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Adenotonsillectomy in children
SYMPOSIUM: EYES AND ENT
Adenotonsillectomy in children
Indications for adenotonsillar surgery
Mahmoud Elsayed
Procedure
Indication
Adenotonsillectomy Tonsillectomy
Obstructive sleep apnoea Recurrent tonsillitisa Quinsy PFAPA syndrome Suspected malignancy Otitis media with effusion Recurrent acute otitis media Nasal obstruction due to adenoid tissue (older child) Suspected malignancy
Wiaam Alhasani Purushothaman Sudarshan Lisa Leong
Adenoidectomy
Matthew Hurley Mat Daniel
Abstract
PFAPA: periodic fever, aphthous stomatitis, pharyngitis, cervical adenitis syndrome. a SIGN/NICE recommends referral for consideration of tonsillectomy for children who have had seven or more significant sore throats (with impact to patient and family) in the preceding 12 months or 5 or more episodes in each of the preceding two years, or 3 or more in each of the preceding three years).
Adenotonsillar disorders are a frequent complaint in children and adenotonsillectomy is one of the commonest surgical procedures. The two main indications for adenotonsillectomy are recurrent tonsillitis and obstructive sleep apnoea (OSA). Both are associated with significant morbidity. How best to diagnose OSA is currently unclear. Some centres routinely use sleep studies whilst others rely on history alone. Intracapsular subtotal tonsillectomy, as opposed to complete tonsillectomy, is a good choice in OSA. It is as effective in relieving obstruction but typically has lower morbidity with less pain and bleeding. Postoperative complications are relatively common, and good pain management is essential. There is controversy about effectiveness of tonsil and adenoid surgery, with on-going arguments for and against. Appropriate patient selection based on clinical need and evidence, rather than rationing, is essential.
Table 1
Introduction Acute and chronic adenotonsillar disorders are among the most common reasons for consultations in Paediatrics, General Practice, Emergency Medicine and Otorhinolaryngology. Presenting symptoms and conditions include acute tonsillitis, quinsy, snoring, obstructive sleep apnoea (OSA), and nasal obstruction. There may also be sequelae of adenotonsillar disease such as deep neck space infection, acute otitis media (AOM), and otitis media with effusion (OME). Adenotonsillectomy surgery is among the commonest procedures performed in children. Table 1 shows the commoner indications for removal of tonsils and adenoids. Tonsillectomy rates in Belgium, Finland and Norway are almost double the rates in the UK, but in Poland, Italy, and Spain rates are much lower. The rate of tonsillectomy in US is three times higher than in UK, with some 289,000 ambulatory procedures performed annually in children under 15 years of age in 2010. The UK National Health Service carried out approximately 37,000 childhood tonsillectomies between the 2016/2017 year, at a cost of £42 million.
Keywords adenoids; child; palatine tonsil; sleep apnoea syndromes; tonsillectomy
Mahmoud Elsayed MSc FRCS, ENT Trust Registrar, ENT Department, Nottingham University Hospitals, Nottingham, UK. Conflicts of interest: none declared. Wiaam Alhasani MSc MRCS (ENT), ENT Teaching Fellow, ENT Department, Nottingham University Hospitals, Nottingham, UK. Conflicts of interest: none declared.
Tonsils and adenoids
Purushothaman Sudarshan MB BS MD DNB FRCA, Consultant Paediatric Anaethetist, Department of Paediatric Anaesthesia, Nottingham University Hospitals, Nottingham, UK. Conflicts of interest: none declared.
The tonsils and adenoids are part of the Waldeyer’s ring, a collection of lymphoid tissue encircling the pharynx. They play an important part in both cellular and humoral immunological defence mechanisms. Their location at the entrance of the aerodigestive tract makes them the first stage for antigen recognition and presentation. The interior of adenotonsillar tissue is lymphoid, but the exterior is covered by squamous epithelium. The palatine tonsils (also known as just “tonsils”) are located on each side of the lateral pharyngeal wall, visible through the mouth. The adenoid tissue is located in the nasopharynx, at the back of the nasal cavity, and not normally visible without an endoscope. The adenoid is a midline structure, but colloquially referred to as the adenoids.
Lisa Leong MBBCh DA(SA) FCA(SA), Consultant Paediatric Anaethetist, Department of Paediatric Anaesthesia, Nottingham University Hospitals, Nottingham, UK. Conflicts of interest: none declared. Matthew Hurley BSc(Hons) MB BCh PhD MRCPCH, Consultant Respiratory Paediatrician, Department of Paediatric Respiratory Medicine, Nottingham University Hospitals, Nottingham, UK. Conflicts of interest: none declared. Mat Daniel MMEd PhD FRCS, Consultant Paediatric Otorhinolaryngologist, ENT Department, Nottingham University Hospitals, Nottingham, UK. Conflicts of interest: none declared.
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Crown Copyright Ó 2019 Published by Elsevier Ltd. All rights reserved.
Please cite this article as: Elsayed M et al., Adenotonsillectomy in children, Paediatrics and Child Health, https://doi.org/10.1016/ j.paed.2019.10.001
SYMPOSIUM: EYES AND ENT
Symptoms such as altered voice, limited neck movement, and drooling may suggest a more serious pathology.
Tonsillar size is directly proportional to the number of lymphocytes contained within the tissue and thus indirectly to the inflammatory infective load. Adenotonsillar hypertrophy is most pronounced before the age of 6 years. Later, significant involution starts after the age of seven and the tonsils size shrink in early teenage years.
Quinsy: peritonsillar abscess Peritonsillar abscess occurs when pus collects between the palatine tonsil and the lateral pharyngeal wall. It is usually unilateral, and happens in young adults and teenagers more frequently than in younger children. Presentation is similar to tonsillitis, which often precedes/causes the quinsy. The key feature is trismus (limited jaw range of motion), with others being fever, odynophagia, muffled voice (hot potato speech), and otalgia. Throat examination reveals a unilateral swelling above and lateral to the tonsil, displacing the tonsil and the uvula medially. If not recognized and treated early, life-threatening consequences of quinsy can result in airway obstruction, rupture with inhalation of pus, or extension into other deep neck spaces. Treatment, in addition to antibiotics, hydration and analgesia, ideally includes abscess aspiration or formal incision and drainage. In teenagers abscess aspiration may be done on the ward. However, in younger children general anaesthesia may be required, and in those circumstances it may be better to actually remove the tonsil as a way of draining the pus; tonsil removal thus prevents any further pus accumulation as well as recurrence at a later date, but “hot” tonsillectomy carries a greater risk of bleeding that elective surgery.
