Clinical practice guidelines for tonsillectomy

Tonsillectomy is the second most commonly performed surgery in the United States with more than 5,30,000 procedures performed on children younger than 15 years each year.

Although tonsillectomy is a routine procedure performed by general and pediatric otolaryngologists, there is significant variation in preoperative, intraoperative, and postoperative patient treatment among clinicians.

In order to avoid such variations and to have an evidence-based recommendation on the management of children between 1 to 18 years old, selected for adenotonsillectomy, an expert panel constituted by American Academy of Otolaryngology-Head and Neck Surgery (AAO–HNS) in 2011 proposed the first version of AAO-HNS guidelines for tonsillectomy. These guidelines for tonsillectomy was recently updated in 2018.

We have also summarized indications for pediatric tonsillectomy in another article.

Action statements for Tonsillectomy in children

Strong recommendations for

  1. Clinicians should recommend watchful waiting for recurrent throat infection if there have been <7 episodes in the past year, <5 episodes per year in the past 2 years, or <3 episodes per year in the past 3 years.
  2. Clinicians should administer a single intraoperative dose of intravenous dexamethasone to children undergoing tonsillectomy.
  3. Clinicians should recommend ibuprofen, acetaminophen, or both for pain control after tonsillectomy.

Recommendations for

  1. Clinicians should assess the child with recurrent throat infection who does not meet criteria in KAS 2 for modifying factors that may nonetheless favor tonsillectomy, which may include but are not limited to multiple antibiotic allergies/intolerance, PFAPA (periodic fever, aphthous stomatitis, pharyngitis, and adenitis), or history of >1 peritonsillar abscess.
  2. Clinicians should ask caregivers of children with obstructive sleep-disordered breathing and tonsillar hypertrophy about comorbid conditions that may improve after tonsillectomy, including
    growth retardation, poor school performance, enuresis, asthma, and behavioral problems.
  3. Before performing tonsillectomy, the clinician should refer children with obstructive sleep-disordered breathing for polysomnography if they are <2 years of age or if they exhibit any of the
    following: obesity, Down syndrome, craniofacial abnormalities, neuromuscular disorders, sickle cell disease, or mucopolysaccharidoses.
  4. The clinician should advocate for polysomnography prior to tonsillectomy for obstructive sleep-disordered breathing in children without any of the comorbidities listed in KAS 5 for whom the need for tonsillectomy is uncertain or when there is discordance between the physical examination and the reported severity of oSDB.
  5. Clinicians should recommend tonsillectomy for children with obstructive sleep apnea documented by overnight polysomnography.
  6. Clinicians should counsel patients and caregivers and explain that obstructive sleep-disordered breathing may persist or recur after tonsillectomy and may require further management.
  7. The clinician should counsel patients and caregivers regarding the importance of managing post tonsillectomy pain as part of the perioperative education process and should reinforce this counseling at the time of surgery with reminders about the need to anticipate, reassess, and adequately treat pain after surgery.
  8. Clinicians should arrange for overnight, inpatient monitoring of children after tonsillectomy if they are <3 years old or have severe obstructive sleep apnea (apnea-hypopnea index 10 obstructive events/hour, oxygen saturation nadir <80%, or both).
  9. Clinicians should follow up with patients and/or caregivers after tonsillectomy and document in the medical record the presence or absence of bleeding within 24 hours of surgery (primary bleeding) and bleeding occurring later than 24 hours after surgery (secondary bleeding).
  10. Clinicians who perform tonsillectomy should determine their rate of primary and secondary post-tonsillectomy bleeding at least annually.

Strong recommendations against

  1. Clinicians should not administer or prescribe perioperative antibiotics to children undergoing tonsillectomy.
  2. Clinicians must not administer or prescribe codeine, or any medication containing codeine, after tonsillectomy in children younger than 12 years.

Optional recommendation for

  1. Clinicians may recommend tonsillectomy for recurrent throat infection with a frequency of at least 7 episodes in the past year, at least 5 episodes per year for 2 years, or at least 3 episodes per year for 3 years with documentation in the medical record for each episode of sore throat and 1 of the following: temperature .38.3C (101F), cervical adenopathy, tonsillar exudate, or positive test for group A beta-hemolytic streptococcus.

