INDICATIONS FOR TONSIL AND ADENOIDECTOMY Margaretha L. Casselbrant, MD, PhD Eberly Professor of Pediatric Otolaryngology University of Pittsburgh School

INDICATIONS FOR TONSILAND ADENOIDECTOMY

Margaretha L. Casselbrant, MD, PhDEberly Professor of Pediatric OtolaryngologyUniversity of Pittsburgh School of Medicine

Pittsburgh, Pennsylvania

Historic BackgroundHistoric Background

TONSILLECTOMYTONSILLECTOMY10 A.D. Celsus first to report removal of tonsils10 A.D. Celsus first to report removal of tonsils66thth century century Aetius of Amida on the Tigris described a Aetius of Amida on the Tigris described a

technique for tonsillectomytechnique for tonsillectomy625625 Paul of Aegina described tonsillar forcepsPaul of Aegina described tonsillar forceps17571757 Caque of Rheims first tonsillectomyCaque of Rheims first tonsillectomy18271827 Physick described the first tonsillar guillotinePhysick described the first tonsillar guillotine1919thth century century Mackenzie popularized the surgeryMackenzie popularized the surgery

ADENOIDECTOMYADENOIDECTOMY18681868 Meyer first to recommend removal of Meyer first to recommend removal of adenoids adenoids

using a ring knifeusing a ring knife18851885 Goldstein first adenoid curetteGoldstein first adenoid curetteprof. M.L. Casselbrant, USAprof. M.L. Casselbrant, USA

Frequency (x1000) of Tonsillectomy, Frequency (x1000) of Tonsillectomy, Adenoidectomy, and BothAdenoidectomy, and Both

100

200

300

400

500

600

700

800

900

1000

Fre

qu

ency

of

Pro

ced

ure

x1

00

0

1971 1979 1987 1996

T&A T A

prof. M.L. Casselbrant, USAprof. M.L. Casselbrant, USA

Indications for TonsillectomyIndications for Tonsillectomyand Adenoidectomyand Adenoidectomy

I ObstructionI Obstruction

II InfectionII Infection

III Other causesIII Other causes


Hypertrophic/ Obstructive Tonsils Hypertrophic/ Obstructive Tonsils and Adenoidsand Adenoids

Does it matter?prof. M.L. Casselbrant, USAprof. M.L. Casselbrant, USA


Hypertrophic Tonsils and Adenoids Hypertrophic Tonsils and Adenoids May CauseMay Cause

Snoring/Obstructive sleep apneaSnoring/Obstructive sleep apneaSnortingSnorting

ChokingChoking

Pauses of 10-40 secondsPauses of 10-40 seconds

Restless sleepRestless sleep

PositioningPositioningSniffing positionSniffing position

Neck hyperextendedNeck hyperextended

EnuresisEnuresisprof. M.L. Casselbrant, USAprof. M.L. Casselbrant, USA

Hypertrophic Tonsils and Adenoids Hypertrophic Tonsils and Adenoids May Cause May Cause (cont’d)(cont’d)

LethargyLethargy

Behavioral changesBehavioral changes

Daytime hypersomnolence Daytime hypersomnolence

Dysphagia with choking episodesDysphagia with choking episodes

Growth disturbance/failure to thriveGrowth disturbance/failure to thrive

Affect overall quality of lifeAffect overall quality of life


Methods to Assess UpperMethods to Assess UpperAirway ObstructionAirway Obstruction

HistoryHistorySnoringSnoringMouth breathingMouth breathingSleep, pauses, apneaSleep, pauses, apneaDaytime somnolenceDaytime somnolenceEnuresis Enuresis Behavior problemsBehavior problems


Methods to Assess UpperMethods to Assess UpperAirway Obstruction Airway Obstruction (cont’d)(cont’d)

Physical ExaminationPhysical ExaminationMouth breathingMouth breathingLack of lip sealLack of lip sealHyponasal speechHyponasal speechDistorted speech “Hot Potato Voice”Distorted speech “Hot Potato Voice”Adenoid faciesAdenoid faciesEvidence of congestive heart failureEvidence of congestive heart failureTonsil sizeTonsil sizeAdenoid sizeAdenoid size


Methods to Assess UpperMethods to Assess UpperAirway ObstructionAirway Obstruction (cont.)(cont.)

