Tonsillectomy in the modern era
There have been some reports in the media that have concluded
that tonsillectomy in the 21st Century is an
“unnecessary” operation. This, however, is not the true state
of medical opinion with regard to diseased tonsils in the
paediatric population and it is therefore timely to summarise the
proven good indications for this type of surgery.
Any recommendation for surgery should never be given without a
consideration of possible morbidity and any remote risk associated
with the proposed procedure. The health of the child, the
impact on the family of having a convalescing child at home and the
plans for emergency care if complications arise should all be
discussed with parents. However it should be emphasised that
tonsillectomy in children is a safe, well-tolerated and effective
operation.
This review highlights the role of
tonsillectomy in the management of a variety of conditions and
discusses some of the important issues related to the surgical
procedure.
Obstructive Sleep Apnoea (OSA)
Obstructive Sleep Apnoea is probably the
strongest indication for tonsillectomy, (usually combined with an
adenoidectomy), in children under 5 years of age. OSA in this
age group is caused by enlargement of the tonsils and adenoids, and
is usually secondary to previous infection. Untreated OSA can lead
to changes in heart and lung function and eventually to heart
failure. Children with OSA are fitful sleepers with poor
sleep quality secondary to restlessness and wakefulness.
There may be an associated failure to thrive and other features of
an obstructed airway such as daytime nasal obstruction, nasal
discharge, difficulty in swallowing, choking with solid food and
drooling. There may also be an association with abnormal
mid-facial growth and malocclusion of the teeth. Removal of
the tonsils and adenoids results in an opening of the airway and
the clearance of any chronic infection. and has a hugely beneficial
effect on such children. .
Any surgical procedure on a child is a worry
for parents but the outcomes in OSA are very good indeed, and
experience has shown that the procedure can be truly life
changing. There is a high satisfaction rate amongst parents
whose children have undergone surgical treatment. Skilled
anaesthesia is required to manage a small child with breathing
problems but with a specialist Paediatric Anaesthetist, working
within a specialist unit such as the Cromwell Hospital, where there
is access to facilities for cardio-respiratory support in the very
young or very small child, this surgery is safe and well
tolerated.
In the recent National Audit of Tonsillectomy
outcomes, the Cromwell paediatric unit did extremely well, with
only one minor complication recorded in 12 months.
Recurrent Acute Tonsillitis
Recurrent tonsillitis is perhaps the most
common indication for tonsillectomy in school-age children.
In children under 5 years of age there may be a relative
immuno-deficiency to certain bacterial infections, rather like
recurrent acute middle ear infection (otitis media). Treatment of
each episode of infection on its own merits, including at times
long term antibiotics and general health measures, is usually
adequate.
In those over 5 years of age frequent
tonsillitis is highly suggestive of chronic infection of the
tonsils, leading to regular acute flare-ups of tonsillitis.
Surgery may be considered if attacks are frequent, (at least 6
times per year or 4 times per year for 2 consecutive years), and
especially if the attacks are accompanied by a general disturbance
of health, with fever (systemic upset).
Chronic Tonsillitis
Chronic tonsillitis is a diagnosis of a
smouldering long-term infection of the tonsils, without significant
associated acute episodes. Affected children, (often
adolescents), have a history of fatigue, daily sore throats and
perhaps halitosis. Diagnosis is often difficult and requires
a positive throat swab for identification of infection and the
exclusion of other possible throat irritants such as voice abuse,
or chronic dental problems.
Tonsillectomy as a Biopsy
Malignant conditions of the tonsil such as
lymphoma can present as a tonsillar enlargement, particularly if
this affects only one tonsil. The diagnosis should be
suspected in the older child over 7 years of age in whom there is
associated enlargement of lymph glands and general symptoms such as
night sweats. Possible investigations include including
radiological imaging or needle aspiration cytology of any enlarged
lymph glands. These investigations should be completed before
surgery is considered.
Immuno-competence post-Tonsillectomy
Parents sometimes ask if tonsillectomy can
compromise the competence of a child’s immune system, and result in
an increased risk of infection. There is, in fact, no
evidence that children suffer more respiratory infections than
other healthy children. The tonsils make up only a small
fraction of the lymphoid tissue within the upper airway and a
chronically infected tonsil has little function. In most children
the adenoids shrink spontaneously after the age of 6 years and do
not appear to be part of the adult airway immune defences.
Disposable Instruments
Concern regarding re-usable instruments arose
about 5 years ago in relation to the variant CJD infection
crisis. There was a theoretical concern that CJD prions could
survive on tonsillectomy instruments despite conventional
sterilisation techniques. Prions are found in lymphoid and
brain tissues and so the ENT speciality was the first to have
disposable sets of surgical instruments. Unfortunately the
complication rates of the operations performed with these
instruments rose significantly. Re-usable instruments were
brought back into use. Subsequently the prion concern has
diminished with the fall off of new cases of vCJD. It is also
clear that ENT is not any different from all other surgical
specialities regarding the risk of prion contamination of
instruments. and that we should all switch to disposable
instruments if suitable quality sets can be developed but these are
as yet inadequate for purpose.
Every decision regarding a child’s health
requires careful thought and tonsillectomy should be no
different. Despite the recent superficial reporting,
tonsillectomy remains a useful, low risk, well tolerated procedure
by the vast majority of children and should continue to be an
important part of Paediatric practice.
Contributed by Mr J Harcourt, Consultant
ENT Surgeon.