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The Great Unknowns: Panel discusses research on pediatric tonsillitis, ottitis, sinusitis

From: ENT Today, March 2010

by Tom Valeo

ORLANDO, Fla.—The title of this session at the Triological Society’s Combined Sections Meeting held here Feb. 4-7 asked a tough question: Why are otolaryngologists still talking about pediatric tonsillitis, otitis and sinusitis?

As members of the panel demonstrated, not everything is known about these all-too-common childhood illnesses.

Indications for tonsillectomy have changed.
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Indications for tonsillectomy have changed.

Tonsillectomy

The incidence of tonsillectomy and adenotonsillectomy, for example, has changed, said Laura J. Orvidas, MD, associate professor of otolaryngology at the Mayo Clinic in Rochester, Minn.

The Mayo Clinic has access to a database that contains records of more than 8,000 patients who underwent tonsillectomy or adenotonsillectomy from 1970 to 2005. “We thought the incidence of tonsillectomy was going down, but it’s actually going up,” Dr. Orvidas said, noting that from 1970 to 1974 there were 369 (tonsillectomies) per 100,000; from 2001-2005 that number went up to 642 per 100,000.

The indications for these procedures have changed too. “We used to take tonsils out primarily for infection,” Dr. Orvidas said. “Now it’s more commonly performed for sleep-disordered breathing.”

Research also suggests tonsillectomy can help improve psoriasis. “There are no random controlled trials for this, but one retrospective and one prospective trial have showed improvement in psoriasis after adenotonsillectomy,” Dr. Orvidas said. This improvement, she added, is believed to be associated with a reduction in strep infections after surgery.

A study in Japan found that about 90 percent of patients with a variation of psoriasis known as pustulosis palmaris et plantaris, which produces pustules rather than bumps on the hands and feet, improved after tonsillectomy. The improvement lasted at least five years. In addition, a study in the U.S. of six patients who had IgA nephropathy found that five of them experienced fewer renal symptoms after tonsillectomy. Several larger studies in Japan have confirmed this finding, Dr. Orvidas said.

Tonsillectomy has also been considered as a treatment for pediatric autoimmune neuropsychiatric disorders associated with streptococcal infection (PANDAS), but only a few cases in which tonsillectomy helped are documented in the literature as case reports, said David E. Tunkel, MD, director of pediatric otolaryngology at Johns Hopkins University in Baltimore.

PANDAS describes sudden onset of symptoms and signs of obsessive-compulsive disorder, Tourette syndrome and tic disorders following a Group A strep infection. Up to 10 percent of children who have tic disorder or OCD symptoms may have PANDAS, according to Dr. Tunkel. “It seems to be more common in boys,” he said. “The onset of symptoms is abrupt, and group A strep infection precedes the onset or exacerbation of these symptoms. Neurologic abnormalities of movement are seen during these exacerbations.”

While the pathogenesis of PANDAS remains unclear, “it’s suspected of being an autoimmune disorder brought on by strep in a susceptible host,” Dr. Tunkel said.

Treatments for immune dysregulation, such as corticosteroids, plasma exchange and intravenous immunoglobulin (IVIG) infusion, have produced some success, “but the literature is full of conflicting data about how such therapies should be used,” Dr. Tunkel said.

Researchers have developed a mouse model that may help clarify the relationship between strep infection and the symptoms associated with PANDAS.

While research has suggested tonsillectomy might help alleviate symptoms of PANDAS, Dr. Tunkel is skeptical. “It’s hard to recommend tonsillectomy as a treatment,” he said.

Two randomized studies, however, have produced evidence that tonsillectomy may alleviate the symptoms of periodic fever, aphthous stomatitis, pharyngitis, cervical adenitis syndrome (PFAPA).

PFAPA causes cyclic high fevers that last less than 10 days, recur more than six times and are accompanied by pharyngitis, adenitis and sometimes aphthous stomatitis. “Families say they can mark on their calendars when the fevers will recur,” Dr. Tunkel said.

First reported in 1987, the cause of the syndrome remains unknown. “Some think it’s an infectious phenomenon; others believe it’s the result of immune dysregulation,” Dr. Tunkel said.

Corticosteroids effectively quell the fevers but result in more frequent episodes of fever, according to Dr. Tunkel. Cimetidine (Tagamet) has been used with varying results.

A 2009 prospective, randomized study of 39 children with PFAPA found that 63 percent of children who received adenotonsillectomy had no further episodes of fever, compared to only 5 percent of the children who did not undergo surgery. Based on such evidence, Dr. Tunkel said tonsillectomy may well be indicated for children with PFAPA, “but probably not for PANDAS, at least not yet.”

Chronic Sinusitis

Kenny H. Chan, MD, of Children’s Hospital, Denver, talked about chronic sinusitis in children, which differs in its pathogenesis between children and adults. “In children, you see predominately lymphocytes, while eosinophils are the primary immune cells seen in adults with chronic sinusitis,” he said.

The bacterial slime structure of biofilm, which is found in adults and presumed to be present in children, may account for part of the pathogenesis in children.

“How little we know about the treatment of pediatric rhinosinusistis,” Dr. Chan said. “The effectiveness of treatments using antibiotics is controversial in the literature. Biofilm may be influencing the outcome. Adenoidectomy may have a role in eliminating the biofilm reservoir.”

Otitis Media

To highlight some of the issues in pediatric otitis media, Joseph Haddad, Jr., MD, of Columbia University, presented a case study involving a child who was treated for otalgia with amoxicillin. A few weeks later the child developed ear pain and went to a different pediatrician, who treated the otalgia with azithromycin for five days.

While on azithromycin, the child developed fever, ear pain and headache. A rapid strep test came back negative, and the child was presumed to have a viral infection.

Three days later, the child returned to the emergency department (ED) with symptoms of otalgia, lethargy, and headache. While in the ED, the child had a seizure, and was admitted to the ICU with meningitis. Currently the child is stable, but was left with hearing loss in the left ear.

“A spinal tap showed strep pneumococcus, which in this case was sensitive to everything except azithromycin,” Dr. Haddad said. “If this child had been given standard treatment with amoxicillin or amoxicillin-clavulanate, the complication might have been avoided.”

So should antibiotics be used in children with otitis media? “The current guidelines are that antibiotics remain the mainstay for children two and under,” Dr. Haddad said. “Above age two, the practitioner has the option of observing the child to see if there’s improvement without the use of antibiotics.”

Surveillance studies show high levels of resistance to macrolides such as azithromycin. “The temptation to use macrolides is high, since they can be given once a day for five days,” Dr. Haddad said, “but because of issues related to resistance, I think it’s important for practitioners to know about potential problems.” ENTtoday

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