Pediatric Tonsillectomies on the Rise

However, obese children’s scores do not improve as much as non-obese children. Behavior improves post-operatively to a similar extent in all children regardless of obesity (Dev Neuropsychol. 2009;34(5):650-661). “It is possible that in some children the condition resolves over time, while in others, postponing early intervention with adenotonsillectomy leads to significant long-term neurobehavioral problems,” Dr. Mitchell said. “It remains unknown whether too many or too few adenotonsillectomies are currently being performed.”

Determining Candidates

Tonsillectomy offers considerable relief to children with recurring serious symptoms, such as strep throat, but its benefits to those with milder indications are more questionable. A Cochrane review revealed a modest advantage for tonsillectomy or adenotonsillectomy over nonsurgical treatment for chronic-recurrent acute tonsillitis (Cochrane Database Syst Rev. 2009;1:DC001802).

The review of five studies—four undertaken in children (719 participants) and one in adults (70 participants)—indicated that this advantage applied to youngsters with the most severe disease. “One reason why the impact of surgery is so modest is that many untreated patients get better spontaneously,” the review’s authors stated. “There is a trade-off for the physician and patient who must weigh a number of different uncertainties: What proportion of the symptoms are attributable to my tonsils, and will it get better without any treatment? Similarly, the potential ‘benefit’ of surgery must be weighed against the risks of the procedure.”

To help clinicians determine the best candidates for tonsillectomy, the American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS) issued new evidence-based guidelines in January 2011 (Otolaryngol Head Neck Surg. 2011;144:S1-S30). The guidelines also aim to optimize peri-operative management, address the needs of special populations, improve family counseling and education, account for modifying factors, and decrease inappropriate or unnecessary variations in care. The recommendations include watchful waiting for recurrent tonsillar infections in the case of fewer than seven episodes in the prior year, fewer than five episodes per year in the prior two years or fewer than three episodes per year in the previous three years.

Childhood Adenotonsillectomy Trial

Even though tonsillectomy is such a common and longstanding procedure, there are a limited number of high-quality outcome studies on the procedure. To date, published studies have compared children with sleep-disordered breathing before and after adenotonsillectomy. The National Heart, Lung, and Blood Institute recently supported the first randomized controlled clinical trial in children, comparing patients with sleep-disordered breathing who underwent adenotonsillectomy with those who were observed without surgical intervention.