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Evidence-Based Practice
E v i d e n c e - B a s e d Pr a c t i c e Pediatric Tonsillectomy Karin P.Q. Oomen, MD, PhDa, Vikash K. Modi, Michael G. Stewart, MD, MPHb
MD
a,
*,
KEYWORDS Tonsillectomy Children Throat infections Sleep-disordered breathing Evidence-based medicine KEY POINTS The following points are expanded at the conclusion of this article and additional critical points are presented. Gaps in knowledge about perioperative management for tonsillectomy in children remain. Outcome measures in sleep-disordered breathing and recurrent throat infections should focus on not only recurrence of disease but also quality of life and school performance as indicators of well-being. No consensus exists on indications for a preoperative polysomnogram in children without comorbidities. Currently, physicians are recommended to advocate for polysomnogram in patients with sleep-disordered breathing without comorbidities if the need for surgery is uncertain or in the presence of discordance between symptoms and physical examination. Reported success rates of tonsillectomy for sleep-disordered breathing in obese children are 10% to 20%; in normal-weight children they are 70% to 80%. Current guidelines do not recommend specific tonsillectomy techniques. The development of intracapsular tonsillectomy represents a different surgical strategy rather than a different instrumental technique that, with further study, could lead to new recommendations.
OVERVIEW
Tonsillectomy is one of the most common surgical procedures performed in children in the United States, with more than 530, 000 procedures performed annually.1 Tonsillectomy is defined as a surgical procedure that removes the tonsil. Removal of the tonsil may be specified as complete, through dissecting the peritonsillar space between the The authors have nothing to declare. a Department of Otolaryngology-Head & Neck Surgery, Pediatric Otolaryngology-Head & Neck Surgery, Weill Cornell Medical College, 428 East 72nd Street, Suite 100, New York, NY 10021, USA; b Department of Otolaryngology, Head & Neck Surgery, Weill Cornell Medical College, 1305 York Avenue, 5th Floor, New York, NY 10021, USA * Corresponding author. E-mail address: [email protected] Otolaryngol Clin N Am 45 (2012) 1071–1081 http://dx.doi.org/10.1016/j.otc.2012.06.010 0030-6665/12/$ – see front matter Ó 2012 Elsevier Inc. All rights reserved.
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tonsil capsule and the muscular wall, or partial, through removing a varying amount of tonsillar tissue intracapsularly or subcapsularly.2 Although tonsillectomy is a common procedure, it is associated with morbidity, including anesthesia risks, throat pain, and postoperative bleeding, which may result in admission for observation or further surgery to control bleeding. These and rarer complications have been well described and should be taken into account when considering surgery in children.3 This article provides an evidence-based perspective on perioperative clinical decision making and surgical technique for tonsillectomy. EVIDENCE-BASED CLINICAL ASSESSMENT Indications for Tonsillectomy
Indications for tonsillectomy are multiple, the most common and generally accepted of which are sleep-disordered breathing (SDB) and recurrent throat infections, with a gradual incidence shift toward SDB over the past 2 decades.4 SDB is now the single most common indication for tonsillectomy with or without adenoidectomy; SDB constitutes a range of disorders increasing in severity from snoring and restless sleep to obstructive sleep apnea (OSA).5 SDB has a multifactorial etiology, and hypertrophic tonsils are usually a contributing factor. A recent meta-analysis has shown that tonsillectomy is effective for treating SDB in children with tonsillar hypertrophy,6 and a recent clinical practice guideline recommends tonsillectomy in children with tonsil hypertrophy who have a polysomnography indicative of SDB.2 Success rates are significantly lower for tonsillectomy in obese children with SDB.7 Throat infections are defined as episodes of sore throat caused by viral or bacterial infection of the pharynx, palatine tonsils, or both, and include a variety of terms, such as tonsillitis, pharyngitis, and strep throat.2 Throat infections may be documented for each episode of sore throat with one or more of the following: temperature higher than 38.3 C, cervical adenopathy, tonsillar exudates, or positive test for group A b-hemolytic streptococci. The actual benefit of tonsillectomy compared with observation in children with throat infections remains a subject of controversy. In 1984, a randomized controlled trial by Paradise and colleagues8 showed a reduction in frequency and severity of infections in severely affected children with recurrent throat infections in the 2 years after tonsillectomy. In moderately affected children, the same group found only a modest benefit of tonsillectomy, which the authors believed was not sufficient to outweigh the risks, morbidity, and costs of surgery.9 A recent clinical practice guideline recommended tonsillectomy in children with recurrent throat infections with a frequency of at least seven episodes in the prior year, at least five episodes per year in the prior 2 years, or at least three episodes per year in the prior 3 years.2,8 Although the guideline recommended watchful waiting for recurrent throat infections with a lesser frequency, tonsillectomy is recommend in children with fewer throat infections if they exhibit modifying factors, such as multiple antibiotic allergy or intolerance, a combination of periodic fever, aphthous stomatitis, pharyngitis, and adenitis (PFAPA), or a history of peritonsillar abscess.2 Other rarer indications for surgery include orthodontic concerns, tonsiliths, halitosis, and chronic tonsillitis, all for which substantial evidence is currently not available or of lesser quality.10–12 Clinical Assessment of Tonsils
Careful history taking is vital and should include symptoms of Throat infections Snoring
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Apneas Restless sleep Nocturnal enuresis Somnolence Growth retardation Poor school performance Behavioral problems Attention deficit hyperactivity disorder
Physical examination should focus on the anatomy, which includes the size of the tonsils in relation to the position and size of the palate, tongue, and chin. Tonsil size is currently identified using a tonsil grading scale,13,14 with tonsillar hypertrophy defined as 31 or 41. An important limitation of this grading system is that it does not provide a three-dimensional assessment of tonsil size, which would be more accurate in quantifying tonsillar hypertrophy. A previous study has shown that tonsillar size alone does not correlate with the severity of SDB,10 but the combined volume of the tonsils and the adenoids do correlate more closely with SDB severity.15 Polysomnography
Unfortunately, neither history nor physical examination alone can reliably predict the presence or severity of SDB.16 Currently, polysomnography is the gold standard for diagnosing and quantifying SDB in children, and can be a useful diagnostic tool before tonsillectomy.17 Polysomnography is the electrical recording of physiologic variables during sleep, including gas exchange, respiratory effort, airflow, snoring, sleep stage, body position, limb movement, and heart rhythm. Not only does polysomnography identify the presence of SDB, it also helps define its severity and may serve as an aid in perioperative planning and assessing the risk of postoperative complications. Since 2002, the American Academy of Pediatrics has recommended overnight polysomnography in all children with suspected SDB to confirm diagnosis.17 A recent clinical practice guideline on polysomnography in children recommended referral for polysomnography in children with SDB before tonsillectomy if they exhibited one of the following comorbid conditions5:
Obesity Down syndrome Craniofacial abnormalities Neuromuscular disorders Sickle cell disease Mucopolysaccharidosis
