Fewer Children Likely to Need Tonsillectomy, According to New Clinical Practice Guideline
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‘Tis the season for childhood throat infections and the inevitable discussions about their tonsils. However, according to new published guidelines, many children who get recurrent throat infections probably don’t need to undergo tonsillectomy—a procedure that was once a rite of passage for many kids.
Tonsillectomy is one of the most common surgical procedures in the United States, with more than 530,000 procedures performed annually in children younger than age 15. Despite the frequency of tonsillectomy, until now there have been no evidence-based guidelines to assist clinicians in assessing children who are good candidates for the surgery, to provide information about best practices during the procedure, and to help children recover safely and rapidly from the removal of tonsils.
Tonsillectomies carry risks and side effects; in addition to infections, up to 3% of patients have bleeding and an estimated 1 in 35,000 patients dies. Post-recovery is painful.
The new, multidisciplinary guidelines published by the American Academy of Otolaryngology–Head and Neck Surgery (AAO–HNS) provide evidence-based recommendations on the pre-, intra-, and postoperative care and management of children aged 1 to 18 years under consideration for tonsillectomy and is intended for all clinicians in any setting who care for these patients. This guideline also addresses practice variation in medicine and the significant public health implications of tonsillectomy.
Important Points About the AAO-HNS Tonsillectomy Guidelines
- Most children with frequent and severe throat infections get better on their own. Watchful waiting is appropriate for most children with less than 7 episodes in the past year, 5 per year in the past 2 years, or 3 per year in the past 3 years. Severe throat infections are those with fever of higher than 101ºF, swollen or tender neck glands, coating on the tonsils, or a positive test for strep throat.
- Children with less frequent or severe throat infections may still benefit from tonsillectomy if there are modifying factors, including antibiotic allergy/intolerance, a history of peritonsillar abscess, or PFAPA syndrome (periodic fever, aphthous stomatitis, pharyngitis, and adenitis).
- Large tonsils can obstruct breathing at night, causing sleep-disordered breathing (SDB), with snoring, mouth breathing, pauses in breathing, and sometimes sleep apnea. Assess children with SDB and large tonsils for problems that might be exacerbated without tonsillectomy, including growth delay, poor school performance, bedwetting, and behavioral issues.
- Although most children with SDB improve after tonsillectomy, some children, especially those who are obese or have syndromes affecting the head and neck, may require further management.
- A single, intravenous dose of dexamethasone should be given during the tonsillectomy to reduce pain, nausea, and vomiting after surgery.
- Do not routinely prescribe antibiotics to improve recovery following tonsillectomy surgery because medical studies show no consistent benefits over placebo and there are associated risks and side effects.
- Try to educate parents about the importance of managing and reassessing pain after tonsillectomy. Strategies include drinking plenty of fluids, using acetaminophen or ibuprofen for pain control, giving pain medicine early and regularly, and encouraging their child to tell them if their throat hurts.
The guideline pertains only to complete tonsillectomy, with or without adenoidectomy, and does not apply to tonsillotomy, intracapsular surgery, or any partial removal of a tonsil.
Published on January 11, 2011
Source: Baugh RF, Archer SM, Mitchell RB, et al. Clinical practice guideline: tonsillectomy in children. Otolaryngol Head Neck Surg. 2010;144(Suppl 1):S1-S30.