Adenotonsillectomy (AT) is one of the most common pediatric surgical procedures performed in the United States; more than 530,000 are performed annually in children younger than 15 years of age. AT was traditionally performed for recurrent tonsillitis and its sequelae but in recent times, sleep-disordered breathing/obstructive sleep apnea in children has emerged as the primary indication for surgical removal of adenoids and tonsils. The new guidelines used by clinicians to identify children who are appropriate candidates for AT address indications based primarily on obstructive and infectious causes.
Key points
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Adenotonsillectomy is the second most common procedure performed in children.
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Sleep-disordered breathing/obstructive sleep apnea is the most common indication for pediatric adenotonsillectomy.
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New stringent criteria (Paradise criteria) have been developed for consideration of tonsillectomy for recurrent tonsillitis.
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Tylenol Codeine should be used with caution for postoperative pain control.
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Parents need to be counseled regarding obesity, adenotonsillectomy, and postoperative cure rates and complications.
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No studies have shown adverse effects on immunity after adenotonsillectomy.
Introduction
Adenotonsillectomy (AT) is one of the most common pediatric surgical procedures performed in the United States; more than 530,000 are performed annually in children younger than 15 years of age. AT was traditionally performed for recurrent tonsillitis and its sequelae but, in recent times, sleep-disordered breathing (SDB)/obstructive sleep apnea (OSA) in children has emerged as the primary indication for surgical removal of adenoids and tonsils. The new guidelines used by clinicians to identify children who are appropriate candidates for AT address indications based primarily on obstructive and infectious causes.
Introduction
Adenotonsillectomy (AT) is one of the most common pediatric surgical procedures performed in the United States; more than 530,000 are performed annually in children younger than 15 years of age. AT was traditionally performed for recurrent tonsillitis and its sequelae but, in recent times, sleep-disordered breathing (SDB)/obstructive sleep apnea (OSA) in children has emerged as the primary indication for surgical removal of adenoids and tonsils. The new guidelines used by clinicians to identify children who are appropriate candidates for AT address indications based primarily on obstructive and infectious causes.
Anatomy
The Waldeyer ring of lymphoid tissue at the nasopharyngeal and oropharyngeal openings constitutes the first line of defense against ingested and inhaled pathogens. The lingual tonsils, the palatine tonsils, and the nasopharyngeal tonsils (adenoids) constitute the Waldeyer tonsillar ring.
The palatine tonsils are located at the junction of the oral cavity and the oropharynx. The tonsillar fossa is composed of 3 muscles: the palatoglossus, which forms the anterior tonsillar pillar; the palatopharyngeus, which is the posterior tonsillar pillar; and the superior constrictor muscle of the pharynx, which forms the tonsillar bed. The tonsil lies between the palatoglossus and palatopharyngeal muscles. The tonsillar fossa is innervated by the tonsillar branches of the glossopharyngeal nerve and branches of the lesser palatine nerves. The blood supply to the tonsil enters primarily at the lower pole through the tonsillar branch of the dorsal lingual artery and the tonsillar branch of the facial artery. The ascending pharyngeal artery and the lesser palatine artery supply the tonsil via its upper pole. Venous blood drains into the internal jugular vein. The efferent lymphatic drainage is via the upper deep cervical nodes (jugulodigastric or tonsillar nodes) behind the angle of the mandible.
The palatine tonsil differs from the lingual and nasopharyngeal tonsils (adenoids) in that it has a thin capsule on the deep surface. This capsule is a portion of the pharyngobasilar fascia and extends into the tonsil to form septa that conduct nerves, blood vessels, and lymphatic vessels. The surface of the tonsil is lined by stratified squamous epithelium, which extends deep into the tissue forming tonsillar crypts.
The nasopharyngeal tonsils (adenoids) are located with the apex pointing toward the nasal septum and the base toward the roof and posterior wall of the nasopharynx. Adenoids are fully developed during the seventh month of gestation and continue to grow until the fifth year of life. Adenoid tissue is lined by respiratory epithelium; its exposed surface is covered by stratified and pseudostratified ciliated columnar epithelium. Unlike the palatine tonsils, there is no capsule surrounding the adenoids. The blood supply to the adenoids is from the ascending pharyngeal artery, the ascending palatine artery, the pharyngeal branch of the maxillary artery, the artery of the pterygoid canal, and the tonsillar branch of the facial artery. Venous drainage occurs via the internal jugular and facial veins. The pharyngeal plexus provides the nerve supply to the adenoids. The lymphatic drainage is to the retropharyngeal and pharyngomaxillary space lymph nodes.
