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TONSILLECTOMY AND ADENOIDECTOMY
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PEDIATRIC OTOLARYNGOLOGY
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TONSILLECTOMY AND ADENOIDECTOMY Changing Indications Ellen S. Deutsch, MD, FAAP, FACS
Every pediatrician has wrestled with the question of appropriate criteria for recommending tonsillectomy, adenoidectomy, or both for an individual child, and each develops a personal algorithm for decision making. Multiple factors, both mundane and complex, influence this decision. Rigidly structured criteria are tempered by the anecdotal experiences of the physician and the family and a lack of universally accepted criteria. Both advocates and detractors make claims about the indications, efficacy, and risk of tonsillectomy, with lesser controversy surrounding adenoidectomy. Tonsillectomy was described 3000 years ago in Hindu writings’, 45, 63 and again 2 millenia ago by Celsus and Paul of Aegir1a.4~.65 The procedure involved scraping the mucous membrane with a finger and enucleating the tonsil.“ Adenoidectomy may have first been performed in the late 1800s, when Meyer of Copenhagen suggested that adenoid vegetations were responsible for impaired hearing and nasal symptoms.65 In the first half of this century, great enthusiasm existed for tonsillectomies, which were considered by some to be a ”public health measure,”63and they were performed for minimal symptomatology. Bake? describes an incident occurring in about 1920:
”. . . The doctors had coolly descended on the school, taken possession, lined the children up, marched them past, taken one look down each child’s throat, and then two strong arms seized and held the child while the doctor used his instruments to reach down into the throat and rip out whatever came nearest to hand, leaving the boy or girl frightened out of a year‘s growth and bleeding ~~~
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From the Department of Pediatric Otolaryngology, St. Christopher’s Hospital for Children, Philadelphia, Pennsylvania PEDIATRIC CLINICS OF NORTH AMERICA
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VOLUME 43 * NUMBER 6 DECEMBER 1996
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savagely. No attempt at psychological preparation, no explanation to the child or warning to the parents. . . . It was an outrage-as cruel and as stupid as an initiation ceremony in an African tribe." Skepticism about the appropriate indications for tonsillectomy developed in the next few decades. Paradise65credits this to (1) the natural decline in the incidence of upper respiratory infections in children with age, (2) an increased risk for poliomyelitis after tonsillectomy prior to the availability of an effective vaccine, (3) the development of antimicrobial agents for treating upper respiratory infections, and (4) studies purporting that tonsil and adenoid surgery was ineffective. The number of tonsillectomies performed annually peaked at 1.4 million in 1959 and then declined.63 Although the total number of tonsillectomies has decreased, the percentage performed for upper airway obstruction has increased.**In the 1960s, reports described patients with serious sequelae of upper airway obstruction caused by adenotonsillar hypertrophy.'", *l, 36, 48, 60, 63, 87 Most upper airway obstruction in children is caused by adenotonsillar hypertrophy, and most symptoms are reversible after relief of the upper airway obstruction, usually by tonsillectomy, adenoidectomy, or both.44,63, 87*98 Since then, the pendulum of public and professional opinion concerning tonsillectomy and adenoidectomy continues to swing between enthusiasm and condemnation.
INDICATIONS FOR TONSILLECTOMY AND ADENOIDECTOMY
The indications for tonsillectomy and adenoidectomy overlap but are not identical (Table 1).
Table 1. INDICATIONS FOR TONSILLECTOMY AND/OR ADENOIDECTOMY indications
Tonsillectomy
Adenoidectomy
Definite indications Obstructive sleep apnea Tonsil or adenoid hypertrophy with upper airway obstruction Suspicion of malignancy Hemorrhagic tonsillitis Otitis media (see text) Failure to thrive* Speech abnormalities* Eating and swallowing disorders* Dental malocclusion* Orofacial growth abnormalities' Sinusitis*
+ + + + Not an indication + + + + +
+
Relative Indications Recurrent infections (see text) Streptococcus carrier Peritonsillar abscess Halitosis
+
See text
?
+ + + +
*If due to, or exacerbated by, adenotonsillar hypertrophy.
+ + Not an indication +
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Recurrent Throat Infections
Recurrent throat infections are generally accepted as an indication for tonsillectomy, adenoidectomy, or both; however, there is no absolute consensus as to how many infections constitute too many infections. The American Academy of Pediatrics (AAP) advises parents that surgery is a reasonable option for children with ”many severe sore throats.”94The American Academy of OtolaryngologyHead and Neck Surgery quantifies three or more infections per year as an adequate indication for surgery. A series of studies from the Children’s Hospital of Pittsburgh demonstrated a statistically significant decrease in the number of episodes of sore throats compared with controls following tonsillectomy in children with tonsillitis, pharyngitis, or tonsillopharyngitis that had occurred at least three times per year for 3 years, five times per year for 2 years, or seven times in 1 year.65Paradise reports that ”undocumented histories of recurrent throat infection do not validly forecast subsequent experience and hence do not constitute an adequate basis for subjecting children to tonsillectomy.”68 Chronic tonsillitis, persisting for at least 3 months, and chronic adenoiditis are also potential indications for surgery; the latter can manifest with postnasal drainage and chronic cough.36,45, 63, 65 Tonsillar crypt debris may be mistaken for chronic tonsillitis; in a cooperative patient this can be expressed and thereby “cured” in the office. Obstructive Sleep Apnea
Obstructive sleep apnea (OSA) caused by adenotonsillar hypertrophy constitutes a definite indication for surgery.19,63, 65, 94 Some of the manifestations and complications of severe OSA are now classic: cor pulmonale, right ventricular hypertrophy, congestive heart failure, alveolar hypoventilation, pulmonary hypertension, failure to thrive, pulmonary edema, cardiomegaly, permanent neurologic damage, and even death.’O, 36, 37, 48, 87 In 1965, Noonan@ reported reversible cor pulmonale caused by adenotonsillar hypertrophy. In 1988, Sofer reported several children with OSA-related respiratory distress, pulmonary edema and cor pulmonale with severe right ventricular and right atrial dilatation and reduced right ventricular ejection fraction. All children improved following removal of hypertrophied tonsils, adenoids, or b0th.8~Pasterkamp reported a child with Arnold-Chiari malformation and syringomyelia whose intermittent increased intracranial pressure resolved after removal of hypertrophied tonsils.7o Even Arnold; who states that “every attempt should be made to postpone the operation” in children 2 to 3 years of age, considers ”severe aerodigestive tract obstruction” to be an “absolute indication” for tonsillectomy. There is no universally accepted definition of obstructive upneu. Some investigators use lack of airflow despite continued respiratory effort for 6 seconds, 8 seconds, 10 seconds, 15 seconds, or 2.5 breaths to signify obstructive a ~ n e a . * ~ , 27, 73 Some criteria are derived from adult criteria and some from criteria for central apnea more often found in neonates. These criteria are not necessarily applicable to children older than neonates. Even with a working definition of OSA, detection is not always straightforward, and both history and physical examination must be carefully evaluated. Sometimes the physician does not ask about signs or symptoms of o b s t r ~ c t i o n . ~ ~ Often the physician does not witness the most severe manifestations because they occur during sleep. Sometimes parents underestimate or misinterpret their child’s symptoms. Some consider snoring normal because it is the baseline state
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of the or of another family member; some incorrectly ascribe the airway symptoms to constant colds, allergy, or asthma. Demonstrating the sounds of obstruction, snoring, snorting, gasping, or catching up after an obstructive pause in breathing helps parents recognize these manifestations in their children. Although some children with OSA are obese and "Pickwickian" like typical adults with OSA, many children with OSA are neither obese nor hypersomnolent. In fact, OSA can cause failure to thrive, short stature, and poor growth.5,24.44. 48. 6 5 90 Manifestations of upper airway obstruction include noisy breathing, a lack of lip seal, chronic mouth breathing, nasal obstruction, rhinorrhea, nasal congestion, halitosis, otitis media, hyponasality, or speech distortion.*,9, 73 Children without airway obstruction should breathe primarily through the nose, comfortably and quietly. Some manifestations of OSA are more subtle. Snoring is present but is not necessarily loud. Nocturnal coughing, choking, and restless sleep may occur? Chronic sleep disruption may cause behavioral abnormalities, including poor school performance, daytime hypersomnolence, and learning disabilities.'0,20, 90 Adults with OSA have higher automobile crash rates and worse driving simulator performancez6;this may be applicable to teenagers. Kravath describes children with apparent mental retardation who appeared more intelligent after surgery.48Sleep disturbance also may contribute to enuresis20, and night terr o r ~ Other . ~ ~ manifestations include pectus exca~atum,4~, 6o polycythemia, and systemic hypertension.'" Brouillette and colleagues12 advocate an OSA score based on the parent's evaluation of (1)the child's difficulty in breathing during sleep, (2) apnea, and (3) snoring that accurately predicts the presence or absence of OSA. The tonsils and adenoids are largest in relation to the pharynx from approximately 2 to 7 years of age.7Bluestone8 suggests using the term obstructive rather than hypertrophied because both the size of the tonsils and adenoids and the size of the pharynx in which they are contained must be considered. Adenotonsillar hypertrophy is most often seen in young, otherwise normal children fewer than 3 years of age.6oTonsils may appear relatively larger if the child gags during the examination, moving both tonsils toward the midline. On the other hand, if the inferior poles of the tonsils are not visualized, the full extent of hypertrophy may not be appreciated. Direct evaluation of adenoids is difficult in routine office examinations. Flexible fiberoptic endoscopy or lateral neck radiographs may be useful. Adenotonsillar Hypertrophy with Upper Airway Obstruction
Hypopnea may occur when airflow is impaired but not completely obstru~ted.~* Clinically significant obstructive hypopnea with partial upper airway obstruction (i.e., increased respiratory effort with decreased airflow) is more common in children than is OSA with complete obstruction (i.e., increased respiratory effort without any airflow).58, 73, 74, 79 Adult criteria for OSA based on the number of apneic events with complete airway obstruction per hour99fails to identify the majority of children with serious upper airway obstruction during sleep.79Prolonged partial airway obstruction during sleep may result in significant hypercarbia and hypoxemia," as well as daytime somnolence, enuresis, hypertension, and decreased school performance.", 38, 51, 53, 55, 56, Even children with adenotonsillar hypertrophy who do not have oxygen desaturation can have significant respiratory resistive load during sleep with cardiac abnor-
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malities that improve after surgery.40Suggestive findings include intermittent paradoxical breathing, snorting, or arousals.79 Most upper airway obstruction in children is caused by adenotonsillar hypertrophy. Most symptoms are reversible after relief of the upper airway obstruction, usually by tonsillectomy or adenoidectomy.44,63, 87, 98 Improvement in mouth breathing, behavioral problems, enuresis, poor weight gain, right ventricular strain, ability to mentally concentrate, disordered breathing, hypercarbia, and hypoxemia have been documented following adenotonsillectomy in patients with upper airway obstruction from adenotonsillar hypertrophy.’, 58, 74, 95 Ahlqvist-Rastad and colleagues’ reported that ”in many families, the psychosocial situation improved greatly after surgery. Disturbed sleep was a problem also for the parents who often did not dare to sleep themselves in order to cope with their child’s apnea.” Adenotonsillar hypertrophy with upper airway obstruction, even without frank OSA, is an indication for tonsillectomy or adenoide~tomy.’~, SJ.94 Suspicion of Malignancy
Malignancies, particularly lymphomas, may present as asymmetric adenotonsillar hypertrophy. Biopsy (tonsillectomy) is indicated for lesions suspicious for neoplasia? 19, 65 with the exception of particular suspected neoplasms, such as juvenile nasopharyngeal angiofibroma, which require individualized management protocols.46 Speech Abnormalities
Hyponasal speech and hypemasal speech are confused by parents and practitioners. Hyponasal speech can be approximated by pinching one‘s nostrils and speaking. Parents sometimes refer to it as ”nasal” speech or state that the patient is ”talking through his nose,” but the abnormality actually results from a blockage of nasal airflow. If this blockage results from adenoid hypertrophy, it may be alleviated by adenoidectomy?,9, 63 Hypernasal speech results from an inability to prevent inappropriate airflow through the nasopharynx because of an inability to seal the soft palate against the posterior pharyngeal wall (Fig. 1). It may result from submucous or apparent cleft palate or from tonsillar hypertrophy?, Tonsillar hypertrophy also may cause a ”hot potato” voice with mushy, muffled, or garbled ~ p e e c h . ~ ~ , ~ Eating and Swallowing Disorders
Dysphagia resulting from adenotonsillar hypertrophy is a definite indication for surgery?, 19, ffi,94 Orofacial Growth Abnormalities and Dental Malocclusion
Adenoid fucies describes the open-mouth posture, long face, and open anterior bite that may result from upper airway obstruction, particularly from adenoid hypertr~phy.~, 39, 43 When adenoid or tonsillar hypertrophy is the cause, surgery is i n d i ~ a t e d l ffi,94 ~ , ~and , is particularly effective in normalizing malocclusion when performed before the child is 6 years of
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Figure 1. Lateral neck radiograph demonstrating changes in soft palate location with phonation. A, During quiet respiration, the soft palate allows air passage through the nasopharynx. B, During phonation, the soft palate is elevated, occluding the nasopharynx.
