Introduction

Tonsillectomy was first performed over 2000 years ago, with the oldest reference to the procedure dating back to 1000 BC. As the safety and indications evolved, so did the popularity of tonsillectomy. Most notably, the 1970s and 1980s saw a transition of the most common indication for tonsillectomy from recurrent throat infections to sleep-disordered breathing (SDB). Today, more than 500,000 tonsillectomies are performed annually in the United States, making it the most common major surgery and the second most commonly performed procedure on children behind myringotomy with tube insertion. As a consequence, tonsillectomy has garnered significant attention in the literature with high-quality evidence in the form of randomized controlled trials, systematic reviews, and the 2011 clinical practice guideline (CPG) published by the American academy of otolaryngology-head and neck surgery (AAO-HNS).

Unless otherwise specified, tonsillectomy refers to the removal of the palatine tonsils bilaterally. Continuous with the adenoids, lingual tonsils, Eustachian tonsils, and lateral pharyngeal bands, the palatine tonsils make up Waldeyer’s ring, a collection of lymphoid organs belonging to the secondary immune system. This lymphoid tissue is ideally situated to serve as a first barrier for sampling of antigens entering the upper aerodigestive tract. The tonsils have deep, epithelial-lined crypts that significantly enhance interaction between antigen-presenting cells and foreign substances. The peak immune activity and size of the palatine tonsils occurs between age 3 and 10 years. Such a proposed function notwithstanding, there is little to no evidence to suggest that children who undergo bilateral pharyngeal tonsillectomy sustain clinically significant immune deficiency.

Key Operative Learning Points

  • Tonsillectomy is most commonly indicated for SDB and recurrent pharyngotonsillitis.

  • Identification of the plane between the capsule of the tonsil and the constrictor muscle will facilitate the procedure.

Preoperative Period

History

History of Present Illness

In patients referred for the evaluation of SDB, sleep symptoms such as enuresis, snoring, gasping, choking, coughing, and frank apneas are reported by the caregiver. The treating physician can confirm this with sleep video-sonograms readily recorded by caretakers given the widespread availability of cellular telephone video cameras. Caregivers and schoolteachers may also report a range of nonsleep manifestations and consequences including poor school performance, growth failure, and behavioral problems such as aggression, hyperactivity or hypersomnolence, and depression.

The otolaryngologist is rarely consulted for recurrent tonsillitis in the midst of an acute episode of pharyngotonsillitis. Hence, to meet evidence-based criteria to justify tonsillectomy, each episode of sore throat must be documented by the primary care physician with accompanying fever greater than 38.3°C, positive group A β-hemolytic streptococcal (GABHS) culture, tonsillar exudate, tender cervical lymphadenopathy, or lymph nodes greater than 2 cm. Primary care records are often no longer a single source of documentation with the evolution of acute care (express and urgent care centers) where health care providers diagnose and treat this common disorder. Patients may also present with complaints of chronic halitosis, recurrent tonsil stones, dysphagia, or muffled voice.

Past Medical History

  • Prior treatment

  • Past medical history

    • Bleeding disorders or signs of easy bleeding or bruising (given the risk of posttonsillectomy hemorrhage)

  • Family history

    • A family history of rheumatic fever or heart disease should prompt a discussion of tonsillectomy in a child with GABHS pharyngotonsillitis, regardless of the frequency.

    • Because this often represents a child’s first operation, family history of excessive bleeding or adverse reactions to anesthesia should be queried.

  • Medications

    • Medications with anticoagulant activity should be noted and, if possible, discontinued prior to and immediately following surgery.

  • Allergies

    • Patients who have developed multiple antibiotic allergies during the treatment of recurrent pharyngotonsillitis may be offered tonsillectomy.

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.

    Fig. 192.1, Brodsky tonsillar grading system.

  • 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.

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