No Surgery for Moderate Tonsillitis, New Guidelines Say
THURSDAY Jan. 6, 2011 -- Doctors should use antibiotics and a wait-and-see approach when treating repeated throat infections in children and resort to a tonsillectomy only in the most severe cases, new medical guidelines suggest.
A panel of experts formed to address the costs and risks of unnecessary tonsillectomies -- surgical removal of the tonsils -- found that most children with frequent sore throats get better without surgery.
"Tonsillectomy is [one of the] most common childhood operations in the United States, so it's critical for those of us who perform the procedure to know who should get it, and how to manage the patient," said Dr. Lee P. Smith, chief of pediatric otolaryngology at the Steven and Alexandra Cohen Children's Medical Center of New York on Long Island.
The tonsils are walnut-size lumps of lymph tissue at the back of the throat.
The guidelines, published in the January issue of Otorlaryngology -- Head and Neck Surgery, identify appropriate candidates for tonsillectomy who are between the ages of 1 and 18, and they set down a standard of care for those patients.
More than half a million tonsillectomies are performed annually in the United States on children younger than 15. For certain patients -- perhaps those with tonsil-related sleep problems or repeated infections that don't respond to antibiotics -- the operation can improve health and quality of life, the experts say.
But for patients with moderate cases of throat infection, tonsillectomy may be unnecessary and even dangerous, the panel finds. Risks include the possibility of hemorrhage, anesthesia complications, trauma to the jaw, infection, airway damage and, in rare cases, death.
Instead of rushing into surgery, the Academy of Otolaryngology guidelines recommends a cautious approach for children who have had fewer than seven infections during the past year, fewer than five a year over the past two years, and fewer than three annually over the past three years. (Parents should keep at-home records of children's health history, the panel says).
"I think the guidelines are a great collaboration between otolaryngologists, pediatricians and infectious disease experts to help standardize the care of children with tonsillar disease," said Dr. Jerry Schreibstein of the Ear, Nose and Throat Surgeons of Western New England in Springfield, Mass.
"They highlight that the indications for tonsillectomy are not just in cases of strep infections but in cases of severe tonsillitis manifested by fever, swollen glands -- enlargement of the lymph nodes -- and exudate [fluid]," said Schreibstein.
Also, "the indication for tonsillectomy in cases of snoring, mouth breathing and obstructive breathing is stressed," he added.
For such children, whose disrupted sleep results in daytime drowsiness or hyperactivity, tonsillectomy may improve daytime functioning, the experts said.
For these and other cases where tonsillectomy is warranted, the experts also recommend that doctors:
- Inject the steroid dexamethasone during the procedure to minimize postoperative pain, nausea and vomiting, a frequent cause of hospital readmission.
- Avoid routine use of antibiotics, currently used by about 80 percent of doctors, before and after surgery. The researchers found no benefit from antibiotics and cited risks such as allergic reaction.
- Educate caregivers about the need for adequate pain control.
Schreibstein called those recommendations "good points about the management of tonsillectomy patients."
Smith said he supports the caution against routine antibiotic use, noting it is necessary only in about 2 percent of cases.
Noting that the panel left decisions about using non-steroidal anti-inflammatory drugs for pain management up to doctors, Smith said the risk of bleeding would make doctors "uncomfortable" using these medications.
As part of the immune system, the tonsils "were probably more important before we had antibiotics and modern sanitary practices," Smith said. No known medical problems arise from life without tonsils.
For tips on tonsillectomy, visit the Nemours Foundation.
Posted: January 2011