Failure to Thrive
Case reports beginning in the 1980s document adenotonsillar hypertrophy as a reversible cause of failure to thrive.24,42 Streptococcus Carriers
Most asymptomatic carriers of group A beta hemolytic streptococcus (GABHS) do not require further treatment.7' Eradication of GABHS carriage
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might be desirable in children with recurrent GABHSpositive episodes of pharyngitis and those with a history of rheumatic fever in the child or a family member.66Eradication may be accomplished by antibiotic therapy66or, infrequently, adenotonsillectomy. INDICATIONS FOR TONSILLECTOMY (WITHOUT ADENOIDECTOMY) Hemorrhagic Tonsillitis
Tonsillar hemorrhage during acute tonsillitis is an indication for a tonsillectomy to control bleeding?, 65 Peritonsillar Abscess
Peritonsillar abscess is a controversial indication for tonsillectomy.8,19, 45, 63, If a tonsillectomy is performed, some surgeons proceed with the tonsillectomy during the abscess incision and drainage (i.e., quinsy tonsillectomy)8,45* 63 because a portion of the dissection already has been accomplished by the abscess, post-infection scarring may make a delayed tonsillectomy more difficult, and another episode of anesthesia may be avoided. Others wait until the acute inflammation has subsided to perform a tonsillectomy (interval tonsillectomy): 63 which may decrease the risk for infection or hemorrhage. Recurrent peritonsillar abscess is a more definitive indication for ton~illectomy.6~ 65,
INDICATIONS FOR ADENOIDECTOMY (WITHOUT TONSILLECTOMY) Otitis Media
Adenoidectomy contributes to the management of otitis media and is discussed in detail elsewhere in this issue.7,9, 17, 19, 20, 3133, 59, 63, 69, 94 The adenoids are located adjacent to the eustachian tube orifices in the nasopharynx.33Adenoids are thought to contribute to the pathophysiology of otitis media by harboring bacteria.33Adenoidectomy hastened resolution of otitis media and decreased the incidence of recurrence compared with controls in a study of 4- to 8-year-old chi1dre1-1.~~ Sinusitis
The relationship between adenoid hypertrophy or chronic adenoid infection and sinusitis has not been rigorously studied. The clinical findings in each of these conditions are similar. Adenoid hypertrophy causing stasis of secretions may mimic sin~sitis,5~ as can adenoid infection. It is reasonable, but unproven, that adenoid infection or hypertrophy contributes to sinusitis? 9, 20, 33, 63 just as adenoid infection or hypertrophy contributes to otitis media. The symptoms overlap, and differentiating the diagnoses on clinical grounds may be difficult. LuskM considers it prudent to remove enlarged obstructive adenoids before proceeding to sinus surgery in children failing medical management.
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Special Circumstances
Children with congenital or acquired craniofacial abnormalities, including Down syndrome, achondroplasia, or mucopolysaccharide storage disorders, may have upper airway obstruction with lesser degrees of adenotonsillar hypertro~ h y .9, ~44, ,51 In these patients, spasticity, hypotonicity, redundant soft tissue, and narrowed bony confines of the airway may be present. Upper airway obstruction should be considered in children with unexplained pulmonary hyperten~ion.5~ In children with neuromuscular disease, adenotonsillar hypertrophy may compound the upper airway dysfunction that results from hypotonia or spast i ~ i t y .35,~51, , 72 Aspiration of pharyngeal secretions during snoring and interrupted breathing may aggravate lower respiratory disease." The AAP advises consideration of adenotonsillectomy for enlarged, tender cervical nodes if present for 6 months and unresponsive to antibiotic therapy.94Halitosis and dysgeusia may result from chronic infection and may be alleviated by surgery.19,36, 63, Children undergoing tonsillectomy for OSA are generally younger than children undergoing tonsillectomy for recurrent infection.82Hodges and Wail~o*~ state that "early adenotonsillectomy in children with failure to thrive, enlarged tonsils and associated obstructive apnoea will lead to dramatic improvement in weight gain and general well-being." The youngest child in their case series was 23 months of age. Berkowitz and Zalza16 studied tonsillectomy in children fewer than 3 years of age and concluded that "the decision to perform tonsillectomy should be made without regard to the age of the patient, provided that surgery is carried out for appropriate indications and is performed in an appropriate institution." Hot tonsillectomy, a tonsillectomy performed during an acute infection, may be indicated during incision and drainage of a peritonsillar abscess.8,45,63 Occasionally, children with acute onset or exacerbation of upper airway obstruction during an episode of infectious mononucleosis fail conservative management and require acute adenotonsillectomy to alleviate the obstruction (Fig. 2). Improvement in quality of life is difficult to quantify. Factors to be considered include the child's discomfort, inconvenience, and impact of school absences; and the parents' anxiety, time missed from work, inconvenience, and cost of office visits and medications.63,65 These factors should be balanced against the anxiety, risks, discomfort, and costs involved in surgery.65,66
Alternatives to Adenotonsillectomy
Alternative treatments for upper airway obstruction from adenotonsillar hypertrophy that have been proposed include antimicrobial management, allergy management in atopic patients, intranasal or systemic anti-inflammatory agents, supplemental oxygen, nasal continuous or bilevel positive airway pressure, nasopharyngeal intubation, craniofacial operations for specific conditions, mandibular advancement and hyoid resuspension, uvulopalatopharyngoplasty, weight loss in obese children, and tracheotomy8,lo,20, 44, 63, 65, 73, 89 (Fig. 3). These options are of varying effectiveness and appropriateness, and factors, such as compliance and potential side effects, must be considered. Antibiotics, steroids, and nasopharyngeal intubation may be of use in the management of acute upper airway obstruction, such as when adenotonsillar hypertrophy is exacerbated by acute infection. The use of antibiotics for prophylaxis of recurrent tonsillitis is not supported by the literature.*,63, 66
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Figure 2. Adenotonsillar hypertrophy exacerbated by infectious mononucleosis causing OSA. A, Lateral neck radiograph of 5-year-old boy with massive enlargement of adenoids obstructing the nasopharyngeal airway. Retropharyngeal soft tissue is also thickened. B, Axial CT scan of same patient demonstrating enlarged adenoids pushing the soft palate forward. C,Female adolescent with tonsillar hypertrophy exacerbated by infectious mononucleosis.
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Figure 3. Obese 5-year-old boy with obstructive sleep apnea. A, Bilevel positive airway pressure did not prevent oxygen desaturation. 8,Hypertrophied tonsils prior to tonsillectomy. Episodes of oxygen desaturation resolved after tonsillectomy.
Contraindications to Surgery
Uncorrected coagulopathy is a contraindication for both tonsillectomy and adenoidectomy.2l.33, 65 Appropriate anesthetics must be used in patients at risk for malignant hyperthermia or with intolerance of certain agents. Overt and submucous cleft palate and related manifestations, such as bifid uvula, hypernasal voice, velopharyngeal insufficiency, and nasal regurgitation, are relative contraindications to an adenoidectomy? 33, 36, 65 although a partial adenoidectomy may be advantageous in selected patients. The discrete risks of surgery must be compared with the morbidity and risks of not having surgery. Laboratory Studies
Diagnostic laboratory studies are of limited value, except in special circumstances.~Infectious mononucleosis can be confirmed by a complete blood count with a ,differential including atypical lymphocytes or a positive heterophile antibod agglutination test ("mon~spot").~~ Throat cultures are more reliable than "r , pid strep tests" in evaluating the presence of GABHS.76 Lateral neck radiographs are useful in evaluating adenoidal hypertrophy8, 16, 29 and can be of help in evaluating tonsillar size if the clinical examination is difficult or equivocal (Fig. 4).A "limited" sinus CT scan (i.e., four or five coronal images including each of the sinuses) may be useful to evaluate sinusitis. The scout view includes the adenoids. Flexible fiberoptic nasopharyngoscopy allows evaluation of the adenoidsz0 and the palate and velopharyngeal functi0n.4~Voice and palate function also may be evaluated by eliciting the speech sounds that are affected by velopharyngeal abnormalities. Hypernasality may be demonstrated by having the child say "puppy," "Bobby, " "pig," "ssssoap," or counting from 60 to 70 while the physician listens for air escape.21Hyponasality can be demonstrated by having the child say "nine, nine, nine"36 or "bring me some bananas." In complicated patients, a formal speech and language evaluation may be indicated.
B:
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Figure 4. Lateral neck radiograph of extremely large tonsils in a child with OSA and failure
to thrive.
Beginning in the 1980s, polysomnograms (PSGs) have been advocated for evaluation of upper airway obstr~ction.~~, TI Despite disagreement on exact definitions of apnea and even less consensus on defining hypopnea,79PSGs are considered the gold standard for evaluation of OSA. To differentiate obstructive from central apnea, a PSG must include at least four parameters: (1)chest wall motion for respiratory effort, (2) nasal airflow, (3) heart rate, and (4) pulse oximetry (Fig. 5). More complex studies may include a pH probe and electroencephalogram or electromyogram. PSGs may be useful when there is a discrepancy between the patient’s history and findings on clinical examination or when other mitigating factors are present, such as very young age (<2 years old); or neurologic, cardiac, hematologic, craniofacial, or pulmonary In part because of the expense of PSGs (as much as $1500),63alternative methods of evaluation have been proposed. Sleep sonography may be used to assess irregularities of respiration but cannot differentiate central from obstructive apnean, 73 and requires computer-assisted analysis. Audio tapes have been advocateds and might, in theory, assess both episodes of apnea and quality of breathing but have not been substantiated in the literature. Sleep videofluoroscopy; multisensor manometry; or nasal, tracheal, or laryngeal sound recordings all have been advocated but are not commonly used.ls,2 5 ~ 96, lo2 49r
Perioperative Laboratory Studies
Because bleeding is one of the more serious potential complications of adenotonsillectomy, a baseline blood count is reasonable. Preoperative screening for coagulopathy may be limited to a detailed history of the patient and the patient’s family.13,36 If risk factors are identified, further studies may include prothrombin time, partial thromboplastin time, bleeding time, or a hematology consultation. Postoperative laboratory studies are not routinely required.
