Tonsillectomy Revisited: New guidelines represent a clinical shift for some otolaryngologists

According to Dr. Mitchell, the number of tonsillectomies performed for recurrent throat infections has been decreasing, while they’ve been increasing for children with sleep-disordered breathing.

Saying that the relationship between sleep and tonsillar hypertrophy is underappreciated in the community, he urged otolaryngologists to be advocates for children with sleep problems. The guidelines, he said, emphasize the effectiveness of tonsillectomies in these children, including improving sleep, daytime functioning and school performance.

Dr. Rosenfeld also emphasized that although otolaryngologists are aware that sleep-disordered breathing is a main indication for tonsillectomy in children, there is a need to educate primary care doctors, as well as parents and caregivers, of the benefit of tonsillectomies in children with this problem.

Implementation

Generating guidelines is difficult enough, but implementing them can be even more challenging. Although guidelines are meant to guide and not replace clinical judgment, changing a long-held clinical practice based on evolving evidence is an expected outcome that underlies the drive to generate evidence-based medicine, and clinicians are therefore increasingly faced with the need to look at their own practices in the context of the evidence.

“Although some of the guidelines may represent a paradigm shift, such as discontinuing the use of antibiotics, we need to embrace the work that was done to provide us with the appropriate justification for what we do,” said Laura J. Orvidas, MD, associate professor of otorhinolaryngology at the Mayo Clinic in Rochester, Minn., who has experience developing a practice guideline and emphasized that evidence-based medicine is a current and future reality.

“The more we help ourselves learn what is best and practice best medicine, the less the government and insurance companies will be able to dictate how we practice,” she said. “I would encourage my colleagues to embrace these guidelines and those developed in the future.”

Acknowledging the hesitancy many clinicians are expected to feel about implementing some of the recommendations, specifically the recommendation advising against routinely using antibiotics, Dr. Rosenfeld nonetheless hopes that otolaryngologists read the guidelines.

“If you do tonsillectomy, read this document,” he said. “Even if you don’t like guidelines or don’t agree with the concept of guidelines, I have no doubt that a reader will find some useful information in the guidelines to provide the best quality of care for the kids who are getting their tonsils out.”