Tonsillectomy

So, if you follow me on Instagram (Ampersand.PA), you know that I will regularly share an ENT #TeachingTuesday topic on my InstaStory.

As a request, I was asked to talk about the indications for a tonsillectomy.

What is a tonsillectomy?  A tonsillectomy is the removal of your tonsils (oval-shaped padding of tissues located in the back of the throat that play a role in the body’s immune system).

Tonsillectomies are one of the most commonly performed surgical procedures. A tonsillectomy may be performed with or without an adenoidectomy (adenoids and tonsils removal).

 

What are the clinical indications for a tonsillectomy? Although there are 6 criteria, commonly in our practice, we follow Criteria #1 and Criteria #3 (#4 for the little ones).

  • Criteria #1 (based on the Paradise Criteria for Tonsillectomy):
  • Minimum frequency of sore throat episodes:
    • 7 or more episodes in the past year, OR
    • 5 or more episodes in each of the preceding 2 years, OR
    • 3 or more episodes in each of the preceding 3 years
  • Sore throat should include at least one of the following:
    • Temperature greater than 38.3oC or 100.94oF
    • Cervical adenopathy
    • Tonsillar exudate or erythema
    • Positive test for Group A beta-hemolytic streptococcus (GABHS)
  • Criteria #2
  • A history of recurrent throat infections not meeting criteria #1
  • Additional factors that favor a tonsillectomy that also includes one or more of the following:
    • Multiple antibiotic allergy/intolerance
    • PFAPA syndrome (period fever, aphthous stomatitis, pharyngitis, and adenitis)
    • Peritonsillar abscess
    • Parapharyngeal abscess
  • Criteria #3
  • A diagnosis of sleep disordered breathing (SDB)
  • Must have ALL of the following:
    • Tonsillar hypertrophy, abnormality of respiratory pattern (snoring, mouth breathing, pauses in breathing), condition related to SBD such as growth retardation, poor school performance, enuresis, excessive sleepiness, inattention, aggression, depression, hyperactivity, and behavioral problems
  • Criteria #4
  • Similar to that of 3, but applies for children less than 3 YO with a diagnosis of SBD
    • Tonsillar hypertrophy, > 3 months duration, parent/caregiver reports regular episodes of nocturnal gasping, apnea
  • Criteria #5
  • Diagnosis of obstructive sleep apnea
    • Tonsillar hypertrophy and a polysomnogram with an apnea hypopnea index (AHI) > 1.0
  • Criteria #6
    • Suspicion of tonsillar malignancy

Risks and Complications:

  • Hemorrhage, infection, prolonged pain, impaired healing, permanent change in voice, failure to improve airway, resolve snoring, sleep apnea, or mouth breathing, nasal regurgitation – velopharyngeal insufficiency (VPI), death (rare)
  • Postoperative pain in adults can last up to 2 weeks vs 10 days or less in children
  • We often spend a great amount of time talking to our adult patients about post op pain. Unfortunately, adults do not handle the surgery as well as the kiddos. They say it’s like have the worst sore throat of your life for 2 weeks.

And it makes sense! Essentially, to remove the tonsils, you are burning off the encapsulated tonsils. This 1. leaves you with foul breath 2. a scab that is forever coming off.

We describe this healing pattern as 2 peaks. The patient does well until about day 7-10, when the scab starts to slough off and cause immense pain. You don’t realize how often you swallow, or move your mouth when you’re talking.

For those that were fortunate enough to have their tonsills as a child, thank your parents.  If you’re reading this as an adult, I’m sorry! Stay hydrated and hoping for a speedy recovery!

Xx,
Ngan

Source: Uptodate

 

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