Tonsillectomy in children: Update to guidelines for treating and managing care

Includes education and counselling component for caregivers

American Academy of Otolaryngology – Head and Neck Surgery

The American Academy of Otolaryngology-Head and Neck Surgery Foundation published the Clinical Practice Guideline: Tonsillectomy in Children (Update) today in Otolaryngology-Head and Neck Surgery. The update to the 2011 publication, which includes a large amount of new information that applies to a child considered for tonsillectomy, emphasizes education, counseling, and pain management with several tables and handouts that are user-friendly and helpful to caregivers.

“The purpose of this multidisciplinary guideline is to identify quality improvement opportunities in managing children, 18 years of age or less, who are under consideration for tonsillectomy and to create explicit and actionable recommendations. The goal is to educate clinicians and caregivers on the indications and the perioperative management of children undergoing tonsillectomy. There is an emphasis on the need for evaluation and intervention in special populations. We highlight the need for counseling and education of families,” said Ron B. Mitchell, MD, Chair of the guideline update group.

Tonsillectomy is a surgical procedure performed with or without adenoidectomy that completely removes the tonsil, including its capsule, by dissecting the peritonsillar space between the tonsil capsule and the muscular wall. Tonsillectomy is one of the most common ambulatory surgery procedures performed on children in the U.S. In the most recent report of the National Health Stat Report, published in 2017, 289,000 ambulatory tonsillectomy procedures were performed in children less than 15 years of age. This is a decline in incidence from the National Health Stat Report, published in 2009, which cited more than 530,000 tonsillectomies in children under 15. The two most common indications for tonsillectomy are recurrent throat infections and obstructive sleep-disordered breathing (oSDB).

Changes in practice since the 2011 guideline include a reduction in the use of routine postoperative antibiotics as well as a Food and Drug Administration black box warning on the use of codeine in children posttonsillectomy.

“The frequency of performing tonsillectomy in children, coupled with the significant practice variations in diagnosing and managing children undergoing the surgery, supported the need for an updated evidence-based clinical practice guideline to replace the 2011 version,” said Dr. Mitchell.

Changes from the prior guideline include two consumer advocates added to the update group; evidence from one new clinical practice guideline, 26 new systematic reviews, and 13 new randomized controlled trials; enhanced emphasis on patient education and shared decision-making; the addition of an algorithm to clarify action statement relationships; changes to five of the key action statements (KASs) from the original guideline; incorporation of new evidence profiles to include the role of patient preferences, confidence in the evidence, differences of opinion, quality improvement opportunities, and any exclusion to which the action statement does not apply; and the addition of seven new KASs.

Of the 15 KASs, the guideline update group made strong recommendations against the following: 1) Clinicians should not administer or prescribe perioperative antibiotics to children undergoing tonsillectomy; and 2) Clinicians must not administer or prescribe codeine, or any medication containing codeine, after tonsillectomy in children younger than 12 years. Refer to the updated guideline for a complete listing of all KASs as well as Table 1. For changes to the KASs from the original guideline, see page 4.

FACT SHEET

AAO-HNSF Clinical Practice Guideline: Tonsillectomy in Children (Update)

1. What is a tonsillectomy?

Tonsillectomy is defined as a surgical procedure performed with or without adenoidectomy that completely removes the tonsil, including its capsule, by dissecting the peritonsillar space between the tonsil capsule and the muscular wall.

2. Why is the update to this guideline important?

Tonsillectomy is one of the most common surgical procedures performed on children in the United States. Caregivers considering a tonsillectomy for their child will be presented with a summary of how to ensure the best care for a child before, during and after tonsillectomy. Since the guideline’s initial publication in 2011, there has been a large amount of new information that applies to a child considered for tonsillectomy. The update panel included representation from several specialties involved in the care of children who undergo tonsillectomy in addition to two consumer advocates. There is emphasis on education, counseling and pain management with several tables and handouts that are user-friendly and should be helpful to caregivers.

• The target population for the guideline is any child 1 to 18 years of age who may be a candidate for tonsillectomy.

3. What is the incidence of tonsillectomy?

In the most recent National Health Stat Report, published in 2017, 289,000 ambulatory tonsillectomy procedures were performed in children less than 15 years of age. This is a decline in incidence from the National Health Stat Report, published in 2009, which cited more than 530,000 tonsillectomies in children under 15. The two most common indications for tonsillectomy are recurrent throat infections and obstructive sleep-disordered breathing (oSDB).

4. What is oSDB?

oSDB is a general term for breathing difficulties during sleep. It is usually caused by large tonsils and adenoids. oSDB can be worse in children who are overweight or obese, have muscle weakness, or have certain genetic problems or diseases that affect nerves. Children with oSDB may be sleepy during the day, act out, struggle in school, have nighttime bedwetting, and be small for their age.