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Tt;emistor
Figure 5. Four-channel polysomnogram tracing demonstrating OSA. Arrow indicates episode of decreased nasal airflow (thermister) and decreased oxygen saturation despite continued respiratory effort indicated by chest wall motion (impedance).
Surgical Techniques
A variety of techniques are used for removal of tonsils and adenoids. The choice is made by the individual surgeon. Most pediatric otolaryngologists use a mirror to visualize the nasopharynx during adenoide~tomy~ to ensure complete removal. Many pediatric otolaryngologists use a Bovie cautery to perform the tonsillectomy,h which allows precise dissection along the tonsillar capsule and minimal bleeding. Typically, blood loss in a child fewer than 3 years of age is less than 20 mL. Postoperative Course
After adenotonsillectomy, parents are warned to expect that their child will have a significant sore throat, halitosis, possibly a stiff neck, and sometimes referred otalgia. Emesis is uncommon after the first 24 hours. If the parents inspect the tonsillar fossae, they will see a shaggy gray eschar, which may give the mistaken impression of infection (Fig. 6). Infection in the tonsillar fossae is uncommon and is manifested by pain and erythema around the margins of the tonsillar pillars. Amoxicillin given for 7 days postoperatively ameliorates postoperative pain and Sucralfate has been shown to decrease postoperative pain in adults.= Strenuous activity is restricted for 2 weeks. A narcotic analgesic combined with acetaminophen is often required, although theoretic concerns exist about the use of respiratory depressants in patients with disordered respiratory con-
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Figure 6. Typical tonsillar fossae eschar 4 days after tonsillectomy.
trol. Analgesics that interfere with coagulation, such as ibuprofen, should be avoided. Parents are instructed to contact their surgeon for inability to tolerate liquids, severe pain, fevers of more than 101"F, or any bleeding. Bleeding should be reported immediately; the amount of blood visualized may be only a portion of the actual blood Postoperative Complications
Respiratory distress and airway obstruction may occur after adenoidectomy or tonsillectomy, particularly in children who are fewer than 3 years of age, who develop significant palate or tongue edema during the procedure or who have other risk factors for airway obstruction, including OSA, neuromuscular disorders, obesity, and craniofacial an~malies.~,75,82* 97 Severe OSA can disrupt respiratory control; this persists temporarily after relief of the obstruction.", 82 Management options include systemic steroids, supplemental oxygen, continuous or bilevel positive airway pressure, nasopharyngeal airway, endotracheal intubation, and intensive supportive care.R*8o Immediate postoperative hemorrhage occurs within the first 24 hours of tonsillectomy in a small percentage of patients and is thought to be related to surgical t e c h n i q ~ e . ~85,86 ~ , ~Delayed ~ , ~ , or secondary hemorrhage occurs in up to 3% of patients after tonsillectomy, generally within 2 weeks of surgery, and often without an identifiable cause.14,15, 22,41,45,100 If active bleeding or a clot is present in the tonsillar fossae, the child is returned to the operating room for 91 Aspirin%, 86 and other nonsteroiidentification and control of the bleeding dal anti-inflammatory agents increase the risk of postoperative hemorrhage and are not recommended for 2 weeks before and 2 weeks after surgery. The administration of antiemetics, such as ondansetron," and avoidance of morphine postoperatively decrease the incidence of postoperative emesis. Transient velopharyngeal insufficiency may occur after removal of a large adenoid or in patients with abnormal palate anatomy or function but usually resolves quickly.u Persistent velopharyngeal insufficiency may require speech therapy or a pharyngeal flap procedure.33Anesthetic complications, such as idiosyncratic reactions to anesthetic agents, cardiac arrhythmias, or malignant hyperthermia, are rare.ffi,78, 85 Mortality rates are difficult to obtain, because death is a rare complication of adenotonsillectomy. Reports include 330,000 (England, 1945-1965),1O0 20200,000
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(England, 1957-1961)," 10:84,000 (England, 1979),6O and 1:16,000 in the 1960s improving to 1:35,000 in the 1970s.3" It is reasonable to assume that the availability of better methods to control the airway, better anesthetic agents, and better postanesthetic monitoring and care will continue to decrease mortality.h,30 Other uncommon complications of tonsillectomy and adenoidectomy include nasopharyngeal stenosis, refractory torticollis or subluxation of the atlantoaxial joint, bacterial meningitis, or depressionP7r6s, 85 The belief that tonsil or adenoid surgery in children precipitates the development of asthma has not been tested in clinical studies.65The concern that tonsillectomy might predispose to the development of Hodgkin's disease seems to have been dispelled by later epidemiologic investigations.6s There is pressure from insurance companies to perform tonsillectomy on an outpatient basis. Many insurance carriers now refuse to reimburse for the additional costs of inpatient surgery.8zOvernight observation with appropriate monitoring is recommended for patients with craniofacial anomalies affecting the pharyngeal airway, failure to thrive, hypotonia, cor pulmonale, morbid obesity, previous upper airway trauma, severe upper airway obstruction, or chronic medical problems; and for patients concurrently undergoing a uvulopalatopharyngoplasty and children fewer than 2 to 3 years of age.62,*", 83, 93 Other factors, such as the distance to the patient's home, the reliability of the parents, or inclement weather, may appropriately influence the decision.*
AN ALGORITHM FOR EVALUATING PATIENTS WITH UPPER AIRWAY OBSTRUCTION
In a tertiary care pediatric hospital, most of the children the author evaluates for adenotonsillectomy have adenotonsillar hypertrophy with upper airway obstruction, and most are 5 years of age or younger. This algorithm is based on the author's professional training and clinical experience, and the author presents it as a starting point. The assessment begins informally on entering the examination room and greeting the family. Without attracting the child's attention to the process, and while the child is comfortable and not self-conscious, the quality of breathing should be evaluated. Is it quiet and comfortable or noisy and obstructed? Does the child sit with his or her mouth open? Does the child have a "long" or "adenoid" face? While obtaining the child's history, symptoms present during sleep and during the daytime should be determined. Obstructive symptoms that are present while the child is awake are often worse when the child is asleep. Is this a typical day (is the breathing always noisy, or does the child happen to have an upper respiratory tract infection on the day of the examination)? Does the child "always" have a "cold" or nasal congestion? Is the nose congested only occasionally or most of the time? Some parents incorrectly attribute upper airway obstruction to asthma. During sleep, does the patient snore? Does the child "work hard to breathe" or breathe comfortably during sleep? If the parent were to imitate the breathing sounds of the child, would the parent become exhausted? Some parents do not recognize snoring or obstructive pauses followed by "gasping" or "catching up" until they are demonstrated. Some parents become defensive when asked if their child "stops breathing" and are more comfortable with questions about breathing "pauses." Some do not consider their child's snoring significant be-
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cause the child or another family member snores chronically. Others may use the term "apnea," asking for details helps to elucidate their definition. Physical examination includes the ears, nose, oral cavity, and neck. The ears are evaluated for serous effusions; many children with upper airway obstruction have effusions. The nose is examined with a hand-held otoscope using a large ear speculum and barely entering the nasal vestibule. The mucosa usually appears a bit erythematous. Crusting suggests rhinorrhea or allergy. The floor of the nose should be examined. Purulence only along the floor may be coming from the adenoids. The inferior turbinate should be identified (the most anterior and inferior structure bulging medially from the lateral nasal wall). Boggy or hypertrophied inferior turbinates suggest congestion or obstruction. Cyanotic turbinates suggest allergy or obstruction. Clear rhinorrhea around the turbinates suggests allergy. The inferior turbinate should be examined, starting from the area that protrudes the closest to the nasal septum and sweeping upward along the superior surface. Following this surface superiorly and laterally leads to the middle meatus, which is the space between the inferior turbinate and the middle turbinate and is the area where most of the sinuses drain. The middle turbinate is located more posteriorly, as well as superior to, the inferior turbinate. Purulence or congestion in the middle meatus is suggestive of sinusitis. This region can be visualized by careful anterior rhinoscopy in many children. In the oral cavity, the entire tonsil sometimes may be seen by having the child stick his or her tongue out and say "ahhh." Often the dorsum of the tongue must be depressed to visualize the most inferior portion of the tonsils; this may be the largest part of the tonsil. If the child gags, the tonsils approach the midline and may appear falsely enlarged. The size of the tonsil must be considered in relation to the size of the pharynx in which it is contained. Necrotic-appearing tonsils with shaggy exudate are suggestive of infectious mononucleosis. Purulent or thick postnasal drainage may be appreciated dripping down the posterior pharyngeal wall from the nasopharynx. In the neck, massive, bilateral, enlarged, tender jugulodigastic lymph nodes accompanying acute tonsillitis are suggestive of infectious mononucleosis. Laboratory testing is individualized. If a child is to undergo tonsillectomy because of obstructive symptoms and tonsillar hypertrophy, the adenoids usually are removed without separately documenting their hypertrophy. If a child has obstructive symptoms without tonsillar hypertrophy, a lateral neck radiograph is used to confirm adenoid hypertrophy prior to adenoidectomy. Occasionally, a lateral neck radiograph is helpful to evaluate tonsil size in relation to the pharynx when direct examination is equivocal or difficult in an uncooperative child. If there is a history or suspicion of sinusitis, a limited sinus CT scan allows evaluation of both the sinuses and adenoids in one study. PSGs are obtained under the following circumstances: (1)when the parents are uncertain as to whether to proceed with surgery and request additional data; (2) when there is an increased risk for complications, such as a patient fewer than 2 years of age or a child with morbid obesity or neurologic or cardiac abnormalities; or (3) when a discrepancy exists between the history and the physical examination. The history may be suggestive of obstruction and the examination benign, or the history may be benign and the examination suggestive. An alternative method that gathers less quantitative information is to demonstrate and explain symptoms of obstruction to the parents and have them observe the child during sleep on several nights. Occasionally, a sleep tape is requested or is brought by the parents. The sampling obtained is limited and there are no standardized criteria for evaluation. In preparation for surgery, a baseline complete blood count is obtained.