Acute tonsillitis Acute tonsillitis is inflammation of the tonsillar tissue as a result of a bacterial or viral infection. It is a part of the pharyngitis spectrum that ranges from localised tonsillar infection to generalised pharyngitis. Tonsillitis is diagnosed clinically with a combination of sore throat, odynophagia, fever, tonsillar enlargement and inflammation with possible exudate, and cervical lymphadenopathy. Between 50 and 80% are caused by viral infections, including influenza, and up to 10% by Epstein Barr Virus. The most common bacterial cause is Group A betahaemolytic streptococci, with others including Staphylococcus aureus and Streptococcus pneumoniae. The differentiation between viral and bacterial tonsillitis is difficult and of limited clinical importance in mild cases. When should I prescribe antibiotics? FeverPAIN score and Centor criteria may help when assessing for possible bacterial tonsillitis (Boxes 1 and 2). Although tonsillitis can be caused by multiple types of bacteria, FeverPAIN and Centor were developed mainly to look for Group A beta haemolytic streptococci. The scores’ main benefit is the negative predictive value, i.e. ability to rule out streptococcal infection. UK NICE guidelines recommends no antibiotics for FeverPAIN score 0/1 and Centor 0/1/2, no antibiotics or back up antibiotics for FeverPAIN 2/3, and antibiotics for FeverPAIN 4/5 and Centor 3/4. Centor was originally developed to be used for adults, and may not be adequately validated in children. The differential diagnosis of painful throat and fever is wide, and includes deep neck space infections and epiglottitis.
Obstructive sleep apnoea (OSA) OSA is defined by European Respiratory Society as “a syndrome of upper airway dysfunction during sleep, characterized by snoring and/or increased respiratory effort secondary to increased upper airway resistance and pharyngeal collapsibility”. This can result in hypoxia, hypercapnia, increased respiratory effort, and fragmented sleep. It is a common condition, affecting up to 5% of children. OSA is a part of a spectrum of sleep-disordered breathing, which range from simple snoring and upper airways resistance
FeverPAIN Criteria. Each item scores 1 point (maximum score is 5). The probability of symptoms being caused by streptococcal infection is 13e18% for score 0 or 1, 34 e40% for score 2 or 3, and 62e65% for score 4 or 5.
Clinical features of OSA Night time/sleeping features
Fever (during previous 24 h) Purulence (pus on tonsils) Attend rapidly (symptom onset 3 days) Inflammation (severely tonsil inflammation) No cough or coryza
Morning features Box 1 Daytime features
Centor criteria. The probability of symptoms being caused by streptococcal infection is 3e17% for score 0 or 1 or 2, and 32e56% for score 3 or 4. Sequelae
Tonsillar exudates Tender anterior cervical lymphadenopathy or lymphadenitis History of fever (over 38 C) Absence of cough Box 2
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Snoring, stopping breathing, “hard breathing” at night, choking sounds, gasping, frequent waking, restless sleep, bed wetting, witnessed increased respiratory effort, sweating, unusual sleeping positions, repositioning of pillows and bedding overnight Difficulty of waking, unrested, dry mouth, headache Tiredness, headaches, poor attention, poor concentration, restlessness, hyperactivity, aggression, features of adenoid hypertrophy (mouth breathing, stertor, blocked-nose speech, drooling) Faltering growth, poor educational achievement, pulmonary hypertension, cardiovascular complications, metabolic syndrome
Table 2
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Please cite this article as: Elsayed M et al., Adenotonsillectomy in children, Paediatrics and Child Health, https://doi.org/10.1016/ j.paed.2019.10.001
SYMPOSIUM: EYES AND ENT
syndrome, to severe OSA. OSA is characterized by habitual snoring with periods of intermittent airway obstruction. Table 2 shows clinical features of OSA in children. The distinction between simple snoring and OSA is important (surgery would not be recommended for simple snoring), but not always easy to make. Typically, simple snoring lacks obstructive features or daytime consequences that characterise OSA. However, not all features may be present in a child with OSA and individual features are common in children without OSA. In addition, there is controversy about the significance of individual findings, and in exactly what the sequelae of untreated OSA may be. OSA is caused by a combination of airway narrowing and pharyngeal collapsibility. Adenotonsillar hypertrophy is by far the most common cause in children. The most widely adopted grading scale for tonsil size is the Brodsky grading scale, in which the tonsils are assigned a grade from 1 to 4, depending on the % of oropharyngeal airway occupied by the tonsils (Table 3). It is important to keep in mind that there is no linear correlation between the size of the tonsils on clinical examination of the oropharynx and the severity of OSA and even apparently small tonsils may contribute to clinically significant OSA. Obesity is also becoming an increasingly important cause. Other less common causes include neurological or skeletal medical conditions that reduce the size of the airway or affect pharyngeal tone, such as Cerebral palsy, Down’s syndrome, micrognathia, achondroplasia, and other syndromes that affect tone or craniofacial anatomy. The gold standard for OSA diagnosis is polysomnography (PSG) done in a monitored, in-patient setting, measuring various parameters including breathing efficiency - gas exchange (oxygen saturation and CO2 level), respiratory effort (chest and abdominal movement), air flow (pressure and temperature sensors), along with sleep staging electroencephalogram (EEG), electromyogram, heart rate and acoustic sensors. While PSG has the advantage of being able to discriminate between obstructive and central respiratory events, PSG is expensive and inconvenient for the family. There are also a considerable proportion of children who are unable to tolerate such a study. Unfortunately, parental history often correlates poorly with PSG findings, and there are no questionnaires able to reliably diagnose OSA. There is also a significant placebo effect of interventions aimed at improving reported sleep quality. It is perhaps surprising that parental history doesn’t correlate well with PSG, suggesting that PSG may not be measuring those things that are important to parents. As a compromise, many centres use either cardiorespiratory studies (oximetry, effort and airflow channels) or oximetry alone
to help make a diagnosis and assess OSA severity. Home oximetry is more convenient for families and cheaper, but still requires skilled interpretation and has a variable level of sensitivity and specificity for OSA depending upon the population studied. Largely, whilst oximetry has good positive predictive value for significant OSA, it lacks ability to reliably exclude OSA. Therefore, it can be useful when it forms part of a multi-faceted assessment, but it cannot be used to exclude OSA. In clinical practice there is a lack of consensus regarding the optimal method to diagnose OSA. Some rely on history alone, whilst others perform PSG on all children. Still others rely on history, supported (in select children) by home oximetry, and reserving PSG for those complex children where a detailed work up is deemed essential. In real life, clinical practice in the UK is dictated by local experience and availability, rather than by national guidelines. Whilst the diagnostic pathways in otherwise healthy children may be open to debate, it is clear that in some children with comorbidities formal respiratory investigations are required (Box 3).
