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Acta Otorrinolaringol Esp 2006; 57: 59-65
REVIEW ARTICLE
Indications for tonsillectomy and adenoidectomy:
consensus document by the Spanish Society of ORL
and the Spanish Society of Pediatrics
J. Cervera Escario*, F. Del Castillo Martín**, J. A. Gómez Campderá**, J. R. Gras Albert*, B. Pérez
Piñero*, M. A. Villafruela Sanz*
*Representante de la SEORL. **Representante de la AEP.
Abstract: Tonsillectomy and adenoidectomy are probably
the most common as well as the most controversial
operations performed within the ENT field. There are
very few consensus documents available for these two
types of surgery. One was published in 1997, written by
the Spanish ENT Society, (SEORL), and the Spanish
Pediatric Association, (AEP), on the indications for
tonsillectomy and adenoidectomy in children and
adolescents. In order to update that document,
representatives from both scientific societies met again
earlier this year and a new document was drawn up. The
diagnostic criteria for pharyngotonsillitis and adenoiditis
were described, as well as that of obstructive sleep apnea
syndrome, with the aim of understanding these processes
better when a decision needs to be taken regarding
surgery. The indications and contraindications for
tonsillectomy and adenoidectomy are given.
EVALUATION OF DIAGNOSTIC CRITERIA FOR
PHARYNGOTONSILLITIS
Pharyngotonsillitis is described as the acute
inflammation of the pharynx and/or of the palatine
tonsils, which is generally caused by infectious agents,
although it can also be caused by non-infectious
processes. Around 80% of pharyngotonsillitis cases are
due to viral infections, with viral etiology being the most
common during infancy.
There are a number of symptoms that allow us to opt
for one diagnosis or another; these are described in Table
1.
It is also important to consider the analytical
alterations produced in the processes of tonsillitis that can
make it possible to differentiate between streptococcal
pharyngotonsillitis and other types of viral pharyngitis.
Fecha de recepción: 15-11-2005
Fecha de aceptación: 3-1-2006
Acute phase reactants are proteins synthesized in the liver
that increase their plasma concentration in different
infectious or inflammatory processes and which,
depending on the level reached -or rather on their
presence or absence- would indicate infections of possible
bacterial, viral or non-infectious origin, requiring different
kinds of treatment. These are described in Table 2
depending on the values reached in each situation.
INDICATIONS AND RECOMMENDATIONS FOR
TONSILLECTOMY IN INFECTIOUS PROCESES
1. Recurrent tonsillitis
The following clinical situations define recurrent
tonsillitis
- 7 or more episodes of acute tonsillitis a year in the
last year, or,
- 5 episodes a year in the last 2 years, or,
- 3 episodes a year in the last 3 years.
- Persistent symptoms for at least 1 year.
Each episode should also meet at least one of the
following criteria:
- Purulent exudate on the tonsils.
- A temperature over 38°C.
- Anterior cervical lymphadenopathy.
- Pharyngeal culture positive for group A betahemolytic streptococcus.
These are the minimally acceptable criteria. However,
each case should be evaluated individually, weighing up
the following factors:
- The episodes of tonsillitis are incapacitating and
hinder the normal activities of the child.
- Adequate treatment was administered during each
episode.
- The tonsillitis episodes disrupt family life and
parents' work.
- The child's growth curve does not advance and
there is no other reason to explain it.
- The episodes of tonsillitis should be documented in
the patient's medical file, otherwise, if the medical history
is unclear, the patient will need a check-up after 6 months
to confirm the clinical pattern and to be able to assess the
indication for surgery.
59
J. CERVERA ESCARIO ET AL.
Table 1: Differential epidemiological characteristics of streptococcal and non-streptococcal pharyngitis
CAUSAL AGENT
Group A beta-hemolytic streptococcus
Virus/other bacteria
Season
Winter-spring
All
Age
>4 years (4-11 years of age)
All
Onset
Sudden
Gradual
Odynophagia
Intense
Moderate-slight
Signs/symptoms
Anterior cervical lymphadenopathies
Lateral and retro cervical adenitis
Difficulty swallowing
Affectation of multiple mucosas
Sore throat for at least 3 days
Conjunctivitis
General state affected
Rhinitis
Tonsillar purulent exudate
Can present tonsillar, pharyngeal exudate, in
the palate and retropharynx
Cephalea/headache
Abdominal pain
Cough
Nasal scabs
Diarrhea
Absence of cough
Temperature over 38°C
Pharyngeal culture (+) for SBHG A
Exanthema
Scarlatiniform
Multiple
Table 2: Acute phase reactants
ASLO
Protein C
Leucocytosis/ml
Neutrophilia
VSG/1st
hour
Streptococcal pharyngitis
Viral pharyngitis
It begins to go up a week into the infection
from streptococcus. It remains raised for more
than 6 months.