In these children, polysomnography helps determine the need for postoperative pulse oximetry and admission. The same guideline recommends polysomnography before tonsillectomy in children without any of the aforementioned comorbidities, but only if the need for surgery is uncertain or in the presence of discordance between the clinical history and/or tonsillar size on physical examination and the reported severity of SDB. Polysomnography may be performed in a sleep laboratory or in an ambulatory setting, the latter being referred to as portable monitoring (PM). Because of the cost and inconvenience of laboratory-based polysomnography, several forms of PM have developed, but few devices have been tested in children, and substantial evidence for this method is lacking. Laboratory-based polysomnography is currently
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the gold standard for evaluation of SDB in children and is recommended in children for whom polysomnography is indicated to assess SDB before tonsillectomy.5 EVIDENCE-BASED SURGICAL TECHNIQUE FOR TONSILLECTOMY Procedure Total tonsillectomy via cold dissection
Traditional techniques for tonsillectomy consist of cold dissection with metal instruments including knife, scissor, or snare. These techniques involve complete removal of the tonsil with its capsule by dissecting the peritonsillar space, with hemostasis obtained through ligation of blood vessels during tonsil removal or cauterization of the wound bed. Complete dissection or total tonsillectomy (TT) with cold steel is still the technique against which effectiveness and safety of other techniques are compared.2 Total tonsillectomy via electrosurgery, cautery dissection, coblation, radiofrequency
In recent years, many new surgical approaches for TT have been explored to reduce perioperative morbidity. Electrosurgical or cautery dissection are common techniques used for complete tonsillectomy. Many newer techniques, including radiofrequency, coblation, harmonic scalpel, and PEAK PlasmaBlade, have been introduced to reduce postoperative pain and hemorrhage. Outcomes of total tonsillectomy techniques
A recent systematic review has studied randomized controlled trials comparing TT performed using vessel sealing systems, harmonic scalpel, or coblation technique with conventional techniques of cold steel and/or cautery dissection.18 No significant differences in postoperative pain were found in the coblation and/or harmonic scalpel method compared with the cold steel and/or cautery technique. Furthermore, several randomized controlled trials have compared traditional TT with other techniques, including coblation, cautery, and ultrasonic scalpel, without finding a significant difference in postoperative pain.19–22 Intracapsular tonsillectomy
A growing body of evidence suggests lower postoperative morbidity with a partial intracapsular tonsillectomy (IT) technique, in which most tonsillar tissue is removed, leaving a small amount of tonsillar tissue in the tonsillar fossa.23–25 The belief is that the rim of tonsillar tissue left in the tonsillar fossa provides a buffer zone that prevents damage to the surrounding pharyngeal muscles, thereby reducing severity and duration of postoperative pain.23,25 IT is also thought to reduce the amount of postoperative hemorrhage.26 Several instruments have been used to perform IT, including the microdebrider, the coblator, and traditional cold steel. A study by Bitar and colleagues25 compared the effects of microdebrider-assisted IT to electrocauteryassisted TT in children, showing no difference in surgical time or postoperative bleeding, but an earlier return to normal activity and reduced need for analgesics in the IT group. A study by Wilson and colleagues23 compared microdebrider-assisted IT, coblator-assisted IT, and electrocautery-assisted TT and showed a significantly earlier return to normal diet and preoperative activity level, and reduction of days of pain in both IT groups. No significant differences were seen in occurrence of postoperative complications, such as hemorrhage. Chang27 showed a significantly shorter postoperative recovery period for coblator-assisted IT compared with electrocautery-assisted TT in children. A potential concern with IT might be regrowth of tonsillar tissue and need for revision surgery. Derkay and colleagues26 showed a significantly higher incidence of residual tonsillar tissue in children who underwent microdebrider-assisted IT compared with
Evidence-Based Practice
those who had electrocautery-assisted TT. However, the incidence of recurrence of obstruction or infection in this group was unknown. Chan and colleagues28 also showed a significantly higher incidence of residual tonsillar tissue, but no difference in recurrence of obstructive disease, pharyngitis, or antibiotic use. Ericsson and colleagues24 and Bitar and colleagues25 did not shown tonsillar regrowth at 12 and 20 months after IT, and no recurrence of symptoms after 3 years and 20 months, respectively. Irrespective of tonsillar regrowth, a retrospective chart review by Schmidt and colleagues29 compared the efficacy of IT versus TT in treating recurrent tonsillitis and showed no difference in postoperative infection rates. Postoperative Management of Tonsillectomy: Hospitalization
Several studies have established that pediatric tonsillectomy may be safely performed in an outpatient setting.28,30,31 A previous clinical guideline recommends that children with complicated medical histories, including cardiac complications of OSA, neuromuscular disorders, prematurity, obesity, failure to thrive, craniofacial anomalies, or a recent upper respiratory tract infection, should be admitted overnight because of a higher risk of postoperative respiratory complications.17 SDB severity has also been identified as a risk factor for postoperative respiratory complications and is therefore considered an indication for postoperative admission by many. Although tonsillectomy resolves or at least significantly improves OSA in most children, they may continue to experience upper airway obstruction and oxygen desaturation in the direct postoperative period.32,33 An apnea-hypopnea index of 10 or more obstructive events per hour and/or oxygen saturation nadir less than 80% is currently considered the level of severity required for postoperative hospitalization with monitoring.5,34 Admission after total tonsillectomy is also recommended for children younger than 3 years, regardless of indication, because of postoperative pain resulting in poor oral intake.35–37 With the advent of techniques such as IT, reduction of postoperative morbidity might lead to new insights on postoperative management. Bent and colleagues38 compared children younger than 3 years with children aged 3 years or older undergoing IT for postoperative parameters such as pain, oral intake, or analgesic requirements. Because no significant differences were found between the age groups, the investigators concluded that children younger than 3 years may undergo IT on an outpatient basis. Postoperative Hemorrhage in Tonsillectomy
Postoperative hemorrhage is a well-known complication of tonsillectomy and may be categorized as primary or secondary. Primary hemorrhage is defined as bleeding within the first 24 hours after tonsillectomy, and occurs in 0.2% to 2.2% of patients.2 Secondary hemorrhage occurs more than 24 hours after surgery, often between 5 and 10 days, because of sloughing of the primary eschar during healing of the tonsil bed. Rates of secondary hemorrhage for tonsillectomy range from 0.1% to 3%.39 Clinicians who perform tonsillectomy are recommended to always inquire about bleeding after surgery, and determine their rate of primary and secondary posttonsillectomy hemorrhage at least annually.2 Surgical technique can have an impact on postoperative bleeding. Several new techniques were recently introduced to reduce postoperative hemorrhage. Many previous studies have focused on comparison of “hot” (electrosurgery or electrocautery techniques) versus cold tonsillectomy with respect to postoperative bleeding, with similar unequivocal outcomes.18–22 Several systematic reviews18,40–43 have summarized randomized controlled trials on conventional cold steel tonsillectomy versus diathermy, monopolar cautery, coblation, or harmonic scalpel techniques, but none has shown a significant difference in postoperative hemorrhage rates among techniques.