5. Are there risks related to tonsillectomy?

Tonsillectomy is a surgical procedure that includes some risks. After surgery, a child may have:

• Throat pain that lasts up to two weeks
• Vomiting or a feeling like they have to vomit
• Thirst or dryness, especially if they are vomiting (dehydration)
• Bleeding in their mouth (from the tonsils)
• Temperature greater than 101°F

6. What are the Key Action Statements (KASs) or significant points made in the guideline:

KAS1: WATCHFUL WAITING FOR RECURRENT THROAT INFECTION
Clinicians should recommend watchful waiting for recurrent throat infection if there have been fewer than seven episodes in the past year, fewer than five episodes per year in the past two years, or fewer than three episodes per year in the past three years.

KAS2: RECURRENT THROAT INFECTION WITH DOCUMENTATION
Clinicians may recommend tonsillectomy for recurrent throat infection with a frequency of at least seven episodes in the past year, at least five episodes per year for two years, or at least three episodes per year for three years with documentation in the medical record for each episode of sore throat and one or more of the following: Temperature greater than 38.3°C or 101°F, cervical adenopathy, tonsillar exudate, or positive test for group A betahemolytic streptococcus.

KAS3: TONSILLECTOMY FOR RECURRENT INFECTION WITH MODIFYING FACTORS
Clinicians should assess the child with recurrent throat infection who does not meet criteria in KAS2 for modifying factors that may nonetheless favor tonsillectomy, which may include but are not limited to: multiple antibiotic allergies/intolerance, PFAPA (periodic fever, aphthous stomatitis, pharyngitis, and adenitis), or history of more than one peritonsillar abscess.

KAS4: TONSILLECTOMY FOR OBSTRUCTIVE SLEEP-DISORDERED BREATHING
Clinicians should ask caregivers of children with obstructive sleep-disordered breathing (oSDB) and tonsillar hypertrophy about comorbid conditions that may improve after tonsillectomy, including growth retardation, poor school performance, enuresis, asthma, and behavioral problems.

KAS5: INDICATIONS FOR POLYSOMNOGRAPHY
Before performing tonsillectomy, the clinician should refer children with oSDB for polysomnography (PSG) if they are under two years of age or if they exhibit any of the following: obesity, Down syndrome, craniofacial abnormalities, neuromuscular disorders, sickle cell disease, or mucopolysaccharidoses.

KAS6: ADDITIONAL RECOMMENDATIONS FOR PSG
The clinician should advocate for PSG prior to tonsillectomy for oSDB in children without any of the comorbidities listed in KAS5 for whom the need for tonsillectomy is uncertain or when there is discordance between the physician examination and the reported severity of oSDB.

KAS7: TONSILLECOMY FOR OBSTRUCTIVE SLEEP APNEA
Clinicians should recommend tonsillectomy for children with obstructive sleep apnea (OSA) documented by overnight PSG.

KAS8: EDUCATION REGARDING PERSISTENT OR RECURRENT oSDB
Clinicians should counsel patients and caregivers and explain that oSDB may persist or recur after tonsillectomy and may require further management.

KAS9: PERIOPERATIVE PAIN COUNSELING
The clinician should counsel patients and caregivers regarding the importance of managing posttonsillectomy pain as part of the perioperative education process and should reinforce this counseling at the time of surgery with reminders about the need to anticipate, reassess, and adequately treat pain after surgery.

KAS10: PERIOPERATIVE ANTIBIOTICS
Clinicians should not administer or prescribe perioperative antibiotics to children undergoing tonsillectomy.

KAS11: INTRAOPERATIVE STERIODS
Clinicals should administer a single, intraoperative dose of intravenous dexamethasone to children undergoing tonsillectomy.

KAS12: INPATIENT MONITORING FOR CHILDREN AFTER TONSILLECTOMY
Clinicians should arrange for overnight, inpatient monitoring of children after tonsillectomy if they are under the age of three years old or have severe obstructive sleep apnea (OSA); apnea-hypopnea index [AHI] of 10 or more obstructive events/hour, oxygen saturation nadir less than 80 percent, or both).

KAS13: POSTOPERATIVE IBUPROFEN AND ACETAMINOPHEN
Clinicians should recommend ibuprofen, acetaminophen, or both for pain control after tonsillectomy.

KAS14: POSTOPERATIVE CODEINE
Clinicians must not administer or prescribe codeine, or any medication containing codeine, after tonsillectomy in children younger than 12 years.

KAS15A: OUTCOME ASSESSMENT FOR BLEEDING
Clinicians should follow up with patients and/or caregivers after tonsillectomy and document in the medical record the presence or absence of bleeding within 24 hours of surgery (primary bleeding) and bleeding occurring later than 24 hours after surgery (secondary bleeding).

KAS15B: POSTTONSILLECTOMY BLEEDING RATE
Clinicians should determine their rate of primary and secondary posttonsillectomy bleeding at least annually.

10. Where can I get more information?
Visit http://www.entnet.org/tonsillectomyCPG for more information.