Special methods of evaluationsSpecial methods of evaluationsRadiographsRadiographs

Lateral neck to assess adenoid and tonsil sizeLateral neck to assess adenoid and tonsil size

Flexible endoscopyFlexible endoscopyTo assess degree of obstruction by enlarged adenoidsTo assess degree of obstruction by enlarged adenoids

Sleep tapeSleep tape

Formal sleep study (polysomnography)Formal sleep study (polysomnography)To determine degree and type of sleep disturbance To determine degree and type of sleep disturbance




Indications for PolysomnographyIndications for Polysomnography

High-risk patientsHigh-risk patients

Young children Young children 2 years of age2 years of age

Morbidly obese patientsMorbidly obese patients

Unconvincing historyUnconvincing history

Contra indication for T&AContra indication for T&A


Chronic obstructive Chronic obstructive adenotonsillar hypertrophy adenotonsillar hypertrophy

often has aoften has a

bacterial etiologybacterial etiology


Microbiology of Obstructive/ Microbiology of Obstructive/ Hypertrophic and Recurrent TonsillitisHypertrophic and Recurrent Tonsillitis

Polymicrobial organismsPolymicrobial organisms

S. pyogenes high rate in both groupsS. pyogenes high rate in both groups

Beta-lactamase-producing Beta-lactamase-producing aerobic/anaerobic organisms commonaerobic/anaerobic organisms common

Kielmovitch, Keleti, Bluestone et al.Kielmovitch, Keleti, Bluestone et al.

Arch Otolaryngol Head Neck SurgArch Otolaryngol Head Neck Surg, June 1989, June 1989


A therapeutic trial with a broad-spectrum antimicrobial agent that is effective against beta-lactamase producing micro-organisms

given for 20 to 30 days, should be considered prior to tonsil/adenoidectomy as it may be

effective in reducing the obstruction


Conclusions

Tonsil and adenoidectomy is indicated for hypertrophic tonsils and adenoids causing symptoms of obstruction and affecting quality of life in children who

failed maximum medical therapy


Recurrent Tonsillitis


Tonsillitis:When is Enough

Enough?


Efficacy of Tonsillectomy for RecurrentThroat Infections in Severely

Affected Children – Randomized Clinical Trial

Inclusion CriteriaMinimum episodes of tonsillitis

3 per year x 3 years, or5 per year x 2 years, or7 in one year

Clinical features (at least one)Fever>38.3 CTonsillar exudateEnlarged (>2cm) and/or tender cervical nodesPositive Group A beta-hemolytic Paradise et al 1984prof. M.L. Casselbrant, USAprof. M.L. Casselbrant, USA

Number of Observed Episodes of ThroatInfections According to Year of Follow up in

the Surgical vs. the Control Groups

0

1

2

3

Mea

n N

um

ber

of

Ep

isod

es

Year I p< 0.001

Year II p< 0.001

Year III NS

Surgical Control


Academy of OtolaryngologyGuidelines for Tonsillectomy

“Three or more infections of

tonsils and adenoids per year despite adequate medical therapy”


Tonsillectomy and Adenoidectomyfor Recurrent Throat Infectionsin Moderately Affected Children

Inclusion Criteria Less stringent criteria than in the 1984 study (>3

episodes) followed for 3 years

Results The modest benefits conferred by tonsil and

adenoidectomy in children moderately affected with recurrent throat infection seems not to justify the inherent risk, morbidity and cost of the operation

Paradise et al 2002Paradise et al 2002


Conclusion II

Elective tonsillectomy for stringent

criteria is a reasonable alternative

to medical treatment for

frequently recurrent throat infections


Indication for Tonsillectomy for Indication for Tonsillectomy for Recurrent TonsillitisRecurrent Tonsillitis