Other pathology related to tonsils and adenoids Periodic fever, aphthous stomatitis, pharyngitis, and cervical adenitis (PFAPA) syndrome usually starts before 5 years of age, and is characterised by fevers occurring every 3e4 weeks plus additional symptoms contained within the name. Oral corticosteroids will delay or prevent attacks in most children and response to oral steroids is a useful test in clinical practice when the diagnosis is suspected. Tonsillectomy is usually curative. Adenoids have been implicated in the pathogenesis of otitis media with effusion (OME, glue ear) and acute otitis media. The pathophysiology is related to the fact that adenoid tissue sits at the opening of the Eustachian tube in the nasopharynx. In some instances the adenoid tissue acts as a reservoir of bacteria that then ascend the Eustachian tube from the nasopharynx to the middle ear. Mechanical obstruction of the Eustachian tube/ nasopharynx probably also increases the risk of OME. Adenoidectomy can be of benefit in the treatment of otitis media with effusion and recurrent acute otitis media (RAOM), as an addition to ventilation tube insertion. However, adenoidectomy has significant additional risks; because not every child will require it/ benefit from it, adenoidectomy is not routinely recommended for all children having ventilation tubes for OME/RAOM. The
Some of the commoner indications for paediatric respiratory investigations C C C C
Brodsky grading scale Grade
C
% Oropharyngeal airway occupied by the tonsils
C C C
1 2 3 4
25 26e50 51e75 >75
C C
C
Table 3
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Diagnosis of OSA unclear or inconsistent Age <2 years Weight <15 kg Down’s syndrome Cerebral palsy Hypotonia or neuromuscular disorders Craniofacial anomalies Mucopolysaccharidosis Obesity Significant co-morbidity such as congenital heart disease, chronic lung disease Residual symptoms after adenotonsillectomy
Box 3
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SYMPOSIUM: EYES AND ENT
children that most benefit from adenoidectomy in addition to ventilation tubes are those children with OME that are aged 4 years or older, but in every child an individual discussion/decision are required. Other less common indications for adenoidectomy include severe chronic rhinosinusitis not resolving with conservative or medical treatment, or nasal obstruction caused by adenoid hypertrophy in a child that is 8 years or older. Adenoidectomy for blocked nose/nasal discharge would not normally be justified in younger children because spontaneous age-related adenoid regression would be expected to occur in vast majority of children.
morbidity is essential, whilst use of excess hot techniques may be best avoided. Adenoidectomy Methods for performing adenoidectomy include curettage, suction diathermy, coblation, and microdebrider. Similar to tonsillectomy, no single technique is universally used. In children at risk of postoperative velopharyngeal insufficiency (for example those with submucous or overt cleft palate), a partial adenoidectomy may be recommended: only the part of the adenoid occluding the posterior nasal choanae is removed, but the adenoid tissue that sits opposite the soft palate and aids velopharyngeal closure is left intact.
Surgical techniques Anaesthetic considerations and analgesia
Tonsillectomy The techniques of tonsillectomy can be generally divided into two categories: extracapsular (total tonsillectomy) and intracapsular (partial, subtotal, tonsillotomy). Extracapsular tonsillectomy involves dissecting lateral to the tonsil in the plane between the pharyngeal musculature and the tonsillar capsule, and the tonsil is removed as a single unit. Intracapsular tonsillectomy involves removal of majority of tonsillar tissue, while preserving a rim of lymphoid tissue and tonsillar capsule to cover the pharyngeal muscles. The most common extracapsular methods involve tonsil removal either using cold steel (surgical steel instruments without any electrical devices or heat), or diathermy devices. Haemostasis in both cases can use further diathermy and/or ties. The common methods of intracapsular tonsillectomy involve either a microdebrider, or a plasma field device (coblator). There is on-going discussion about the relative advantages of the various techniques. In extracapsular tonsillectomy, use of hot techniques/electricity (vs cold steel) appears to increase rates of bleeding overall, particularly secondary bleeding (5e10 days post op). However, complete intra-operative haemostasis without reliance on hot techniques is difficult to achieve, so that avoidance of diathermy may well reduce rate of secondary bleeding, but at the expense of increased primary bleed rate. In addition, use of a lot of diathermy may be an indicator that surgery was complex, so increased risk of bleeding may be due to the fact that surgery was more complex rather than due to diathermy use itself. When treating OSA, the intracapsular technique appears to be as effective as extracapsular, with less postoperative pain and bleeding, but a (small) risk of tonsil regrowth requiring repeat surgery. For tonsillitis, usually complete tonsil removal is recommended. As indications for tonsillectomy surgery over time have shifted from infective to obstructive, the number of centres offering intracapsular tonsillectomy as routine has also increased. The techniques used are determined by patient factors, country, institution and surgeon preference, and are additionally based on device cost and availability, set-up complexity, and surgery duration. There is no consensus, other than requirement for surgeons and departments to monitor their own complication rates to ensure that they practice within acceptable parameters. In general, intracapsular techniques appear a good choice for OSA particularly in complex children when minimisation of
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Adenotonsillar surgery in children requires a high degree of anaesthetic expertise, due to potential complications associated with sharing of the airway between the surgeon and the anaesthetist and (often) in the presence of OSA. In addition to general pre-operative assessment, any sequelae of long standing hypoxia/hypercarbia (including right heart changes) should be established. During surgery, in addition to analgesia, hypnosis, and akinesia, adequate hydration and attention to blood loss should also be ensured. Intraoperative dexamethasone is often given to reduce post-operative nausea/vomiting and pain, as adenotonsillar surgery is associated with a high risk of both. Pain management can be a particular challenge as a proportion of children with OSA have been shown to be sensitive to opioid induced respiratory depression. Multi-modal analgesia using paracetamol, non-steroidal anti-inflammatory drugs, and/ or other adjuncts such as clonidine (alpha 2 antagonist) is recommended. Codeine phosphate is a pro-drug and is converted to morphine in the liver by the enzyme CYP2D6, of which there are several genetic variations. Some individuals are ultra-fast metabolisers and will have an excessive plasma morphine concentration relative to others, with the associated increased action of morphine on respiration and the brain. Therefore, codeine is no longer used in children under the age of 12 years, and is contraindicated in all children (0e18 years) with OSA as they are already sensitive to the respiratory effects of morphine.
