Tubes and Tonsils

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Tubes and Tonsils
Lawrence M. Simon, M.D. Department of Pediatrics
Noon Lecture Series Louisiana State University
Health Sciences Center Childrens Hospital of
New Orleans August 31, 2010
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History of Tonsillectomy

• First description in 30 A.D. by Aulus Cornelius
  Celsus, a Roman encyclopedist. He described
  scraping the tonsils and tearing them out or
  picking them up with a hook and excising them
  with a scalpel.
• William Meyer in 1867 adenoidectomy performed
  through a ring forceps through the nasal cavity

• 1917 Samuel J. Crowe published his report on 1000
  tonsillectomies, and popularized the use of the
  Crowe-Davis mouth gag and sharp dissection

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History of Tonsillectomy
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History of Tonsillectomy
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Anatomy of the Tonsils and Adenoids
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Size of the Tonsils
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What do the tonsils do?

• Part of secondary immune system
• Exposed to ingested or inspired antigens passed
  through the epithelial layer
• Membrane cells and antigen presenting cells are
  involved in transport of antigen from the surface
  to the lymphoid follicle
• Antigen is presented to T-helper cells?induce B
  cells in germinal center to produce antibody
  (sIgA)

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Incidence

• Tonsillectomies in U.S.
• 1959 1.4 million
• 1979 500,000
• 1985 340,000
• 1996 287,000
• 1950s primary indication - chronic infection
• 2000s obstructive sleep apnea (80)
• Improvement in medical management with antibiotics

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Indications

• Three or more infections a year
• (not stringent enough)
• Tonsillar Hypertrophy
• Upper airway obstruction
• Sleep disorders
• Dental malocclusion
• Orofacial growth affected
• Dysphagia
• Cardiopulmonary complications
• Peritonsillar abscess (2 or more)
• Halitosis due to chronic tonsillitis (more than 3
  months)
• Chronic/recurrent tonsillitis with Strep carrier
  state
• Unilateral hypertrophy, presumed neoplasm
• Tonsillar disease refractory to medical therapy

American Academy of Otolaryngology-Head and Neck
Surgery 1995 Clinical indicators compendium,
Alexandria, Virginia, 1995, American Academy of
Otolaryngology-Head and Neck Surgery
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Indications

• Recurrent or chronic tonsillitis
• Much more common during the teenage years
• Obstructive sleep apnea/Sleep disordered
  breathing
• Most common age group 2-5

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Microbiology of Tonsillitis
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Recurrent Tonsillitis

• Paradise JL, Bluestone CD, Bachman RZ, et al
  Efficacy of tonsillectomy for recurrent throat
  infection in severely affected children results
  of parallel randomized and nonrandomized clinical
  trials, N Engl J Med. 310674683, 1984.

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Recurrent Tonsillitis

• Criteria
• 7/ episodes in last 1 year
• 5/ episodes in last 2 years
• 3/ episodes in last 3 years
• Clinical features of each episode
• Fever (38.5 C)
• Lymphadenopathy (tender, gt2cm)
• Tonsillar/pharyngeal exudate and erythema
• Positive ß-hemolytic streptococcus test
• Medically treated

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Recurrent Tonsillitis

• Paradise conclusions
• Tonsillectomy was efficacious for 2 years and
  possibly a third in reducing frequency and
  severity of subsequent episodes
• Paradise criteria adopted by many
  otolaryngologists

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Recurrent Tonsillitis

• Paradise JL, et al Tonsillectomy and
  Adenotonsillectomy for Recurrent Throat Infection
  in Moderately Affected Children, Pediatrics
  110(1)7, 2002.

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Recurrent Tonsillitis

• Surgical criteria not as stringent as those in
  previous study
• Incidence of subsequent pharyngitis in surgical
  groups significantly lower than control group for
  3 years postoperatively
• Overall incidence was low 0.16-0.43 per year
• Overall, surgical complication risk was high 7.9
  (unusually high malignant hyperthermia, intraop
  hemorrhage requiring packing and ligation,
  post-op hemorrhage 3.5, transfusion, allergic
  rash and throat infection)
• Conclusion modest benefit from surgery does not
  justify the inherent risks, morbidity and cost of
  surgery

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Obstructive Sleep Apnea

• Clinical Practice Guideline Diagnosis and
  Management of Childhood Obstructive Sleep Apnea
  Syndrome
• AMERICAN ACADEMY OF PEDIATRICS Section on
  Pediatric Pulmonology, Subcommittee on
  Obstructive Sleep Apnea Syndrome
• Pediatrics 2002109704-712

