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Patient History
A 9-year-old boy began contracting sore throats associated with fever and lethargy
at the age of 5 years. When he was 6 years old, he had four throat infections.
During the past 2 years, he had five infections per year, which were documented
with either a rapid streptococcal test or throat culture to verify the presence of
group A betahemolytic streptococcus. He was treated with antibiotics for each
infection, usually amoxicillin or amoxicillin/clavulanate. During a previous bout
of pharyngotonsillitis, he had been treated with clindamycin for 2 weeks.
Although there were no signs of recent ear infections, symptoms of nasal obstruction were
present. During the spring and fall, he had itchy, watery eyes and sneezing; however, his throat
infections were not seasonal. He sometimes snored at night, which significantly worsened in the
spring and fall. There were no signs of apneic pauses during sleep. He missed 2 to 3 days of
school each time he developed pharyngotonsillitis. On presentation, he did not have subjective
fever or sore throat. His past medical history was otherwise noncontributory.
Physical Examination
On physical examination, the patient was noted to be thin, healthy, well developed, and in no
acute distress. He was in the 10th percentile for weight and 50th percentile for height. Craniofacially,
his midface was elongated slightly, and infraorbital congestion was noted under his skin
(so-called allergic shiners). His speech was slightly hyponasal and he breathed through his mouth.
On otoscopic examination, the ears were clear. Nasal examination via anterior rhinoscopy
revealed mild paleness and enlargement of the inferior turbinates, with no congestion or erythema
seen in his middle meatus (the area between the middle turbinate and lateral nasal wall). Examination
of the oral cavity and oropharynx showed bumpy, pale-yellowish lymphoid tissue on the posterior
oropharyngeal wall and 2+ to 3+ symmetrical tonsils with irritated and globular medial borders.
There was no erythema or edema of the tonsils or anterior tonsillar pillar. Examination of the
neck revealed symmetrical, mildly enlarged lymph nodes (1.5 cm) in the jugulodigastric region of both sides of the neck.
Treatment Regimen
Based on the patient’s history of recurrent infections, he underwent tonsillectomy. In addition,
because of the symptoms of obstruction of the nasal airway, the adenoids were evaluated intraoperatively
and noted to be significantly enlarged,blocking 75% of the choana in the supine positionwith the palate
elevated. Therefore, the adenoids also were removed. Prior to removal of the adenoids,
the anterior tonsillar pillar and fossa were injected with Marcaine® with 1/100,000 epinephrine.
The tonsils were removed via Coblation®. Coblation is a soft-tissue surgery system that uses
low-temperature radiofrequency energy applied to a sterile solution to dissolve soft tissue. The adenoids
were removed with a curette, and hemostasis was performed with suction electrocautery in the adenoid bed in the nasopharynx.
He was able to drink liquids and consume a soft diet throughout the postoperative course, but
his condition worsened on days 5 to 7. On postoperative day 9, he was seen for a routine followup
visit. His symptoms had improved, and the scabs in the tonsillar fossa had healed. The hypernasal
speech he experienced for the first few days postoperatively had resolved. He still had mild
nasal congestion and was prescribed a nasal saline spray and a topical nasal steroid spray. By 3 weeks
postoperatively, the nasal congestion had resolved and all medicines were discontinued. At 6-month
follow-up, there were no tonsillar infections.
Discussion
Tonsillectomy is one of the most commonly performed procedures in the United States. It is often
combined with adenoidectomy. Historically, indications for removal of these lymphoid structures
have been based on surgeons’ beliefs as well as certain diseases occurring in different eras.
In the early part of the 1900s, during the preantibiotic area, tonsillectomy/ adenoidectomy was
routinely performed when the tonsils and adenoids were considered to be reservoirs of infection.