Complications Tonsillectomy has an expected recovery period of 1e2 weeks. Post tonsillectomy, the throat often has a white appearance, which should not be taken to indicate infection (infection would be suggested by severe pain, not eating/drinking, fever, and bad breath). Often, due to additional space created after surgery, a child’s voice may sound different. Tonsillectomy complications include haemorrhage, infection, pain, and damage to teeth or lips or temporomandibular joint. With adenoidectomy, velopharyngeal insufficiency manifesting as nasal regurgitation or hypernasal voice is also possible. Bleeding is a common complication, and can occur up to two weeks after surgery. The rate of primary bleeding after tonsillectomy (within 24 h of surgery) ranges from 0.2% to 2.2%. The rate of secondary bleeding (>24 h after surgery) ranges from 0.1% to 3%. Readmission for observation is usually
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SYMPOSIUM: EYES AND ENT
tonsillectomy are unlikely to benefit. The authors did not consider paediatric OSA as justifying surgical intervention. A
recommended, and rarely further surgery to control bleeding. In general, secondary bleeding is more likely to happen with techniques using diathermy (presumably due to thermal damage). Intracapsular tonsillectomy has a lower bleed rate than total tonsillectomy. After tonsillectomy, about 1.5% of children experience delayed discharge, and up to 4% have secondary complications requiring readmission. The primary reasons for readmission or prolonged initial stay include pain, vomiting, fever, infection and tonsillar bleeding. Complications are thought to be more common in children with craniofacial disorders, cerebral palsy, Down’s syndrome, neuromuscular diseases, major heart disease, bleeding disorders, and in children <3 years of age. Recent data emerging from the UK “Getting It Right First Time” project, which analysed real world data rather that research studies, have found a post-tonsillectomy readmission rate in adults of up to 16%. Readmission rates in children are much lower, but tonsillectomy is clearly a procedure with potential significant sequelae. Thankfully, deaths are rare, but attract significant media attention due to the ubiquity of tonsillar surgery.
REFERENCES 1 Douglas CM, Altmyer U, Cottom L, Young D, Redding P, Clark LJ. A 20 year observational cohort of a 5 million patient populationdtonsillectomy rates in the context of two national policy changes. Clin Otolaryngol 2019; 44: 7e13. 2 Marcus CL, Moore RH, Rosen CL, et al. A randomized trial of adenotonsillectomy for childhood sleep apnoea. N Engl J Med 2013; 368: 2366e76. 3 Sumilo D, Nichols L, Ryan R, Marshall T. Incidence of indications for tonsillectomy and frequency of evidence-based surgery: a 12year retrospective cohort study of primary care electronic records. Br J Gen Pract 2019; 69: e33e41. FURTHER READING ENT UK. Tonsillectomy revised commissioning guide. 2016. Available at: https://www.rcseng.ac.uk/-/media/files/rcs/standards-andresearch/commissioning/ent-uk-tonsillectomy-revisedcommissioning-guide-2016-published.pdf (accessed 3 October 2019). MHRA drug safety update6. Mitchell RB, Archer SM, Ishman SL, et al. Clinical practice guideline: tonsillectomy in children (update). Otolaryngol Head Neck Surg 2019; 160(suppl 1): S1e42. Robb PJ, Bew S, Kubba H, et al. Tonsillectomy and adenoidectomy in children with sleep-related breathing disorders: consensus statement of a UK multidisciplinary working party. Ann R Coll Surg Engl 2009; 91: 371e3. Todd CA, Bareiss AK, McCoul ED, Rodriguez KH. Adenotonsillectomy for obstructive sleep apnoea and quality of life: systematic review and meta-analysis. Otolaryngol Head Neck Surg 2017; 157: 767e73.
Are we doing too many or too few adenotonsillectomies? In UK, tonsillectomy and adenoidectomy are restricted procedures in NHS hospitals in many regions, meaning that they are only funded under strict conditions and assuming that prior permission is granted. There is wide international variation in the rates of adenotonsillectomy, with criticism being levelled both at unnecessary surgery and at insufficient surgery rates. Overall, surgery rates have fallen, which is likely to be a reflection in improvement in general health, as well as a refinement of indications criteria so that surgery is only offered in circumstances where benefit is clear. Adenotonsillar infections can cause deep neck space infections, which are potentially life-threatening emergencies. The incidence of deep neck space infections has increased in the recent years, and concerns have been expressed that this may be result of restricting antibiotic prescribing and access to surgery. A recent Scottish nationwide study1 of five million population over 20 years found a decrease in tonsillectomy rates of 48%, but an increase in tonsillitis and quinsy admission rates (136% and 167%, respectively), and a 500% increase in deep neck space abscesses. In the case of OSA, the children whose neurocognitive development or quality of life may have been impaired are unlikely to show up on any hospital admission statistics, and require detailed neuropsychology to detect. Arguments continue as to what long term effect OSA might have. The CHAT study2 compared adenotonsillectomy to watchful waiting and found that adenotonsillectomy was associated with improved quality of life, PSG findings and parental reported behaviour but the primary outcome of attention and executive function was not significantly different between the active and watchful waiting groups. There is, however, ample longitudinal case series evidence that OSA affects academic achievement, quality of life, and has a socioeconomic impact, and that surgery helps. Despite this, controversy remains. A recent paper3 somewhat controversially concluded that 7 out of 8 children having
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Practice points C
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Adenotonsillectomy is one of the commonest surgical procedures Internationally, there are variations in surgical rates Recurrent tonsillitis and OSA are the main indications of surgery It is not clear how best to diagnose OSA, and whether sleep studies are routinely required Both complete tonsillectomy and intracapsular tonsillectomy are accepted methods, with latter resulting in less pain and bleeding, but a (small) possibility of tonsillar tissue regrowth Risk of surgical intervention should be weighed against the benefits. Postoperative complications, including bleeding, are relatively common For many children, adenotonsillectomy results in significant improvements to the quality of life
Crown Copyright Ó 2019 Published by Elsevier Ltd. All rights reserved.
