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

Historic Background TONSILLECTOMY ADENOIDECTOMY 10 A.D. Celsus first to report removal of tonsils 6th century Aetius of Amida on the Tigris described a technique for tonsillectomy 625 Paul of Aegina described tonsillar forceps 1757 Caque of Rheims first tonsillectomy 1827 Physick described the first tonsillar guillotine 19th century Mackenzie popularized the surgery ADENOIDECTOMY 1868 Meyer first to recommend removal of adenoids using a ring knife 1885 Goldstein first adenoid curette prof. M.L. Casselbrant, USA

Frequency (x1000) of Tonsillectomy, Adenoidectomy, and Both prof. M.L. Casselbrant, USA

Indications for Tonsillectomy and Adenoidectomy I Obstruction II Infection III Other causes prof. M.L. Casselbrant, USA

Hypertrophic/ Obstructive Tonsils and Adenoids Does it matter? prof. M.L. Casselbrant, USA

prof. M.L. Casselbrant, USA

Hypertrophic Tonsils and Adenoids May Cause Snoring/Obstructive sleep apnea Snorting Choking Pauses of 10-40 seconds Restless sleep Positioning Sniffing position Neck hyperextended Enuresis prof. M.L. Casselbrant, USA

Hypertrophic Tonsils and Adenoids May Cause (cont’d) Lethargy Behavioral changes Daytime hypersomnolence Dysphagia with choking episodes Growth disturbance/failure to thrive Affect overall quality of life prof. M.L. Casselbrant, USA

Methods to Assess Upper Airway Obstruction History Snoring Mouth breathing Sleep, pauses, apnea Daytime somnolence Enuresis Behavior problems prof. M.L. Casselbrant, USA

Methods to Assess Upper Airway Obstruction (cont’d) Physical Examination Mouth breathing Lack of lip seal Hyponasal speech Distorted speech “Hot Potato Voice” Adenoid facies Evidence of congestive heart failure Tonsil size Adenoid size prof. M.L. Casselbrant, USA

Methods to Assess Upper Airway Obstruction (cont.) Special methods of evaluations Radiographs Lateral neck to assess adenoid and tonsil size Flexible endoscopy To assess degree of obstruction by enlarged adenoids Sleep tape Formal sleep study (polysomnography) To determine degree and type of sleep disturbance prof. M.L. Casselbrant, USA

prof. M.L. Casselbrant, USA

prof. M.L. Casselbrant, USA

Indications for Polysomnography High-risk patients Young children 2 years of age Morbidly obese patients Unconvincing history Contra indication for T&A prof. M.L. Casselbrant, USA

Chronic obstructive adenotonsillar hypertrophy often has a bacterial etiology prof. M.L. Casselbrant, USA

Microbiology of Obstructive/ Hypertrophic and Recurrent Tonsillitis Polymicrobial organisms S. pyogenes high rate in both groups Beta-lactamase-producing aerobic/anaerobic organisms common Kielmovitch, Keleti, Bluestone et al. Arch Otolaryngol Head Neck Surg, June 1989 prof. M.L. Casselbrant, USA

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 prof. M.L. Casselbrant, USA

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 prof. M.L. Casselbrant, USA

Recurrent Tonsillitis prof. M.L. Casselbrant, USA

Tonsillitis: When is Enough Enough? prof. M.L. Casselbrant, USA

Efficacy of Tonsillectomy for Recurrent Throat Infections in Severely Affected Children – Randomized Clinical Trial Inclusion Criteria Minimum episodes of tonsillitis 3 per year x 3 years, or 5 per year x 2 years, or 7 in one year Clinical features (at least one) Fever>38.3 C Tonsillar exudate Enlarged (>2cm) and/or tender cervical nodes Positive Group A beta-hemolytic Paradise et al 1984 prof. M.L. Casselbrant, USA

Number of Observed Episodes of Throat Infections According to Year of Follow up in the Surgical vs. the Control Groups prof. M.L. Casselbrant, USA

Academy of Otolaryngology Guidelines for Tonsillectomy “Three or more infections of tonsils and adenoids per year despite adequate medical therapy” prof. M.L. Casselbrant, USA

Tonsillectomy and Adenoidectomy for Recurrent Throat Infections in 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 2002 prof. M.L. Casselbrant, USA

Conclusion II Elective tonsillectomy for stringent criteria is a reasonable alternative to medical treatment for frequently recurrent throat infections prof. M.L. Casselbrant, USA

Indication for Tonsillectomy for Recurrent Tonsillitis ≥ 7/1 year ≥ 5/2 years ≥ 3/ years Paradise et al. 1984 prof. M.L. Casselbrant, USA

