He recommends a shared decision-making approach, which is particularly helpful in situations where the evidence is incomplete. “Shared decision making is a model that’s being widely applied to adult decisions, includes a much fuller discussion of the benefits and tradeoffs of a procedure and directly invites the patient or the family to work with a clinician on their decision,” said Dr. Goodman.—SK
When compared with figures from a half-century ago, the overall rate of tonsillectomies has declined dramatically, said Richard Rosenfeld, MD, MPH, professor and chairman of otolaryngology at SUNY Downstate Medical Center in Brooklyn, N.Y. and president of the American Society of Pediatric Otolaryngology. He added that the recent reports require some perspective. “You can’t just look at the number of tonsillectomies. You have to look at why they’re being done.”
Indications for Sleep-Disordered Breathing
Historically, tonsillectomies were performed in cases of infection and, according to a National Health Statistics report published in 2009, they are still one of the most commonly performed pediatric surgeries. “Years ago, it was sort of a rite of passage that you had your tonsils out,” said Dr. Rosenfeld. That was until better antibiotics became available and indications for surgery were more clearly defined.
In the 1980s, many children presented to physicians with sleep-related symptoms, and airway obstruction became the primary indication for tonsillectomy. Today, more than half of tonsillectomies are performed to treat sleep apnea and other sleep-related conditions in children. (Ann Otol Rhinol Laryngol. 1990;99(3 Pt 1):187-191) “There is greater awareness of the implications of untreated sleep apnea,” said Norman Friedman, MD, associate professor of otolaryngology and director of Children’s Hospital Colorado Sleep Center in Denver. “For younger children [with sleep apnea], most of the time, a tonsillectomy with an adenoidectomy is the first line of treatment.”
Obesity in children has contributed to a higher prevalence of sleep apnea. “Obesity causes fat deposits within soft tissues of the neck to collapse, and that makes the airway more likely to collapse and produce the symptoms of sleep apnea,” said Scott Brietzke, MD, MPH, director of pediatric otolaryngology and residency program director at Walter Reed National Military Medical Center in Bethesda, Md.
Left untreated, sleep-disordered breathing can adversely affect a child’s behavior, school performance and quality of life. (See Testing Recommendation for Children with Sleep-Disordered Breathing, p. 31). Adenotonsillectomy has been highly effective in normalizing sleep and reversing the negative impact on most children, said Ron B. Mitchell, MD, professor and chief of pediatric otolaryngology at University of Texas Southwestern Medical Center and Children’s Medical Center Dallas.