillitis. Schraff et al. reported the findings in their own group
An important study from Children's Hospital of Pitts- of pediatric patients (n = 83) in the USA: 31% of them
burgh (2), showed that the incidence of pharyngitis due needed a tonsillectomy " chaud," while 18% under-
to GAS declined by 1.3 episodes per year in the two went tonsillectomy at some time after resolution of the
years subsequent to adenotonsillectomy, compared to a acute infectious episode (e3).
control group that had undergone conservative therapy,
when surgery was performed for the following indications: Tonsillar hyperplasia
> 7 episodes of tonsillitis in a single year, Breathing disturbances during sleep that arise because
> 5 episodes in each of 2 consecutive years, or of adenotonsillar hyperplasia are the most important and
> 3 episodes in each of 3 consecutive years. most common indication for (adeno-)tonsillectomy in
Both the Mayo Clinic's recommendations regard- childhood. Adenotonsillar hyperplasia in children is
ing tonsillectomy, which have been published on the caused by a normal response of the lymphatic system
Internet (3), and the joint recommendation on ton- and is not a pathological condition in itself. If the hyper-
sillectomy of the Austrian Societies of Otorhinolaryn- plasia is only mild, there may be no symptoms at all, or
gology, Head and Neck Surgery, and Pediatrics and else symptoms may arise only in certain situations, e.g.,
Adolescent Medicine (4) are based on this publication in the presence of a concomitant upper respiratory
and rely on the same inclusion criteria. Tonsillectomy infection. On the other hand, severe adenotonsillar
is an effective instrument for reducing the frequency hyperplasiaparticularly when combined with other
of GAS-positive tonsillitis only when the indication risk factors such as obesity or craniofacial malforma-
for surgery has been established according to these tionsmay produce very marked symptoms, including
criteria (5, 6). Roughly two-thirds of all cultures from the full clinical picture of sleep apnea with nocturnal
"peritonsillar and parapharyngeal abscesses" reveal snoring and respiratory pauses (9, e4). Obstructive sleep
mixed flora consisting of both aerobes and anaerobes, apnea in childhood is, in turn, often associated with
particularly Prevotella species and Peptostreptococcus hyperactivity and a wide variety of other behavioral
species. GAS, on the other hand, is found in only about disturbances, as well as poor performance in school
one-quarter of all peritonsillar abscesses. The major (10, e5e8). Moreover, adequate evidence indicates an
manifestation of this condition is severe pain on swal- impairment of the quality of life (11, e9, e10) and a
lowing, which is almost always unilateral. In unclear worsening of cardiovascular and metabolic parameters
cases, the diagnosis can be established by needle aspi- (12). On the other hand, the classic signs of hypersomnia
ration. The usual first line of treatment all over the that are seen in adults are often absent in children or,
world for children and adolescents with peritonsillar at least, are generally not reported spontaneously (12).
abscess is needle aspiration and antibiotic administra- Tonsillectomy, often combined with adenotomy, is the
tion (7). The abscess must be surgically opened after primary treatment for sleep apnea with adenotonsillar
needle aspiration if it seems likely that a large quantity hyperplasia in childhood and is highly effective in
of pus still remains in the abscess. eliminating the symptoms mentioned above (12, 13,
Tonsillectomy " chaud," i.e., surgical removal of e11).
the tonsils while they are inflamed, is a controversial Establishing the indications for (adeno-)tonsillec-
matter. Procedures of this type are commonly performed tomy in children with (adeno-)tonsillar hyperplasia is
in the German-speaking countries, yet the current problematic for two reasons. First, there is no objective
scientific literature provides no evidence that they offer procedure for quantifying hyperplasia of the tonsils or
any advantage compared to needle aspiration/abscess adenoids. A large tonsil that seems to one examiner to be
drainage in combination with antibiotic treatment (8). physiological and of no clinical consequence may be
The proponents of abscess tonsillectomy argue that it judged by another to be pathologically enlarged and in
prevents the development of further abscesses, yet the need of treatment (figure).
