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

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.

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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.”