Tonsillectomy

History

Physical Examination

• Tonsils are most commonly graded from 0 to 4+, based on their position relative to the tonsillar pillars and oropharyngeal opening ( Fig. 192.1 ). Interestingly, Brodsky tonsil size (see Fig. 192.1 ) does not correlate with the severity of obstructive sleep apnea (OSA); however, patients with larger tonsils are more likely to have complete resolution of SDB after removal.

  

• The examiner should carefully evaluate for the presence of a bifid uvula, zona pellucida, and notch of the posterior hard palate bearing, in mind that even in the absence of any of these oropharyngeal stigmata of submucous cleft palate, an occult submucous cleft palate may nonetheless be present and may become symptomatic following an their adenoidectomy.

• A narrow hard palate in a child with OSA may require palatal expansion in addition to adenotonsillectomy.

• A patient with adenoid hypertrophy, which frequently coexists with tonsillar hypertrophy, may exhibit an elongated face, open mouth breathing, and hyponasal speech.

• If adenoidectomy is being considered, nasal endoscopy, a lateral neck radiograph, or physical examination at the time of tonsillectomy can reveal adenoid hypertrophy.

Imaging/Diagnostics

• 1.

  No imaging is indicated prior to routine tonsillectomy.

• 2.

  Flexion/extension cervical spine films should be obtained in Down syndrome children due to the risk of C1-C2 subluxation.

  • a.

    Alternative: Cervical spine magnetic resonance imaging (MRI)

  • b.

    The appropriate age at which such evaluations are appropriate and the most cost-effective studies are subjects of ongoing debate.

  • c.

    Many experts consider clinical manipulation of the neck in the office to elicit symptoms and no evaluation at all to be sufficient.

  • d.

    Shoulder roll should be avoided regardless.

• 3.

  A computed tomography (CT) angiogram may be pursued in a child with 22q11.2 syndrome to assess the degree of carotid artery medialization.

• 4.

  In-lab overnight polysomnography (PSG) is the gold standard for the diagnosis of OSA.

  • a.

    Home sleep study has not yet been approved for the diagnosis of pediatric OSA.

  • b.

    An apnea-hypopnea index (AHI) of 1 to 5 represents mild OSA, 5 to 15 moderate OSA, and greater than 15 severe OSA.

  • c.

    O ₂ saturation of less than 92% is considered abnormal in children.

  • d.

    PSG is indicated in children with a discordance between reported severity of signs/symptoms and tonsil size as well as those with complex medical histories such as Down syndrome, obesity, craniofacial abnormalities, sickle cell anemia, neuromuscular disorders, or mucopolysaccharidoses.

• 5.

  Drug-induced sleep endoscopy (DISE) is a useful adjunctive tool in children with OSA but an uncertain level of obstruction.

• 6.

  Sleep cine-MRI has been suggested as a valuable diagnostic means by which to investigate patients with persistent OSA despite adenotonsillectomy surgery.

Indications

• SDB describes partial or complete upper airway obstruction during sleep and affects approximately 12% of children. The condition ranges from nonobstructive snoring to OSA, which occurs in about 1% to 3% of children. Adenotonsillar hypertrophy is the most common cause of SDB in children and thus SDB represents the most common indication for pediatric tonsillectomy.

  • An AHI greater than 1 and oxygen desaturations below 92% are indications for tonsillectomy, but the decision to proceed with surgery should be made in the context of the history and physical examination.

  • Children with a history strongly suggestive of SDB or OSA and physical examination revealing tonsillar and/or adenoid hypertrophy do not necessarily require a preoperative PSG. Indeed, about 90% of children proceed to tonsillectomy based on clinical history and physical examination alone.

• Recurrent pharyngotonsillitis represents the second most common indication for tonsillectomy. The definitions for a sore throat episode and requirements for tonsillectomy are based on randomized controlled trial data from 1984 ( Table 192.1 ).

  • The “Paradise criteria” state that at least seven documented episodes of pharyngotonsillitis in 1 year, five in each of the last 2 years, or three in each of the last 3 years should be present to perform tonsillectomy for recurrent pharyngitis. There should be complete medical record documentation rather than caregiver report.

  TABLE 192.1

  Paradise Criteria

  From Baugh RF, Archer SM, Mitchell RB, et al.: Clinical practice guideline: tonsillectomy in children. Otolaryngol Head Neck Surg, 2011.

