Tonsillectomy for Children – New Clinical Practice Guidelines

Tonsillectomy for Children

Should my child have their tonsils removed?

Tonsil problems in children are among the most common health concerns that result in a referral of a child to an ear, nose, and throat doctor (ENT or otolaryngologist).  Management methods of tonsil concerns such as frequent throat infections and problems associated with large tonsils continuously change over time as data from new research and clinical results are analyzed.

Tonsillectomy, which almost always also includes adenoidectomy (removal of the tonsil tissue from the back of the nasal passage) is the definitive gold standard for resolving tonsil and adenoid-related problems. Occasionally, medical societies review new information to update these Clinical Practice Guidelines as additional data are considered. These modifications are helpful to physicians and patients alike and are designed to improve the results of care and patient safety.

Although tonsillectomy is a routine and safe procedure when done by a Board Certified ENT doctor, the general consensus is to avoid the discomfort and rare procedural risks associated with removing tonsils (and adenoids) in children unless tonsil problems cannot be adequately treated medically.

Tonsillectomy has long been considered to be an effective treatment for children suffering frequent bacterial throat infections and difficulty breathing while sleeping due to large tonsils and adenoids. Due to the small but present risk of surgery, tonsillectomies are not generally performed in response to occasional throat infections or simple snoring alone.  Similarly, just having “big tonsils” is not enough of a reason to remove tonsils without some clinical concern for problems they may be causing, as the tonsils invariably reduce in size as the child continues to grow older.

How many throat infections should my child suffer before discussing tonsillectomy? How do we distinguish between childhood apnea and snoring? What other reasons might cause an ENT doctor to recommend tonsillectomy in children?

Frequent throat infections

The new Guidelines published February 2019 recommend consideration of tonsillectomy once your child has suffered 7 or greater acute tonsil infections (strep throat) in 1 year, 5 or greater infections each year for the past 2 years, or 3 or greater infections every year for the past 3 years. This new higher threshold suggests that tonsillitis can be a short-lived recurring problem for some children and that treating with antibiotics and continuing to watchfully wait often allows the child to grow out of the problem. This may be one reason pediatricians and family physicians are sometimes perceived by parents as being slow to refer their patients for removal of tonsils.

There are other factors to consider as well, including but not limited to antibiotic intolerance, sleep-disordered breathing, presence or absence of Group A strep positive cultures. Other related medical conditions that strep infections or obstructed breathing while sleeping might worsen should also be considered if present and they include among others ADD, ADHD, enuresis, seizure disorder, PANDAS, other neurological issues, scarlet fever, rheumatic fever, history of renal problems, evidence of strep-related kidney problems, and history of a peritonsillar abscess. Finally, there are cases, especially in older children when tonsils never fully clear an infection and the tonsillitis becomes chronic despite medical treatment. That would also be a reasonable reason to remove them.

Sleep Apnea

Many children snore while sleeping and some snore quite loudly, which can disrupt their normal healthy sleep patterns.  Snoring is a result of partial airway obstruction in the throat which may or may not result in part from large tonsils (and adenoids).  The newly published guidelines do not recommend consideration for tonsillectomy based on snoring alone but the presence of apnea demands further investigation.

Sleep apnea is a condition in which the airway becomes blocked during sleep leading to moments with no breathing despite the child trying to breathe. This can be observed or even recorded by parents to assist the ENT doctor in distinguishing simple snoring from disruptive obstructive breathing or obstructive apnea. Sleep apnea reduces oxygen saturation in your child’s body and can negatively affect their brain function, mood, school performance, and cardiovascular health. Sleep studies in a sleep lab are the gold standard for diagnosis, but given enough evidence or a clear enough description of the concern by the parents, they often are not necessary with children.

Prior to performing a tonsillectomy, new guidelines recommend that a sleep study is ordered for any possibly apneic child under the age of 2, children with specific physical features noted on examination such as obesity or structural boney abnormalities of the head or face, and when the presence of apnea is uncertain. In addition, as children grow to teenagers and more closely resemble adults in their stature, the desire by the ENT doctor to assess the degree of apnea with a sleep study prior to any treatment tends to increase. Most commonly, though, in children over age 3 with large tonsils, a simple tonsillectomy with adenoidectomy will completely resolve the obstruction and allow for a quiet restful sleep. Often in these cases, other medical and social issues and school performance may also improve in these children after tonsil removal.

There are many things to consider in the management of your child’s health.  If you are concerned about possible infectious or obstructive problems associated with their tonsils, talk to your pediatrician or call our office to schedule a consultation.

Karen Greene, PA-C
About the Author
Physician Assistant at CornerStone Ear, Nose & Throat, PA
As a Physician Assistant, Karen Greene works closely with our physicians to provide the highest level of care for children and adults suffering from ear, nose, or throat disorders. From chronic ear and throat infections to allergies and sinus problems, Karen assists with the diagnosis and treatment of all ENT disorders.
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