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Other studies have focused on comparison of IT and TT with respect to postoperative complications such as hemorrhage.23,25,26,28,44–50 Three large retrospective case series have shown a significantly lower rate of postoperative bleeding for IT compared with TT.44,47,49 However, most prospective trials fail to demonstrate a significant difference in postoperative hemorrhage between IT and TT,23,25,26,28,45,46 although one trial reports a significantly lower intraoperative blood loss with IT.45 SDB and Other Postoperative Concerns in Tonsillectomy
With SDB being the most common indication for tonsillectomy, postoperative monitoring for possible residual SDB is an important consideration. Before surgery, caregivers must be counseled that tonsillectomy is not curative in all cases of SDB in children, especially in children with obesity, and further treatment may be required after surgery.2 Clinical guidelines do not recommend routine polysomnography after tonsillectomy in children with SDB. When SDB or related comorbid conditions, such as growth retardation, poor school performance, enuresis, or behavioral problems, have been the indication for surgery, SDB is considered cured when the caregiver reports that symptoms are resolved postoperatively. In these cases, postoperative polysomnography is deemed unnecessary, but substantial evidence for this assumption is lacking. Any postoperative report of continuing symptoms of SDB should be taken seriously and indicates the need for further evaluation, including consideration of formal polysomnography.2 A recent systematic review does recommend postoperative polysomnography for children with perioperative evidence of moderate to severe OSA, obesity, craniofacial anomalies, and neurologic disorders.50 WHAT THE EVIDENCE INDICATES
Tonsillectomy is a safe surgical procedure performed on a large scale, most commonly for SDB and recurrent throat infections. The positive effect of tonsillectomy has been established for severely affected children with recurrent throat infections in a randomized controlled trial but could not be shown for children who were less severely affected (grade B evidence).8,9 A systematic review of cohort studies and a few case series found tonsillectomy to be an effective treatment for SDB (grade B–C evidence).6 Polysomnography is the gold standard for diagnosing SDB, but guidelines do not recommend that polysomnography be performed routinely preoperatively in children with suspected SDB and tonsil hypertrophy. Polysomnography is recommended in children with specific comorbidities based on results from observational studies (grade C evidence).5 In children without comorbidities but an uncertain need for surgery or discordance between history and examination, preoperative polysomnography should be performed (grade C evidence).5 In an attempt to reduce postoperative hemorrhage rates, several tonsillectomy techniques have been developed, but systematic reviews of randomized controlled trials have thus far not provided evidence of such a reduction using any particular technique (grade A evidence).40,41 Many randomized controlled trials have compared various newer and conventional TT techniques but could not demonstrate differences in postoperative pain (grade B evidence).19–22 Studies comparing TT and IT show faster recovery and pain reduction in patients treated with IT but no significantly lower risk of postoperative bleeding (grade B evidence).23,25,26,28,45,46,48 Retrospective case series, however, do show a significantly lower postoperative bleeding rate for IT (grade C evidence).44,47,49 Evidence grades and conclusions are summarized in Table 1.
Table 1 Conclusions and grades of evidence for tonsillectomy References
Description
n
Level of Evidence
Evidence Grade
Effects of tonsillectomy
8
Parallel randomized and nonrandomized clinical trials Parallel randomized and nonrandomized clinical trials
187
1b
B
515
1b
B
6
Systematic review and meta-analysis of randomized controlled trials and observational studies
1097
2a
B–C
5
Clinical practice guideline–based observational studies Clinical practice guideline–based on observational studies
246
2b–3b
C
723
2b
C
40,41
Systematic review of two randomized controlled trials
254
1a
A
44,47,49
Retrospective case series with chart review
5812
4
C
19–22
Prospective randomized controlled trials
362
1b
B
23,25,26,28,45,46,48
Prospective randomized controlled trials
842
1b
B
8,9
Preoperative polysomnography
5
Postoperative hemorrhage
Postoperative pain
Conclusion Tonsillectomy reduces throat infections in severely affected children Tonsillectomy does not reduce throat infections in less severely affected children Tonsillectomy is an effective treatment for sleep-disordered breathing Polysomnography is recommended in children with specific comorbidities Polysomnography is recommended in children without specific comorbidities if uncertain need for surgery or discordance between history and examination No differences in postoperative hemorrhage rates are seen between TT techniques IT might be associated with a lower risk of postoperative bleeding No differences in postoperative pain rates are seen between TT techniques IT is not associated with a lower rate of postoperative pain
Evidence-Based Practice
Category
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CRITICAL POINTS
Although a large amount of literature is available and clinical guidelines exist, certain gaps in knowledge remain about perioperative management for tonsillectomy in children. Large, multicenter, prospective, randomized, controlled trials are needed on the effect of tonsillectomy on recurrent throat infections and SDB. Outcome measures should focus on not only recurrence of disease but also quality of life and school performance as indicators of well-being. Although a randomized controlled trial has shown reduction of throat infections after tonsillectomy in severely affected children, this effect in not seen in milder cases or for a postoperative period for more than 2 years.8,9 Because the effect of tonsillectomy on throat infections was shown in a single study conducted in 1984, additional, newer, randomized, controlled trials may be needed to confirm these findings. Regarding SDB as an indication for surgery, certain topics must be addressed in more detail. No consensus exists on indications for a preoperative polysomnography in children without comorbidities. Currently, physicians are recommended to advocate for polysomnography in patients with SDB without comorbidities if the need for surgery is uncertain or in the presence of discordance between symptoms and physical examination. Future studies on polysomnography for SDB might be able to specify these rather wide criteria. Because some children may lack access to a sleep laboratory or have difficulty sleeping in a foreign environment, studies are need to evaluate PM. PM studies should focus on which parameters should be measured to replicate laboratory findings and accurately predict which children are at risk for postoperative complications. To the same extent, indications for postoperative polysomnography for SDB after tonsillectomy must be specified and studied further. With obesity rates increasing worldwide, a subject of growing concern is the management of obese children with SDB. A previous meta-analysis of four studies showed success rates of 10% to 20% for tonsillectomy for SDB in obese children,7 whereas the resolution reported in normal-weight children is around 70% to 80%.51 This discrepancy warrants future investigation of the extent to which obesity plays a role in failure to respond after tonsillectomy for SDB, and determination of the exact role of tonsillectomy in obese children. Currently, guidelines do not recommend specific tonsillectomy techniques. Although a large body of literature discusses various TT techniques that differ mainly in the instruments used, no substantial evidence exists for a general benefit of one instrument over another. The development of IT, which represents a different surgical strategy rather than a different instrumental technique, may be a field of further study that could eventually lead to new recommendations. Several studies have established benefits of IT over TT with respect to postoperative recovery and pain.23,25,26,28,45,46,48 The finding of significantly lower postoperative bleeding rates for IT in retrospective case series44,47,49 warrants further investigation and confirmation in prospective trials, but might hold the promise of future recommendations for surgical technique. Specific studies are needed on postoperative management after IT in patients in the younger age group (age<3 years) to confirm previous findings.38 If positive, these studies may influence recommendations on inpatient versus outpatient surgery.