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Postoperative hemorrhage is rare but can be severe. The family is specifically questioned about easy bruisability or bleeding problems in both the patient and other family members. If the history is negative, no further laboratory studies are obtained. If the history is mildly positive, such as epistaxis or easy bruisability, a partial thrombopastin time, prothrombin time, and bleeding time are obtained. If the history is strongly positive, such as another family member with a known coagulopathy, a hematology consultation is obtained. SUMMARY Obstructive sleep apnea and upper airway obstruction (even without complete apnea) from adenotonsillar hypertrophy is either occurring more frequently or is becoming better recognized. Tonsillectomy or adenoidectomy is indicated for these children. Most patients who would benefit from surgery can be identified by a thorough history and physical examination. Occasionally, additional methods of evaluation, such as lateral neck radiographs or polysomnograms, are helpful. The indications for tonsillectomy and adenoidectomy are varied. No review can cogently encompass all clinical scenarios. Tonsillectomy and adenoidectomy remain valuable procedures for carefully selected patients. References 1. Ahlqvist-Rastad J, Hultcrantz E, Svanholm H Children with tonsillar obstruction: Indications for and efficacy of tonsillectomy. Acta Paediatr Scand 77831, 1988 2. Arnold JE: Tonsils and adenoids. In Behrman RE, Kleigman RM, Nelson WE (eds): Nelson Textbook of Pediatrics, ed 14. Philadelphia, WB Saunders, 1992 3. Arnold JE, Allphin A L Sleep apnea in the neurologically impaired child. ENT J 72230. 1993 4. Baker SJ: Fighting for Life. New York, Macmillan, 1939, p p 140-141 5. Bate TWP, Price DA, Holme CA, et al: Short stature caused by obstructive apnoea during sleep. Arch Dis Child 59:78, 1984 6. Berkowitz RG, Zalzal GH: Tonsillectomy in children under 3 years of age. Arch Otolaryngol Head Neck Surg 116685, 1990 7. Bicknell P G Role of adenotonsillectomy in the management of pediatric ear, nose and throat infections. Pediatr Infect Dis J 13:S75, 1994 8. Bluestone C D Current Indications for Tonsillectomy and Adenoidectomy. Ann Otol Rhino1 Laryngol 101:58, 1992 9. Brodsky L Modern assessment of tonsils and adenoids. Pediatr Clin North Am 36:1551, 1989 10. Brooks LJ: Treatment of otherwise normal children with obstructive sleep apnea. ENT J 7277,1993 11. Brouillette RT, Fernback SK, Hunt CE: Obstructive sleep apnea in infants and children. J Pediatr 100:31, 1982 12. Brouillette RT, Hanson D, David R, et al: A diagnostic approach to suspected obstructive sleep apnea in children. J Pediatr 105:10, 1984 13. Burk CD, Miller L, Handler SD, et al: Preoperative history and coagulation screening in children undergoing tonsillectomy. Pediatrics 89:691, 1992 14. Capper JWR, Randall C: Post-operative haemorrhage in tonsillectomy and adenoidectomy in children. J Laryngol Otol 98363, 1984 15. Carmody D, Vamadevan T, Cooper S M Post tonsillectomy haemorrhage. J Laryngol Otol 96635, 1982 16. Cohen LM, Koltai PJ, Scott J R Lateral cervical radiographs and adenoid size: Do they correlate? ENT J 71:638, 1992
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17. Cotton RT The surgical management of chronic otitis media with effusion. Pediatr Ann 20:628, 1991 18. Cummiskev 1. Williams TC. KrumDe PE. et al: The detection and auantification of sleep apnei by tracheal so&d rec&dings. Am Rev Respir Dis 126:22?, 1982 19. Dana ST: 1995 clinical indicators compendium. Alexandria, VA: American Academy of Otolaryngology-Head and Neck Surgery; 1995 20. Demain JG, Goetz D W Pediatric adenoidal hypertrophy and nasal airway obstruction: Reduction with aqueous nasal beclomethasone. Pediatrics 95:355,1995 21. Deutsch ES, Isaacson GC: Tonsils and adenoids: An update. Pediatr Rev 1617,1995 22. Dey FL Late hemorrhage following tonsillectomy. Arch Otolaryngol87558, 1968 23. Eliaschar I, Lavie P, Halperin E, et a1 Sleep apneic episodes an indication for adenotonsillectomy. Arch Otolaryngol 106:492, 1980 24. Everett AD, Koch WC, Saulsbury FT: Failure to thrive due to obstructive sleep apnea. Clin Pediatr 26:90, 1987 25. Felman AH, Loughlin GM, Leftridge CA Jr, et al: Upper airway obstruction during sleep in children. Am J Roentgenol 133213, 1979 26. Findley LJ, Fabrizio MJ, Knight H, et al: Driving simulator performance in patients with sleep apnea. Am Rev Respir Dis 140:529,1989 27. Frank Y, Kravath RE, Pollak CP, et a1 Obstructive sleep apnea and its therapy: Clinical and polysomnographic manifestations. Pediatrics 71:737, 1983 28. Freeman SB, Markwell JK. Sucralfate in alleviating post-tonsillectomy pain. Laryngoscope 102:1242, 1992 29. Fujioka M, Young LW, Girdany BR Radiographic evaluation of adenoidal size in children: Adenoidal-nasopharyngealratio. Am J Roentgenol 133:401,1979 30. Gates GA, Folbre Tw: Indications for adenotonsillectomy: Commentary. Arch Otolaryngol Head Neck Surg 112:501, 1986 31. Gates GA, Avery CA, Prihoda TJ: Effect of adenoidectomy upon children with chronic otitis media with effusion. Laryngmope 9858, 1988 32. Gates GA, Cooper JC Jr, Avery CA, et a 1 Chronic secretory otitis media: Effects of surgical management. Ann Otol Rhinol Laryngol 138(suppl):2,1989 33. Gates GA, Muntz HR, Gaylis B: Adenoidectomy and otitis media. Ann Otol Rhinol Laryngol 101:24, 1992 34. Gluckman JL, Righi P D Inflammatory disease of the mouth and pharynx. In Bluestone CD, Stool SE, Kenna MA (eds): Pediatric Otolaryngology, ed 3, vol 2. Philadelphia, WB Saunders, 1996 35. Grundfist K, Berkowitz R, Fox L Outcome and complications following surgery for obstructive adenotonsillar hypertrophy in children with neuromuscular disorders. ENT J 48758,1969 36. Grundfast KM: Tonsil and adenoid disorders the method of Kenneth M. Grundfast, MD. In Current Therapy in Otolaryngology-Head and Neck Surgery. Toronto, BC Decker Inc, 1984 37. Grundfast KM, Wittich DJ Jr: Adenotonsillar hypertrophy and upper airway obstruction in evolutionary perspective. Laryngoscope 92650,1982 38. Guilleminault C, Eldridge FL, Simmons FB, et al: Sleep apnea in eight children. Pediatrics 58:23, 1976 39. Guilleminault C, Partinen M, Praud JP, et al: Morphometric facial changes and obstructive sleep apnea in adolescents. J Pediatr 114997, 1989 40. Guilleminault C, Winkle R, Korobkin R, et a 1 Children and nocturnal snoring: Evaluation of the effects of sleep related respiratory resistive load and daytime functioning. Eur J Pediatr 139:165, 1982 41. Handler SD, Miller L, Richmond KH, et al: Post-tonsillectomy hemorrhage: Incidence, prevention and management. Laryngoscope 961243, 1986 42. Hodges S, Wailoo MP: Tonsillar enlargement and failure to thrive. Br Med J 295:541, 1987 43. Hultcrantz E, Larson M, Hellquist R, et a1 The influence of tonsillar obstruction and tonsillectomy on facial growth and dental arch morphology. Int J Pediatr Otorhinolaryngol22125,1991 44. Hunt CE, Brouillette RT Disorders of breathing during sleep. In Chemick V, Kendig
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EL Jr (eds): Kendig’s Disorders of the Respiratory Tract in Children, ed 5. Philadelphia, WB Saunders, 1990 45. Kearns DB, Pransky SM, Seid AB: current concepts in pediatric adenotonsillar disease. ENT J 70:15, 1991 46. Kern EB: Nasal obstruction. In Meyerhoff WL, Rice DH (eds): Otolaryngology-Head and Neck Surgery. Philadelphia, WB Saunders, 1992 47. Klausner RD, Tom LWC, Schindler PD, et al: Depression in children after tonsillectomy. Arch Otolaryngol Head Neck Surg 121:105, 1995 48. Kravath RE, Pollak CP, Borowiecki B: Hypoventilation during sleep in children who have lymphoid airway obstruction treated by nasopharyngeal tube and T and A. Pediatrics 59365, 1977 49. Krumpe PE, Cummiskey JM: Use of laryngeal sound recordings to monitor apnea. Am Rev Res Dis 122:797, 1980 50. Levy AM, Tabakin BS, Hanson JS, et al: Hypertrophied adenoids causing pulmonary hypertension and severe congestive heart failure. N Engl J Med 277:506, 1967 51. Lind MG, Lundell BPW: Tonsillar hyperplasia in children: A cause of obstructive sleep apneas, CO, retention, and retarded growth. Arch Otolaryngol 108:650, 1982 52. Litman RS, Wu CL, Catanzaro FA: Ondansetron decreases emesis after tonsillectomy in children. Anesth Analg 78:478, 1994 53. Luke MJ, Mehrizi A, Folger GM, et al: Chronic nasopharyngeal obstruction as a cause of cardiomegaly, cor pulmonale, and pulmonary edema. Pediatrics 37762, 1966 54. Lusk Rp: Surgical modalities other than ethmoidectomy. J Allergy Clin Immunol 90538, 1992 55. Macartney FJ, Panday J, Scott 0:Cor pulmonale as a result of chronic nasopharyngeal obstruction due to hypertrophied tonsils and adenoids. Arch Dis Child 44585, 1969 56. Mangat D, Orr WC, Smith RO: Sleep apnea, hypersomnolence, and upper airway obstruction secondary to adenotonsillar enlargement. Arch Otolaryngol 103:383, 1977 57. Marcus CL, Keens TG, Bautista DB, et al: Obstructive sleep apnea in children with Down syndrome. Pediatrics 88:132, 1991 58. Mauer KW, Staats BA, Olsen K D Upper airway obstruction and disordered nocturnal breathing in children. Mayo Clin Proc 58:349, 1983 59. Maw AR Chronic otitis media with effusion (glue ear) and adenotonsillectomy: Prospective randomised controlled study. Br Med J 2871586, 1983 60. Maw AR Tonsillectomy today: Annotations. Arch Dis Child 61:421, 1986 61. Menashe VD, Farrehi C, Miller M: Hypoventilation and cor pulmonale due to chronic upper airway obstruction. J Pediatr 67198, 1965 62. Nicklaus PJ, Herzon FS, Steinle EW IV: Short-stay outpatient tonsillectomy. Arch Otolaryngol Head Neck Surg 121:521, 1995 63. Noel PE, Guarisco J L Tonsillectomy and adenoidectomy in children: Current indications. J La State Med SOC146:473, 1994 64. Noonan J: Reversible cor pulmonale due to hypertrophied tonsils and adenoids: Studies in two cases [abstract]. Circulation 32:164, 1965 65. Paradise JL: Tonsillectomy and adenoidectomy. In Bluestone CD, Stool SE, Kenna MA (eds): Pediatric Otolaryngology, ed 3, vol 2. Philadelphia, WB Saunders, 1996 66. Paradise JL: Etiology and management of pharyngitis and pharyngotonsillitis in children: A current review. Ann Otol Rhino1 Laryngol 101:51, 1992 67. Paradise JL, Bluestone CD, Bachman RZ, et al: Efficacy of tonsillectomy for recurrent throat infection in severely affected children: Results of parallel randomized and nonrandomized clinical trials. N Engl J Med 310:674, 1984 68. Paradise JL, Bluestone CD, Bachman RZ, et al: History of recurrent sore throat as an indication for tonsillectomy: Predictive limitations of histories that are undocumented. N Engl J Med 298:409, 1978 69. Paradise JL, Bluestone CD, Rogers KD, et al: Efficacy of adenoidectomy for recurrent otitis media in children previously treated with tympanostomy-tube placement results of parallel randomized and nonrandomized trials. JAMA 263:2066, 1990 70. Pasterkamp H, Cardoso ER, Booth FA: Obstructive sleep apnea leading to increased intracranial pressure in a patient with hydrocephalus and syringomyelia. Chest 95:1064, 1989