Please cite this article as: Elsayed M et al., Adenotonsillectomy in children, Paediatrics and Child Health, https://doi.org/10.1016/ j.paed.2019.10.001
Adenotonsillectomy in children
Indications for adenotonsillar surgery
Mahmoud Elsayed
Procedure
Indication
Adenotonsillectomy Tonsillectomy
Obstructive sleep apnoea Recurrent tonsillitisa Quinsy PFAPA syndrome Suspected malignancy Otitis media with effusion Recurrent acute otitis media Nasal obstruction due to adenoid tissue (older child) Suspected malignancy
Wiaam Alhasani Purushothaman Sudarshan Lisa Leong
Adenoidectomy
Matthew Hurley Mat Daniel
Abstract
PFAPA: periodic fever, aphthous stomatitis, pharyngitis, cervical adenitis syndrome. a SIGN/NICE recommends referral for consideration of tonsillectomy for children who have had seven or more significant sore throats (with impact to patient and family) in the preceding 12 months or 5 or more episodes in each of the preceding two years, or 3 or more in each of the preceding three years).
Adenotonsillar disorders are a frequent complaint in children and adenotonsillectomy is one of the commonest surgical procedures. The two main indications for adenotonsillectomy are recurrent tonsillitis and obstructive sleep apnoea (OSA). Both are associated with significant morbidity. How best to diagnose OSA is currently unclear. Some centres routinely use sleep studies whilst others rely on history alone. Intracapsular subtotal tonsillectomy, as opposed to complete tonsillectomy, is a good choice in OSA. It is as effective in relieving obstruction but typically has lower morbidity with less pain and bleeding. Postoperative complications are relatively common, and good pain management is essential. There is controversy about effectiveness of tonsil and adenoid surgery, with on-going arguments for and against. Appropriate patient selection based on clinical need and evidence, rather than rationing, is essential.
Table 1
Introduction Acute and chronic adenotonsillar disorders are among the most common reasons for consultations in Paediatrics, General Practice, Emergency Medicine and Otorhinolaryngology. Presenting symptoms and conditions include acute tonsillitis, quinsy, snoring, obstructive sleep apnoea (OSA), and nasal obstruction. There may also be sequelae of adenotonsillar disease such as deep neck space infection, acute otitis media (AOM), and otitis media with effusion (OME). Adenotonsillectomy surgery is among the commonest procedures performed in children. Table 1 shows the commoner indications for removal of tonsils and adenoids. Tonsillectomy rates in Belgium, Finland and Norway are almost double the rates in the UK, but in Poland, Italy, and Spain rates are much lower. The rate of tonsillectomy in US is three times higher than in UK, with some 289,000 ambulatory procedures performed annually in children under 15 years of age in 2010. The UK National Health Service carried out approximately 37,000 childhood tonsillectomies between the 2016/2017 year, at a cost of £42 million.
Keywords adenoids; child; palatine tonsil; sleep apnoea syndromes; tonsillectomy
Mahmoud Elsayed MSc FRCS, ENT Trust Registrar, ENT Department, Nottingham University Hospitals, Nottingham, UK. Conflicts of interest: none declared. Wiaam Alhasani MSc MRCS (ENT), ENT Teaching Fellow, ENT Department, Nottingham University Hospitals, Nottingham, UK. Conflicts of interest: none declared.
Tonsils and adenoids
Purushothaman Sudarshan MB BS MD DNB FRCA, Consultant Paediatric Anaethetist, Department of Paediatric Anaesthesia, Nottingham University Hospitals, Nottingham, UK. Conflicts of interest: none declared.
The tonsils and adenoids are part of the Waldeyer’s ring, a collection of lymphoid tissue encircling the pharynx. They play an important part in both cellular and humoral immunological defence mechanisms. Their location at the entrance of the aerodigestive tract makes them the first stage for antigen recognition and presentation. The interior of adenotonsillar tissue is lymphoid, but the exterior is covered by squamous epithelium. The palatine tonsils (also known as just “tonsils”) are located on each side of the lateral pharyngeal wall, visible through the mouth. The adenoid tissue is located in the nasopharynx, at the back of the nasal cavity, and not normally visible without an endoscope. The adenoid is a midline structure, but colloquially referred to as the adenoids.
Lisa Leong MBBCh DA(SA) FCA(SA), Consultant Paediatric Anaethetist, Department of Paediatric Anaesthesia, Nottingham University Hospitals, Nottingham, UK. Conflicts of interest: none declared. Matthew Hurley BSc(Hons) MB BCh PhD MRCPCH, Consultant Respiratory Paediatrician, Department of Paediatric Respiratory Medicine, Nottingham University Hospitals, Nottingham, UK. Conflicts of interest: none declared. Mat Daniel MMEd PhD FRCS, Consultant Paediatric Otorhinolaryngologist, ENT Department, Nottingham University Hospitals, Nottingham, UK. Conflicts of interest: none declared.
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SYMPOSIUM: EYES AND ENT
Symptoms such as altered voice, limited neck movement, and drooling may suggest a more serious pathology.
Tonsillar size is directly proportional to the number of lymphocytes contained within the tissue and thus indirectly to the inflammatory infective load. Adenotonsillar hypertrophy is most pronounced before the age of 6 years. Later, significant involution starts after the age of seven and the tonsils size shrink in early teenage years.
Quinsy: peritonsillar abscess Peritonsillar abscess occurs when pus collects between the palatine tonsil and the lateral pharyngeal wall. It is usually unilateral, and happens in young adults and teenagers more frequently than in younger children. Presentation is similar to tonsillitis, which often precedes/causes the quinsy. The key feature is trismus (limited jaw range of motion), with others being fever, odynophagia, muffled voice (hot potato speech), and otalgia. Throat examination reveals a unilateral swelling above and lateral to the tonsil, displacing the tonsil and the uvula medially. If not recognized and treated early, life-threatening consequences of quinsy can result in airway obstruction, rupture with inhalation of pus, or extension into other deep neck spaces. Treatment, in addition to antibiotics, hydration and analgesia, ideally includes abscess aspiration or formal incision and drainage. In teenagers abscess aspiration may be done on the ward. However, in younger children general anaesthesia may be required, and in those circumstances it may be better to actually remove the tonsil as a way of draining the pus; tonsil removal thus prevents any further pus accumulation as well as recurrence at a later date, but “hot” tonsillectomy carries a greater risk of bleeding that elective surgery.