Evidence-Based Practice
REFERENCES
1. Cullen KA, Hall MJ, Golosinsky A. Ambulatory surgery in the United States. Natl Health Stat Rep 2009;11:1–28. 2. Baugh R, Archer S, Mitchell R, et al. Clinical practice guideline: tonsillectomy in children. Otolaryngol Head Neck Surg 2011;144(Suppl):S1–30. 3. Johnson L, Elluru R, Myer C. Complications of adenotonsillectomy. Laryngoscope 2002;112:35–6. 4. Erickson B, Larson D, Stauver J. Changes in incidence and indications of tonsillectomy and adenotonsillectomy, 1970-2005. Otolaryngol Head Neck Surg 2009; 140(6):894–901. 5. Roland P, Rosenfeld R, Brooks L, et al. Clinical practice guideline: polysomnography for sleep-disordered breathing prior to tonsillectomy in children. Otolaryngol Head Neck Surg 2011;145(Suppl):S1–15. 6. Friedman M, Wilson M, Lin CH, et al. Updated systematic review of tonsillectomy and adenoidectomy in the treatment of obstructive sleep apnea/hypopnea syndrome: a meta-analysis. Otolaryngol Head Neck Surg 2009;140(6):800–8. 7. Costa DJ, Mitchell R. Adenotonsillectomy for obstructive sleep apnea in obese children: a meta-analysis. Otolaryngol Head Neck Surg 2009;140(4):455–60. 8. Paradise JL, Bluestone CD, Bachmann 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 1984;310(11):674–83. 9. Paradise J, Bluestone CD, Colborn DK, et al. Tonsillectomy and adenotonsillectomy for recurrent throat infection in moderately affected children. Pediatrics 2002;110(1):7–15. 10. Morawska A, Lyszczarz J, Skladzien J. An analysis of orthodontic indications for surgical treatment of Waldeyer ring hyperplasia in pediatric patients of the otolaryngology and stomatology department of the university hospital of Krakow. Otolaryngol Pol 2008;62(3):272–7. 11. Burton MJ, Glasziou PP. Tonsillectomy or adenotonsillectomy versus non-surgical treatment for chronic/recurrent acute tonsillitis. Cochrane Database Syst Rev 2009;(1):CD001802. 12. Tanyeri HT, Polat S. Temperature-controlled radiofrequency tonsil ablation for the treatment of halitosis. Eur Arch Otorhinolaryngol 2011;268(2):267–72. 13. Brodsky L. Modern assessment of tonsils and adenoids. Pediatr Clin North Am 1989;36(6):1551–69. 14. Howard N, Brietzke S. Pediatric tonsil size: objective vs subjective measurements correlated to overnight polysomnogram. Otolaryngol Head Neck Surg 2009; 140(5):675–81. 15. Arens R, McDonough J, Corbin A, et al. Upper airway size analysis by magnetic resonance imaging of children with obstructive sleep apnea syndrome. Am J Respir Crit Care Med 2003;167(1):65–70. 16. Brietzke SE, Katz ES, Robertson DW. Can history and physical examination reliably diagnose pediatric obstructive sleep apnea/hypopnea syndrome? A systematic review of the literature. Otolaryngol Head Neck Surg 2004;131(6):827–32. 17. Subcommittee on Obstructive Sleep Apnea Syndrome, American Academy of Pediatrics. Clinical practice guideline: diagnosis and management of childhood obstructive sleep apnea syndrome. Pediatrics 2002;109(4):704–12. 18. Vangelis AG, Salazar-Salvia MS, Jervis PN, et al. Modern technology-assisted vs conventional tonsillectomy: a meta-analysis of randomized controlled trials. Arch Otolaryngol Head Neck Surg 2011;137(6):558–70.
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19. Parsons SP, Cordes SR, Comer B. Comparison of posttonsillectomy pain using the ultrasonic scalpel, coblator, and electrocautery. Otolaryngol Head Neck Surg 2006;134(1):106–13. 20. Stoker KE, Don DM, Kang DR, et al. Pediatric total tonsillectomy using coblation compared to conventional electrosurgery: a prospective, controlled single-blind study. Otolaryngol Head Neck Surg 2004;130(6):666–75. 21. Ba¨ck L, Paloheimo M, Ylikoski J. Traditional tonsillectomy compared with bipolar radiofrequency thermal ablation tonsillectomy in adults: a pilot study. Arch Otolaryngol Head Neck Surg 2001;127(9):1106–12. 22. Philpott CM, Wild DC, Mehta D, et al. A double-blinded randomized controlled trial of coblation versus conventional dissection tonsillectomy on postoperative symptoms. Clin Otolaryngol 2005;30(2):143–8. 23. Wilson YL, Merer DM, Moscatleoo AL. Comparison of three common tonsillectomy techniques: a prospective randomized, double blinded clinical study. Laryngoscope 2009;119(1):162–70. 24. Ericsson E, Graf J, Hultcrantz E. Pediatric tonsillotomy with radiofrequency technique: long term follow-up. Laryngoscope 2006;116(10):1851–7. 25. Bitar MA, Rameh C. Microdebrider-assisted partial tonsillectomy: short- and longterm outcomes. Eur Arch Otorhinolaryngol 2008;265(4):459–63. 26. Derkay CS, Darrow DH, Welch C, et al. Post-tonsillectomy morbidity and quality of life in pediatric patients with obstructive tonsils and adenoid: microdebrider vs electrocautery. Otolaryngol Head Neck Surg 2006;134(1):114–20. 27. Chang KW. Randomized controlled trial of coblation versus electrocautery tonsillectomy. Otolaryngol Head Neck Surg 2005;132(2):273–80. 28. Chan KH, Friedman NR, Allen GC, et al. Randomized, controlled, multisite study of intracapsular tonsillectomy using low-temperature plasma excision. Arch Otolaryngol Head Neck Surg 2004;130(11):1303–7. 29. Schmidt R, Herzog A, Cook S, et al. Powered intracapsular tonsillectomy in the management of recurrent tonsillitis. Otolaryngol Head Neck Surg 2007;137(2): 338–40. 30. Haberman RS, Shattuck TG, Dion NM. Is outpatient suction cautery tonsillectomy safe in a community hospital setting? Laryngoscope 1990;100(5):511–5. 31. Helmus C, Grin M, Westfall R. Same-day-stay adenotonsillectomy. Laryngoscope 1990;100(6):593–6. 32. McColley SA, April MM, Carroll JL, et al. Respiratory compromise after adenotonsillectomy in children with obstructive sleep apnea. Arch Otolaryngol Head Neck Surg 1992;118(9):940–3. 33. Nixon GM, Kermack AS, McGregor CD, et al. Sleep and breathing on the first night after adenotonsillectomy for obstructive sleep apnea. Pediatr Pulmonol 2005;39(4):332–8. 34. Nixon GM, Kermack AS, Davis GM, et al. Planning adenotonsillectomy in children with obstructive sleep apnea: the role of overnight oximetry. Pediatrics 2004; 113(1 Pt 1):e19–25. 35. Tom LW, DeDio RM, Cohen DE, et al. Is outpatient tonsillectomy appropriate for young children? Laryngoscope 1992;102(3):277–80. 36. Rothschild MA, Catalano P, Biller HF. Ambulatory pediatric tonsillectomy and the identification of high-risk subgroups. Otolaryngol Head Neck Surg 1994;110(2): 203–10. 37. Mitchell RB, Pereira KD, Friedman NR, et al. Outpatient adenotonsillectomy: is it safe in children younger than 3 years? Arch Otolaryngol Head Neck Surg 1997; 123(7):681–3.
