Patient History

A 7-year-old girl presented with a 3-year history of recurrent episodes of tonsillitis manifesting with fever, sore throat, fatigue, and poor appetite. She had been treated with a variety of antibiotics. She also had had two episodes of scarlet fever associated with the tonsillitis. Four times during the past year, the results of throat cultures were positive for group A beta-hemolytic streptococcus (GABHS). Additionally, the patient was reported to have noisy mouth breathing, snoring, problems breathing at night, and difficulty swallowing food. Her symptoms became significantly worse when she was acutely ill. Whenever an episode occurred, the patient saw her physician, took antibiotics, missed school for 2 to 3 days, and her mother missed work.

Physical Examination

On presentation, the patient was afebrile and stable with normal vital signs. General appearance revealed a healthy girl with noisy open-mouth breathing, an elongated face, and protruding elongated narrow maxilla with a high-arched palate indicative of adenoid enlargement facies. Examination of the ears was normal. Examination of the mouth and throat revealed enlarged, cryptic tonsils (+3). Nasal examination indicated slightly inflamed nasal mucosa. Fiberoptic nasal endoscopy revealed enlarged adenoids with obstruction of the posterior nasal choana and nasopharynx. On examination of the neck, several shotty lymph nodes were found. The remaining physical examination was normal. A review of the patient’s systems, social history, and past medical history was unrevealing.

Treatment

Tonsillectomy and adenoidectomy were recommended after a lengthy discussion regarding the indications, alternatives, risks, complications, and outcome. The patient underwent tonsillectomy and adenoidectomy using Coblation®, a soft-tissue surgery system. She was discharged from the hospital the same day of the procedure.

At 3-week follow-up, her breathing and sleeping had improved, she no longer snored, and was able to eat and swallow without difficulty. Her mother indicated that she had to use the prescribed pain medication only once per day for the first 4 postoperative days. The tonsillectomy sites were well healed. There were no abnormal findings.

Discussion

Tonsillectomy and adenoidectomy are among the most common procedures performed under general anesthesia in children every year. More than 400,000 tonsillectomies and adenoidectomies are performed annually in the United States.¹ When these procedures are performed for the proper indications with appropriate technique, updated instruments, and specialized professionals, they have proved to be effective in significantly improving the quality of life of these patients.² However, many physicians may be uncomfortable or unfamiliar with tonsillitis, current techniques, or results and may make inadequate recommendations, comments, or decisions regarding tonsillectomy and adenoidectomy.

The indications for tonsillectomy include a variety of conditions. In the majority of cases, hyperplastic enlarged tonsils and adenoid tissue occupy a disproportionate space of the upper airway in preschool children, resulting in obstruction of the upper airway and manifesting as heavy snoring, difficulty breathing, and sleep disturbance.³ Symptoms may range from a mild form of airway obstruction known as upper airway resistance syndrome (UARS) to the more severe obstructive sleep apnea syndrome (OSAS). Adenoidectomy/tonsillectomy is considered first -line therapy for these patients. Usually, patients with tonsil and adenoid hyperplasia also present with dysphagia and hyponasal speech or muffled voice. Additionally, abnormal dentofacial growth, e.g., vertical elongation of the face with high, narrow palate vault and a secondary posterior dental crossbite, may occur.^{4, 5}

Another indication for tonsillectomy is to prevent infections. The criteria for tonsillectomy for the treatment of recurrent tonsillitis include patients who have had at least seven episodes of tonsillitis during 1 year, five episodes per year for 2 years, or three episodes per year for 3 years.⁶ Other indications for tonsillectomy include recurrent (two to three) peritonsillar abscesses,^7,8 episodes of rheumatic fever, tonsillar asymmetry,⁹ or suspicion of tonsillar tumor/malignancy. The indications for tonsillectomy in this case were recurrent tonsillitis (five episodes/year for 2 years), adenotonsillar hypertrophy with symptoms of upper airway resistance syndrome, and obstructive sleep apnea. She also had scarlet fever with several episodes of streptococcal infection resistant to antibiotic therapy.

The outcome and benefit of surgery were encouraging and rewarding. When the need for a particular procedure is measured, the decision must be based on the outcome, risks, and quality of life. In this case, quality of life included patients/parents anxiety and expectations, cost, absence from school/work, economic losses, and health benefits. Coblation-Assisted Tonsillectomy was the treatment of choice for this patient because it delivered a solution in an effective, safe, manner and resulted in a quicker recovery compared with traditional techniques (e.g., cold knife and electrosurgery). The use of Coblation-Assisted Tonsillectomy improved the postoperative experience of the patient and her family. The patient required pain medication for only 4 days postoperatively, compared with 10 to 14 days of pain medication usually needed after tonsillectomy via standard techniques.

Clinical Pearls

There are several indications for tonsillectomy and adenoidectomy. A safe and effective approach and experience must be used when choosing candidates for these procedures. Although there are numerous techniques used to perform tonsillectomy, Coblation provides an excellent outcome with a quicker patient recovery and less postoperative medication than noted with traditional techniques.

References

1. National Center for Health Statistics, Centers for Disease Control, Advance data 283: Ambulatory surgery in the United States, 1994. National Center for Health
   Statistics. www.edc.gov/nchs.
2. Darrow DH, Siemens C: Indications for tonsillectomy and adenoidectomy. Laryngoscope 2002;112:6-10.
3. Jeans WD, Fernando DC, et al: A longitudinal study of the growth of the nasopharynx and its contents in normal children. Br J Radiol 1981;54:117-121.
4. Klein JC: Nasal respiratory function and craniofacial growth. Arch Otolaryngol Head Neck Surg 1986;112:843-849.
5. Smith RM, Gonzalez C: The relationship between nasal obstruction and craniofacial growth. Pediatr Clin North Am 1989;36:1423-1434.
6. Paradise JL, Bluestone CD, et al: Efficacy of tonsillectomy for recurrent throat infection in severely affected children: Results of parallel randomized and nonrandomized clinical trials. N Engl J Med 1984;810:674-683.
7. Herzon FS, Harris P: Peritonsillar abscess: Incidence, current management practices, and a proposal for treatment guidelines (Mosher Award thesis). Laryngoscope 1995;105(suppl 74):1-17.
8. Herzon FS, Nicklaus P: Pediatric peritonsillar abscess: Management guidelines. Curr Prob Pediatr 1998;26:270-278.
9. Berkowitz RG, Mahadevan M: Unilateral tonsillar enlargement and tonsillar lymphoma in children. Ann Otol Rhinol Laryngol 1999;108:876-879.