Acute tonsillitis Acute tonsillitis is inflammation of the tonsillar tissue as a result of a bacterial or viral infection. It is a part of the pharyngitis spectrum that ranges from localised tonsillar infection to generalised pharyngitis. Tonsillitis is diagnosed clinically with a combination of sore throat, odynophagia, fever, tonsillar enlargement and inflammation with possible exudate, and cervical lymphadenopathy. Between 50 and 80% are caused by viral infections, including influenza, and up to 10% by Epstein Barr Virus. The most common bacterial cause is Group A betahaemolytic streptococci, with others including Staphylococcus aureus and Streptococcus pneumoniae. The differentiation between viral and bacterial tonsillitis is difficult and of limited clinical importance in mild cases. When should I prescribe antibiotics? FeverPAIN score and Centor criteria may help when assessing for possible bacterial tonsillitis (Boxes 1 and 2). Although tonsillitis can be caused by multiple types of bacteria, FeverPAIN and Centor were developed mainly to look for Group A beta haemolytic streptococci. The scores’ main benefit is the negative predictive value, i.e. ability to rule out streptococcal infection. UK NICE guidelines recommends no antibiotics for FeverPAIN score 0/1 and Centor 0/1/2, no antibiotics or back up antibiotics for FeverPAIN 2/3, and antibiotics for FeverPAIN 4/5 and Centor 3/4. Centor was originally developed to be used for adults, and may not be adequately validated in children. The differential diagnosis of painful throat and fever is wide, and includes deep neck space infections and epiglottitis.
Obstructive sleep apnoea (OSA) OSA is defined by European Respiratory Society as “a syndrome of upper airway dysfunction during sleep, characterized by snoring and/or increased respiratory effort secondary to increased upper airway resistance and pharyngeal collapsibility”. This can result in hypoxia, hypercapnia, increased respiratory effort, and fragmented sleep. It is a common condition, affecting up to 5% of children. OSA is a part of a spectrum of sleep-disordered breathing, which range from simple snoring and upper airways resistance
FeverPAIN Criteria. Each item scores 1 point (maximum score is 5). The probability of symptoms being caused by streptococcal infection is 13e18% for score 0 or 1, 34 e40% for score 2 or 3, and 62e65% for score 4 or 5.
Clinical features of OSA Night time/sleeping features
Fever (during previous 24 h) Purulence (pus on tonsils) Attend rapidly (symptom onset 3 days) Inflammation (severely tonsil inflammation) No cough or coryza
Morning features Box 1 Daytime features
Centor criteria. The probability of symptoms being caused by streptococcal infection is 3e17% for score 0 or 1 or 2, and 32e56% for score 3 or 4. Sequelae
Tonsillar exudates Tender anterior cervical lymphadenopathy or lymphadenitis History of fever (over 38 C) Absence of cough Box 2
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Snoring, stopping breathing, “hard breathing” at night, choking sounds, gasping, frequent waking, restless sleep, bed wetting, witnessed increased respiratory effort, sweating, unusual sleeping positions, repositioning of pillows and bedding overnight Difficulty of waking, unrested, dry mouth, headache Tiredness, headaches, poor attention, poor concentration, restlessness, hyperactivity, aggression, features of adenoid hypertrophy (mouth breathing, stertor, blocked-nose speech, drooling) Faltering growth, poor educational achievement, pulmonary hypertension, cardiovascular complications, metabolic syndrome
Table 2
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syndrome, to severe OSA. OSA is characterized by habitual snoring with periods of intermittent airway obstruction. Table 2 shows clinical features of OSA in children. The distinction between simple snoring and OSA is important (surgery would not be recommended for simple snoring), but not always easy to make. Typically, simple snoring lacks obstructive features or daytime consequences that characterise OSA. However, not all features may be present in a child with OSA and individual features are common in children without OSA. In addition, there is controversy about the significance of individual findings, and in exactly what the sequelae of untreated OSA may be. OSA is caused by a combination of airway narrowing and pharyngeal collapsibility. Adenotonsillar hypertrophy is by far the most common cause in children. The most widely adopted grading scale for tonsil size is the Brodsky grading scale, in which the tonsils are assigned a grade from 1 to 4, depending on the % of oropharyngeal airway occupied by the tonsils (Table 3). It is important to keep in mind that there is no linear correlation between the size of the tonsils on clinical examination of the oropharynx and the severity of OSA and even apparently small tonsils may contribute to clinically significant OSA. Obesity is also becoming an increasingly important cause. Other less common causes include neurological or skeletal medical conditions that reduce the size of the airway or affect pharyngeal tone, such as Cerebral palsy, Down’s syndrome, micrognathia, achondroplasia, and other syndromes that affect tone or craniofacial anatomy. The gold standard for OSA diagnosis is polysomnography (PSG) done in a monitored, in-patient setting, measuring various parameters including breathing efficiency - gas exchange (oxygen saturation and CO2 level), respiratory effort (chest and abdominal movement), air flow (pressure and temperature sensors), along with sleep staging electroencephalogram (EEG), electromyogram, heart rate and acoustic sensors. While PSG has the advantage of being able to discriminate between obstructive and central respiratory events, PSG is expensive and inconvenient for the family. There are also a considerable proportion of children who are unable to tolerate such a study. Unfortunately, parental history often correlates poorly with PSG findings, and there are no questionnaires able to reliably diagnose OSA. There is also a significant placebo effect of interventions aimed at improving reported sleep quality. It is perhaps surprising that parental history doesn’t correlate well with PSG, suggesting that PSG may not be measuring those things that are important to parents. As a compromise, many centres use either cardiorespiratory studies (oximetry, effort and airflow channels) or oximetry alone
to help make a diagnosis and assess OSA severity. Home oximetry is more convenient for families and cheaper, but still requires skilled interpretation and has a variable level of sensitivity and specificity for OSA depending upon the population studied. Largely, whilst oximetry has good positive predictive value for significant OSA, it lacks ability to reliably exclude OSA. Therefore, it can be useful when it forms part of a multi-faceted assessment, but it cannot be used to exclude OSA. In clinical practice there is a lack of consensus regarding the optimal method to diagnose OSA. Some rely on history alone, whilst others perform PSG on all children. Still others rely on history, supported (in select children) by home oximetry, and reserving PSG for those complex children where a detailed work up is deemed essential. In real life, clinical practice in the UK is dictated by local experience and availability, rather than by national guidelines. Whilst the diagnostic pathways in otherwise healthy children may be open to debate, it is clear that in some children with comorbidities formal respiratory investigations are required (Box 3).
