Tonsillectomy

Parents often worry about their kids' tonsils, either because they seem big or because they get strep throat a lot.

But it doesn't seem like Pediatric ENT specialists take out tonsils (tonsillectomy) as much as they used to.

So when do tonsils need to come out?

Although it is true most doctors aren't as quick to do a tonsillectomy as they were in the past, kids do still get their tonsils out.

In fact, 'tonsillectomy remains the most common major operation performed on children in the United States,'¹ ranking just above getting ear tubes.

Tonsillitis

Two common indications for a tonsillectomy include chronic tonsillitis, or having continuous symptoms for more than three to six months, or recurrent tonsillitis, which is usually defined as having tonsillitis at least five times in one year or three times a year for at least three years.²

On the other hand, the American Academy of Otolaryngology - Head and Neck Surgery recommends that children have a tonsillectomy if they have three or more episodes of tonsillitis in a year.

Keep in mind that a recent study, Tonsillectomy and Adenotonsillectomy for Recurrent Throat Infection in Moderately Affected Children, concluded that 'the modest benefit conferred by tonsillectomy or adenotonsillectomy in children moderately affected with recurrent throat infection seems not to justify the inherent risks, morbidity, and cost of the operations.'³ And this study used even more stringent criteria before doing a tonsillectomy, only including children who had seven or more episodes of tonsillitis in one year, five or more episodes in two years, or three or more episodes in each of the previous three years.

So don't be surprised if your Pediatrician isn't quick to refer your child to get his tonsils out anymore.

What is tonsillitis? It is a throat infection, which can either be caused by the strep bacteria or a virus. While getting strep throat over and over is not the only reason to get your tonsils out, if your child has a sore throat because he has a cold and some post nasal drip, that shouldn't count as an episode of tonsillitis, unless his throat is also red and/or his tonsils have pus (exudate) on them.

In addition to the number of throat infections your child gets each year, you might also think about how mild or severe they are before considering a tonsillectomy. If your child has severe symptoms and misses a week of school each time he gets tonsillitis, then you might be a little quicker to get his tonsils out than if he has more mild symtoms.

Other infectious indications to get a tonsillectomy might include having a peritonsillar abscess two or more times or having cervical adenitis because of chronic tonsillitis.

Sleep Apnea

The other major reason that children get their tonsils out is because they are too large and they, along with large adenoids, are causing obstructive sleep apnea. Children with OSA usually snore, and may have 'labored breathing during sleep, observed apnea, restless sleep, diaphoresis, enuresis, cyanosis, excessive daytime sleepiness, and behavior or learning problems (including attention-deficit/hyperactivity disorder).'⁴

Once a diagnosis of OSA is confirmed, these children usually get both a tonsillectomy and adenoidectomy (T&A), unlike children who have a lot of tonsil infections, who usually just get their tonsils out.

Large Tonsils

In addition to sleep apnea, large tonsils (obstructive tonsil hyperplasia) can sometimes lead to feeding and swallowing problems, failure to thrive, mouth breathing, and speech problems. These children may also need a tonsillectomy.

What You Need To Know

• If you think your child has had too many throat infections or that his tonsils are simply too big, then ask your Pediatrician for a referral to a Pediatric ENT specialist to discuss if a tonsillectomy would be appropriate.
  
  
• On the other hand, if your Pediatrician recommends a tonsillectomy but you are hesitant to have surgery, then ask if it would be appropriate to wait a little longer.
  
  
• Keep in mind that a child's tonsils will often naturally get smaller as they get older and kids do usually get fewer infections as they get older, so your child might outgrow his tonsil problems before he needs to get them taken out.
  
  
• Since sleep apnea is a serious condition, you don't usually want to wait for your child to outgrow it and you should usually proceed with a T&A if your doctor suggests it.
  
  

References

1. Infectious indications for tonsillectomy. Discolo CM - Pediatr Clin North Am - 01-APR-2003; 50(2): 445-58
2. Common topics in pediatric otolaryngology. Pizzuto MP - Pediatr Clin North Am - 01-AUG-1998; 45(4): 973-91
3. Tonsillectomy and Adenotonsillectomy for Recurrent Throat Infection in Moderately Affected Children Jack L. Paradise, MD. PEDIATRICS Vol. 110 No. 1 July 2002, pp. 7-15
4. Clinical Practice Guideline: Diagnosis and Management of Childhood Obstructive Sleep Apnea Syndrome PEDIATRICS Vol. 109 No. 4 April 2002, pp. 704-712