Differences from 2011 guidelines

  1. Incorporating new evidence profiles to include the role of patient preferences, confidence in the evidence, differences of opinion, quality improvement opportunities, and any exclusion to which the action statement does not apply.
  2. There were 1 new clinical practice guideline, 26 new systematic reviews, and 13 new randomized controlled trials included in the 2018 guideline update.
  3. Inclusion of 2 consumer advocates on the guideline update group.
  4. Changes to 5 KASs from the original guideline:
    1. KAS 1 (Watchful waiting for a recurrent throat infection) – Changed from recommendation to strong recommendation
    2. KAS 3 (Tonsillectomy for recurrent infection with modifying factors) – Change to >1 peritonsillar abscess
    3. KAS 4 (Tonsillectomy for obstructive sleep-disordered breathing) – Changed to obstructive sleep-disordered breathing throughout the document. “Asthma” added to the list of comorbid conditions.
    4. KAS 9 (Perioperative pain counseling) – Updated statement emphasizes patient and/or caregiver counseling and education in the perioperative period
    5. KAS 10 (Perioperative antibiotics) – The word “routinely” was removed
  5. Seven new KASs:
    1. KAS 5 (Indications for polysomnography),
    2. KAS 6 (Additional recommendations for polysomnography),
    3. KAS 7 (Tonsillectomy for obstructive sleep apnea),
    4. KAS 12 (Inpatient monitoring for children after tonsillectomy),
    5. KAS 13 (Postoperative ibuprofen and acetaminophen),
    6. KAS 14 (Postoperative codeine), and
    7. KAS 15a (Outcome assessment for bleeding).
  6. Addition of an algorithm outlining KASs.
  7. Enhanced emphasis on patient and/or caregiver education and shared decision making.

Polysomnography for sleep-disordered breathing prior to tonsillectomy in children

When adenotonsillectomy is planned for obstructive sleep apnea (OSA), in children, aged 2 to 18 years, the following guidelines are recommended by the action panel.

Recommendations on polysomnography prior to adenotonsillectomy for OSA

  • Before determining the need for tonsillectomy, the clinician should refer children with sleep-disordered breathing for polysomnography if they exhibit certain complex medical conditions such as obesity, Down syndrome, craniofacial abnormalities, neuromuscular disorders, sickle cell disease, or mucopolysaccharidoses.
  • The clinician should advocate for polysomnography prior to tonsillectomy for sleep-disordered breathing in children without any of the comorbidities listed in the above statement for whom the need for surgery is uncertain or when there is discordance between tonsillar size on physical examination and the reported severity of sleep-disordered breathing.
  • Clinicians should communicate polysomnography results to the anesthesiologist prior to the induction of anesthesia for tonsillectomy in a child with sleep-disordered breathing.
  • Clinicians should admit children with obstructive sleep apnea documented on polysomnography for inpatient, overnight monitoring after tonsillectomy if they are younger than age 3 or have severe obstructive sleep apnea (apnea-hypopnea index of 10 or more obstructive events/hour, oxygen saturation nadir less than 80%, or both).
  • In children for whom polysomnography is indicated to assess sleep-disordered breathing prior to tonsillectomy, clinicians should obtain laboratory-based polysomnography, when available.

References

  1. Baugh RF, Archer SM, Mitchell RB, Rosenfeld RM, Amin R, Burns JJ, Darrow DH, Giordano T, Litman RS, Li KK, Mannix ME. Clinical practice guideline: tonsillectomy in children. Otolaryngology–Head and Neck Surgery. 2011 Jan;144(1_suppl):S1-30.
  2. Roland PS, Rosenfeld RM, Brooks LJ, Friedman NR, Jones J, Kim TW, Kuhar S, Mitchell RB, Seidman MD, Sheldon SH, Jones S. Clinical practice guideline: polysomnography for sleep-disordered breathing prior to tonsillectomy in children. Otolaryngology–Head and Neck Surgery. 2011 Jul;145(1_suppl):S1-5.
  3. Mitchell RB, Archer SM, Ishman SL, Rosenfeld RM, Coles S, Finestone SA, Friedman NR, Giordano T, Hildrew DM, Kim TW, Lloyd RM. Clinical practice guideline: tonsillectomy in children (update). Otolaryngology–Head and Neck Surgery. 2019 Feb;160(1_suppl):S1-42.

Meet the author

Dr Sanu P Moideen is an Indian-born oto-rhino-laryngologist (ENT) based in Cochin, Kerala, India. He is currently working as Post-Doctoral Fellow in Head and Neck Oncology at Regional Cancer Center, Trivandrum, Kerala.

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