Mr. Burton summarized results from reviews of perioperative management studies, which also revealed equivocal results. For instance, use of nonsteroidal anti-inflammatory drugs (NSAIDs) did not appear to increase bleeding, but the number of participants was small (13 trials with 155 children), so it is possible that rare bleeding events were not detected. In another review of nine trials, antibiotics significantly reduced fever, but had no effect on pain reduction. He also cited the dexamethasone study,4 undertaken to study the drug’s efficacy in decreasing post operative nausea and vomiting in children undergoing tonsillectomy. That study was halted early because although postoperative nausea and vomiting were reduced, there was a disturbing increase in postoperative hemorrhage in the group randomized to dexamethasone.
Explore This IssueDecember 2009
The Pittsburgh Criteria Backstory
Dr. Rosenfeld then took the floor to address the integration of evidence with individual patient care. He noted that before Paradise published the 1984 study showing a benefit for tonsillectomy, the researcher had conducted an earlier study following children to monitor their episodes of infection. Recruited via local media and referrals from pediatricians, the children met the Pittsburgh criteria and were observed for the next year. Sure enough, said Dr. Rosenfeld, almost half the kids had one or fewer episodes [of throat infection] in the next year. So, the natural history is good.
There is no doubt, he conceded, that the sicker the child, the more impact the surgery will have. It remains difficult, however, to show real benefit after surgery for those who are only mildly symptomatic. On the other hand, the risks of tonsillectomy are real, said Dr. Rosenfeld. In addition to the more common side effects of pain and postoperative hemorrhage, there are uncommon risks, such as endotracheal tube ignitions, cervical facial emphysema, bacterial meningitis, and psychological trauma. Surgeons would do well, he said, to always consider the magnitude of the expected benefit against the risks.
The decrease in tonsillectomy procedures has, however, introduced another iatrogenic consequence, according to Dr. Rosenfeld: sleep-disordered breathing. This is a disorder that was barely mentioned 50 years ago, but now represents the primary indication for tonsillectomy. The current trials weighing surgical versus nonsurgical treatment for sleep apnea, he said, fail to address quality of life and neurocognitive sequelae (such as failure to thrive, nocturnal enuresis, underperformance at school).
The decisions for surgeons remain complex, Dr. Rosenfeld concluded. If you were hoping for an easy decision, an easy strategy, we’ve probably not provided that here. He urged participants to include their expertise and patient preference in the decision-making equation. He also cautioned his colleagues to resist gizmo idolatry as described in a recent paper5-that the newest technology is always superior-and to thoughtfully consider the evidence, indications and complications that go along with this nontrivial surgery.