By Eric Gantwerker MD, MMSc (MedEd), FACS
May 23, 2019
Recently the American Academy of Otolaryngology-Head and Neck Surgery updated their clinical practice guidelines (CPG) on Tonsillectomy in Children (Mitchell et al., 2019). As more studies are published, a periodic review of the literature is necessary. The last CPG was released in 2011 (Baugh et al., 2011). Since that time 2,190 studies have been indexed in PubMed under the search term “pediatric sleep apnea” with over half of those occurring just since 2016 (1140) (“US National Library of Medicine – NCBI PubMed,” n.d.).
Several keys areas were revisited by the authors and recommendations were made by the multidisciplinary group. Most common indications for tonsillectomy with or without adenoidectomy in children continue to be recurrent tonsillitis or obstructive sleep-disordered breathing (oSDB)/obstructive sleep apnea (OSA). Key action statements (KAS) that were revisited included threshold for recurrent tonsillitis indications, peri-operative antibiotic and steroid use, pain control, sleep study usage, and clinical signs of oSDB in children including nocturnal enuresis and hyperactivity.
Clinicians have discussed how many recurrent tonsillitis episodes are needed before tonsillectomy and the guidelines, after reviewing the literature, concluded that the 7/5/3 threshold is best to follow. This means 7 infections in one year, or 5 infections per year in 2 consecutive years or 3 infections per year in 3 consecutive years. The work group strongly recommended watchful waiting if the recurrent infections are less than the 7/5/3 threshold.
Peri-operative antibiotics and steroids has been discussed as well. For many years, the common practice was to administer both steroids and antibiotics intra-operatively, but recent studies suggest that peri-op antibiotics are not needed, and the work group strongly recommended against this practice. The work group however does strongly recommend a single dose IV steroid in the operating room at time of surgery to minimize nausea and vomiting.
Pain control has also been a big discussion point among clinicians. Since the black box warning on postoperative codeine in children under 12 years of age, clinicians have been scrambling for alternative pain regimens. Ibuprofen, which was avoided for many years due to presumed increase risk of post-op hemorrhage, has recently been strongly recommended, often in combination with acetaminophen. Several studies have been in place to look at differences in number of bleeds and severity of bleeds post-tonsillectomy with ibuprofen use but have been inconclusive. The work group expanded to strongly recommend against codeine use in patients under 12 years of age.
Use of pediatric sleep studies has also been a huge discussion among clinicians treating pediatric oSDB. Utilization and cost have been at the center of this discussion as well. Often times, cost and delay in treatment are common reasons clinicians do not order sleep studies and instead rely on clinical indications that oSDB is occurring. These symptoms are often split into daytime and nighttime symptoms and include snoring, witnessed apneas or gasping, poor school performance, behavioral issues, and enuresis. The work group specifically state that “up to 40% of children with oSDB exhibit behavioral problems, including enuresis, hyperactivity, aggression, anxiety, depression, and somatization” (Mitchell et al., 2019).
Regarding enuresis, Basha et al. in a 2005 study looked at 326 children who had undergone tonsillectomy with 32.8% of them having symptoms of nocturnal enuresis. They showed that there was significant improvement or resolution in the majority of patients following the tonsillectomy with 61.4% having complete resolution, 22.8% having decreased symptoms, and only 15.8% had persistence of their enuresis (Basha, Bialowas, Ende, & Szeremeta, 2005).
Behavior and Attention
Regarding behavior and attention, several studies have looked at neurobehavioral characteristics of children with oSDB and OSA. O’Brien at al. in 2003 screened over 5,000 children aged 5 to 7 years via questionnaires, and a subset of 83 patients were further assessed using the Conners’ Parent Rating Scale and overnight polysomnography (PSG). Interestingly, they found that only 5% of the patients with significant AHDH symptoms had OSA whereas 26% of the children with mild ADHD symptoms had OSA, and 5% of the children without ADHD symptoms had OSA. Their conclusion was that those children with mild ADHD-like neurobehavioral manifestations can be misdiagnosed with ADHD when, in fact, they have oSDB/OSA (O’Brien et al., 2004).
In conclusion, parents and primary care providers (PCPs) should be informed about the updated recommendations from this multidisciplinary work group on pediatric tonsillectomy. Guidelines are continually revisited and updated. Parents and their PCPs should consider referral to ENT for patients with nocturnal enuresis and/or mild ADHD-like behaviors who have nighttime snoring and concerns for oSDB/OSA. Parents and PCPs should also be aware that polysomnography is not always needed, and they should consult their ENT colleagues. Also, remember that these are meant to be guidelines and are not meant to be dictum.
Basha, S., Bialowas, C., Ende, K., & Szeremeta, W. (2005). Effectiveness of adenotonsillectomy in the resolution of nocturnal enuresis secondary to obstructive sleep apnea. Laryngoscope. https://doi.org/10.1097/01.MLG.0000163762.13870.83
Baugh, R. F., Archer, S. M., Mitchell, R. B., Rosenfeld, R. M., Amin, R., Burns, J. J., Setzen, G. (2011). Clinical Practice Guideline: Tonsillectomy in Children. https://doi.org/10.1177/0194599810389949
Mitchell, R. B., Archer, S. M., Ishman, S. L., Rosenfeld, R. M., Coles, S., Finestone, S. A., … Nnacheta, L. C. (2019). Clinical Practice Guideline: Tonsillectomy in Children (Update)—Executive Summary. Otolaryngology – Head and Neck Surgery (United States), 160(2), 187–205. https://doi.org/10.1177/0194599818807917
O’Brien, L. M., Holbrook, C. R., Mervis, C. B., Klaus, C. J., Bruner, J. L., Raffield, T. J., … Gozal, D. (2004). Sleep and Neurobehavioral Characteristics of 5- to 7-Year-Old Children With Parentally Reported Symptoms of Attention-Deficit/Hyperactivity Disorder. PEDIATRICS. https://doi.org/10.1542/peds.111.3.554
US National Library of Medicine – NCBI PubMed. (n.d.). Retrieved May 5, 2019, from https://www.ncbi.nlm.nih.gov/pubmed/?term=pediatric+sleep+apnea
Eric Gantwerker MD, MMSc (MedEd), FACS is a pediatric otolaryngologist and assistant professor of otolaryngology at Loyola University Medical Center who hold degrees in physiology, biophysics, and medical education with a focus on ed tech.
He is also the vice president, medical director of Level Ex where he provides clinical oversight for all its video games developed for physicians and works closely with partners from medical societies and industry to develop innovative programs using the company’s mobile, AR, and VR experiences.