Negative
High/Elevated > 10
<5
High > 15,500
<10,000
High > 60%
<40%
High > 30
<30
2. Recurrent peritonsillar abscess/PTA/Quinsy
Two consecutive cases of a peritonsillar abscess are
considered to be an indication for surgery3.
2. Recurrent cervical adenitis
The following set of symptoms is defined as
cervical adenitis:
Acute inflammation of multiple cervical adenopathies.
- A temperature over 38° and general malaise.
- Lasting more than 3 days.
- No lower respiratory infection.
- Higher respiratory infection and acute tonsillitis
together.
Recurrent cervical adenitis is defined as the clinical
symptoms mentioned above being repeated with the
same frequency as for recurrent tonsillitis.
The considerations for assessing these cases are the
same as those described above for recurrent tonsillitis4.
60
SCIENTIFIC EVIDENCE
Tonsillectomy is a widely-used procedure for
chronic or recurrent acute tonsillitis. There are no
controlled studies with random selection that could
provide evidence that clinicians could use as a guide for
formulating indications for surgery in adults or
children5.
OBSTRUCTIVE SLEEP APNEA SYNDROME (OSAS)
Definition
OSAS is an alteration produced during sleep,
characterized by a partial and prolonged obstruction of the
upper airway and/or by a complete intermittent
obstruction (obstructive apnea), that interrupts normal
ventilation during sleep and alters normal sleep patterns6,7.
INDICATIONS FOR TOSILLECTOMY AND ADENOIDECTOMY
Epidemiology
OSAS affects 3% of children, of whom, 8-12% snore
every night8,9. The peak prevalence is produced between
the ages of 2 and 8, which is when the hypertrophy of
the lymphoid tissue reaches its greatest size. However,
the obstruction of the airway in the child during sleep
should not only be attributed to the tonsil and adenoid
hypertrophy.
Complications: Untreated OSAS can lead to serious
complications, such as slow development, learning
difficulties and cor pulmonale10.
Symptoms
Night-time symptoms:
• Habitual nocturnal snoring
• Restless sleep, bed clothes disarranged.
• Ineffective respiratory efforts, with arousals
during sleep.
• Periods
without
respiratory
airflow
(apnea/hypopnea) lasting more than 5 seconds.
• Enuresis.
Daytime symptoms:
Difficulty breathing.
Closed rhinolalia.
Nasal voice.
Somnolence can occur, but is more common in
adults.
• Hyperactivity.
• Repercussions on physical development affecting
the child’s height and weight.
• A noticeable decline in academic performance.
• Behavioral problems.
• Cor pulmonale in serious cases.
•
•
•
•
The risk factors are adenotonsillar hypertrophy,
obesity,
craneofacial
anomalies,
neuromuscular
alterations and Down's Syndrome.
It is necessary to distinguish between OSA and
Primary Snoring (PS), the latter being defined as
snoring without obstructive apnea, frequent arousals or
alterations in oxygenation.
Although Primary Snoring is normally considered
benign, it has not been properly assessed because most
studies on children who snore do not often distinguish
between OSA and PS11.
Methods of diagnosis
Medical history.
Physical examination.
Pulsoximetry
Polysomnography (PSM).
It is necessary to make an exact diagnosis, not only
to be able to treat the patient correctly and to avoid
unnecessary treatment (surgical or other), but also to
determine which children are at risk from complications
resulting from the treatment.
Nighttime polysomnography is the only diagnostic
technique that quantifies ventilatory and sleep
anomalies associated with sleep respiratory disorders. It
can be done at any age and is currently the Gold
Standard of diagnostic techniques. PSM can distinguish
between OSAS and PS.
Nocturnal oximetry can be useful if it shows a
pattern of cyclic desaturations, Brouillette12 conducted
oximetry on a group of children with suspected OSAS
and compared them with the PSM. Brouillette found
positive predictive values of 97% and negative ones of
47%, which indicates that if the results are positive,
oximetry is useful. If the oximetry is negative, it is
necessary to carry out a PSM for an accurate diagnosis.
OBSTRUCTIVE SLEEP APNEA DURING SLEEP
The degree of severity is defined by the most severe
degree of the 3 circumstances that are assessed:
drowsiness and/or somnolence, abnormalities in the
gas
exchange,
and
respiratory
alterations
(apnea/hypopnea index) (AHI)13.
