• Nalaka de Silva

Indications for Tonsillectomy in Children

Updated: Jun 16, 2019



Please note that the following is a general guideline only.





The above topic was addressed in a joint Position paper in 2008. These guidelines were set out by Paediatrics & Child Health Division of The Royal Australasian College of Physicians and The Australian Society of Otolaryngology Head and Neck Surgery



REASONS FOR THE DISCUSSION


In Australia and New Zealand, only 1 in 7-10 children who could benefit from adenotonsillectomy is being treated.

Given the potential for permanent long term adverse effects in the younger age group, children under 5 years should be the first target group for increased services.


The article published in JAMA in 2018 "Association of Long-Term Risk of Respiratory, Allergic, and Infectious Diseases With Removal of Adenoids and Tonsils in Childhood" has MANY weaknesses. In summary, there is NO evidence to suggest that those who get tonsillectomy have any increase in allergies as adults.


To begin with, this article did not compare apples with apples. They tried to compare health of those adults who never had tonsil issues as children with those who did and had tonsils removed as children. Then they attempted to suggest that the reason for health issues in the latter group was due to their surgery. It is perhaps more likely that the reason for health issues was due to excess intake of antibiotics and the number of infections its self. In fact, those who had both tonsils and adenoids removed had fewer illnesses as adults than who had incomplete surgery (such as leaving adenoids behind).


In my own experience, most kids who undergo tonsillectomy are brought in by parents whom themselves had their tonsils and adenoids removed and benefitted, apart from the short term risks of bleeding etc. I have not come across any child who has had any long term adverse effects from their tonsillectomy.



RECOMMENDATIONS


1st Indication is Obstructive Breathing


8 -12 per cent of all children are thought to have primary snoring. Significant upper airway obstruction in children can result in the following.


Medical effects:

developmental delay, growth failure and heart failure


Cognitive effects:

verbal and non-verbal intelligence, memory, psychomotor efficiency, attention,

concentration, executive and psychosocial functioning


Behavioural effects:

aggression, hyperactivity, inattention and anxiety; while

learning, memory and executive functioning




Recommendations:

adenotonsillectomy is the first line of treatment moderate/severe OSA.


In children, OSA is challenging to diagnose. Those children who snore regularly with no apnea noted on sleep studies may still suffer the above effects of poor sleep.


For primary snoring, a conservative approach is reasonable, though these children need to be followed up and monitored.


Cure rates:

Over 90% (80% -97% on various studies) of the children are likely to be cured. However there is a group of patients who may fail due to underlying other disorders, and they need to be followed up.







2nd Indication- recurrent acute tonsillitis.

7 episodes in one year

5 in each year for over two years.

3 per year over 3 years;


An account should be taken of the clinical severity of the episodes

This may result in as little as one less episode of sore throat with fever per year qualifying for surgery





3 rd Indication: Peritonsillar Abscess


Usually, if there have been two abscesses, it is an indication.


However even one episode of an abscess, with further episodes of tonsillitis, should qualify for tonsillectomy.


Abscess tends to recur in about 20% of the patients.






4th Indication: Suspected Neoplasm – this is an absolute indication for tonsillectomy

This includes

-If one enlarged tonsil, if there is a short history [2-6 weeks],

-If the tonsil size is larger than 3 cm,

-If there is associated significant other neck nodeds

-If the liver or spleen is affected





5th: Uncommon indication


Because these presentations are uncommon, the recommendations are based upon

Expert opinion.

o Chronic diphtheria carrier status after failed antibiotic eradication

o Recurrent large tonsilloliths or tonsillar cysts

o Recurrent tonsillar haemorrhage











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