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71. Pichichero M E Recurrent streptococcal pharyngitis: Indications for tonsillectomy and penicillin prophylaxis Q&A. Pediatr Infect Dis J 1383, 1994 72. Potsic WP: Comparison of polysomnography and sonography for assessing regularity of respiration during sleep in adenotonsillar hypertrophy. Laryngoscope 971430,1987 73. Potsic WP: Obstructive sleep apnea. Pediatr Clin North Am 36:1435, 1989 74. Potsic WP, Pasquariello PS,Baranak CC, et a1 Relief of upper airway obstruction by adenotonsillectomy. Otolaryngol Head Neck Surg 94476, 1986 75. Price SC, Hawkins DB, Kahlstrom EJ: Tonsil and adenoid surgery for airway obstruction: Perioperative respiratory morbidity. ENT J 72526, 1993 76. Radetsky M, Solomon JA, Todd J K Identification of streptococcal pharyngitis in the office laboratory: Reassessment of new technology. Pediatr Infect Dis J 6:556, 1987 77. Richardson MR, Seid AB, Cotton RT, et a1 Evaluation of tonsils and adenoids in sleep apnea syndrome. Laryngoscope 901106,1980 78. Richmond KH, Wetmore RF, Baranak CC: Postoperative complications following tonsillectomy and adenoidectomy-who is at risk? Int J Pediatr Otorhinolaryngol 13:117, 1987 79. Rosen CL, DAndrea L, Haddad GG: Adult criteria for obstructive sleep apnea do not identify children with serious obstruction. Am Rev Respir Dis 1463231 80. Rosen GM, Muckle RP,Mahowald MW,et a1 Postoperative respiratory compromise in children with obstructive sleep apnea syndrome: Can it be anticipated? Pediatrics 93:784, 1994 81. Rosenfeld RM, Green Rp. Tonsillectomy and adenoidectomy: Changing trends. Ann Otol Rhino1 Laryngol99187,1990 82. Rothschild MA, Catalan0 P, Biller HF: Ambulatory pediatric tonsillectomy and the identification of high-risk subgroups. Otolaryngol Head Neck Surg 110203, 1994 83. Shott SR, Myer CM 111, Cotton RT: Efficacy of tonsillectomy and adenoidectomy as an outpatient procedure: A preliminary report. Int J Pediatr Otorhinolaryngol 13157, 1987 84. Shprintzen RJ, Sher AE, Croft C B Hypemasal speech caused by tonsillar hypertrophy. Int J Pediatr Otorhinolaryngol 1445, 1987 85. Singer J I Evaluation of the patient with neck complaints following tonsillectomy or adenoidectomy. Ped Emerg Care 8276, 1992 86. Siodlak M Z , Gleeson MJ, Wengraf C L Post-tonsillectomy secondary haemorrhage. Ann Roy Coll Surg Eng 67:167,1985 87. Sofer S, Weinhouse E, Tal A, et a1 Cor pulmonale due to adenoidal or tonsillar hypertrophy or both in children: Non&vasive diagnosis and follow-up. Chest 93:119, 1988 88. Stool SE, Eavey RD, Stein N L The ”chubby puffer” syndrome upper airway obstruction and obesity, with intermittent somnolence and cardiorespiratory embarrassment. Clin Pediatr 16:43, 1977 89. Strohl KP, Redline S Nasal CPAP therapy, upper airway muscle activation, and obstructive sleep apnea. Am Rev Respir Dis 134555, 1986 90. Suen JS, Arnold JE, Brooks LJ: Adenotonsillectomy for treatment of obstructive sleep apnea in children. Arch Otolaryngol Head Neck Surg 121:525, 1995 91. Tate N: Deaths from tonsillectomy. Lancet 2:1090, 1963 92. Telian SA, Handler SD, Fleisher GR, et al: The effect of antibiotic therapy on recovery after tonsillectomy in children. Arch Otolaryngol Head Neck Surg 112:610, 1986 93. Tom LWC, DeDio RM, Cohen DE, et a1 Is outpatient tonsillectomy appropriate for young children? Laryngoscope 102:277,1992 94. Tonsils and Adenoids Guidelines for Parents. Elk Grove Village, American Academy of Pediatrics, 1994 95. Weider DJ, Sateia MJ, West Rp: Nocturnal enuresis in children with upper airway obstruction. Otolaryngol Head Neck Surg 105427,1991 96. Werthammer J, Krasner J, DiBenedetto J, et a1 Apnea monitoring by acoustic detection of airflow. Pediatrics 71:53, 1983 97. Wiatrak BJ, Myer CM 111, Andrews TM: Complications of adenotonsillectomy in children under 3 years of age. Am J Otolaryngol 12:170, 1991
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98. Wilkinson AR, McCormick MS, Freeland AP, et al: Electrocardiographic signs of pulmonary hypertension in children who snore. Br Med J 282:1579, 1981 99. Williams EF 111, Woo P, Miller R, et al: The effects of adenotonsillectomy on growth in young children. Otolaryngol Head Neck Surg 104509, 1991 100. Williams RG: Haemorrhage following tonsillectomy and adenoidectomy a review of 18,184 operations. J Laryngol Otol 81:805, 1967 101. Wolf M, Kronenberg J, Kessler A, et al: Peritonsillar abscess in children and its indication for tonsillectomy. Int J Pediatr Otorhinolaryngol 16:113, 1988 102. Woodson BT, Wooten MR A multisensor solid-state pressure manometer to identify the level of collapse in obstructive sleep apnea. Otolaryngol Head Neck Surg 107651, 1992
Address reprint requests to Ellen S. Deutsch, MD, FAAP, FACS Department of Pediatric Otolaryngology St. Christopher’s Hospital for Children Erie Avenue at Front Street Philadelphia, PA 19134-1095
PEDIATRIC OTOLARYNGOLOGY
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TONSILLECTOMY AND ADENOIDECTOMY Changing Indications Ellen S. Deutsch, MD, FAAP, FACS
Every pediatrician has wrestled with the question of appropriate criteria for recommending tonsillectomy, adenoidectomy, or both for an individual child, and each develops a personal algorithm for decision making. Multiple factors, both mundane and complex, influence this decision. Rigidly structured criteria are tempered by the anecdotal experiences of the physician and the family and a lack of universally accepted criteria. Both advocates and detractors make claims about the indications, efficacy, and risk of tonsillectomy, with lesser controversy surrounding adenoidectomy. Tonsillectomy was described 3000 years ago in Hindu writings’, 45, 63 and again 2 millenia ago by Celsus and Paul of Aegir1a.4~.65 The procedure involved scraping the mucous membrane with a finger and enucleating the tonsil.“ Adenoidectomy may have first been performed in the late 1800s, when Meyer of Copenhagen suggested that adenoid vegetations were responsible for impaired hearing and nasal symptoms.65 In the first half of this century, great enthusiasm existed for tonsillectomies, which were considered by some to be a ”public health measure,”63and they were performed for minimal symptomatology. Bake? describes an incident occurring in about 1920:
”. . . The doctors had coolly descended on the school, taken possession, lined the children up, marched them past, taken one look down each child’s throat, and then two strong arms seized and held the child while the doctor used his instruments to reach down into the throat and rip out whatever came nearest to hand, leaving the boy or girl frightened out of a year‘s growth and bleeding ~~~
~
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From the Department of Pediatric Otolaryngology, St. Christopher’s Hospital for Children, Philadelphia, Pennsylvania PEDIATRIC CLINICS OF NORTH AMERICA
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savagely. No attempt at psychological preparation, no explanation to the child or warning to the parents. . . . It was an outrage-as cruel and as stupid as an initiation ceremony in an African tribe." Skepticism about the appropriate indications for tonsillectomy developed in the next few decades. Paradise65credits this to (1) the natural decline in the incidence of upper respiratory infections in children with age, (2) an increased risk for poliomyelitis after tonsillectomy prior to the availability of an effective vaccine, (3) the development of antimicrobial agents for treating upper respiratory infections, and (4) studies purporting that tonsil and adenoid surgery was ineffective. The number of tonsillectomies performed annually peaked at 1.4 million in 1959 and then declined.63 Although the total number of tonsillectomies has decreased, the percentage performed for upper airway obstruction has increased.**In the 1960s, reports described patients with serious sequelae of upper airway obstruction caused by adenotonsillar hypertrophy.'", *l, 36, 48, 60, 63, 87 Most upper airway obstruction in children is caused by adenotonsillar hypertrophy, and most symptoms are reversible after relief of the upper airway obstruction, usually by tonsillectomy, adenoidectomy, or both.44,63, 87*98 Since then, the pendulum of public and professional opinion concerning tonsillectomy and adenoidectomy continues to swing between enthusiasm and condemnation.
INDICATIONS FOR TONSILLECTOMY AND ADENOIDECTOMY
The indications for tonsillectomy and adenoidectomy overlap but are not identical (Table 1).
Table 1. INDICATIONS FOR TONSILLECTOMY AND/OR ADENOIDECTOMY indications
Tonsillectomy
Adenoidectomy
Definite indications Obstructive sleep apnea Tonsil or adenoid hypertrophy with upper airway obstruction Suspicion of malignancy Hemorrhagic tonsillitis Otitis media (see text) Failure to thrive* Speech abnormalities* Eating and swallowing disorders* Dental malocclusion* Orofacial growth abnormalities' Sinusitis*
+ + + + Not an indication + + + + +
+
Relative Indications Recurrent infections (see text) Streptococcus carrier Peritonsillar abscess Halitosis
+
See text
?
+ + + +
*If due to, or exacerbated by, adenotonsillar hypertrophy.