• Sleep-Disordered Breathing, Behavior, and
  Cognition in Children Before and After
  Adenotonsillectomy
• Chervin RD, et al. Pediatrics
  2006117e769-e778

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Definition

• OSA - disorder of breathing during sleep
  characterized by prolonged partial upper airway
  obstruction and/or intermittent complete
  obstruction (obstructive apnea) that disrupts
  normal ventilation during sleep and normal sleep
  patterns

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Guideline Recommendations

• All children should be screened for snoring
• Complex high-risk patients should be referred to
  a specialist
• Patients with cardiorespiratory failure cannot
  await elective evaluation
• Diagnostic evaluation is useful in discriminating
  between primary snoring and OSAS, the gold
  standard being polysomnography
• Adenotonsillectomy is the first line of treatment
  for most children, and continuous positive airway
  pressure is an option for those who are not
  candidates for surgery or do not respond to
  surgery
• High-risk patients should be monitored as
  inpatients postoperatively
• Patients should be reevaluated postoperatively to
  determine whether additional treatment is
  required.

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Symptoms

• Habitual (nightly) snoring (often with
  intermittent pauses, snorts, or gasps)
• labored breathing during sleep,
• observed apnea,
• diaphoresis, enuresis, cyanosis
• Disturbed sleep -Restless sleeper
• Daytime neurobehavioral problems
• Daytime sleepiness may occur but is uncommon in
  young children

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Risk Factors for OSA

• Adenotonsillar hypertrophy
• Chronic nasal congestion/obstruction
• Obesity
• Craniofacial anomalies
• Neuromuscular disorders
• Down syndrome

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Complications of OSA

• Neurocognitive impairment
• Behavior problems
• Poor school performance
• Failure to thrive
• Cor pulmonale, particularly in severe cases (very
  rare now due to the increased awareness)

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Prevalence

• Most common among pre-school children adenoid
  and tonsil size largest relative to the size of
  the upper airway
• Primary snoring 10-12
• OSA 2-3
• Boys Girls
• Slightly higher in African American children

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Diagnosis History and Physical

• Size of the tonsil does NOT correlate well with
  OSA (plain film does not help for tonsils)
• Loudness of the snoring does NOT correlate well
  with OSA
• OSA most common during REM sleep early in the
  morning when parents are not watching
• Obstructive hypoventilation vs. cyclic apneas
• OSA scoring questionnaires not very successful
  at predicting OSA

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Diagnosis

• Nocturnal polysomnography (sleep study) is
  currently the gold standard
• Age-appropriate criteria need to be used
• Severe shortage of pediatric facilities

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Diagnosis other methods

• Audiotape or Videotape
• Nocturnal pulse oximetry
• Daytime nap polysomnography
• Reasonable PPV, but poor NPV when result is
  positive, it is very helpful

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What to do in the real world?

• Rely on parental history
• Follow-up visit after parental monitoring
• Review symptoms/signs with parents
• Treat underlying allergic rhinitis or nasal
  obstruction
• Videotapes can help
• In selective patient, Sleep Study is appropriate
• Parental request
• Complicated high risk patients to assess
  severity and the need for post-op study
• Patient not a good candidate for TA

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Risk for Post-op Complications

• Age younger than 3 years
• Severe OSAS on polysomnography
• Cardiac complications of OSAS (eg, right
  ventricular hypertrophy)
• Failure to thrive
• Obesity
• Prematurity
• Recent respiratory infection
• Craniofacial anomalies
• Neuromuscular disorders

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Post-op Complications

• Anesthesia complications
• Respiratory problems
• Post-obstructive pulmonary edema
• Chronic lung disease transient worsening of OSA
• Pain and poor PO intake ? dehydration
• Post-tonsillectomy hemorrhage 1-2

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Results from TA

• 75-100 resolution of symptoms
• Additional treatment
• Weight management result is less optimal in
  obese children
• CPAP severe OSA
• Other surgical procedures in high risk patients
  tongue reduction, tongue base suspension,
  maxillomandibular advancement, etc.

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Adenoidectomy alone?

• OSA very small tonsils, but prominent adenoids
  with significant daytime nasal congestion
  symptoms
• Chronic mouth breathing without significant apnea
  component
• Chronic otitis media with effusions
  adenoidectomy generally at the second set of
  tubes
• Recurrent sinusitis
• Complications 11500 VPI