Approximately 530,000 tonsillectomies are performed each year in the United States, making these surgeries the second most routinely performed operation on children. The two most common indications for tonsillectomy are recurrent throat infections and sleep-disordered breathing (SDB). The overall incidence rate of tonsillectomy appears to have significantly increased in the past 35 years, with SDB as the primary indication for surgery. Children with SDB have a significantly higher rate of antibiotic use, 40% more hospital visits, and a 215% higher rate of healthcare usage. A growing body of evidence indicates that tonsillectomy is an effective treatment for resolving SDB and improving quality of life (QOL).
In an issue of Otolaryngology–Head and Neck Surgery, the American Academy of Otolaryngology–Head and Neck Surgery published a multidisciplinary clinical practice guideline on tonsillectomy in children. “It’s important that clinicians have evidence-based guidelines for these procedures so that they will be empowered to help patients make the best treatment decisions,” says Reginald F. Baugh, MD, who chaired the guideline committee. “The goals of the guidelines are to make surgery safer and to improve QOL for children who undergo tonsillectomy.” The guideline is intended for all clinicians who care for children between the ages of 1 and 18 being considered for tonsillectomy. It helps identify children who are the best candidates for tonsillectomy. It also provides information on perioperative care, management options for special patient populations, and counseling strategies.
Guideline Recommendations for Tonsillectomy
The clinical practice guidelines for tonsillectomy in children outlined 10 specific recommendation statements to assist clinicians who manage these patients (Table 1). The statements describe specific aspects to consider with regard to surgical indications and planning, perioperative care, and postoperative care. Within each statement, the guideline considered the aggregate evidence quality, assessment of potential harms and benefits, costs, the role of patient preferences, and whether any value judgments or exclusions factored into the recommendation.
“Educating and counseling of caregivers is paramount to executing a successful pain management strategy after surgery.”
When deciding on tonsillectomy, the guidelines recommend that clinicians counsel and educate caregivers of patients who may require further management (Table 2). To accomplish this, the guideline suggests discussing briefly the reasons why SDB may persist or recur after tonsillectomy and why further assessment and management may be required. Providing informational brochures or summary handouts of the tonsillectomy decision-making process is recommended.
“Pain after surgery is a concern of children undergoing tonsillectomy and their parents/caregivers,” says Dr. Baugh. “Clinicians should convey to caregivers that throat pain is greatest the first few days following surgery and may last up to 2 weeks. Caregivers should encourage their children to communicate with them if they’re experiencing significant throat pain. Pain may not always be expressed and, therefore, not recognized promptly. Educating and counseling caregivers is paramount to executing a successful pain management strategy after surgery.” The guidelines recommend that strategies for pain control be discussed with caregivers before and after surgery. The role of antibiotics, the importance of fluids, and the use of pain medications should also be discussed following careful consideration of the patient’s complete medical history to ensure that all relevant factors are considered. Caregivers should also understand what to expect with regard to perioperative events associated with tonsillectomy and the potential for complaints of pain after surgery.
Overcoming Guideline Obstacles
The guidelines identified several potential areas in which obstacles to guideline implementation might occur. “Clinicians may be unfamiliar with the criteria for tonsillectomy or may not recognize the importance of key elements in the patients’ medical history,” Dr. Baugh says. “Overcoming these knowledge gaps or current beliefs will require the development and deployment of successful implementation strategies for this body of knowledge into continuing medical education venues for clinicians who assess tonsillectomy candidates. Educational material will also be needed for caregivers of children with recurrent throat infection to explain the rationale for watchful waiting instead of earlier surgical intervention.”
The body of literature from which the guidelines were developed is robust, but Dr. Baugh notes that significant knowledge gaps remain. “Several research needs have been identified, including more studies comparing treatment approaches for recurrent throat infections and SDB. Data are also needed to determine optimal follow-up schedules, when preoperative polysomnograms are indicated, and the role of weight gain and obesity in patient selection. Additionally, cost-effectiveness analyses, the role of shared decision-making, and the identification of areas of improvement for postoperative care would be beneficial. The hope is that this literature continues to evolve so that we can enhance our care of children being considered for tonsillectomy in the future.”
Baugh RF, Archer SM, Mitchell RB, et al. Clinical practice guideline: tonsillectomy in children. Otolaryngol Head Neck Surg. 2011;144:S1-S30. Available at: http://www.entnet.org/HealthInformation/upload/CPG-TonsillectomyInChildren.pdf.
Goldstein NA, Stewart MG, Witsell DL, et al. Quality of life after tonsillectomy in children with recurrent tonsillitis.Otolaryngol Head Neck Surg. 2008;138:S9-S16.
Wei JL, Mayo MS, Smith HJ, et al. Improved behavior and sleep after adenotonsillectomy in children with sleep-disordered breathing. Arch Otolaryngol Head Neck Surg. 2007;133:974-979.
Erickson BK, Larson DR, St Sauver JL, et al. Changes in incidence and indications of tonsillectomy and adenotonsillectomy, 1970-2005. Otolaryngol Head Neck Surg. 2009;140:894-901.