following objections can be made to this argument: Second, there are no generally accepted objective
> 85% of cases of tonsillar abscess are single events, (polysomnographic) criteria in children for the ruling
and out of a respiratory disturbance during sleep that
postoperative observation. Such differences between elevation of the risk of postoperative hemorrhage after
studies make it difficult to compare their results. the use of electrodissection or coblation tonsillectomy
Furthermore, the term "postoperative hemorrhage" has (23). This finding is particularly important because the
no uniform definition: commonly, in prospective studies, study was conducted in such a way that systematic
every hemorrhagic event is registered and analyzed, errors could largely be excluded. It confirms the obser-
while retrospective studies usually count only hemorr- vations of authors who reported even higher rates of
hagic events that require intubation and surgery. Simi- hemorrhage after coblation tonsillectomy (e33) and
larly, the reported rates of postoperative hemorrhage lends additional support to the views of others
requiring blood transfusion vary from 0% (e27) to 2.3% (e34e36) who prefer not to use any heat-generating
(e28). Deaths due to postoperative hemorrhage are not apparatus at all during the procedure, not only for dis-
systematically recorded on an international level, and section, but also for hemostasis.
any data that have been published till now on this subject It seems plausible to assume that the thermal irritation
are purely speculative. A questionnaire on this subject produced by heating to 300C to 400C during tonsillar
for the year 2006 was circulated to 156 major clinical dissection with electrocautery causes more pain than
departments in Germany, of which 138 sent back replies, "cold dissection" with scissors, raspatory, and loop
containing data on a total of 54 572 tonsillectomies. (e37e42). This may also explain why newer techniques
There were no postoperative deaths at all in this collec- operating at lower temperatures are often portrayed as
tive; only one death after an elective tonsillectomy and "gentler" than the traditional electrosurgical techniques
one death after tonsillotomy were reported, both of (e43). Current prospective studies show that the use of
which occurred in patients who had undergone surgery bipolar electrocautery for dissection (e44) or for coagula-
elsewhere (22). tion (e31) indeed lowers the risk of intraoperative bleeding
Many potential means of reducing postoperative (as do all electrosurgical techniques), yet also elevates the
morbidity are suggested in the literature. The standardized risk of postoperative bleeding. In Germany, unlike the
administration of infusions, analgesics, or cortisone is United States (e45) and England (23), tonsillectomy is
recommended, while attempts are made to identify risk mainly performed with scissors and raspatory, while
factors for postoperative hemorrhage. The surgeon's intraoperative hemostasis is mainly performed with
degree of experience, the age and sex of the patient, the bipolar coagulation, with or without suture ligature (e46).
type of anesthesia, and also the operative technique and
method of hemostasis can all make a difference New developments
regarding the incidence and severity of postoperative Many studies report a shorter recovery period, lower
hemorrhage (e29, e30). Simply changing the technique intraoperative blood loss, and less postoperative pain
of intraoperative hemostasis can have an effect on the when new instruments of various types are used (boxes
timing and severity of hemorrhage (e31). 3 and 4). Such advantages, however, have not been
In the past, repeated attempts were made to reduce demonstrated convincingly enough to establish any of
postoperative morbidity by means of new technical ap- these techniques as the new standard. Economic aspects
paratus. The putative improvements, however, were not must be considered as well, as some of these techniques
always due to the new methods themselves, but rather to are quite expensive, particularly those that use disposable
the deliberate sparing of the surgical capsule of the tonsil, equipment.
known in the German-speaking countries as "tonsillo-
tomy." The lesser incidence of hemorrhage after tonsillo- Emergency management of postoperative
tomy is generally not due to the apparatus used; rather, complications
sparing the surgical capsule of the tonsil limits injury to The main objective of treating complications, especially
the larger blood vessels that supply it (e32). In addition, hemorrhage, after tonsillectomy in children is the securing
the very sensitive palatal musculature is also spared in of adequate oxygenation and tissue perfusion. Particu-
tonsillotomy, which explains the reported lesser intensity larly in children, the severity of bleeding can often be
and duration of postoperative pain after the procedure. difficult or impossible to assess, because children tend
On the subject of correlations between hemorrhage to swallow the blood. A relatively long time may elapse
and surgical technique, an extensive, recently published till projectile hematemesis finally occurs, generally
multicenter study has revealed an at least threefold resulting in still more severe bleeding.
