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
prof. M.L. Casselbrant, USAprof. M.L. Casselbrant, USA
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
prof. M.L. Casselbrant, USAprof. M.L. Casselbrant, USA
Methods to Assess UpperMethods to Assess UpperAirway ObstructionAirway Obstruction
HistoryHistorySnoringSnoringMouth breathingMouth breathingSleep, pauses, apneaSleep, pauses, apneaDaytime somnolenceDaytime somnolenceEnuresis Enuresis Behavior problemsBehavior problems
prof. M.L. Casselbrant, USAprof. M.L. Casselbrant, USA
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
prof. M.L. Casselbrant, USAprof. M.L. Casselbrant, USA
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
prof. M.L. Casselbrant, USAprof. M.L. Casselbrant, USA
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
prof. M.L. Casselbrant, USAprof. M.L. Casselbrant, USA
Chronic obstructive Chronic obstructive adenotonsillar hypertrophy adenotonsillar hypertrophy
often has aoften has a
bacterial etiologybacterial etiology
prof. M.L. Casselbrant, USAprof. M.L. Casselbrant, USA
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
prof. M.L. Casselbrant, USAprof. 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, USAprof. 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, USAprof. M.L. Casselbrant, USA
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
prof. M.L. Casselbrant, USAprof. M.L. Casselbrant, USA
Academy of OtolaryngologyGuidelines for Tonsillectomy
“Three or more infections of
tonsils and adenoids per year despite adequate medical therapy”
prof. M.L. Casselbrant, USAprof. M.L. Casselbrant, USA
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
prof. M.L. Casselbrant, USAprof. 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, USAprof. M.L. Casselbrant, USA
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
prof. M.L. Casselbrant, USAprof. M.L. Casselbrant, USA
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
prof. M.L. Casselbrant, USAprof. M.L. Casselbrant, USA
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
prof. M.L. Casselbrant, USAprof. 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 diseaseRecurrent tonsillitis
Recurrent peritonsillar abscesses
Peritonsillar abscess with history of recurrent throat infections
prof. M.L. Casselbrant, USAprof. M.L. Casselbrant, USA
Non-infectious Indications for Non-infectious Indications for TonsillectomyTonsillectomy
Unilateral tonsil enlargementUnilateral tonsil enlargement
Suspect malignancySuspect malignancy
Hemorrhagic tonsillitisHemorrhagic tonsillitis
Lingual tonsillitisLingual tonsillitis
TonsillolithiasisTonsillolithiasis
prof. M.L. Casselbrant, USAprof. M.L. Casselbrant, USA
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
Other Indications for Adenoidectomy
Nasal obstruction (Non-OSA)
Recurrent/persistent otitis media
Recurrent/persistent sinusitis
prof. M.L. Casselbrant, USAprof. M.L. Casselbrant, USA
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
prof. M.L. Casselbrant, USAprof. M.L. Casselbrant, USA
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
prof. M.L. Casselbrant, USAprof. 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, USAprof. M.L. Casselbrant, USA
Adenoidectomy for Preventionof Chronic Sinusitis
Reservoir for bacteriaInterfere with nasal mucociliary functionStasis of nasal secretion
prof. M.L. Casselbrant, USAprof. 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, USAprof. 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, USAprof. M.L. Casselbrant, USA
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
prof. M.L. Casselbrant, USAprof. M.L. Casselbrant, USA
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)
prof. M.L. Casselbrant, USAprof. M.L. Casselbrant, USA
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
prof. M.L. Casselbrant, USAprof. 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, USAprof. 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, USAprof. M.L. Casselbrant, USA