Drowsiness and/or somnolence:
• Slight: drowsiness and/or somnolence only while
the patient is sitting down or carrying out an activity
that requires little attention, it might not last all day.
• Moderate: drowsiness and/or somnolence on a
daily basis that occurs while carrying out minimal
activity or activities that require a moderate level of
attention.
• Severe: drowsiness and/or somnolence on a daily
basis during work-related activities or tasks that require
a lot of attention. Also, when significant deterioration
occurs in social and occupational activities.
Anomalies in the gas exchange:
• Slight: The average oxygen saturation is equal to
or greater than 90% and the minimum oxygen
saturation is greater than or equal to 85%.
• Moderate: The average oxygen saturation is equal
to or greater than 90% with the minimum oxygen
saturation being greater than or equal to 70%.
• Severe: The average oxygen saturation is less than
90% or the minimum oxygen saturation is less than 70%
• Slight: AHI 6 – 20.
• Moderate: AHI 21 – 40.
• Severe: AHI > 40.
In children, daytime sleepiness and/or somnolence
during school activities, associated with a drop equal to
or greater than 4% in oxygen saturation and/or
associated with a change in the heartbeat equal to or
61
J. CERVERA ESCARIO ET AL
greater than 25%, and a AHI equal to or greater than 5,
should be considered a severe degree14.
TREATMENT
Tonsillectomy and adenoidectomy are the most
appropriate forms of treatment for most children who
suffer from OSA, and those that significantly reduce
changes in behavior, learning, and other day- and
nighttime symptoms15.
An adenoidectomy alone may not be enough.
In obese children, an adenotonsillectomy can
produce less satisfactory results, but in general, it is the
first line of treatment chosen for these patients16.
TONSILLECTOMY CONTRAINDICATIONS
Whether to perform a tonsillectomy or not is a
difficult decision to make because medical, moral and
economic factors are involved. Furthermore, it has been
the subject of tremendous debate over time, and the
theories on which the decision is based have changed
over the years. Neither has this matter been a purely
medical/scientific concern; it has reached public
opinion with pressure of a more or less indirect nature
coming from the press, literature and government
health ministers.
If we take a look back to different times, we can see
how much the indications have changed. There are even
cases of two different professionals maintaining the
same line of reasoning, using the same argument, but
one as an indication and the other as a contraindication.
As a consequence of this, professionals have had a lot
freedom when explaining why very few studies backed
either one of these positions. At this point, criticisms
relating to the lack of rationale behind the indications
began to appear in the literature. An example is
Bolande’s an article entitled “Ritualistic surgery:
Circumcision and tonsillectomy”17.
Later, in 1976, Shaikh et al18, stressed the need to
stop carrying out tonsillectomies until some clear
scientific criteria verified the benefits of performing the
operation. After that, Einhorn19 stated that there was no
real indication that justified tonsillectomy.
Tables have been established to facilitate the
decision whether to perform the intervention or not20.
We intend to reach an agreement, signaling the
situations in which tonsillectomy is contraindicated.
Patients whose episodes of tonsillitis are not clearly
documented or confirmed should be excluded from the
surgical option.
A contraindication of surgery would also be an
alteration in the functioning of the palate: an evident
palatine fissure or submucosal lesion, neurological or
62
neuromuscular pathology affecting the functioning of
the palate and/or the pharynx.
Tonsillar surgery is usually bloody. The most
common and most worrying complication is early and
delayed hemorrhaging. This operation should be
avoided in patients with hematological alterations such
as anemia or a coagulation affectation. First,
hemoglobin concentrations below 10gm/dl or when the
hematocrit is less than 30% must be corrected. It is
necessary to know the family medical history of
frequent bleeding or blood diseases. The presence of
hematological pathology is not a contraindication for
this surgery, but the aforementioned alterations must be
adequately treated.
The respiratory state must be assessed. Lower
airway diseases, such as asthma that has not been
controlled for a long period of time, should be a
contraindication until good respiratory functionality has
once again been established21.
Carrying out the intervention on patients who have
recently had infections is not recommended; it is
necessary to wait at least 3 weeks in order to reduce the
risk of hemorrhaging, except when the vital situation of
the patient means it is not possible to wait (respiratory
obstruction).
There is no connection between tonsillar disease
and middle ear diseases, which is why there is no
scientific justification for performing it in order to treat
these processes22.
More and more often an association is found
between children with allergies and recurrent tonsillitis.
It is necessary to treat the allergic process first as this
can change the chances of the infection recurring in the
future.