+ + Not an indication +
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Recurrent Throat Infections
Recurrent throat infections are generally accepted as an indication for tonsillectomy, adenoidectomy, or both; however, there is no absolute consensus as to how many infections constitute too many infections. The American Academy of Pediatrics (AAP) advises parents that surgery is a reasonable option for children with ”many severe sore throats.”94The American Academy of OtolaryngologyHead and Neck Surgery quantifies three or more infections per year as an adequate indication for surgery. A series of studies from the Children’s Hospital of Pittsburgh demonstrated a statistically significant decrease in the number of episodes of sore throats compared with controls following tonsillectomy in children with tonsillitis, pharyngitis, or tonsillopharyngitis that had occurred at least three times per year for 3 years, five times per year for 2 years, or seven times in 1 year.65Paradise reports that ”undocumented histories of recurrent throat infection do not validly forecast subsequent experience and hence do not constitute an adequate basis for subjecting children to tonsillectomy.”68 Chronic tonsillitis, persisting for at least 3 months, and chronic adenoiditis are also potential indications for surgery; the latter can manifest with postnasal drainage and chronic cough.36,45, 63, 65 Tonsillar crypt debris may be mistaken for chronic tonsillitis; in a cooperative patient this can be expressed and thereby “cured” in the office. Obstructive Sleep Apnea
Obstructive sleep apnea (OSA) caused by adenotonsillar hypertrophy constitutes a definite indication for surgery.19,63, 65, 94 Some of the manifestations and complications of severe OSA are now classic: cor pulmonale, right ventricular hypertrophy, congestive heart failure, alveolar hypoventilation, pulmonary hypertension, failure to thrive, pulmonary edema, cardiomegaly, permanent neurologic damage, and even death.’O, 36, 37, 48, 87 In 1965, Noonan@ reported reversible cor pulmonale caused by adenotonsillar hypertrophy. In 1988, Sofer reported several children with OSA-related respiratory distress, pulmonary edema and cor pulmonale with severe right ventricular and right atrial dilatation and reduced right ventricular ejection fraction. All children improved following removal of hypertrophied tonsils, adenoids, or b0th.8~Pasterkamp reported a child with Arnold-Chiari malformation and syringomyelia whose intermittent increased intracranial pressure resolved after removal of hypertrophied tonsils.7o Even Arnold; who states that “every attempt should be made to postpone the operation” in children 2 to 3 years of age, considers ”severe aerodigestive tract obstruction” to be an “absolute indication” for tonsillectomy. There is no universally accepted definition of obstructive upneu. Some investigators use lack of airflow despite continued respiratory effort for 6 seconds, 8 seconds, 10 seconds, 15 seconds, or 2.5 breaths to signify obstructive a ~ n e a . * ~ , 27, 73 Some criteria are derived from adult criteria and some from criteria for central apnea more often found in neonates. These criteria are not necessarily applicable to children older than neonates. Even with a working definition of OSA, detection is not always straightforward, and both history and physical examination must be carefully evaluated. Sometimes the physician does not ask about signs or symptoms of o b s t r ~ c t i o n . ~ ~ Often the physician does not witness the most severe manifestations because they occur during sleep. Sometimes parents underestimate or misinterpret their child’s symptoms. Some consider snoring normal because it is the baseline state
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of the or of another family member; some incorrectly ascribe the airway symptoms to constant colds, allergy, or asthma. Demonstrating the sounds of obstruction, snoring, snorting, gasping, or catching up after an obstructive pause in breathing helps parents recognize these manifestations in their children. Although some children with OSA are obese and "Pickwickian" like typical adults with OSA, many children with OSA are neither obese nor hypersomnolent. In fact, OSA can cause failure to thrive, short stature, and poor growth.5,24.44. 48. 6 5 90 Manifestations of upper airway obstruction include noisy breathing, a lack of lip seal, chronic mouth breathing, nasal obstruction, rhinorrhea, nasal congestion, halitosis, otitis media, hyponasality, or speech distortion.*,9, 73 Children without airway obstruction should breathe primarily through the nose, comfortably and quietly. Some manifestations of OSA are more subtle. Snoring is present but is not necessarily loud. Nocturnal coughing, choking, and restless sleep may occur? Chronic sleep disruption may cause behavioral abnormalities, including poor school performance, daytime hypersomnolence, and learning disabilities.'0,20, 90 Adults with OSA have higher automobile crash rates and worse driving simulator performancez6;this may be applicable to teenagers. Kravath describes children with apparent mental retardation who appeared more intelligent after surgery.48Sleep disturbance also may contribute to enuresis20, and night terr o r ~ Other . ~ ~ manifestations include pectus exca~atum,4~, 6o polycythemia, and systemic hypertension.'" Brouillette and colleagues12 advocate an OSA score based on the parent's evaluation of (1)the child's difficulty in breathing during sleep, (2) apnea, and (3) snoring that accurately predicts the presence or absence of OSA. The tonsils and adenoids are largest in relation to the pharynx from approximately 2 to 7 years of age.7Bluestone8 suggests using the term obstructive rather than hypertrophied because both the size of the tonsils and adenoids and the size of the pharynx in which they are contained must be considered. Adenotonsillar hypertrophy is most often seen in young, otherwise normal children fewer than 3 years of age.6oTonsils may appear relatively larger if the child gags during the examination, moving both tonsils toward the midline. On the other hand, if the inferior poles of the tonsils are not visualized, the full extent of hypertrophy may not be appreciated. Direct evaluation of adenoids is difficult in routine office examinations. Flexible fiberoptic endoscopy or lateral neck radiographs may be useful. Adenotonsillar Hypertrophy with Upper Airway Obstruction
Hypopnea may occur when airflow is impaired but not completely obstru~ted.~* Clinically significant obstructive hypopnea with partial upper airway obstruction (i.e., increased respiratory effort with decreased airflow) is more common in children than is OSA with complete obstruction (i.e., increased respiratory effort without any airflow).58, 73, 74, 79 Adult criteria for OSA based on the number of apneic events with complete airway obstruction per hour99fails to identify the majority of children with serious upper airway obstruction during sleep.79Prolonged partial airway obstruction during sleep may result in significant hypercarbia and hypoxemia," as well as daytime somnolence, enuresis, hypertension, and decreased school performance.", 38, 51, 53, 55, 56, Even children with adenotonsillar hypertrophy who do not have oxygen desaturation can have significant respiratory resistive load during sleep with cardiac abnor-
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malities that improve after surgery.40Suggestive findings include intermittent paradoxical breathing, snorting, or arousals.79 Most upper airway obstruction in children is caused by adenotonsillar hypertrophy. Most symptoms are reversible after relief of the upper airway obstruction, usually by tonsillectomy or adenoidectomy.44,63, 87, 98 Improvement in mouth breathing, behavioral problems, enuresis, poor weight gain, right ventricular strain, ability to mentally concentrate, disordered breathing, hypercarbia, and hypoxemia have been documented following adenotonsillectomy in patients with upper airway obstruction from adenotonsillar hypertrophy.’, 58, 74, 95 Ahlqvist-Rastad and colleagues’ reported that ”in many families, the psychosocial situation improved greatly after surgery. Disturbed sleep was a problem also for the parents who often did not dare to sleep themselves in order to cope with their child’s apnea.” Adenotonsillar hypertrophy with upper airway obstruction, even without frank OSA, is an indication for tonsillectomy or adenoide~tomy.’~, SJ.94 Suspicion of Malignancy
Malignancies, particularly lymphomas, may present as asymmetric adenotonsillar hypertrophy. Biopsy (tonsillectomy) is indicated for lesions suspicious for neoplasia? 19, 65 with the exception of particular suspected neoplasms, such as juvenile nasopharyngeal angiofibroma, which require individualized management protocols.46 Speech Abnormalities
Hyponasal speech and hypemasal speech are confused by parents and practitioners. Hyponasal speech can be approximated by pinching one‘s nostrils and speaking. Parents sometimes refer to it as ”nasal” speech or state that the patient is ”talking through his nose,” but the abnormality actually results from a blockage of nasal airflow. If this blockage results from adenoid hypertrophy, it may be alleviated by adenoidectomy?,9, 63 Hypernasal speech results from an inability to prevent inappropriate airflow through the nasopharynx because of an inability to seal the soft palate against the posterior pharyngeal wall (Fig. 1). It may result from submucous or apparent cleft palate or from tonsillar hypertrophy?, Tonsillar hypertrophy also may cause a ”hot potato” voice with mushy, muffled, or garbled ~ p e e c h . ~ ~ , ~ Eating and Swallowing Disorders
Dysphagia resulting from adenotonsillar hypertrophy is a definite indication for surgery?, 19, ffi,94 Orofacial Growth Abnormalities and Dental Malocclusion
Adenoid fucies describes the open-mouth posture, long face, and open anterior bite that may result from upper airway obstruction, particularly from adenoid hypertr~phy.~, 39, 43 When adenoid or tonsillar hypertrophy is the cause, surgery is i n d i ~ a t e d l ffi,94 ~ , ~and , is particularly effective in normalizing malocclusion when performed before the child is 6 years of
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DEUTSCH
Figure 1. Lateral neck radiograph demonstrating changes in soft palate location with phonation. A, During quiet respiration, the soft palate allows air passage through the nasopharynx. B, During phonation, the soft palate is elevated, occluding the nasopharynx.
Failure to Thrive
Case reports beginning in the 1980s document adenotonsillar hypertrophy as a reversible cause of failure to thrive.24,42 Streptococcus Carriers
Most asymptomatic carriers of group A beta hemolytic streptococcus (GABHS) do not require further treatment.7' Eradication of GABHS carriage
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might be desirable in children with recurrent GABHSpositive episodes of pharyngitis and those with a history of rheumatic fever in the child or a family member.66Eradication may be accomplished by antibiotic therapy66or, infrequently, adenotonsillectomy. INDICATIONS FOR TONSILLECTOMY (WITHOUT ADENOIDECTOMY) Hemorrhagic Tonsillitis
Tonsillar hemorrhage during acute tonsillitis is an indication for a tonsillectomy to control bleeding?, 65 Peritonsillar Abscess
Peritonsillar abscess is a controversial indication for tonsillectomy.8,19, 45, 63, If a tonsillectomy is performed, some surgeons proceed with the tonsillectomy during the abscess incision and drainage (i.e., quinsy tonsillectomy)8,45* 63 because a portion of the dissection already has been accomplished by the abscess, post-infection scarring may make a delayed tonsillectomy more difficult, and another episode of anesthesia may be avoided. Others wait until the acute inflammation has subsided to perform a tonsillectomy (interval tonsillectomy): 63 which may decrease the risk for infection or hemorrhage. Recurrent peritonsillar abscess is a more definitive indication for ton~illectomy.6~ 65,
INDICATIONS FOR ADENOIDECTOMY (WITHOUT TONSILLECTOMY) Otitis Media
Adenoidectomy contributes to the management of otitis media and is discussed in detail elsewhere in this issue.7,9, 17, 19, 20, 3133, 59, 63, 69, 94 The adenoids are located adjacent to the eustachian tube orifices in the nasopharynx.33Adenoids are thought to contribute to the pathophysiology of otitis media by harboring bacteria.33Adenoidectomy hastened resolution of otitis media and decreased the incidence of recurrence compared with controls in a study of 4- to 8-year-old chi1dre1-1.~~ Sinusitis
The relationship between adenoid hypertrophy or chronic adenoid infection and sinusitis has not been rigorously studied. The clinical findings in each of these conditions are similar. Adenoid hypertrophy causing stasis of secretions may mimic sin~sitis,5~ as can adenoid infection. It is reasonable, but unproven, that adenoid infection or hypertrophy contributes to sinusitis? 9, 20, 33, 63 just as adenoid infection or hypertrophy contributes to otitis media. The symptoms overlap, and differentiating the diagnoses on clinical grounds may be difficult. LuskM considers it prudent to remove enlarged obstructive adenoids before proceeding to sinus surgery in children failing medical management.
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Special Circumstances
Children with congenital or acquired craniofacial abnormalities, including Down syndrome, achondroplasia, or mucopolysaccharide storage disorders, may have upper airway obstruction with lesser degrees of adenotonsillar hypertro~ h y .9, ~44, ,51 In these patients, spasticity, hypotonicity, redundant soft tissue, and narrowed bony confines of the airway may be present. Upper airway obstruction should be considered in children with unexplained pulmonary hyperten~ion.5~ In children with neuromuscular disease, adenotonsillar hypertrophy may compound the upper airway dysfunction that results from hypotonia or spast i ~ i t y .35,~51, , 72 Aspiration of pharyngeal secretions during snoring and interrupted breathing may aggravate lower respiratory disease." The AAP advises consideration of adenotonsillectomy for enlarged, tender cervical nodes if present for 6 months and unresponsive to antibiotic therapy.94Halitosis and dysgeusia may result from chronic infection and may be alleviated by surgery.19,36, 63, Children undergoing tonsillectomy for OSA are generally younger than children undergoing tonsillectomy for recurrent infection.82Hodges and Wail~o*~ state that "early adenotonsillectomy in children with failure to thrive, enlarged tonsils and associated obstructive apnoea will lead to dramatic improvement in weight gain and general well-being." The youngest child in their case series was 23 months of age. Berkowitz and Zalza16 studied tonsillectomy in children fewer than 3 years of age and concluded that "the decision to perform tonsillectomy should be made without regard to the age of the patient, provided that surgery is carried out for appropriate indications and is performed in an appropriate institution." Hot tonsillectomy, a tonsillectomy performed during an acute infection, may be indicated during incision and drainage of a peritonsillar abscess.8,45,63 Occasionally, children with acute onset or exacerbation of upper airway obstruction during an episode of infectious mononucleosis fail conservative management and require acute adenotonsillectomy to alleviate the obstruction (Fig. 2). Improvement in quality of life is difficult to quantify. Factors to be considered include the child's discomfort, inconvenience, and impact of school absences; and the parents' anxiety, time missed from work, inconvenience, and cost of office visits and medications.63,65 These factors should be balanced against the anxiety, risks, discomfort, and costs involved in surgery.65,66
Alternatives to Adenotonsillectomy
Alternative treatments for upper airway obstruction from adenotonsillar hypertrophy that have been proposed include antimicrobial management, allergy management in atopic patients, intranasal or systemic anti-inflammatory agents, supplemental oxygen, nasal continuous or bilevel positive airway pressure, nasopharyngeal intubation, craniofacial operations for specific conditions, mandibular advancement and hyoid resuspension, uvulopalatopharyngoplasty, weight loss in obese children, and tracheotomy8,lo,20, 44, 63, 65, 73, 89 (Fig. 3). These options are of varying effectiveness and appropriateness, and factors, such as compliance and potential side effects, must be considered. Antibiotics, steroids, and nasopharyngeal intubation may be of use in the management of acute upper airway obstruction, such as when adenotonsillar hypertrophy is exacerbated by acute infection. The use of antibiotics for prophylaxis of recurrent tonsillitis is not supported by the literature.*,63, 66
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Figure 2. Adenotonsillar hypertrophy exacerbated by infectious mononucleosis causing OSA. A, Lateral neck radiograph of 5-year-old boy with massive enlargement of adenoids obstructing the nasopharyngeal airway. Retropharyngeal soft tissue is also thickened. B, Axial CT scan of same patient demonstrating enlarged adenoids pushing the soft palate forward. C,Female adolescent with tonsillar hypertrophy exacerbated by infectious mononucleosis.