Recurrent Tonsillitis

≥ 7/1 year

≥ 5/2 years

≥ 3/ years

Paradise et al. 1984


Other “Infectious” Indicationsfor Tonsillectomy

Recurrent acute tonsillitis associated with

Cardiac valvular diseaseRecurrent febrile seizures

Chronic tonsillitis unresponsive to medical therapy associated with

Persistent sore throatHalitosisTender cervical adenitisprof. M.L. Casselbrant, USAprof. M.L. Casselbrant, USA

Other “Infectious” IndicationsOther “Infectious” Indicationsfor Tonsillectomy for Tonsillectomy (cont’)(cont’)

Streptococcal carrier state Streptococcal carrier state unresponsive to medical therapyunresponsive to medical therapy

Mononucleosis with severely Mononucleosis with severely obstructing tonsils unresponsive to obstructing tonsils unresponsive to medical therapymedical therapy

Peritonsillar abscessPeritonsillar abscess


Peritonsillar Abscess


Treatment Options for Treatment Options for Peritonsillar AbscessPeritonsillar Abscess

IV antibiotics (only cellulitis)IV antibiotics (only cellulitis)

Needle aspiration and ABNeedle aspiration and AB

Incision and drainage with/without interval Incision and drainage with/without interval tonsillectomytonsillectomy

Tonsillectomy “a chaud”Tonsillectomy “a chaud”Unilateral vs. bilateral tonsillectomyUnilateral vs. bilateral tonsillectomy


Factors to Consider in the Treatment of Children with Peritonsillar

Abscess

Age and cooperation of the child

History of prior tonsillar diseaseRecurrent tonsillitis

Recurrent peritonsillar abscesses

Peritonsillar abscess with history of recurrent throat infections


Non-infectious Indications for Non-infectious Indications for TonsillectomyTonsillectomy

Unilateral tonsil enlargementUnilateral tonsil enlargement

Suspect malignancySuspect malignancy

Hemorrhagic tonsillitisHemorrhagic tonsillitis

Lingual tonsillitisLingual tonsillitis

TonsillolithiasisTonsillolithiasis


Indications for Tonsillectomy

AbsoluteObstructive sleep apnea/cor pulmonaleObstructive sleep apnea/cor pulmonale

Failure to thriveFailure to thrive

Suspect malignancySuspect malignancy

Persistent/recurrent tonsil hemorrhagePersistent/recurrent tonsil hemorrhage

ElectiveFrequent recurrent acute tonsillitis

Chronic tonsillitis

Obstructive tonsils

Peritonsillar abscessprof. M.L. Casselbrant, USAprof. M.L. Casselbrant, USA

Adenoidectomy


Other Indications for Adenoidectomy

Nasal obstruction (Non-OSA)

Recurrent/persistent otitis media

Recurrent/persistent sinusitis


Adenoidectomy forNasal Obstruction

Snoring/MouthbreathingSnoring/Mouthbreathing

Hyponasal speechHyponasal speech

Olfaction (improve appetite)Olfaction (improve appetite)

Growth and developmentGrowth and development

Quality of life issuesQuality of life issues

Dentofacial morphologyDentofacial morphology


Craniofacial Growth and Adenotonsillar Hypertrophy

Mouth breathing displaces the mandible and Mouth breathing displaces the mandible and tongue down and backwards, which may tongue down and backwards, which may secondarily affect dental occlusion and jaw secondarily affect dental occlusion and jaw growth causing:growth causing:

Open biteOpen bite

Protrusive maxillaProtrusive maxilla

Buccal posterior crossbiteBuccal posterior crossbite


Adenoid Facies in Children with Chronic Nasopharyngeal Obstruction

Longer total anterior face height

Tendency toward a retrognathic mandible

Linder-Aronson et al. 1986



Adenoidectomy for Preventionof Chronic Sinusitis

Reservoir for bacteriaInterfere with nasal mucociliary functionStasis of nasal secretion


Pediatric Chronic Rhinosinusitis

Current therapy for pediatric chronic sinusitis continues to be prolonged courses of antibiotics and if the symptoms persists, staged surgical intervention with initial adenoidectomy followed by partial or anterior ethmoidectomy