Other pathology related to tonsils and adenoids Periodic fever, aphthous stomatitis, pharyngitis, and cervical adenitis (PFAPA) syndrome usually starts before 5 years of age, and is characterised by fevers occurring every 3e4 weeks plus additional symptoms contained within the name. Oral corticosteroids will delay or prevent attacks in most children and response to oral steroids is a useful test in clinical practice when the diagnosis is suspected. Tonsillectomy is usually curative. Adenoids have been implicated in the pathogenesis of otitis media with effusion (OME, glue ear) and acute otitis media. The pathophysiology is related to the fact that adenoid tissue sits at the opening of the Eustachian tube in the nasopharynx. In some instances the adenoid tissue acts as a reservoir of bacteria that then ascend the Eustachian tube from the nasopharynx to the middle ear. Mechanical obstruction of the Eustachian tube/ nasopharynx probably also increases the risk of OME. Adenoidectomy can be of benefit in the treatment of otitis media with effusion and recurrent acute otitis media (RAOM), as an addition to ventilation tube insertion. However, adenoidectomy has significant additional risks; because not every child will require it/ benefit from it, adenoidectomy is not routinely recommended for all children having ventilation tubes for OME/RAOM. The
Some of the commoner indications for paediatric respiratory investigations C C C C
Brodsky grading scale Grade
C
% Oropharyngeal airway occupied by the tonsils
C C C
1 2 3 4
25 26e50 51e75 >75
C C
C
Table 3
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Diagnosis of OSA unclear or inconsistent Age <2 years Weight <15 kg Down’s syndrome Cerebral palsy Hypotonia or neuromuscular disorders Craniofacial anomalies Mucopolysaccharidosis Obesity Significant co-morbidity such as congenital heart disease, chronic lung disease Residual symptoms after adenotonsillectomy
Box 3
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children that most benefit from adenoidectomy in addition to ventilation tubes are those children with OME that are aged 4 years or older, but in every child an individual discussion/decision are required. Other less common indications for adenoidectomy include severe chronic rhinosinusitis not resolving with conservative or medical treatment, or nasal obstruction caused by adenoid hypertrophy in a child that is 8 years or older. Adenoidectomy for blocked nose/nasal discharge would not normally be justified in younger children because spontaneous age-related adenoid regression would be expected to occur in vast majority of children.
morbidity is essential, whilst use of excess hot techniques may be best avoided. Adenoidectomy Methods for performing adenoidectomy include curettage, suction diathermy, coblation, and microdebrider. Similar to tonsillectomy, no single technique is universally used. In children at risk of postoperative velopharyngeal insufficiency (for example those with submucous or overt cleft palate), a partial adenoidectomy may be recommended: only the part of the adenoid occluding the posterior nasal choanae is removed, but the adenoid tissue that sits opposite the soft palate and aids velopharyngeal closure is left intact.
Surgical techniques Anaesthetic considerations and analgesia
Tonsillectomy The techniques of tonsillectomy can be generally divided into two categories: extracapsular (total tonsillectomy) and intracapsular (partial, subtotal, tonsillotomy). Extracapsular tonsillectomy involves dissecting lateral to the tonsil in the plane between the pharyngeal musculature and the tonsillar capsule, and the tonsil is removed as a single unit. Intracapsular tonsillectomy involves removal of majority of tonsillar tissue, while preserving a rim of lymphoid tissue and tonsillar capsule to cover the pharyngeal muscles. The most common extracapsular methods involve tonsil removal either using cold steel (surgical steel instruments without any electrical devices or heat), or diathermy devices. Haemostasis in both cases can use further diathermy and/or ties. The common methods of intracapsular tonsillectomy involve either a microdebrider, or a plasma field device (coblator). There is on-going discussion about the relative advantages of the various techniques. In extracapsular tonsillectomy, use of hot techniques/electricity (vs cold steel) appears to increase rates of bleeding overall, particularly secondary bleeding (5e10 days post op). However, complete intra-operative haemostasis without reliance on hot techniques is difficult to achieve, so that avoidance of diathermy may well reduce rate of secondary bleeding, but at the expense of increased primary bleed rate. In addition, use of a lot of diathermy may be an indicator that surgery was complex, so increased risk of bleeding may be due to the fact that surgery was more complex rather than due to diathermy use itself. When treating OSA, the intracapsular technique appears to be as effective as extracapsular, with less postoperative pain and bleeding, but a (small) risk of tonsil regrowth requiring repeat surgery. For tonsillitis, usually complete tonsil removal is recommended. As indications for tonsillectomy surgery over time have shifted from infective to obstructive, the number of centres offering intracapsular tonsillectomy as routine has also increased. The techniques used are determined by patient factors, country, institution and surgeon preference, and are additionally based on device cost and availability, set-up complexity, and surgery duration. There is no consensus, other than requirement for surgeons and departments to monitor their own complication rates to ensure that they practice within acceptable parameters. In general, intracapsular techniques appear a good choice for OSA particularly in complex children when minimisation of
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Adenotonsillar surgery in children requires a high degree of anaesthetic expertise, due to potential complications associated with sharing of the airway between the surgeon and the anaesthetist and (often) in the presence of OSA. In addition to general pre-operative assessment, any sequelae of long standing hypoxia/hypercarbia (including right heart changes) should be established. During surgery, in addition to analgesia, hypnosis, and akinesia, adequate hydration and attention to blood loss should also be ensured. Intraoperative dexamethasone is often given to reduce post-operative nausea/vomiting and pain, as adenotonsillar surgery is associated with a high risk of both. Pain management can be a particular challenge as a proportion of children with OSA have been shown to be sensitive to opioid induced respiratory depression. Multi-modal analgesia using paracetamol, non-steroidal anti-inflammatory drugs, and/ or other adjuncts such as clonidine (alpha 2 antagonist) is recommended. Codeine phosphate is a pro-drug and is converted to morphine in the liver by the enzyme CYP2D6, of which there are several genetic variations. Some individuals are ultra-fast metabolisers and will have an excessive plasma morphine concentration relative to others, with the associated increased action of morphine on respiration and the brain. Therefore, codeine is no longer used in children under the age of 12 years, and is contraindicated in all children (0e18 years) with OSA as they are already sensitive to the respiratory effects of morphine.