It was considered a treatment of anorexia, mental retardation, enuresis, or simply a good
health practice.1 The tonsils were removed without regard to psychological preparation of the
child or preoperative or postoperative instructions for the parents.2
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In the 1930s and 1940s, the widespread use of tonsillectomy/adenoidectomy became controversial
with the development of antimicrobial agents, such as sulfonamides and penicillins, prescribed to
treat tonsillitis and adenoiditis. Several other factors involved in the decline in tonsillectomies
included the recognition that there was a natural decrease in the incidence of upper respiratory
infections as children became of school age; the publication of several studies showing that tonsillectomy/
adenoidectomy was ineffective; and the belief of an increased risk of developing poliomyelitis after tonsillectomy/adenoidectomy
(prior to the development and use of the vaccine).3 Once the opinion pendulum began to swing to
avoid surgery, prospective clinical trials were needed to prove to the medical and lay communities
that appropriate indications for tonsillectomy/adenoidectomy existed.
In the 1960s and 1970s, data from nonrandomized or controlled studies of year-long prophylactic
treatment with penicillin or sulfa antibiotics were compared with surgery or no treatment,
with mixed results.4
In the early 1980s, Paradise and colleagues published the most cited studies on the rationale
for tonsillectomy in children with recurrent sore throats.5 Their series demonstrated that children
who had tonsillectomy performed for a strictly defined number of infections per year (three
infections per year for 3 years, five infections per year for 2 years, or seven infections per year for 1
year) had a statistically significant decrease in the number of episodes of sore throats after tonsillectomy
for 2 to 3 years, compared with a control group who had not undergone tonsillectomy.
Other indications for tonsillectomy include persistent chronic tonsillitis lasting 3 months,2,6 recurrent
peritonsillar abscess, and being a streptococcal carrier, especially when the family has a history
of rheumatic fever.6
During the past 3 decades, the incidence of tonsillectomy has decreased from approximately 1.5
million times a year in the late 1960s7 to approximately 400,000 times a year in 1994.8 This decrease
resulted in part from the declining incidence of tonsillectomy for chronic or recurrent infections
when strict criteria are applied. Rosenfeld and Green pointed out this changing trend of indications
for tonsillectomy in the 1980s.9 They reported the incidence of tonsillectomies for infections
decreased by 20%, whereas the percentage of tonsillectomies performed for obstructive breathing
increased from 0% to 19%. Since their study, the use of tonsillectomy/adenoidectomy for obstruction
has continued to increase as it becomes more evident in younger children.
Clinical Pearls
The use of cautery for control of hemostasis in the tonsillar fossa seems to have an impact on the
postoperative course, with increasing use causing more pain. However, the temperature used with
Coblation is significantly lower than that used with standard cautery, and decreased heat should
result in less patient discomfort postoperatively. Children whose tonsils are removed without
cautery to control hemorrhage often have minimal pain postoperatively.
References
- Fry J: Are all ‘T’s and A’s really necessary?’
BMJ 1957; 1:124-129.
- Deutsh ES : Tonsillectomy and adenoidectomy:
Changing indications. Pediatr Clin North Am
1996;43:1319-1338.
- Paradise JL: Tonsillectomy and adenoidectomy.
In: Pediatric Otolaryngology, 3rd ed, Bluestone
CD, Stool SE, Kenna MA, eds. Philadelphia, WB
Saunders, 1996.
- Donovan R: Clinical and immunological studies
on children undergoing tonsillectomy for repeated
sore throats. Proc R Med Soc 1973;66:413-416.
- Paradise JL, Bluestone CD, et al: Efficacy of
tonsillectomy for recurrent throat infections in
severely affected children: Results of parallel randomized
and nonrandomized clinical trials. N
Engl J Med 1984;310:674-683.
- Darrow DH, Siemens C: Indications for tonsillectomy
and adenoidectomy. Laryngoscope
1990;99:187-191.
- Evans H: Tonsillectomy and adenoidectomy:
Review of published evidence for and against the
T and A. Clin Pediatr 1968;7:71-75.
- National Center for Health Statistics, Centers
for Disease Control: Advance data 283:
Ambulatory surgery in the United States, 1994.
National Center for Health Statistics. Available on
the web at: www.cdc.gov/nchs
- Rosenfeld RM, Green RP: Tonsillectomy and
adenoidectomy: Changing trends. Ann Otol
Rhinol Laryngol 1990;99:187-191.
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