Tonsillectomy

Dear Lisa,

Should a 14 year old who has had strep for the past six weeks have his tonsils taken out? What are the benefits/risks?

“Tonsillectomy?”

Dear “Tonsillectomy?”,

Tonsillectomy and Adenoidectomy have been performed on children for over a century. There are no definitive criteria established as absolute indication for surgery.(1) A child’s Physician makes this decision based on the child’s clinical history and physical findings. Otolaryngologists (ENT Doctors) are the type of specialists that evaluate children with recurrent Strep or Tonsillitis and decide if surgery is necessary.

One of the major reasons for surgery is recurrent infections with tonsillitis, adenoiditis or adenotonsillitis. (1) Although each individual specialist has different criteria for surgery, generally children with ten Strep infections or episodes of tonsillitis in a period of one year are considered good candidates for surgery.

Tonsillectomy is strongly considered in children with a Peritonsillar Abscess which fails to respond to antibiotic therapy. A child with a Peritonsillar Abscess who has a past history of recurrent tonsillitis is also recommended to have surgery.(1)

Tonsillectomy may also be recommended for children with Strep infections deep within their tonsils. Infections deep within the tonsillar crypts are often difficult to culture and completely cure with antibiotics. (1) Children with this condition tend to complain of chronic sore throats and may frequently have negative Strep culture results. It is difficult to obtain a throat culture of these deep seeded infections and as a result these patients can have throat cultures that remain negative even thought they have a bacterial infection. Tonsillectomy is recommended in these patients because of the inability to eradicate the infection.

In rare situations, asymmetry in tonsillar size may be an indication for surgery. One tonsil can become slightly larger than the other due to an infection. A slight difference in size is not alarming, but a marked difference in size or sudden enlargement should be evaluated by an Otolaryngologist. Although rare in childhood, a sudden enlargement of one tonsil may be indicative of a tumor.(1) In such a scenario, tonsillectomy is recommended.

Infections are not the only reason why children have their tonsils removed. During childhood, tonsils and adenoids become enlarged in response to infections in the upper respiratory tract.(2) In most children this enlargement is tolerated and there are no consequences. In some cases, the enlargement can obstruct the airway and lead to symptoms of upper airway obstruction or Obstructive Sleep Apnea (OSA). Chronic upper airway obstruction and Obstructive Sleep Apnea are major indications for surgery.(1,3)

Signs of upper airway obstruction include mouth breathing, difficulty swallowing, and failure to thrive. (1) Obstructive Sleep Apnea occurs when a child has decreased amounts of oxygen and a disruption in their sleep.(3) Symptoms of OSA include snoring, pauses in breathing during sleep, daytime sleepiness, impaired concentration, impaired attention, morning headaches, bedwetting, dry mouth, interrupted sleep, depression, irritability, and abnormal sleep positions. (1,3)

Obstructive Sleep Apnea is a major health concern because most cases go undetected. The long term effects of untreated OSA can be quite serious.(3) The consequences of having Obstructive Sleep Apnea include glucose intolerance, elevated cholesterol levels and Hypertension. Obstructive Sleep Apnea has also been linked cardiovascular disease and its complications.(4,5) Children with Obstructive Sleep Apnea are strongly recommended to have Tonsillectomy.

The benefits of having a Tonsillectomy in this situation prevents the development of heart changes that lead to cardiovascular disease, improvement in bedwetting, more restful sleep, improvement of concentration and attention during the day. Tonsillectomy also improves jaw alignment in mouth breathers, weight gain in children with failure to thrive, and reduction in the number of infections in children with recurrent Strep infections, tonsillitis and peritonsillar abscess. (1)

If your child’s Physician recommends that your child has a Tonsillectomy, you may want to discuss the reason for this recommendation. Has your child had a long standing history of recurrent tonsillitis or Strep infections? Does he have signs of chronic upper airway obstruction or Obstructive Sleep Apnea? Your doctor will be able to discuss the criteria for surgery as well as the benefits of the risks involved.

Common post-operative complications of Tonsillectomy include throat pain, dehydration, bleeding and reactions to anesthesia. (2) Children who undergo Tonsillectomy experience a lot of throat pain after surgery which typically needs to be controlled with pain medication.(2) In some cases, children refuse to eat or drink because their throat hurts so much. This pain, along with a fear of swallowing puts them at risk for dehydration.

Bleeding is also a risk of Tonsillectomy and is a major concern in children with anemia and bleeding disorders. Tonsillectomy is contraindicated or not recommended in children with certain bleeding disorders because of the risk of hemorrhage.(2)

From my experience, the post operative period is quite demanding on the parents, because of the child’s increased need for attention, pain management and coaxing to drink. Most of the children that I took care of post op did well with the encouragement and assistance from their parents.

When Tonsillectomy is recommended, it is normal for parents to seek out more information regarding the necessity of the procedure as well as the risks and benefits. Many times parents seek a second surgical opinion when Tonsillectomy is recommended in order to make an informed decision.

I hope this information helped and your child is feeling better soon.

References:
(1)Schwartz M, Charney E, Curry T, Ludwig S. Pediatric Primary Care. A Problem Oriented Approach. 2nd Ed. Littleton, Mass:Year Book Medical Publishers, Inc. 1990: 805.
(2)Betz C, Hunsberger M, Wright S. Family-Centered Nursing Care of Children. 2nd ed. Philadelphia, PA:W.B.Saunders Company. 1994:1211-1213.
(3)Butler D. An underdiagnosed cause of daytime fatigue. The Clinical Advisor. 2006. Sept:48-52.
(4)Yaggi HK, Concato J, Kernan WN. Obstructive Sleep Apnea as a risk factor for stroke and death. N Engl J Med. 2005. 353:2034-2041.
(5)Mehra R, Benjamin EJ, Shahar E. Association of nocturnal arrhythmias with sleep-disordered breathing: The Sleep heart Health Study. Am J Respir Crit Care Med. 2006.173:910-916.

Lisa-ann Kelly R.N., P.N.P.,C.
Certified Pediatric Nurse Practitioner

Pediatric Advice for Parents with Sick Children