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38. Bent JP, April MM, Ward RF, et al. Ambulatory powered intracapsular tonsillectomy and adenoidectomy in children younger than 3 years. Arch Otolaryngol Head Neck Surg 2004;130(10):1197–200. 39. Windfuhr JP, Chen YS, Remmert S. Hemorrhage following tonsillectomy and adenoidectomy in 15,218 patients. Otolaryngol Head Neck Surg 2006;132(2): 281–6. 40. Pinder DK, Hilton MP. Dissection versus diathermy for tonsillectomy. Cochrane Database Syst Rev 2001;(4):CD002211. 41. Burton MJ, Doree C. Coblation versus other surgical techniques for tonsillectomy. Cochrane Database Syst Rev 2007;(3):CD004619. 42. Neumann C, Street I, Lowe D, et al. Harmonic scalpel tonsillectomy: a systematic review of evidence for postoperative hemorrhage. Otolaryngol Head Neck Surg 2007;137(3):378–84. 43. Leinbach RF, Markwell SJ, Colliver JA, et al. Hot versus cold tonsillectomy: a systematic review of the literature. Otolaryngol Head Neck Surg 2003;129(4): 360–4. 44. Solares CA, Koempel JA, Hirose K, et al. Safety and efficacy of powered intracapsular tonsillectomy in children: a multi-center retrospective case series. In J Pediatr Otolaryngol 2005;69(1):21–6. 45. Hultcrantz E, Ericsson E. Pediatric tonsillotomy with the radiofrequency technique: less morbidity and pain. Laryngoscope 2004;114(5):871–7. 46. Korkmaz O, Bekas D, Cobanoglu B, et al. Partial tonsillectomy in children with obstructive tonsillar hypertrophy. Int J Pediatr Otorhinolaryngol 2008;72(7): 1007–12. 47. Gallagher TQ, Wilcox L, McGuire E, et al. Analyzing factors associated with major complications after adenotonsillectomy in 4776 patients: comparing three tonsillectomy techniques. Otolaryngol Head Neck Surg 2010;142(6):886–92. 48. Chang KW. Intracapsular versus subcapsular coblation tonsillectomy. Otolaryngol Head Neck Surg 2008;138(2):153–7. 49. Schmidt R, Herzog A, Cook S, et al. Complications of tonsillectomy: a comparison of techniques. Arch Otolaryngol Head Neck Surg 2007;133(9):925–8. 50. Aurora RN, Zak RS, Karippot A, et al. Practice parameters for the respiratory indications for polysomnography in children. Sleep 2011;34(3):379–87. 51. Mitchell RB. Adenotonsillectomy for obstructive sleep apnea in children: outcome evaluated by pre-and postoperative polysomnography. Laryngoscope 2007; 117(10):1844–54.
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*,
KEYWORDS Tonsillectomy Children Throat infections Sleep-disordered breathing Evidence-based medicine KEY POINTS The following points are expanded at the conclusion of this article and additional critical points are presented. Gaps in knowledge about perioperative management for tonsillectomy in children remain. Outcome measures in sleep-disordered breathing and recurrent throat infections should focus on not only recurrence of disease but also quality of life and school performance as indicators of well-being. No consensus exists on indications for a preoperative polysomnogram in children without comorbidities. Currently, physicians are recommended to advocate for polysomnogram in patients with sleep-disordered breathing without comorbidities if the need for surgery is uncertain or in the presence of discordance between symptoms and physical examination. Reported success rates of tonsillectomy for sleep-disordered breathing in obese children are 10% to 20%; in normal-weight children they are 70% to 80%. Current guidelines do not recommend specific tonsillectomy techniques. The development of intracapsular tonsillectomy represents a different surgical strategy rather than a different instrumental technique that, with further study, could lead to new recommendations.
OVERVIEW
Tonsillectomy is one of the most common surgical procedures performed in children in the United States, with more than 530, 000 procedures performed annually.1 Tonsillectomy is defined as a surgical procedure that removes the tonsil. Removal of the tonsil may be specified as complete, through dissecting the peritonsillar space between the The authors have nothing to declare. a Department of Otolaryngology-Head & Neck Surgery, Pediatric Otolaryngology-Head & Neck Surgery, Weill Cornell Medical College, 428 East 72nd Street, Suite 100, New York, NY 10021, USA; b Department of Otolaryngology, Head & Neck Surgery, Weill Cornell Medical College, 1305 York Avenue, 5th Floor, New York, NY 10021, USA * Corresponding author. E-mail address: [email protected] Otolaryngol Clin N Am 45 (2012) 1071–1081 http://dx.doi.org/10.1016/j.otc.2012.06.010 0030-6665/12/$ – see front matter Ó 2012 Elsevier Inc. All rights reserved.