  Criterion	Definition
  Minimum frequency of sore throat episodes	7 or more episodes in the preceding year, OR
  	5 or more episodes in each of the preceding 2 years, OR
  	3 or more episodes in each of the preceding 3 years
  Clinical features (sore throat plus the presence of one of more qualifies as a counting episode)	Temperature >38.3°C, OR
  	Cervical lymphadenopathy (tender lymph nodes or >2 cm), OR
  	Tonsillar exudate, OR
  	Positive culture for group A β-hemolytic streptococcus
  Treatment	Antibiotics were administered in conventional dosage for proved or suspected streptococcal episodes.
  Documentation	Each episode and its qualifying features were substantiated by contemporaneous notation in a clinical record, OR
  	If not fully documented, subsequent observance by the clinician of 2 episodes of throat infection with patterns of frequency and clinical features consistent with the initial history ∗

  ∗ This last statement allows children who meet all other criteria for tonsillectomy except documentation to nonetheless qualify for surgery if the same pattern of reported illness is observed and documented by the clinician in two subsequent episodes. Because of this tendency to improve with time, a 12-month period of observation is usually recommended prior to consideration of tonsillectomy as an intervention.

• There are several other infectious indications for tonsillectomy that are less stringently defined ( Table 192.2 ):

  • Acute or Quinsy tonsillectomy for acute tonsillitis or peritonsillar abscess, generally when causing severe illness, airway obstruction, or refractory to incision and drainage.

  • Interval tonsillectomy for recurrent peritonsillar abscesses (PTAs), generally after two or more. Once the tonsils are removed, recurrent PTA is exceptionally rare.

  • In Lemierre syndrome (thrombophlebitis of the internal jugular vein most often related to tonsillitis and peritonsillar abscess), it is reasonable to perform tonsillectomy following acute treatment with antibiotics and incision and drainage, although there is scant evidence on the incidence of recurrence of Lemierre syndrome.

  • Tonsillectomy is an effective treatment for periodic fever, aphthous stomatitis, pharyngitis and adenitis (PFAPA) and reduces the number, frequency, duration, and severity of episodes as well as the need for steroids.

  • In pediatric autoimmune neuropsychiatric disorders associated with streptococcal (PANDAS) infections, the role of tonsillectomy is not as clear.

  • A child with tonsillar asymmetry alone is not a candidate for tonsillectomy in the absence of other indications or signs and symptoms concerning for lymphoma.

  • Acute upper airway obstruction due to tonsillar enlargement is most often seen in infectious mononucleosis. Acute tonsillectomy for this indication has been shown to reduce the number subsequent episodes of tonsillitis.

  TABLE 192.2

  List of Indications

  Airway	Infectious	Quality of Life
  Sleep-disordered breathing Airway obstruction Tonsillar asymmetry Removal of foreign body	Recurrent pharyngotonsillitis PFAPA Recurrent peritonsillar abscess Lemierre syndrome Psoriasis (guttate) Severe illness Febrile seizures Significant missed school time PANDAS	Severe halitosis Tonsillithiasis Malocclusion Dysphagia

  PANDAS, Pediatric autoimmune neuropsychiatric disorders associated with streptococcal; PFAPA, periodic fever, aphthous stomatitis, pharyngitis, and adenitis.

• Many indications lack concrete evidence and require thorough clinical evaluation and documentation ( Table 192.2 ):

  • Excessive illness requiring significant missed school time

  • Febrile seizures related to tonsillitis

  • The development of multiple antibiotic allergies related to treatment of recurrent tonsillitis

  • Severe halitosis

  • Recurrent tonsillithiasis is an indication in patients in whom improved oral hygiene and self-removal techniques have failed.

  • Malocclusion related to tonsillar hypertrophy

  • Guttate psoriasis

Contraindications

• In patients with significant bleeding disorders, tonsillectomy is not contraindicated but the risks should be adequately justified by the benefits and clearly outlined to the patient and family.

Preoperative Preparation

• Informed consent from the caregiver and assent from the patient where appropriate should include the major risks described in the following sections. The child should plan to miss 1 to 2 weeks of school.

• When a personal or family history is suggestive of a bleeding disorder, serologic coagulation testing with consideration of a hematology consultation should be obtained.

• Routine blood tests are not cost-effective.