Immunology of the adenoids and tonsils
The adenoids and tonsils are strategically positioned to serve as secondary lymphoid organs. They initiate an immune response against airborne antigens entering the body through the nose and mouth. Both contain predominantly B-cell lymphocytes (50%–65%); they also contain T-cell lymphocytes (40%) and mature plasma cells (3%). Both are involved in inducing secretory immunity and regulating secretory immunoglobulin production. The tonsils are immunologically most active between the ages of 3 and 10 years. In patients with chronic or recurrent tonsillitis, the process of antigen presentation within the tonsil and adenoids is altered, which results in reduced activation of local B cells and decreased antibody production.
There are conflicting studies regarding the effects of AT on immunity. One study showed that in children previously immunized with live polio vaccine, there was a 3- to 4-fold decrease in the level of IgA antibody in their nasopharyngeal secretions. The study also showed a delay and a lowered nasopharyngeal secretory immune response in seronegative children who had undergone AT and subsequent live oral polio vaccine administration. Another study has shown better neutrophil chemotaxis after tonsillectomy and another demonstrated increased IgG and IgM production. Overall, there are no studies that indicate a significant clinical impact on the immune system after AT.
Indications for tonsillectomy and adenoidectomy
Recurrent throat infections and chronic adenotonsillar hypertrophy associated with airway obstruction are the most common indications for AT.
SDB/OSA
SBD is characterized by recurrent or complete upper obstruction during sleep, resulting in disruption of normal ventilation and sleep patterns. OSA is diagnosed when SDB is present in combination with an abnormal sleep study showing obstructive events. A sleep study or polysomnography (PSG) is considered the gold standard for diagnosing and assessing the severity of OSA but it is not necessary in every child with suspected sleep apnea. PSG is discussed in detail later in this article.
In otherwise healthy children, adenotonsillar hypertrophy is the major cause of SDB. There are several grading systems for assessing tonsillar size. The most commonly used grading scale for tonsillar hypertrophy was described by Brodsky. The Brodsky grading scale ( Table 1 ) from 0 to 4 is based on the percentage of oropharyngeal airway occupied by the tonsils. The oropharyngeal airway is designated by the linear distance between the 2 anterior tonsillar pillars. Tonsillar hypertrophy is defined as 3+ or 4+ ( Fig. 1 ). Tonsils need not be kissing to be graded as 4+. Although this grading system is easy to understand and follow, many studies have shown that the volume of the adenoids and tonsils relative to the oropharynx is a better determinant of the severity of SDB/OSA. Both SDB and OSA have been known to increase the risk of behavioral problems such as irritability, aggression, and depression and may exacerbate symptoms of attention-deficit hyperactivity disorder. Patients may have poor school performance because of daytime sleepiness, and problems with memory and attention. Children with severe SDB may also suffer from morning headaches, failure to thrive, and enuresis. These symptoms have been shown to improve or resolve after tonsillectomy for SDB/OSA. However, SDB is often multifactorial and may persist after tonsillectomy, particularly in children with other comorbid conditions, especially obesity.
| Grade | Description |
|---|---|
| 0 | Tonsils within the tonsillar fossa |
| 1 | Tonsils just outside the tonsillar fossa and occupy ≤25% of the oropharyngeal width |
| 2 | Tonsils occupy 26%–50% of oropharyngeal width |
| 3 | Tonsils occupy 51%–75% of oropharyngeal width |
| 4 | Tonsils occupy >75% of the oropharyngeal width |
Obesity and AT
The prevalence of OSA/SDB in obese children is 25% to 40%. Factors that contribute to SDB/OSA in obese children include adenotonsillar hypertrophy, altered neuromuscular tone resulting in greater upper airway collapsibility during sleep, central adiposity, and an excess mechanical load on the chest wall resulting in increased work of breathing. AT can reduce the severity of OSA/SDB in obese children but is usually curative in only about 10% to 25% compared with 80% in children of normal weight, other parameters being comparable. Obese children are also more likely to have respiratory complications after AT. Obese children should be counseled regarding weight loss and the future need for use of positive airway pressure techniques.