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tonsil capsule and the muscular wall, or partial, through removing a varying amount of tonsillar tissue intracapsularly or subcapsularly.2 Although tonsillectomy is a common procedure, it is associated with morbidity, including anesthesia risks, throat pain, and postoperative bleeding, which may result in admission for observation or further surgery to control bleeding. These and rarer complications have been well described and should be taken into account when considering surgery in children.3 This article provides an evidence-based perspective on perioperative clinical decision making and surgical technique for tonsillectomy. EVIDENCE-BASED CLINICAL ASSESSMENT Indications for Tonsillectomy
Indications for tonsillectomy are multiple, the most common and generally accepted of which are sleep-disordered breathing (SDB) and recurrent throat infections, with a gradual incidence shift toward SDB over the past 2 decades.4 SDB is now the single most common indication for tonsillectomy with or without adenoidectomy; SDB constitutes a range of disorders increasing in severity from snoring and restless sleep to obstructive sleep apnea (OSA).5 SDB has a multifactorial etiology, and hypertrophic tonsils are usually a contributing factor. A recent meta-analysis has shown that tonsillectomy is effective for treating SDB in children with tonsillar hypertrophy,6 and a recent clinical practice guideline recommends tonsillectomy in children with tonsil hypertrophy who have a polysomnography indicative of SDB.2 Success rates are significantly lower for tonsillectomy in obese children with SDB.7 Throat infections are defined as episodes of sore throat caused by viral or bacterial infection of the pharynx, palatine tonsils, or both, and include a variety of terms, such as tonsillitis, pharyngitis, and strep throat.2 Throat infections may be documented for each episode of sore throat with one or more of the following: temperature higher than 38.3 C, cervical adenopathy, tonsillar exudates, or positive test for group A b-hemolytic streptococci. The actual benefit of tonsillectomy compared with observation in children with throat infections remains a subject of controversy. In 1984, a randomized controlled trial by Paradise and colleagues8 showed a reduction in frequency and severity of infections in severely affected children with recurrent throat infections in the 2 years after tonsillectomy. In moderately affected children, the same group found only a modest benefit of tonsillectomy, which the authors believed was not sufficient to outweigh the risks, morbidity, and costs of surgery.9 A recent clinical practice guideline recommended tonsillectomy in children with recurrent throat infections with a frequency of at least seven episodes in the prior year, at least five episodes per year in the prior 2 years, or at least three episodes per year in the prior 3 years.2,8 Although the guideline recommended watchful waiting for recurrent throat infections with a lesser frequency, tonsillectomy is recommend in children with fewer throat infections if they exhibit modifying factors, such as multiple antibiotic allergy or intolerance, a combination of periodic fever, aphthous stomatitis, pharyngitis, and adenitis (PFAPA), or a history of peritonsillar abscess.2 Other rarer indications for surgery include orthodontic concerns, tonsiliths, halitosis, and chronic tonsillitis, all for which substantial evidence is currently not available or of lesser quality.10–12 Clinical Assessment of Tonsils
Careful history taking is vital and should include symptoms of Throat infections Snoring
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Apneas Restless sleep Nocturnal enuresis Somnolence Growth retardation Poor school performance Behavioral problems Attention deficit hyperactivity disorder
Physical examination should focus on the anatomy, which includes the size of the tonsils in relation to the position and size of the palate, tongue, and chin. Tonsil size is currently identified using a tonsil grading scale,13,14 with tonsillar hypertrophy defined as 31 or 41. An important limitation of this grading system is that it does not provide a three-dimensional assessment of tonsil size, which would be more accurate in quantifying tonsillar hypertrophy. A previous study has shown that tonsillar size alone does not correlate with the severity of SDB,10 but the combined volume of the tonsils and the adenoids do correlate more closely with SDB severity.15 Polysomnography
Unfortunately, neither history nor physical examination alone can reliably predict the presence or severity of SDB.16 Currently, polysomnography is the gold standard for diagnosing and quantifying SDB in children, and can be a useful diagnostic tool before tonsillectomy.17 Polysomnography is the electrical recording of physiologic variables during sleep, including gas exchange, respiratory effort, airflow, snoring, sleep stage, body position, limb movement, and heart rhythm. Not only does polysomnography identify the presence of SDB, it also helps define its severity and may serve as an aid in perioperative planning and assessing the risk of postoperative complications. Since 2002, the American Academy of Pediatrics has recommended overnight polysomnography in all children with suspected SDB to confirm diagnosis.17 A recent clinical practice guideline on polysomnography in children recommended referral for polysomnography in children with SDB before tonsillectomy if they exhibited one of the following comorbid conditions5:
Obesity Down syndrome Craniofacial abnormalities Neuromuscular disorders Sickle cell disease Mucopolysaccharidosis
In these children, polysomnography helps determine the need for postoperative pulse oximetry and admission. The same guideline recommends polysomnography before tonsillectomy in children without any of the aforementioned comorbidities, but only if the need for surgery is uncertain or in the presence of discordance between the clinical history and/or tonsillar size on physical examination and the reported severity of SDB. Polysomnography may be performed in a sleep laboratory or in an ambulatory setting, the latter being referred to as portable monitoring (PM). Because of the cost and inconvenience of laboratory-based polysomnography, several forms of PM have developed, but few devices have been tested in children, and substantial evidence for this method is lacking. Laboratory-based polysomnography is currently
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the gold standard for evaluation of SDB in children and is recommended in children for whom polysomnography is indicated to assess SDB before tonsillectomy.5 EVIDENCE-BASED SURGICAL TECHNIQUE FOR TONSILLECTOMY Procedure Total tonsillectomy via cold dissection
Traditional techniques for tonsillectomy consist of cold dissection with metal instruments including knife, scissor, or snare. These techniques involve complete removal of the tonsil with its capsule by dissecting the peritonsillar space, with hemostasis obtained through ligation of blood vessels during tonsil removal or cauterization of the wound bed. Complete dissection or total tonsillectomy (TT) with cold steel is still the technique against which effectiveness and safety of other techniques are compared.2 Total tonsillectomy via electrosurgery, cautery dissection, coblation, radiofrequency
In recent years, many new surgical approaches for TT have been explored to reduce perioperative morbidity. Electrosurgical or cautery dissection are common techniques used for complete tonsillectomy. Many newer techniques, including radiofrequency, coblation, harmonic scalpel, and PEAK PlasmaBlade, have been introduced to reduce postoperative pain and hemorrhage. Outcomes of total tonsillectomy techniques
A recent systematic review has studied randomized controlled trials comparing TT performed using vessel sealing systems, harmonic scalpel, or coblation technique with conventional techniques of cold steel and/or cautery dissection.18 No significant differences in postoperative pain were found in the coblation and/or harmonic scalpel method compared with the cold steel and/or cautery technique. Furthermore, several randomized controlled trials have compared traditional TT with other techniques, including coblation, cautery, and ultrasonic scalpel, without finding a significant difference in postoperative pain.19–22 Intracapsular tonsillectomy
