1. Tubes and Tonsils Lawrence M. Simon, M.D. Department of Pediatrics Noon Lecture Series Louisiana State University Health Sciences Center Children’s Hospital of New Orleans August 31, 2010

2. History of Tonsillectomy First description in 30 A.D. by Aulus Cornelius Celsus, a Roman encyclopedist. He described scraping the tonsils and tearing them out or picking them up with a hook and excising them with a scalpel. William Meyer in 1867 – adenoidectomy performed through a ring forceps through the nasal cavity 1917 Samuel J. Crowe published his report on 1000 tonsillectomies, and popularized the use of the Crowe- Davis mouth gag and sharp dissection

3. History of Tonsillectomy

5. Anatomy of the Tonsils and Adenoids

6. Size of the Tonsils “Kissing”

7. What do the tonsils do? Part of secondary immune system Exposed to ingested or inspired antigens passed through the epithelial layer Membrane cells and antigen presenting cells are involved in transport of antigen from the surface to the lymphoid follicle Antigen is presented to T-helper cells  induce B cells in germinal center to produce antibody (sIgA)

8. Incidence Tonsillectomies in U.S. –1959: 1.4 million –1979: 500,000 –1985: 340,000 –1996: 287,000 1950s primary indication - chronic infection 2000s obstructive sleep apnea (80%) –Improvement in medical management with antibiotics

9. Indications Three or more infections a year (not stringent enough) Tonsillar Hypertrophy –Upper airway obstruction –Sleep disorders –Dental malocclusion –Orofacial growth affected –Dysphagia –Cardiopulmonary complications Peritonsillar abscess (2 or more) Halitosis due to chronic tonsillitis (more than 3 months) Chronic/recurrent tonsillitis with Strep carrier state Unilateral hypertrophy, presumed neoplasm Tonsillar disease refractory to medical therapy American Academy of Otolaryngology-Head and Neck Surgery: 1995 Clinical indicators compendium, Alexandria, Virginia, 1995, American Academy of Otolaryngology-Head and Neck Surgery

10. Indications Recurrent or chronic tonsillitis –Much more common during the teenage years Obstructive sleep apnea/Sleep disordered breathing –Most common age group 2-5

11. Microbiology of Tonsillitis

12. Recurrent Tonsillitis Paradise JL, Bluestone CD, Bachman RZ, et al: Efficacy of tonsillectomy for recurrent throat infection in severely affected children: results of parallel randomized and nonrandomized clinical trials, N Engl J Med. 310:674–683, 1984.

13. Recurrent Tonsillitis Criteria –7/+ episodes in last 1 year –5/+ episodes in last 2 years –3/+ episodes in last 3 years Clinical features of each episode –Fever (38.5 C) –Lymphadenopathy (tender, >2cm) –Tonsillar/pharyngeal exudate and erythema –Positive ß-hemolytic streptococcus test –Medically treated

14. Recurrent Tonsillitis Paradise conclusions –Tonsillectomy was efficacious for 2 years and possibly a third in reducing frequency and severity of subsequent episodes Paradise criteria adopted by many otolaryngologists

15. Recurrent Tonsillitis Paradise JL, et al: Tonsillectomy and Adenotonsillectomy for Recurrent Throat Infection in Moderately Affected Children, Pediatrics 110(1):7, 2002.

16. Recurrent Tonsillitis Surgical criteria not as stringent as those in previous study Incidence of subsequent pharyngitis in surgical groups significantly lower than control group for 3 years postoperatively Overall incidence was low 0.16-0.43 per year Overall, surgical complication risk was high 7.9% ( unusually high – malignant hyperthermia, intraop hemorrhage requiring packing and ligation, post-op hemorrhage 3.5%, transfusion, allergic rash and throat infection ) Conclusion: modest benefit from surgery does not justify the inherent risks, morbidity and cost of surgery

