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 pharyngeal wall. In children, a primary indication for this procedure is recurrent throat infection that has demonstrated either resistance to antibiotics or has presented alongside a peritonsillar abscess. Other indications include lymphoproliferative disorders or malignancy, chronic sinus disease, hemorrhagic tonsillitis, dental malocclusion, eating and swallowing disorders, and speech abnormalities. These tonsillectomy indications also serve as prerequisites for adenoidectomy, which is the surgical removal of adenoid lymph nodes from the nasopharynx, performed trans-orally or trans-nasally. Children presenting with chronic adenoiditis, postnasal drainage, and a chronic cough are recommended for the procedure.

Adenoidectomy provides permanent relief from symptoms in over 80% of pediatric patients. It is particularly recommended for children with persisting symptoms of adenoiditis after two courses of antibiotic therapy. Ideal candidates are non-obese children younger than twelve years old. Infections of the ear, as well as chronic rhinosinusitis unresponsive to antibiotic therapy, are common indications for adenoidectomy, while similarly, the failure to resolve recurrent throat infections with antibiotics indicates the need for tonsillectomy.

Obstructive sleep apnea caused by hypertrophy of the adenoids, tonsils, or both indicates the need for adenoidectomy or tonsillectomy accordingly. Surgical intervention is needed to address severe sleep apnea and prevent the progression of conditions such as ventricular hypertrophy, congestive heart failure, and permanent neurologic damage. Tonsillectomy and adenoidectomy will fail to improve sleep apnea in patients with craniofacial disproportion, hypotonia, oropharyngeal soft-tissue redundancy, laryngomalacia, and lingual tonsillar hypertrophy. In patients with lingual tonsillar hypertrophy, other levels of obstruction should be investigated and specialized techniques such as endoscopic-assisted coblation lingual tonsillectomy should be considered.

Tonsillectomy has associated morbidities including hospitalization, anesthesia complications such as vomiting, intraoperative or postoperative bleeding, prolonged throat pain, and financial burden. Because of these associated risks, surgical intervention is usually considered a last resort once all other treatment options have been exhausted. Before and even after performing an adenoidectomy in children diagnosed with obstructive sleep apnea, intranasal steroids and leukotriene inhibitors are recommended adjuncts.

After surgery, care must be taken to prevent the need for further intervention. Intranasal steroids can help prevent the regrowth of adenoids following adenoidectomy, and appropriate follow-up is essential to monitor recovery and reassess symptoms.

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.