Lusk 2006

Adenoids in children with chronic rhinosinusitis are covered with biofilm, which may act as an reservoir for bacteria. The clinical benefit of adenoidectomy may be due to the mechanical debridment of biofilm

Coticchia et al 2007


Adenoidectomy for Otitis Media

Adenoid tissue may block the Eustachian tube preventing ventilation of the middle ear/mastoid system Bluestone 1983

Adenoid tissue may harbor bacteria which may lead to infection of the middle ear

Linder et al. 1997

Adenoids covered with biofilm may also act as a reservoir for bacteria causing middle-ear disease Coticchia et al. 2007




The Role of Adjuvant Adenoidectomyand Tonsillectomy in the Outcome of

Tympanostomy Tube Insertion

Retrospective study including 37,316 childrenRetrospective study including 37,316 childrenAdjuvant adenoidectomy was associated with a Adjuvant adenoidectomy was associated with a reduction in the likelihood of reinsertion of tubes reduction in the likelihood of reinsertion of tubes (RR 0.5; p>.001) and readmission for conditions (RR 0.5; p>.001) and readmission for conditions related to otitis media (RR 0.5; p>.001)related to otitis media (RR 0.5; p>.001)The effect was further reduced if adjuvant The effect was further reduced if adjuvant adenotonsillectomy was performedadenotonsillectomy was performedThe effect was age relatedThe effect was age related

Coyte et al 2001Coyte et al 2001


Indications for AdenoidectomyIndications for Adenoidectomy

Absolute IndicationsObstructive sleep apnea/cor pulmonale

Failure to thrive

Suspect malignancy

Elective IndicationsObstructive adenoids

Recurrent/chronic adenoiditis

Recurrent/chronic sinusitis

Recurrent/chronic otitis mediaprof. M.L. Casselbrant, USAprof. M.L. Casselbrant, USA

Contraindications for Contraindications for AdenotonsillectomyAdenotonsillectomy

Relative(?)Velopharyngeal insufficiencyVelopharyngeal insufficiency

Submucous cleftSubmucous cleft

Overt cleft palateOvert cleft palate

Neuromuscular/ neurologic palate impairmentNeuromuscular/ neurologic palate impairment

Immunodeficiency disordersImmunodeficiency disorders

Blood dyscraiasBlood dyscraiasAnemiaAnemia

Coagulation defectsCoagulation defects

Increased anesthetic riskIncreased anesthetic riskprof. M.L. Casselbrant, USAprof. M.L. Casselbrant, USA

Contraindications for Contraindications for AdenotonsillectomyAdenotonsillectomy (cont.)(cont.)

AbsoluteUncontrolled systemic diseases (heart, Uncontrolled systemic diseases (heart, liver, diabetes, seizures)liver, diabetes, seizures)


Complications Post Adenotonsillectomy*Complications Post Adenotonsillectomy*

Hemorrhage

Primary/ immediate (≥ 24h) 0-5.4%

Secondary/ delayed (> 24h) <8.2%

Emesis (recurrent/protracted) 0.7 – 7.5%

Dehydration 0.3 – 1.9%

Prolonged IV hydration 9 -15%

Airway complications < 3 years 38- 59%*Data from 16 studies*Data from 16 studies

Cunningham 1998Cunningham 1998


Hemorrhage Post-Adenotonsillectomy

Prevalence of hemorrhage 0.1 – 8.1%

Transfusion rate 0.04%

Mortality* 0.002%

*Most fatal bleedings occur within the first 24 hours post operatively


Parent Satisfaction One-Year Post Adenotonsillectomy in Their Children

No of febrile sore throats 6.7 vs. 1.5

Obstructive symptoms resolved 80%

Parents satisfied with benefit

from surgery 91%

Parents who regret surgery was

not done earlier 28%



Documents

INDICATIONS FOR TONSIL AND ADENOIDECTOMY Margaretha L. Casselbrant, MD, PhD Eberly Professor of Pediatric Otolaryngology University of Pittsburgh School