17. Obstructive Sleep Apnea Clinical Practice Guideline: Diagnosis and Management of Childhood Obstructive Sleep Apnea Syndrome AMERICAN ACADEMY OF PEDIATRICS; Section on Pediatric Pulmonology, Subcommittee on Obstructive Sleep Apnea Syndrome Pediatrics 2002;109;704-712 Sleep-Disordered Breathing, Behavior, and Cognition in Children Before and After Adenotonsillectomy Chervin RD, et al. Pediatrics 2006;117;e769-e778

18. Definition OSA - disorder of breathing during sleep characterized by prolonged partial upper airway obstruction and/or intermittent complete obstruction (obstructive apnea) that disrupts normal ventilation during sleep and normal sleep patterns

19. Guideline Recommendations 1.All children should be screened for snoring; 2.Complex high-risk patients should be referred to a specialist; 3.Patients with cardiorespiratory failure cannot await elective evaluation; 4.Diagnostic evaluation is useful in discriminating between primary snoring and OSAS, the gold standard being polysomnography; 5.Adenotonsillectomy is the first line of treatment for most children, and continuous positive airway pressure is an option for those who are not candidates for surgery or do not respond to surgery; 6.High-risk patients should be monitored as inpatients postoperatively; 7.Patients should be reevaluated postoperatively to determine whether additional treatment is required.

20. Symptoms Habitual (nightly) snoring (often with intermittent pauses, snorts, or gasps) –labored breathing during sleep, –observed apnea, –diaphoresis, enuresis, cyanosis Disturbed sleep -“Restless sleeper” Daytime neurobehavioral problems Daytime sleepiness may occur but is uncommon in young children

21. Risk Factors for OSA Adenotonsillar hypertrophy Chronic nasal congestion/obstruction Obesity Craniofacial anomalies Neuromuscular disorders Down syndrome

22. Complications of OSA Neurocognitive impairment Behavior problems Poor school performance Failure to thrive Cor pulmonale, particularly in severe cases (very rare now due to the increased awareness)

23. Prevalence Most common among pre-school children – adenoid and tonsil size largest relative to the size of the upper airway Primary snoring – 10-12% OSA – 2-3% Boys = Girls Slightly higher in African American children

24. Diagnosis – History and Physical Size of the tonsil does NOT correlate well with OSA (plain film does not help for tonsils) Loudness of the snoring does NOT correlate well with OSA OSA most common during REM sleep – early in the morning when parents are not watching Obstructive hypoventilation vs. cyclic apneas OSA scoring questionnaires – not very successful at predicting OSA

25. Diagnosis Nocturnal polysomnography (sleep study) is currently the gold standard Age-appropriate criteria need to be used Severe shortage of pediatric facilities

26. Diagnosis – other methods Audiotape or Videotape Nocturnal pulse oximetry Daytime nap polysomnography Reasonable PPV, but poor NPV – when result is positive, it is very helpful

27. What to do in the real world? Rely on parental history Follow-up visit after parental monitoring –Review symptoms/signs with parents –Treat underlying allergic rhinitis or nasal obstruction Videotapes can help In selective patient, Sleep Study is appropriate –Parental request –Complicated high risk patients – to assess severity and the need for post-op study –Patient not a good candidate for T&A

28. Risk for Post-op Complications Age younger than 3 years Severe OSAS on polysomnography Cardiac complications of OSAS (eg, right ventricular hypertrophy) Failure to thrive Obesity Prematurity Recent respiratory infection Craniofacial anomalies* Neuromuscular disorders*

29. Post-op Complications Anesthesia complications Respiratory problems –Post-obstructive pulmonary edema –Chronic lung disease – transient worsening of OSA Pain and poor PO intake  dehydration Post-tonsillectomy hemorrhage – 1-2%

30. Results from T&A 75-100% resolution of symptoms* Additional treatment –Weight management – result is less optimal in obese children –CPAP – severe OSA –Other surgical procedures in high risk patients – tongue reduction, tongue base suspension, maxillomandibular advancement, etc.

31. Adenoidectomy alone? OSA: very small tonsils, but prominent adenoids with significant daytime nasal congestion symptoms Chronic mouth breathing without significant apnea component Chronic otitis media with effusions: adenoidectomy generally at the second set of tubes Recurrent sinusitis Complications: 1:1500 VPI