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DEUTSCH
Figure 3. Obese 5-year-old boy with obstructive sleep apnea. A, Bilevel positive airway pressure did not prevent oxygen desaturation. 8,Hypertrophied tonsils prior to tonsillectomy. Episodes of oxygen desaturation resolved after tonsillectomy.
Contraindications to Surgery
Uncorrected coagulopathy is a contraindication for both tonsillectomy and adenoidectomy.2l.33, 65 Appropriate anesthetics must be used in patients at risk for malignant hyperthermia or with intolerance of certain agents. Overt and submucous cleft palate and related manifestations, such as bifid uvula, hypernasal voice, velopharyngeal insufficiency, and nasal regurgitation, are relative contraindications to an adenoidectomy? 33, 36, 65 although a partial adenoidectomy may be advantageous in selected patients. The discrete risks of surgery must be compared with the morbidity and risks of not having surgery. Laboratory Studies
Diagnostic laboratory studies are of limited value, except in special circumstances.~Infectious mononucleosis can be confirmed by a complete blood count with a ,differential including atypical lymphocytes or a positive heterophile antibod agglutination test ("mon~spot").~~ Throat cultures are more reliable than "r , pid strep tests" in evaluating the presence of GABHS.76 Lateral neck radiographs are useful in evaluating adenoidal hypertrophy8, 16, 29 and can be of help in evaluating tonsillar size if the clinical examination is difficult or equivocal (Fig. 4).A "limited" sinus CT scan (i.e., four or five coronal images including each of the sinuses) may be useful to evaluate sinusitis. The scout view includes the adenoids. Flexible fiberoptic nasopharyngoscopy allows evaluation of the adenoidsz0 and the palate and velopharyngeal functi0n.4~Voice and palate function also may be evaluated by eliciting the speech sounds that are affected by velopharyngeal abnormalities. Hypernasality may be demonstrated by having the child say "puppy," "Bobby, " "pig," "ssssoap," or counting from 60 to 70 while the physician listens for air escape.21Hyponasality can be demonstrated by having the child say "nine, nine, nine"36 or "bring me some bananas." In complicated patients, a formal speech and language evaluation may be indicated.
B:
TONSILLECTOMYAND ADENOIDECTOMY
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Figure 4. Lateral neck radiograph of extremely large tonsils in a child with OSA and failure
to thrive.
Beginning in the 1980s, polysomnograms (PSGs) have been advocated for evaluation of upper airway obstr~ction.~~, TI Despite disagreement on exact definitions of apnea and even less consensus on defining hypopnea,79PSGs are considered the gold standard for evaluation of OSA. To differentiate obstructive from central apnea, a PSG must include at least four parameters: (1)chest wall motion for respiratory effort, (2) nasal airflow, (3) heart rate, and (4) pulse oximetry (Fig. 5). More complex studies may include a pH probe and electroencephalogram or electromyogram. PSGs may be useful when there is a discrepancy between the patient’s history and findings on clinical examination or when other mitigating factors are present, such as very young age (<2 years old); or neurologic, cardiac, hematologic, craniofacial, or pulmonary In part because of the expense of PSGs (as much as $1500),63alternative methods of evaluation have been proposed. Sleep sonography may be used to assess irregularities of respiration but cannot differentiate central from obstructive apnean, 73 and requires computer-assisted analysis. Audio tapes have been advocateds and might, in theory, assess both episodes of apnea and quality of breathing but have not been substantiated in the literature. Sleep videofluoroscopy; multisensor manometry; or nasal, tracheal, or laryngeal sound recordings all have been advocated but are not commonly used.ls,2 5 ~ 96, lo2 49r
Perioperative Laboratory Studies
Because bleeding is one of the more serious potential complications of adenotonsillectomy, a baseline blood count is reasonable. Preoperative screening for coagulopathy may be limited to a detailed history of the patient and the patient’s family.13,36 If risk factors are identified, further studies may include prothrombin time, partial thromboplastin time, bleeding time, or a hematology consultation. Postoperative laboratory studies are not routinely required.
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Tt;emistor
Figure 5. Four-channel polysomnogram tracing demonstrating OSA. Arrow indicates episode of decreased nasal airflow (thermister) and decreased oxygen saturation despite continued respiratory effort indicated by chest wall motion (impedance).
Surgical Techniques
A variety of techniques are used for removal of tonsils and adenoids. The choice is made by the individual surgeon. Most pediatric otolaryngologists use a mirror to visualize the nasopharynx during adenoide~tomy~ to ensure complete removal. Many pediatric otolaryngologists use a Bovie cautery to perform the tonsillectomy,h which allows precise dissection along the tonsillar capsule and minimal bleeding. Typically, blood loss in a child fewer than 3 years of age is less than 20 mL. Postoperative Course
After adenotonsillectomy, parents are warned to expect that their child will have a significant sore throat, halitosis, possibly a stiff neck, and sometimes referred otalgia. Emesis is uncommon after the first 24 hours. If the parents inspect the tonsillar fossae, they will see a shaggy gray eschar, which may give the mistaken impression of infection (Fig. 6). Infection in the tonsillar fossae is uncommon and is manifested by pain and erythema around the margins of the tonsillar pillars. Amoxicillin given for 7 days postoperatively ameliorates postoperative pain and Sucralfate has been shown to decrease postoperative pain in adults.= Strenuous activity is restricted for 2 weeks. A narcotic analgesic combined with acetaminophen is often required, although theoretic concerns exist about the use of respiratory depressants in patients with disordered respiratory con-
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Figure 6. Typical tonsillar fossae eschar 4 days after tonsillectomy.
trol. Analgesics that interfere with coagulation, such as ibuprofen, should be avoided. Parents are instructed to contact their surgeon for inability to tolerate liquids, severe pain, fevers of more than 101"F, or any bleeding. Bleeding should be reported immediately; the amount of blood visualized may be only a portion of the actual blood Postoperative Complications
Respiratory distress and airway obstruction may occur after adenoidectomy or tonsillectomy, particularly in children who are fewer than 3 years of age, who develop significant palate or tongue edema during the procedure or who have other risk factors for airway obstruction, including OSA, neuromuscular disorders, obesity, and craniofacial an~malies.~,75,82* 97 Severe OSA can disrupt respiratory control; this persists temporarily after relief of the obstruction.", 82 Management options include systemic steroids, supplemental oxygen, continuous or bilevel positive airway pressure, nasopharyngeal airway, endotracheal intubation, and intensive supportive care.R*8o Immediate postoperative hemorrhage occurs within the first 24 hours of tonsillectomy in a small percentage of patients and is thought to be related to surgical t e c h n i q ~ e . ~85,86 ~ , ~Delayed ~ , ~ , or secondary hemorrhage occurs in up to 3% of patients after tonsillectomy, generally within 2 weeks of surgery, and often without an identifiable cause.14,15, 22,41,45,100 If active bleeding or a clot is present in the tonsillar fossae, the child is returned to the operating room for 91 Aspirin%, 86 and other nonsteroiidentification and control of the bleeding dal anti-inflammatory agents increase the risk of postoperative hemorrhage and are not recommended for 2 weeks before and 2 weeks after surgery. The administration of antiemetics, such as ondansetron," and avoidance of morphine postoperatively decrease the incidence of postoperative emesis. Transient velopharyngeal insufficiency may occur after removal of a large adenoid or in patients with abnormal palate anatomy or function but usually resolves quickly.u Persistent velopharyngeal insufficiency may require speech therapy or a pharyngeal flap procedure.33Anesthetic complications, such as idiosyncratic reactions to anesthetic agents, cardiac arrhythmias, or malignant hyperthermia, are rare.ffi,78, 85 Mortality rates are difficult to obtain, because death is a rare complication of adenotonsillectomy. Reports include 330,000 (England, 1945-1965),1O0 20200,000
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DEUTSCH
(England, 1957-1961)," 10:84,000 (England, 1979),6O and 1:16,000 in the 1960s improving to 1:35,000 in the 1970s.3" It is reasonable to assume that the availability of better methods to control the airway, better anesthetic agents, and better postanesthetic monitoring and care will continue to decrease mortality.h,30 Other uncommon complications of tonsillectomy and adenoidectomy include nasopharyngeal stenosis, refractory torticollis or subluxation of the atlantoaxial joint, bacterial meningitis, or depressionP7r6s, 85 The belief that tonsil or adenoid surgery in children precipitates the development of asthma has not been tested in clinical studies.65The concern that tonsillectomy might predispose to the development of Hodgkin's disease seems to have been dispelled by later epidemiologic investigations.6s There is pressure from insurance companies to perform tonsillectomy on an outpatient basis. Many insurance carriers now refuse to reimburse for the additional costs of inpatient surgery.8zOvernight observation with appropriate monitoring is recommended for patients with craniofacial anomalies affecting the pharyngeal airway, failure to thrive, hypotonia, cor pulmonale, morbid obesity, previous upper airway trauma, severe upper airway obstruction, or chronic medical problems; and for patients concurrently undergoing a uvulopalatopharyngoplasty and children fewer than 2 to 3 years of age.62,*", 83, 93 Other factors, such as the distance to the patient's home, the reliability of the parents, or inclement weather, may appropriately influence the decision.*
AN ALGORITHM FOR EVALUATING PATIENTS WITH UPPER AIRWAY OBSTRUCTION
In a tertiary care pediatric hospital, most of the children the author evaluates for adenotonsillectomy have adenotonsillar hypertrophy with upper airway obstruction, and most are 5 years of age or younger. This algorithm is based on the author's professional training and clinical experience, and the author presents it as a starting point. The assessment begins informally on entering the examination room and greeting the family. Without attracting the child's attention to the process, and while the child is comfortable and not self-conscious, the quality of breathing should be evaluated. Is it quiet and comfortable or noisy and obstructed? Does the child sit with his or her mouth open? Does the child have a "long" or "adenoid" face? While obtaining the child's history, symptoms present during sleep and during the daytime should be determined. Obstructive symptoms that are present while the child is awake are often worse when the child is asleep. Is this a typical day (is the breathing always noisy, or does the child happen to have an upper respiratory tract infection on the day of the examination)? Does the child "always" have a "cold" or nasal congestion? Is the nose congested only occasionally or most of the time? Some parents incorrectly attribute upper airway obstruction to asthma. During sleep, does the patient snore? Does the child "work hard to breathe" or breathe comfortably during sleep? If the parent were to imitate the breathing sounds of the child, would the parent become exhausted? Some parents do not recognize snoring or obstructive pauses followed by "gasping" or "catching up" until they are demonstrated. Some parents become defensive when asked if their child "stops breathing" and are more comfortable with questions about breathing "pauses." Some do not consider their child's snoring significant be-