A growing body of evidence suggests lower postoperative morbidity with a partial intracapsular tonsillectomy (IT) technique, in which most tonsillar tissue is removed, leaving a small amount of tonsillar tissue in the tonsillar fossa.23–25 The belief is that the rim of tonsillar tissue left in the tonsillar fossa provides a buffer zone that prevents damage to the surrounding pharyngeal muscles, thereby reducing severity and duration of postoperative pain.23,25 IT is also thought to reduce the amount of postoperative hemorrhage.26 Several instruments have been used to perform IT, including the microdebrider, the coblator, and traditional cold steel. A study by Bitar and colleagues25 compared the effects of microdebrider-assisted IT to electrocauteryassisted TT in children, showing no difference in surgical time or postoperative bleeding, but an earlier return to normal activity and reduced need for analgesics in the IT group. A study by Wilson and colleagues23 compared microdebrider-assisted IT, coblator-assisted IT, and electrocautery-assisted TT and showed a significantly earlier return to normal diet and preoperative activity level, and reduction of days of pain in both IT groups. No significant differences were seen in occurrence of postoperative complications, such as hemorrhage. Chang27 showed a significantly shorter postoperative recovery period for coblator-assisted IT compared with electrocautery-assisted TT in children. A potential concern with IT might be regrowth of tonsillar tissue and need for revision surgery. Derkay and colleagues26 showed a significantly higher incidence of residual tonsillar tissue in children who underwent microdebrider-assisted IT compared with
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those who had electrocautery-assisted TT. However, the incidence of recurrence of obstruction or infection in this group was unknown. Chan and colleagues28 also showed a significantly higher incidence of residual tonsillar tissue, but no difference in recurrence of obstructive disease, pharyngitis, or antibiotic use. Ericsson and colleagues24 and Bitar and colleagues25 did not shown tonsillar regrowth at 12 and 20 months after IT, and no recurrence of symptoms after 3 years and 20 months, respectively. Irrespective of tonsillar regrowth, a retrospective chart review by Schmidt and colleagues29 compared the efficacy of IT versus TT in treating recurrent tonsillitis and showed no difference in postoperative infection rates. Postoperative Management of Tonsillectomy: Hospitalization
Several studies have established that pediatric tonsillectomy may be safely performed in an outpatient setting.28,30,31 A previous clinical guideline recommends that children with complicated medical histories, including cardiac complications of OSA, neuromuscular disorders, prematurity, obesity, failure to thrive, craniofacial anomalies, or a recent upper respiratory tract infection, should be admitted overnight because of a higher risk of postoperative respiratory complications.17 SDB severity has also been identified as a risk factor for postoperative respiratory complications and is therefore considered an indication for postoperative admission by many. Although tonsillectomy resolves or at least significantly improves OSA in most children, they may continue to experience upper airway obstruction and oxygen desaturation in the direct postoperative period.32,33 An apnea-hypopnea index of 10 or more obstructive events per hour and/or oxygen saturation nadir less than 80% is currently considered the level of severity required for postoperative hospitalization with monitoring.5,34 Admission after total tonsillectomy is also recommended for children younger than 3 years, regardless of indication, because of postoperative pain resulting in poor oral intake.35–37 With the advent of techniques such as IT, reduction of postoperative morbidity might lead to new insights on postoperative management. Bent and colleagues38 compared children younger than 3 years with children aged 3 years or older undergoing IT for postoperative parameters such as pain, oral intake, or analgesic requirements. Because no significant differences were found between the age groups, the investigators concluded that children younger than 3 years may undergo IT on an outpatient basis. Postoperative Hemorrhage in Tonsillectomy
Postoperative hemorrhage is a well-known complication of tonsillectomy and may be categorized as primary or secondary. Primary hemorrhage is defined as bleeding within the first 24 hours after tonsillectomy, and occurs in 0.2% to 2.2% of patients.2 Secondary hemorrhage occurs more than 24 hours after surgery, often between 5 and 10 days, because of sloughing of the primary eschar during healing of the tonsil bed. Rates of secondary hemorrhage for tonsillectomy range from 0.1% to 3%.39 Clinicians who perform tonsillectomy are recommended to always inquire about bleeding after surgery, and determine their rate of primary and secondary posttonsillectomy hemorrhage at least annually.2 Surgical technique can have an impact on postoperative bleeding. Several new techniques were recently introduced to reduce postoperative hemorrhage. Many previous studies have focused on comparison of “hot” (electrosurgery or electrocautery techniques) versus cold tonsillectomy with respect to postoperative bleeding, with similar unequivocal outcomes.18–22 Several systematic reviews18,40–43 have summarized randomized controlled trials on conventional cold steel tonsillectomy versus diathermy, monopolar cautery, coblation, or harmonic scalpel techniques, but none has shown a significant difference in postoperative hemorrhage rates among techniques.
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Other studies have focused on comparison of IT and TT with respect to postoperative complications such as hemorrhage.23,25,26,28,44–50 Three large retrospective case series have shown a significantly lower rate of postoperative bleeding for IT compared with TT.44,47,49 However, most prospective trials fail to demonstrate a significant difference in postoperative hemorrhage between IT and TT,23,25,26,28,45,46 although one trial reports a significantly lower intraoperative blood loss with IT.45 SDB and Other Postoperative Concerns in Tonsillectomy
With SDB being the most common indication for tonsillectomy, postoperative monitoring for possible residual SDB is an important consideration. Before surgery, caregivers must be counseled that tonsillectomy is not curative in all cases of SDB in children, especially in children with obesity, and further treatment may be required after surgery.2 Clinical guidelines do not recommend routine polysomnography after tonsillectomy in children with SDB. When SDB or related comorbid conditions, such as growth retardation, poor school performance, enuresis, or behavioral problems, have been the indication for surgery, SDB is considered cured when the caregiver reports that symptoms are resolved postoperatively. In these cases, postoperative polysomnography is deemed unnecessary, but substantial evidence for this assumption is lacking. Any postoperative report of continuing symptoms of SDB should be taken seriously and indicates the need for further evaluation, including consideration of formal polysomnography.2 A recent systematic review does recommend postoperative polysomnography for children with perioperative evidence of moderate to severe OSA, obesity, craniofacial anomalies, and neurologic disorders.50 WHAT THE EVIDENCE INDICATES
Tonsillectomy is a safe surgical procedure performed on a large scale, most commonly for SDB and recurrent throat infections. The positive effect of tonsillectomy has been established for severely affected children with recurrent throat infections in a randomized controlled trial but could not be shown for children who were less severely affected (grade B evidence).8,9 A systematic review of cohort studies and a few case series found tonsillectomy to be an effective treatment for SDB (grade B–C evidence).6 Polysomnography is the gold standard for diagnosing SDB, but guidelines do not recommend that polysomnography be performed routinely preoperatively in children with suspected SDB and tonsil hypertrophy. Polysomnography is recommended in children with specific comorbidities based on results from observational studies (grade C evidence).5 In children without comorbidities but an uncertain need for surgery or discordance between history and examination, preoperative polysomnography should be performed (grade C evidence).5 In an attempt to reduce postoperative hemorrhage rates, several tonsillectomy techniques have been developed, but systematic reviews of randomized controlled trials have thus far not provided evidence of such a reduction using any particular technique (grade A evidence).40,41 Many randomized controlled trials have compared various newer and conventional TT techniques but could not demonstrate differences in postoperative pain (grade B evidence).19–22 Studies comparing TT and IT show faster recovery and pain reduction in patients treated with IT but no significantly lower risk of postoperative bleeding (grade B evidence).23,25,26,28,45,46,48 Retrospective case series, however, do show a significantly lower postoperative bleeding rate for IT (grade C evidence).44,47,49 Evidence grades and conclusions are summarized in Table 1.