Tonsillar asymmetry may raise concern for tumor or lymphoma of the larger tonsil. However, the presence of tonsillar asymmetry alone is not an indication for tonsillectomy. A thorough clinical assessment including history, physical examination, and appropriate laboratory testing is indicated.
Recurrent Tonsillitis
Viral infections are the most common cause of acute tonsillitis/pharyngitis; adenovirus is the most common cause of nonstreptococcal tonsillitis. Group A β-hemolytic streptococcus is the most common bacterial cause of acute pharyngitis; its peak incidence occurs in children 5 to 6 years of age during the winter and spring. The most common viruses and bacteria causing recurrent tonsillitis are outlined in Box 1 .
Viral
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Adenovirus
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Rhinovirus
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Corona
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Influenza virus
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Epstein-Barr virus
Bacterial
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Group A β-hemolytic streptococcus
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Moraxella catarrhalis
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Haemophilus influenzae
Patients with acute tonsillitis may present with malaise, fever, fullness of throat, odynophagia, dysphagia, otalgia, headache, body aches, cervical lymphadenopathy, and shivering. It is important for clinicians to accurately document acute episodes of throat infections, including body temperature, pharyngeal/tonsillar erythema, tonsil size, tonsillar exudate, cervical adenopathy (presence, size, and tenderness), and the results of microbiological testing (throat cultures, rapid strep test) for group A β-hemolytic streptococci.
Clinical Practice Guidelines
New guidelines recommend watchful waiting for a 12-month period for recurrent throat infections in children not meeting the Paradise criteria ( Box 2 ). However, patients with a history of recurrent severe infections requiring hospitalization, or those who have had sequelae such as peritonsillar abscess or Lemierre syndrome may be considered for AT before the end of the 12-month observation period even if they do not meet the frequency criteria. Patients who significantly benefit from a tonsillectomy are those with proper documentation of the severity and frequency of the illness. Such children will see a reduction in the number and severity of subsequent infections for at least 2 years.
Criterion definition
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Minimum frequency of sore throat episodes 7 or more episodes in the preceding year, OR
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5 or more episodes in each of the preceding 2 years, OR
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3 or more episodes in each of the preceding 3 years
Clinical features (sore throat plus the presence of 1 or more qualifies as a counting episode)
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Temperature >38.3°C, OR
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Cervical lymphadenopathy (tender lymph nodes or >2 cm), OR
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Tonsillar exudate, OR
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Positive culture for group A β-hemolytic streptococcus
Treatment
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Antibiotics administered in conventional dosage for proved or suspected streptococcal episodes
Documentation
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Each episode and its qualifying features substantiated by contemporaneous notation in a clinical record, OR
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If not fully documented, subsequent observance by the clinician of 2 episodes of throat infection with patterns of frequency and clinical features consistent with the initial history
In addition, tonsillectomy may be considered in children with recurrent tonsillitis and multiple antibiotic allergies, specific syndromes such as PFAPA (periodic fever, aphthous stomatitis, pharyngitis, and adenitis) and associated tonsillitis even if they do not meet Paradise criteria. Poorly validated indications for tonsillectomy include halitosis, dysphagia, muffled speech, febrile seizures, and malocclusion.
Indication for adenoidectomy (adenoid removal) alone
Adenoid hypertrophy ( Fig. 2 ) is associated with upper airway obstruction, OSA, recurrent otitis media, chronic otitis media with effusion, chronic adenoiditis, and chronic rhinosinusitis. It was initially believed that adenoid size led to mechanical obstruction of the eustachian tube resulting in middle ear effusion. However, studies have shown that biofilms of bacteria in adenoid tissue cause inflammation and mucosal edema leading to eustachian tube dysfunction and development of otitis media. Several studies have demonstrated that adenoid removal in patients with otitis media reduces the incidence of future episodes of otitis media and reduces the need for subsequent ventilation tubes. Therefore, adenoidectomy should be considered in patients who require a second set of ventilation tubes or those patients undergoing their first set of ventilation tubes who have symptoms of chronic nasal obstruction. Indications for adenoidectomy are summarized in Box 3 .