Complications Tonsillectomy has an expected recovery period of 1e2 weeks. Post tonsillectomy, the throat often has a white appearance, which should not be taken to indicate infection (infection would be suggested by severe pain, not eating/drinking, fever, and bad breath). Often, due to additional space created after surgery, a child’s voice may sound different. Tonsillectomy complications include haemorrhage, infection, pain, and damage to teeth or lips or temporomandibular joint. With adenoidectomy, velopharyngeal insufficiency manifesting as nasal regurgitation or hypernasal voice is also possible. Bleeding is a common complication, and can occur up to two weeks after surgery. The rate of primary bleeding after tonsillectomy (within 24 h of surgery) ranges from 0.2% to 2.2%. The rate of secondary bleeding (>24 h after surgery) ranges from 0.1% to 3%. Readmission for observation is usually
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tonsillectomy are unlikely to benefit. The authors did not consider paediatric OSA as justifying surgical intervention. A
recommended, and rarely further surgery to control bleeding. In general, secondary bleeding is more likely to happen with techniques using diathermy (presumably due to thermal damage). Intracapsular tonsillectomy has a lower bleed rate than total tonsillectomy. After tonsillectomy, about 1.5% of children experience delayed discharge, and up to 4% have secondary complications requiring readmission. The primary reasons for readmission or prolonged initial stay include pain, vomiting, fever, infection and tonsillar bleeding. Complications are thought to be more common in children with craniofacial disorders, cerebral palsy, Down’s syndrome, neuromuscular diseases, major heart disease, bleeding disorders, and in children <3 years of age. Recent data emerging from the UK “Getting It Right First Time” project, which analysed real world data rather that research studies, have found a post-tonsillectomy readmission rate in adults of up to 16%. Readmission rates in children are much lower, but tonsillectomy is clearly a procedure with potential significant sequelae. Thankfully, deaths are rare, but attract significant media attention due to the ubiquity of tonsillar surgery.
REFERENCES 1 Douglas CM, Altmyer U, Cottom L, Young D, Redding P, Clark LJ. A 20 year observational cohort of a 5 million patient populationdtonsillectomy rates in the context of two national policy changes. Clin Otolaryngol 2019; 44: 7e13. 2 Marcus CL, Moore RH, Rosen CL, et al. A randomized trial of adenotonsillectomy for childhood sleep apnoea. N Engl J Med 2013; 368: 2366e76. 3 Sumilo D, Nichols L, Ryan R, Marshall T. Incidence of indications for tonsillectomy and frequency of evidence-based surgery: a 12year retrospective cohort study of primary care electronic records. Br J Gen Pract 2019; 69: e33e41. FURTHER READING ENT UK. Tonsillectomy revised commissioning guide. 2016. Available at: https://www.rcseng.ac.uk/-/media/files/rcs/standards-andresearch/commissioning/ent-uk-tonsillectomy-revisedcommissioning-guide-2016-published.pdf (accessed 3 October 2019). MHRA drug safety update6. Mitchell RB, Archer SM, Ishman SL, et al. Clinical practice guideline: tonsillectomy in children (update). Otolaryngol Head Neck Surg 2019; 160(suppl 1): S1e42. Robb PJ, Bew S, Kubba H, et al. Tonsillectomy and adenoidectomy in children with sleep-related breathing disorders: consensus statement of a UK multidisciplinary working party. Ann R Coll Surg Engl 2009; 91: 371e3. Todd CA, Bareiss AK, McCoul ED, Rodriguez KH. Adenotonsillectomy for obstructive sleep apnoea and quality of life: systematic review and meta-analysis. Otolaryngol Head Neck Surg 2017; 157: 767e73.
Are we doing too many or too few adenotonsillectomies? In UK, tonsillectomy and adenoidectomy are restricted procedures in NHS hospitals in many regions, meaning that they are only funded under strict conditions and assuming that prior permission is granted. There is wide international variation in the rates of adenotonsillectomy, with criticism being levelled both at unnecessary surgery and at insufficient surgery rates. Overall, surgery rates have fallen, which is likely to be a reflection in improvement in general health, as well as a refinement of indications criteria so that surgery is only offered in circumstances where benefit is clear. Adenotonsillar infections can cause deep neck space infections, which are potentially life-threatening emergencies. The incidence of deep neck space infections has increased in the recent years, and concerns have been expressed that this may be result of restricting antibiotic prescribing and access to surgery. A recent Scottish nationwide study1 of five million population over 20 years found a decrease in tonsillectomy rates of 48%, but an increase in tonsillitis and quinsy admission rates (136% and 167%, respectively), and a 500% increase in deep neck space abscesses. In the case of OSA, the children whose neurocognitive development or quality of life may have been impaired are unlikely to show up on any hospital admission statistics, and require detailed neuropsychology to detect. Arguments continue as to what long term effect OSA might have. The CHAT study2 compared adenotonsillectomy to watchful waiting and found that adenotonsillectomy was associated with improved quality of life, PSG findings and parental reported behaviour but the primary outcome of attention and executive function was not significantly different between the active and watchful waiting groups. There is, however, ample longitudinal case series evidence that OSA affects academic achievement, quality of life, and has a socioeconomic impact, and that surgery helps. Despite this, controversy remains. A recent paper3 somewhat controversially concluded that 7 out of 8 children having
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Adenotonsillectomy is one of the commonest surgical procedures Internationally, there are variations in surgical rates Recurrent tonsillitis and OSA are the main indications of surgery It is not clear how best to diagnose OSA, and whether sleep studies are routinely required Both complete tonsillectomy and intracapsular tonsillectomy are accepted methods, with latter resulting in less pain and bleeding, but a (small) possibility of tonsillar tissue regrowth Risk of surgical intervention should be weighed against the benefits. Postoperative complications, including bleeding, are relatively common For many children, adenotonsillectomy results in significant improvements to the quality of life
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