Indications for Adenoidectomy and Tonsillectomy

A tonsillectomy is the surgical removal of the tonsil and its capsule, which requires dissecting the peritonsillar space between the tonsil capsule and the muscular wall. In children, a primary indication for this procedure is a recurrent throat infection which has demonstrated either a resistance to antibiotics or has presented alongside a peritonsillar abscess.² Other indications for the procedure include lymphoproliferative disorders or malignancy, chronic sinus diseases, hemorrhagic tonsillitis, dental malocclusion, eating and swallowing disorders, and speech abnormalities.¹ These tonsillectomy indications also serve as a prerequisite for adenoidectomy, which is the surgical removal of adenoid lymph nodes from the nasopharynx area, trans orally or trans nasally. ⁴ Children who present with chronic adenoiditis, postnasal drainage, and a chronic cough are recommended for the procedure.

According to a study published by Schüpper et al., adenoidectomy provides permanent relief from symptoms in over 80% of pediatric patients. It is particularly recommended for those who have persisting symptoms of adenoiditis, after two courses of antibiotic therapy. Ideal patients for an adenoidectomy are those who are non-obese and are younger than twelve years old. Infections of the ear, as well as chronic rhinosinusitis, in children who are unresponsive to antibiotic therapy are common indications for adenoidectomy,⁴ while similarly, the failure to resolve recurrent throat infections with antibiotics indicates the need for a tonsillectomy.³

Obstructive sleep apnea caused by hypertrophy of the adenoids, tonsils, or both indicates the need for adenoidectomy or tonsillectomy accordingly. If hypertrophy is due to blockage in the adenoids, an adenoidectomy is recommended, while a tonsillectomy will be performed when enlarged tonsils are the cause of obstructive sleep apnea. Surgical intervention is needed to address severe sleep apnea and prevent the fatal progression of diseases like ventricular hypertrophy, congestive heart failure, alveolar hyperventilation, pulmonary edema, and permanent neurologic damage.¹ According to a study published by Lin and Koltai, tonsillectomy and adenoidectomy will only fail to improve sleep apnea in patients with craniofacial disproportion, hypotonia, oropharyngeal soft-tissue redundancy typically associated with obesity, laryngomalacia, and lingual tonsillar hypertrophy. Although tonsillectomy and adenoidectomy are the default surgical interventions, lingual tonsillar hypertrophy is a complex indication since it has been shown that only 46% of such patients who undergo surgical intervention recover from obstructive sleep apnea. Therefore, in patients with lingual tonsillar hypertrophy, other levels of obstruction should be investigated, and a specialized surgical technique should be used – endoscopic-assisted coblation lingual tonsillectomy. ²

Tonsillectomy has associated morbidities such as hospitalization, complications from anesthesia such as vomiting, bleeding during or after the surgery, prolonged throat pain, and financial burden.³ In her review on children who qualify for tonsillectomy, Deutsch explains that the American Academy of Pediatrics (AAP) cannot reassure parents on how “many severe sore throats” need to happen before surgery should be recommended.¹ Because of the associated risks, surgical intervention is usually the last resort once all other treatment options have been exhausted. Before and even after performing an adenoidectomy in children diagnosed with obstructive sleep apnea, Schüpper et al. recommend intranasal steroids and leukotriene inhibitors. Alongside indications for tonsillectomy or adenoidectomy, it is important for providers, patients, and caregivers to consider associated side effects and burdens of the procedure.

After surgery, care must be taken to prevent the need for further intervention. Intranasal steroids can prevent the regrowth of adenoids following an adenoidectomy.

References

1. Deutsch, Ellen S. “TONSILLECTOMY AND ADENOIDECTOMY.” Pediatric Clinics of North America, vol. 43, no. 6, Dec. 1996, pp. 1319–38, doi:10.1016/s0031-3955(05)70521-6.
2. Lin, Aaron C. & Koltai, Peter J. “Persistent Pediatric Obstructive Sleep Apnea and Lingual Tonsillectomy.” Otolaryngology-Head and Neck Surgery, vol. 141, no. 1, July 2009, pp. 81–85, doi:10.1016/j.otohns.2009.03.011.
3. Mitchell, Ron B, et al. “Clinical Practice Guideline: Tonsillectomy in Children (Update).” Otolaryngology-Head and Neck Surgery, vol. 160, no. S1, Feb. 2019, doi:10.1177/0194599818801757.
4. Schüpper, Alexander J., et al. “Adenoidectomy in Children: What Is the Evidence and What Is Its Role?” Current Otorhinolaryngology Reports, vol. 6, no. 1, Mar. 2018, pp. 64–73, doi:10.1007/s40136-018-0190-8.