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cause the child or another family member snores chronically. Others may use the term "apnea," asking for details helps to elucidate their definition. Physical examination includes the ears, nose, oral cavity, and neck. The ears are evaluated for serous effusions; many children with upper airway obstruction have effusions. The nose is examined with a hand-held otoscope using a large ear speculum and barely entering the nasal vestibule. The mucosa usually appears a bit erythematous. Crusting suggests rhinorrhea or allergy. The floor of the nose should be examined. Purulence only along the floor may be coming from the adenoids. The inferior turbinate should be identified (the most anterior and inferior structure bulging medially from the lateral nasal wall). Boggy or hypertrophied inferior turbinates suggest congestion or obstruction. Cyanotic turbinates suggest allergy or obstruction. Clear rhinorrhea around the turbinates suggests allergy. The inferior turbinate should be examined, starting from the area that protrudes the closest to the nasal septum and sweeping upward along the superior surface. Following this surface superiorly and laterally leads to the middle meatus, which is the space between the inferior turbinate and the middle turbinate and is the area where most of the sinuses drain. The middle turbinate is located more posteriorly, as well as superior to, the inferior turbinate. Purulence or congestion in the middle meatus is suggestive of sinusitis. This region can be visualized by careful anterior rhinoscopy in many children. In the oral cavity, the entire tonsil sometimes may be seen by having the child stick his or her tongue out and say "ahhh." Often the dorsum of the tongue must be depressed to visualize the most inferior portion of the tonsils; this may be the largest part of the tonsil. If the child gags, the tonsils approach the midline and may appear falsely enlarged. The size of the tonsil must be considered in relation to the size of the pharynx in which it is contained. Necrotic-appearing tonsils with shaggy exudate are suggestive of infectious mononucleosis. Purulent or thick postnasal drainage may be appreciated dripping down the posterior pharyngeal wall from the nasopharynx. In the neck, massive, bilateral, enlarged, tender jugulodigastic lymph nodes accompanying acute tonsillitis are suggestive of infectious mononucleosis. Laboratory testing is individualized. If a child is to undergo tonsillectomy because of obstructive symptoms and tonsillar hypertrophy, the adenoids usually are removed without separately documenting their hypertrophy. If a child has obstructive symptoms without tonsillar hypertrophy, a lateral neck radiograph is used to confirm adenoid hypertrophy prior to adenoidectomy. Occasionally, a lateral neck radiograph is helpful to evaluate tonsil size in relation to the pharynx when direct examination is equivocal or difficult in an uncooperative child. If there is a history or suspicion of sinusitis, a limited sinus CT scan allows evaluation of both the sinuses and adenoids in one study. PSGs are obtained under the following circumstances: (1)when the parents are uncertain as to whether to proceed with surgery and request additional data; (2) when there is an increased risk for complications, such as a patient fewer than 2 years of age or a child with morbid obesity or neurologic or cardiac abnormalities; or (3) when a discrepancy exists between the history and the physical examination. The history may be suggestive of obstruction and the examination benign, or the history may be benign and the examination suggestive. An alternative method that gathers less quantitative information is to demonstrate and explain symptoms of obstruction to the parents and have them observe the child during sleep on several nights. Occasionally, a sleep tape is requested or is brought by the parents. The sampling obtained is limited and there are no standardized criteria for evaluation. In preparation for surgery, a baseline complete blood count is obtained.
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Postoperative hemorrhage is rare but can be severe. The family is specifically questioned about easy bruisability or bleeding problems in both the patient and other family members. If the history is negative, no further laboratory studies are obtained. If the history is mildly positive, such as epistaxis or easy bruisability, a partial thrombopastin time, prothrombin time, and bleeding time are obtained. If the history is strongly positive, such as another family member with a known coagulopathy, a hematology consultation is obtained. SUMMARY Obstructive sleep apnea and upper airway obstruction (even without complete apnea) from adenotonsillar hypertrophy is either occurring more frequently or is becoming better recognized. Tonsillectomy or adenoidectomy is indicated for these children. Most patients who would benefit from surgery can be identified by a thorough history and physical examination. Occasionally, additional methods of evaluation, such as lateral neck radiographs or polysomnograms, are helpful. The indications for tonsillectomy and adenoidectomy are varied. No review can cogently encompass all clinical scenarios. Tonsillectomy and adenoidectomy remain valuable procedures for carefully selected patients. References 1. Ahlqvist-Rastad J, Hultcrantz E, Svanholm H Children with tonsillar obstruction: Indications for and efficacy of tonsillectomy. Acta Paediatr Scand 77831, 1988 2. Arnold JE: Tonsils and adenoids. In Behrman RE, Kleigman RM, Nelson WE (eds): Nelson Textbook of Pediatrics, ed 14. Philadelphia, WB Saunders, 1992 3. Arnold JE, Allphin A L Sleep apnea in the neurologically impaired child. ENT J 72230. 1993 4. Baker SJ: Fighting for Life. New York, Macmillan, 1939, p p 140-141 5. Bate TWP, Price DA, Holme CA, et al: Short stature caused by obstructive apnoea during sleep. Arch Dis Child 59:78, 1984 6. Berkowitz RG, Zalzal GH: Tonsillectomy in children under 3 years of age. Arch Otolaryngol Head Neck Surg 116685, 1990 7. Bicknell P G Role of adenotonsillectomy in the management of pediatric ear, nose and throat infections. Pediatr Infect Dis J 13:S75, 1994 8. Bluestone C D Current Indications for Tonsillectomy and Adenoidectomy. Ann Otol Rhino1 Laryngol 101:58, 1992 9. Brodsky L Modern assessment of tonsils and adenoids. Pediatr Clin North Am 36:1551, 1989 10. Brooks LJ: Treatment of otherwise normal children with obstructive sleep apnea. ENT J 7277,1993 11. Brouillette RT, Fernback SK, Hunt CE: Obstructive sleep apnea in infants and children. J Pediatr 100:31, 1982 12. Brouillette RT, Hanson D, David R, et al: A diagnostic approach to suspected obstructive sleep apnea in children. J Pediatr 105:10, 1984 13. Burk CD, Miller L, Handler SD, et al: Preoperative history and coagulation screening in children undergoing tonsillectomy. Pediatrics 89:691, 1992 14. Capper JWR, Randall C: Post-operative haemorrhage in tonsillectomy and adenoidectomy in children. J Laryngol Otol 98363, 1984 15. Carmody D, Vamadevan T, Cooper S M Post tonsillectomy haemorrhage. J Laryngol Otol 96635, 1982 16. Cohen LM, Koltai PJ, Scott J R Lateral cervical radiographs and adenoid size: Do they correlate? ENT J 71:638, 1992
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17. Cotton RT The surgical management of chronic otitis media with effusion. Pediatr Ann 20:628, 1991 18. Cummiskev 1. Williams TC. KrumDe PE. et al: The detection and auantification of sleep apnei by tracheal so&d rec&dings. Am Rev Respir Dis 126:22?, 1982 19. Dana ST: 1995 clinical indicators compendium. Alexandria, VA: American Academy of Otolaryngology-Head and Neck Surgery; 1995 20. Demain JG, Goetz D W Pediatric adenoidal hypertrophy and nasal airway obstruction: Reduction with aqueous nasal beclomethasone. Pediatrics 95:355,1995 21. Deutsch ES, Isaacson GC: Tonsils and adenoids: An update. Pediatr Rev 1617,1995 22. Dey FL Late hemorrhage following tonsillectomy. Arch Otolaryngol87558, 1968 23. Eliaschar I, Lavie P, Halperin E, et a1 Sleep apneic episodes an indication for adenotonsillectomy. Arch Otolaryngol 106:492, 1980 24. Everett AD, Koch WC, Saulsbury FT: Failure to thrive due to obstructive sleep apnea. Clin Pediatr 26:90, 1987 25. Felman AH, Loughlin GM, Leftridge CA Jr, et al: Upper airway obstruction during sleep in children. Am J Roentgenol 133213, 1979 26. Findley LJ, Fabrizio MJ, Knight H, et al: Driving simulator performance in patients with sleep apnea. Am Rev Respir Dis 140:529,1989 27. Frank Y, Kravath RE, Pollak CP, et a1 Obstructive sleep apnea and its therapy: Clinical and polysomnographic manifestations. Pediatrics 71:737, 1983 28. Freeman SB, Markwell JK. Sucralfate in alleviating post-tonsillectomy pain. Laryngoscope 102:1242, 1992 29. Fujioka M, Young LW, Girdany BR Radiographic evaluation of adenoidal size in children: Adenoidal-nasopharyngealratio. Am J Roentgenol 133:401,1979 30. Gates GA, Folbre Tw: Indications for adenotonsillectomy: Commentary. Arch Otolaryngol Head Neck Surg 112:501, 1986 31. Gates GA, Avery CA, Prihoda TJ: Effect of adenoidectomy upon children with chronic otitis media with effusion. Laryngmope 9858, 1988 32. Gates GA, Cooper JC Jr, Avery CA, et a 1 Chronic secretory otitis media: Effects of surgical management. Ann Otol Rhinol Laryngol 138(suppl):2,1989 33. Gates GA, Muntz HR, Gaylis B: Adenoidectomy and otitis media. Ann Otol Rhinol Laryngol 101:24, 1992 34. Gluckman JL, Righi P D Inflammatory disease of the mouth and pharynx. In Bluestone CD, Stool SE, Kenna MA (eds): Pediatric Otolaryngology, ed 3, vol 2. Philadelphia, WB Saunders, 1996 35. Grundfist K, Berkowitz R, Fox L Outcome and complications following surgery for obstructive adenotonsillar hypertrophy in children with neuromuscular disorders. ENT J 48758,1969 36. Grundfast KM: Tonsil and adenoid disorders the method of Kenneth M. Grundfast, MD. In Current Therapy in Otolaryngology-Head and Neck Surgery. Toronto, BC Decker Inc, 1984 37. Grundfast KM, Wittich DJ Jr: Adenotonsillar hypertrophy and upper airway obstruction in evolutionary perspective. Laryngoscope 92650,1982 38. Guilleminault C, Eldridge FL, Simmons FB, et al: Sleep apnea in eight children. Pediatrics 58:23, 1976 39. Guilleminault C, Partinen M, Praud JP, et al: Morphometric facial changes and obstructive sleep apnea in adolescents. J Pediatr 114997, 1989 40. Guilleminault C, Winkle R, Korobkin R, et a 1 Children and nocturnal snoring: Evaluation of the effects of sleep related respiratory resistive load and daytime functioning. Eur J Pediatr 139:165, 1982 41. Handler SD, Miller L, Richmond KH, et al: Post-tonsillectomy hemorrhage: Incidence, prevention and management. Laryngoscope 961243, 1986 42. Hodges S, Wailoo MP: Tonsillar enlargement and failure to thrive. Br Med J 295:541, 1987 43. Hultcrantz E, Larson M, Hellquist R, et a1 The influence of tonsillar obstruction and tonsillectomy on facial growth and dental arch morphology. Int J Pediatr Otorhinolaryngol22125,1991 44. Hunt CE, Brouillette RT Disorders of breathing during sleep. In Chemick V, Kendig
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