Remember when children used to fear the doctor's words, "It is time to take those tonsils out?" Well today the first clinical practice guidelines regarding tonsillectomies have been released. In fact, most children with throat infections or inflamed tonsils in fact do not need the surgery after all.
This procedure has always been controversial. In 1906 the Tonsillectomy Riots took place in New York. Doctors had performed 83 tonsillectomies at one elementary school in New York City's Lower East Side, and 50,000 immigrant mothers descended on their local public schools demanding to see their children having heard that there was a Board of Health-sanctioned child slaughter taking place. The Tonsillectomy Riots remind us about the durability of profitable medical procedures even in the face of evidence against them.
A tonsillectomy is a 3,000 year-old surgical procedure in which the tonsils are removed from either side of the throat. The procedure is performed in response to cases of repeated occurrence of acute tonsillitis or adenoiditis, obstructive sleep apnea, nasal airway obstruction, snoring, or peritonsillar abscess.
By the mid-1930s, fully one-third of all operations performed under anesthesia in the United States were tonsillectomies. Around that same time, research that included a pioneering study of New York City schoolchildren began to show that the tonsillectomy rate was more dependent on physician preference than on objective indicators. Nonetheless, the growing medical literature on inappropriate and even dangerous tonsillectomies had little effect on actual practice until Congressional hearings in the 1970s spotlighted parents whose children had been harmed or killed. Only then did the profession react. Tonsillectomy is being performed less frequently than in past decades, but it remains one of the most common surgical procedures in children in the United States.
This week the American Academy of Otolaryngology, Head and Neck Surgery (AAO-HNS) has issued new clinical practice guidelines developed using a systematic literature search which was condensed into evidence-based statements with associated balance of benefit and harm.
Guideline co-author Richard Rosenfeld, MD, of SUNY Downstate Medical Center in Brooklyn, N.Y. explains:
"Over half a million tonsillectomies are done every year in the U.S. The tonsillectomy guideline will empower doctors and parents to make the best decisions, resulting in safer surgery and improved quality of life for children who suffer from large or infected tonsils."
So what do the new guidelines explain to doctors?
First, physicians need to watch out for recurrent throat infection, and clinicians should recommend watchful waiting for recurrent throat infection if there have been fewer than seven episodes in the past year or fewer than five episodes per year in the past two years or fewer than three episodes per year in the past three years.
Clinicians should assess the child with recurrent throat infection who does not meet criteria for modifying factors that may nonetheless favor tonsillectomy, which may include but are not limited to multiple antibiotic allergy/intolerance, PFAPA (periodic fever, aphthous stomatitis, pharyngitis, and adenitis), or history of peritonsillar abscess.
In some cases, a tonsillectomy may be necessary for sleep disorders related to breathing. Clinicians should inform parents of children with sleep-disordered breathing and tonsil hypertrophy about some conditions that might improve after tonsillectomy. These include growth retardation, poor school performance, enuresis, and behavioral problems.
There are also new guidelines in medication during and after surgery. Clinicians should administer a single, intraoperative dose of intravenous dexamethasone to children undergoing tonsillectomy. Dexamethasone is designed to break down stored resources (fats, sugars and proteins) so that they may be used as fuels in times of stress. Cortisone would be an example of a related hormone with which most people are familiar, though cortisone is a natural hormone produced by the body's adrenal glands whereas dexamethasone is synthetic.
Guideline panel members were chosen to represent fields of sleep medicine, advanced practice nursing, anesthesiology, infectious disease, family medicine, otolaryngology, pediatrics, and consumers.
The panel concludes:
"Guidelines are never intended to supersede professional judgment; rather, they may be viewed as a relative constraint on individual clinician discretion in a particular clinical circumstance."
The AAO-HNS is the world's largest organization representing specialists who treat the ear, nose, throat, and related structures of the head and neck. The Academy represents more than 12,000 head and neck surgeons (ENTs) who diagnose and treat disorders of those areas.
The complete practice guidelines are published in the January issue of Otolaryngology -- Head and Neck Surgery.
Written by Sy Kraft, B.A.