Other “Infectious” Indications for Tonsillectomy Recurrent acute tonsillitis associated with Cardiac valvular disease Recurrent febrile seizures Chronic tonsillitis unresponsive to medical therapy associated with Persistent sore throat Halitosis Tender cervical adenitis prof. M.L. Casselbrant, USA

Other “Infectious” Indications for Tonsillectomy (cont’) Streptococcal carrier state unresponsive to medical therapy Mononucleosis with severely obstructing tonsils unresponsive to medical therapy Peritonsillar abscess prof. M.L. Casselbrant, USA

Peritonsillar Abscess prof. M.L. Casselbrant, USA

Treatment Options for Peritonsillar Abscess IV antibiotics (only cellulitis) Needle aspiration and AB Incision and drainage with/without interval tonsillectomy Tonsillectomy “a chaud” Unilateral vs. bilateral tonsillectomy prof. M.L. Casselbrant, USA

Factors to Consider in the Treatment of Children with Peritonsillar Abscess Age and cooperation of the child History of prior tonsillar disease Recurrent tonsillitis Recurrent peritonsillar abscesses Peritonsillar abscess with history of recurrent throat infections prof. M.L. Casselbrant, USA

Non-infectious Indications for Tonsillectomy Unilateral tonsil enlargement Suspect malignancy Hemorrhagic tonsillitis Lingual tonsillitis Tonsillolithiasis prof. M.L. Casselbrant, USA

Indications for Tonsillectomy Absolute Obstructive sleep apnea/cor pulmonale Failure to thrive Suspect malignancy Persistent/recurrent tonsil hemorrhage Elective Frequent recurrent acute tonsillitis Chronic tonsillitis Obstructive tonsils Peritonsillar abscess prof. M.L. Casselbrant, USA

Adenoidectomy prof. M.L. Casselbrant, USA

Other Indications for Adenoidectomy Nasal obstruction (Non-OSA) Recurrent/persistent otitis media Recurrent/persistent sinusitis prof. M.L. Casselbrant, USA

Adenoidectomy for Nasal Obstruction Snoring/Mouthbreathing Hyponasal speech Olfaction (improve appetite) Growth and development Quality of life issues Dentofacial morphology prof. M.L. Casselbrant, USA

Craniofacial Growth and Adenotonsillar Hypertrophy Mouth breathing displaces the mandible and tongue down and backwards, which may secondarily affect dental occlusion and jaw growth causing: Open bite Protrusive maxilla Buccal posterior crossbite prof. M.L. Casselbrant, USA

Adenoid Facies in Children with Chronic Nasopharyngeal Obstruction Longer total anterior face height Tendency toward a retrognathic mandible Linder-Aronson et al. 1986 prof. M.L. Casselbrant, USA

prof. M.L. Casselbrant, USA

Adenoidectomy for Prevention of Chronic Sinusitis Reservoir for bacteria Interfere with nasal mucociliary function Stasis of nasal secretion prof. M.L. Casselbrant, USA

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 prof. M.L. Casselbrant, USA

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 prof. M.L. Casselbrant, USA

prof. M.L. Casselbrant, USA

prof. M.L. Casselbrant, USA

The Role of Adjuvant Adenoidectomy and Tonsillectomy in the Outcome of Tympanostomy Tube Insertion Retrospective study including 37,316 children Adjuvant adenoidectomy was associated with a reduction in the likelihood of reinsertion of tubes (RR 0.5; p>.001) and readmission for conditions related to otitis media (RR 0.5; p>.001) The effect was further reduced if adjuvant adenotonsillectomy was performed The effect was age related Coyte et al 2001 prof. M.L. Casselbrant, USA

Indications for Adenoidectomy Absolute Indications Obstructive sleep apnea/cor pulmonale Failure to thrive Suspect malignancy Elective Indications Obstructive adenoids Recurrent/chronic adenoiditis Recurrent/chronic sinusitis Recurrent/chronic otitis media prof. M.L. Casselbrant, USA

Contraindications for Adenotonsillectomy Relative(?) Velopharyngeal insufficiency Submucous cleft Overt cleft palate Neuromuscular/ neurologic palate impairment Immunodeficiency disorders Blood dyscraias Anemia Coagulation defects Increased anesthetic risk prof. M.L. Casselbrant, USA

Contraindications for Adenotonsillectomy (cont.) Absolute Uncontrolled systemic diseases (heart, liver, diabetes, seizures) prof. M.L. Casselbrant, USA

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 Cunningham 1998 prof. M.L. Casselbrant, USA

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 prof. M.L. Casselbrant, USA

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% prof. M.L. Casselbrant, USA

prof. M.L. Casselbrant, USA