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Tonsillectomy Is No Longer a Matter of Course. (Criteria for Selecting Surgery Candidates).

SAN DIEGO -- There was a time when it seemed a tonsillectomy-adenoidectomy was a routine rite of passage for every suburban kid, as predictable as braces or a two-wheel bike.

Those days are gone, even though the operations remain the most common major surgeries performed in children after the newborn period. Clearly, some tonsillectomies are still performed unnecessarily. The trick is to choose the correct candidates for medication or watchful waiting, while referring for surgery the children at risk for serious, even life-threatening, complications, Dr. Charles D. Bluestone said at a pediatric meeting sponsored by Children's Hospital and Health Center.

Dr. Bluestone, director of pediatric otolaryngology at Children's Hospital of Pittsburgh, shared his criteria for selecting patients with definite and potential indications for tonsillectomy and/or adenoidectomy:


* Obstruction. The presence of sleep apnea or evidence of alveolar hypoventilation--with or without cor pulmonale--calls for removal of the tonsils or adenoids, and usually both. Obesity, preexisting congenital heart disease, and craniofacial malformation, such as that seen in children with Down syndrome, may be cofactors contributing to obstruction, as will concurrent upper respiratory tract infections. In children with craniofacial malformations, even small adenoids can completely obstruct a child with a small nasopharynx or pharynx, he said.

* Swallowing impairment. Some children fail to gain weight or lose weight over a 6-month period because of obstructed tonsils or adenoids. "This is not on every radar screen of third-party payers," Dr. Bluestone said at the meeting, also sponsored by California chapter 3 of the American Academy of Pediatrics.

* Asymmetric tonsils. In older children and teenagers, consider a tonsillectomy if the tonsils are not equal in size, especially if there is a lump in the neck. The tonsils should be removed and examined pathologically for lymphoma.

* Persistent recurrent tonsillar hemorrhage. This is another indication that applies to teenagers, especially young women. Recurrent or chronic throat infections unresponsive to medications may lead to repeated hemorrhages that indicate the need for surgery, the physician noted.


* Frequently recurrent acute tonsillitis. Current research has reconfirmed that children with a large number of serious episodes benefit from tonsillectomy while those with fewer or more minor episodes do not. The threshold appears to be three episodes per year for 3 years, five episodes per year for 2 years, or seven or more episodes in 1 year. Signs of severe episodes include a documented fever of >38[degree] C, and/or tonsillar exudate, enlarged and tender cervical nodes, and! or group A streptococcus.

* Chronic tonsillitis or sinusitis. Consider the length and severity of the child's illness. Are documented episodes moderate to severe? Has an appropriate trial of antimicrobial therapy been completed? Dr. Bluestone said he is "wary" of children, especially teenagers, who awaken every morning with a sore throat. Smoking, gastroesophageal reflux disease, and allergies should be ruled out before surgery.

* Obstructive tonsils or adenoids not severe enough to cause sleep apnea or evidence of alveolar hypoventilation or corpulmonale. This sign may be an indication for surgery, depending on duration and severity, especially if medical treatment is unsuccessful and sleep is disrupted.

* Peritonsillar abscess. Tonsillectomy may be unnecessary in an older child whose abscess can be incised and drained or treated with needle aspiration under local anesthetic. Younger children with frequent tonsillitis should be referred for a tonsillectomy when the peritonsillar abscess is treated.

RELATED ARTICLE: Who Needs a Formal Sleep Study?

Not every child with suspected nasopharyngeal obstruction leading to sleep apnea needs a formal sleep study, which can range in cost from $100 to $2,000, Dr. Bluestone said.

For a child with a craniofacial malformation, the formal study is worth the cost. He also obtains a formal evaluation when he is uncertain whether obstruction is central or peripheral. It may help to answer the following question: "Is this something going on in the brain or in the pharynx, or both?"

Finally, Dr. Bluestone orders a sleep study when there is disagreement about the condition or its management. Normal children who have been reported to have breathing pauses of 10 seconds or greater during sleep rarely require a formal sleep study He simply asks parents to tape record their child sleeping on their backs for 10 minutes. If sleep apnea is evident on the tape, he proceeds to surgery.
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Author:Bates, Betsy
Publication:Pediatric News
Geographic Code:1USA
Date:Nov 1, 2001
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