Please answer the following questions to participate in our certified Continuing Medical Education
program. Only one answer is possible per question. Please select the answer that is most appropriate.
Question 1 Question 6
Which of the following diseases or findings is a definite What is the most common risk factor for postoperative
indication for tonsillectomy? respiratory complications after tonsillectomy?
(a) Viral tonsillitis (a) Apert syndrome
(b) Acute bacterial tonsillitis (b) Marked preoperative tonsillar hyperplasia
(c) A suspected infectious focus in the tonsils (c) Marked preoperative snoring
(d) A suspected malignancy (d) Morbid obesity
(e) A positive throat culture (e) Trisomy 21
Question 7
Question 2 Which of the following measures is most suitable in
Under what circumstances is tonsillar infection routine clinical practice for the preoperative detection of
an indication for tonsillectomy? clinically relevant disorders of hemostasis?
(a) If three or more episodes of tonsillitis have occurred in a (a) Bleeding time determination
single year (b) Partial thromboplastin time determination
(b) If five episodes of tonsillitis have occurred in each of two (c) Routine coagulation studies
consecutive years (d) Comprehensive coagulation testing, including a test for
(c) If two episodes of tonsillitis have occurred in each of three von Willebrand disease
consecutive years (e) A standardized coagulation history
(d) If one episode of tonsillitis has occurred in each of four
consecutive years Question 8
(e) If a total of five episodes of tonsillitis have occurred What do the medical specialty societies recommend for
in a five-year period the preoperative assessment of blood coagulation in
children about to undergo adenotomy or tonsillectomy?
(a) Von Willebrand disease does not need to be considered in
Question 3 coagulation testing because it is a rare condition.
Which of the following pathogens most commonly (b) Preoperative coagulation testing before tonsillectomy is
causes clinically relevant bacterial tonsillitis? indispensable.
(a) Haemophilus influenzae (c) Coagulation testing before a tonsillectomy should consist
(b) Moraxella catarrhalis of a prothrombin time test (PT/INR), partial thromboplastin
(c) Pseudomonas aeruginosa time, and bleeding time.
(d) Staphylococcus aureus (d) Preoperative coagulation testing should be performed in
(e) Group A streptococci all pre-school-age children about to undergo tonsillectomy.
(e) If a standardized history reveals evidence of a coagulopathy,
coagulation testing should be performed before
Question 4 surgery.
What combination of measures is most suitable in
routine clinical practice for the detection of a breathing Question 9
disturbance during sleep in children about to undergo What is the most important complication
tonsillectomy? of tonsillectomy?
(a) Outpatient polygraphy and pulmonary function testing (a) Hemorrhage
(b) Blood-gas analysis and polysomnography (b) Lingual nerve injury
(c) Clinical examination and sleep history (c) Disturbance of taste
(d) Differential blood count and nocturnal pulse oximetry (d) Velopharyngeal stenosis
(e) Chest x-ray and standardized questionnaires (e) Dental injury
Question 10
Question 5 Which of the following measures is indicated when
What problem is likely to arise postoperatively in a child who has undergone a tonsillectomy sustains
children with a breathing disturbance during sleep? a clinically relevant postoperative hemorrhage?
(a) More frequent postoperative respiratory complications (a) Outpatient consultation with an ENT specialist
(b) More frequent postoperative nausea and vomiting (b) Watchful waiting
(c) More frequent postoperative hemorrhage (c) Transport to a hospital
(d) Greater analgesic requirement (d) Mask ventilation
(e) Greater fluid requirement (e) Sedation with a suppository
Tonsillectomy in Children
Boris A. Stuck, Jochen P. Windfuhr, Harald Genzwrker,
Horst Schroten, Tobias Tenenbaum, Karl Gtte
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