Table 1 Conclusions and grades of evidence for tonsillectomy References
Description
n
Level of Evidence
Evidence Grade
Effects of tonsillectomy
8
Parallel randomized and nonrandomized clinical trials Parallel randomized and nonrandomized clinical trials
187
1b
B
515
1b
B
6
Systematic review and meta-analysis of randomized controlled trials and observational studies
1097
2a
B–C
5
Clinical practice guideline–based observational studies Clinical practice guideline–based on observational studies
246
2b–3b
C
723
2b
C
40,41
Systematic review of two randomized controlled trials
254
1a
A
44,47,49
Retrospective case series with chart review
5812
4
C
19–22
Prospective randomized controlled trials
362
1b
B
23,25,26,28,45,46,48
Prospective randomized controlled trials
842
1b
B
8,9
Preoperative polysomnography
5
Postoperative hemorrhage
Postoperative pain
Conclusion Tonsillectomy reduces throat infections in severely affected children Tonsillectomy does not reduce throat infections in less severely affected children Tonsillectomy is an effective treatment for sleep-disordered breathing Polysomnography is recommended in children with specific comorbidities Polysomnography is recommended in children without specific comorbidities if uncertain need for surgery or discordance between history and examination No differences in postoperative hemorrhage rates are seen between TT techniques IT might be associated with a lower risk of postoperative bleeding No differences in postoperative pain rates are seen between TT techniques IT is not associated with a lower rate of postoperative pain
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Category
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CRITICAL POINTS
Although a large amount of literature is available and clinical guidelines exist, certain gaps in knowledge remain about perioperative management for tonsillectomy in children. Large, multicenter, prospective, randomized, controlled trials are needed on the effect of tonsillectomy on recurrent throat infections and SDB. Outcome measures should focus on not only recurrence of disease but also quality of life and school performance as indicators of well-being. Although a randomized controlled trial has shown reduction of throat infections after tonsillectomy in severely affected children, this effect in not seen in milder cases or for a postoperative period for more than 2 years.8,9 Because the effect of tonsillectomy on throat infections was shown in a single study conducted in 1984, additional, newer, randomized, controlled trials may be needed to confirm these findings. Regarding SDB as an indication for surgery, certain topics must be addressed in more detail. No consensus exists on indications for a preoperative polysomnography in children without comorbidities. Currently, physicians are recommended to advocate for polysomnography in patients with SDB without comorbidities if the need for surgery is uncertain or in the presence of discordance between symptoms and physical examination. Future studies on polysomnography for SDB might be able to specify these rather wide criteria. Because some children may lack access to a sleep laboratory or have difficulty sleeping in a foreign environment, studies are need to evaluate PM. PM studies should focus on which parameters should be measured to replicate laboratory findings and accurately predict which children are at risk for postoperative complications. To the same extent, indications for postoperative polysomnography for SDB after tonsillectomy must be specified and studied further. With obesity rates increasing worldwide, a subject of growing concern is the management of obese children with SDB. A previous meta-analysis of four studies showed success rates of 10% to 20% for tonsillectomy for SDB in obese children,7 whereas the resolution reported in normal-weight children is around 70% to 80%.51 This discrepancy warrants future investigation of the extent to which obesity plays a role in failure to respond after tonsillectomy for SDB, and determination of the exact role of tonsillectomy in obese children. Currently, guidelines do not recommend specific tonsillectomy techniques. Although a large body of literature discusses various TT techniques that differ mainly in the instruments used, no substantial evidence exists for a general benefit of one instrument over another. The development of IT, which represents a different surgical strategy rather than a different instrumental technique, may be a field of further study that could eventually lead to new recommendations. Several studies have established benefits of IT over TT with respect to postoperative recovery and pain.23,25,26,28,45,46,48 The finding of significantly lower postoperative bleeding rates for IT in retrospective case series44,47,49 warrants further investigation and confirmation in prospective trials, but might hold the promise of future recommendations for surgical technique. Specific studies are needed on postoperative management after IT in patients in the younger age group (age<3 years) to confirm previous findings.38 If positive, these studies may influence recommendations on inpatient versus outpatient surgery.
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REFERENCES
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38. Bent JP, April MM, Ward RF, et al. Ambulatory powered intracapsular tonsillectomy and adenoidectomy in children younger than 3 years. Arch Otolaryngol Head Neck Surg 2004;130(10):1197–200. 39. Windfuhr JP, Chen YS, Remmert S. Hemorrhage following tonsillectomy and adenoidectomy in 15,218 patients. Otolaryngol Head Neck Surg 2006;132(2): 281–6. 40. Pinder DK, Hilton MP. Dissection versus diathermy for tonsillectomy. Cochrane Database Syst Rev 2001;(4):CD002211. 41. Burton MJ, Doree C. Coblation versus other surgical techniques for tonsillectomy. Cochrane Database Syst Rev 2007;(3):CD004619. 42. Neumann C, Street I, Lowe D, et al. Harmonic scalpel tonsillectomy: a systematic review of evidence for postoperative hemorrhage. Otolaryngol Head Neck Surg 2007;137(3):378–84. 43. Leinbach RF, Markwell SJ, Colliver JA, et al. Hot versus cold tonsillectomy: a systematic review of the literature. Otolaryngol Head Neck Surg 2003;129(4): 360–4. 44. Solares CA, Koempel JA, Hirose K, et al. Safety and efficacy of powered intracapsular tonsillectomy in children: a multi-center retrospective case series. In J Pediatr Otolaryngol 2005;69(1):21–6. 45. Hultcrantz E, Ericsson E. Pediatric tonsillotomy with the radiofrequency technique: less morbidity and pain. Laryngoscope 2004;114(5):871–7. 46. Korkmaz O, Bekas D, Cobanoglu B, et al. Partial tonsillectomy in children with obstructive tonsillar hypertrophy. Int J Pediatr Otorhinolaryngol 2008;72(7): 1007–12. 47. Gallagher TQ, Wilcox L, McGuire E, et al. Analyzing factors associated with major complications after adenotonsillectomy in 4776 patients: comparing three tonsillectomy techniques. Otolaryngol Head Neck Surg 2010;142(6):886–92. 48. Chang KW. Intracapsular versus subcapsular coblation tonsillectomy. Otolaryngol Head Neck Surg 2008;138(2):153–7. 49. Schmidt R, Herzog A, Cook S, et al. Complications of tonsillectomy: a comparison of techniques. Arch Otolaryngol Head Neck Surg 2007;133(9):925–8. 50. Aurora RN, Zak RS, Karippot A, et al. Practice parameters for the respiratory indications for polysomnography in children. Sleep 2011;34(3):379–87. 51. Mitchell RB. Adenotonsillectomy for obstructive sleep apnea in children: outcome evaluated by pre-and postoperative polysomnography. Laryngoscope 2007; 117(10):1844–54.
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