EVALUATION OF THE DIAGNOSTIC CRITERIA
OF ADENOIDITIS
The adenoidal tissue, (adenoid vegetation), is made
up of small lymphoid structures distributed throughout
the posterior wall and roof, in particular, of the
nasopharynx and which form part of the Waldeyer's
ring.
Adenoids cause disease when they become
hypertrophic. Their hypertrophy is caused by the
infection of the adenoid tissue itself or as a consequence
of infection in the paranasal structures. The result of
adenoid hypertrophy is nasal obstruction with retention
of secretions, difficulty breathing through this airway
and the facilitation of local infections.
Intense hypertrophy causes serious obstruction of
nasal breathing and causes Obstructive Sleep Apnea
Syndrome (OSA)23. Lesser obstructive symptoms
produce a great variety of symptoms in children, such
as mouth breathing with the risk of palatine deformity,
INDICATIONS FOR TOSILLECTOMY AND ADENOIDECTOMY
snoring, coughing, halitosis and a predisposition to
chronic sinusitis. However, adenoid hypertrophy and
chronic sinusitis have very similar symptoms; this
means that, in many cases, it is difficult to know which
is the main cause of chronic rhinosinusitis24. There are
authors who maintain that bacterial infection of the
adenoid tissue is the main cause and origin of chronic
sinusitis25, although not all the findings confirm this
hypothesis24. Other authors believe that inflammation of
the nasal mucosa by extension of the sinus
inflammation and drainage of its secretions, especially if
this occurs in the large space of the middle meatus in
which the maxillary and ethmoidal sinuses open, can
cause an obstructive symptom similar to that caused by
adenoid hypotrophy26.
The diagnosis of adenoid hypertrophy can be made
by direct examination, lateral radiography of the
pharynx, endoscopy, computed tomography (CT) or
magnetic
resonance.
Direct
exploration
and
conventional radiography have low diagnostic
sensitivity compared with endoscopy27, but it is not
always possible to carry out an endoscopy on a child
due to a lack of sufficient collaboration. The CT is
sensitive, but it has a high radiation index, magnetic
resonance being preferable in this regard28. However,
these two imaging techniques are expensive, and
difficult to perform on a child, which is why they are
restricted to special cases.
Measuring the adenoid size
It is clear that an adenoid hypertrophy that
completely obstructs both choanae will benefit from an
adenoidectomy. Now, either the patient's symptoms are
sufficient to be able to diagnose adenoid hypertrophy or
other methods are required to measure the size of the
adenoids.
Paradise et al29 use a nasal obstruction index based
on clinical data, depending on the degree of mouth
breathing and the changes in the voice when the nose is
blocked They state that this index provides an
important degree of reliability regarding the existence
of adenoid hypertrophy, especially in extreme cases of
no obstruction or of marked obstruction. In this way,
other complementary explorations are avoided in a
certain number of children.
Other methods to measure adenoid size include the
classic lateral skull radiograph30,31 or direct visualization
by fibroscopy32, even acoustic rhinometry has been
proposed in the last few years as a non-invasive method
for measuring adenoid size33.
In the bibliography consulted, the ideal method for
measuring adenoid size appears to be direct
visualization of the nasopharynx by means of
fibroscopy32,34.
Other authors defend the use of Fujioka's adenoid
to nasopharynx ratio (AN ratio)30,31, obtained from the
lateral skull radiograph as a valid method which
adequately correlates with adenoid hypertrophy that
produces significant symptoms. This ratio expresses the
relationship that exists between adenoid size and the
nasopharynx, with values greater than 0.80 suggestive
of adenoid hypertrophy which could benefit from
surgery.
Finally, the most recent studies33 have used acoustic
rhinometry to measure the cross-sectional nasopharynx
area with a good clinical correlation between the data
obtained by acoustic rhinometry and adenoid size,
whether visualized by means of fibroscopy or calculated
on the basis of Fujioka's AN ratio.
Treatment for severe adenoidal hypertrophy is
surgical (an adenoidectomy), but, given the overlap
with chronic sinusitis, some authors26 propose treatment
with antibiotics and anti-inflammatories prior to
surgery in unclear cases in order to rule out the
possibility of an infectious origin.
INDICATIONS FOR AN ADENOIDECTOMY
There are no strict surgical criteria for performing
an adenoidectomy, but rather a series of
recommendations inspired by scientific bases and
supported in the international bibliography and by the
experience of different work groups. To the present day
the indication for an adenoidectomy is personal
judgment, which will depend on the disease, clinical
experience and the surgeon's personality. The final
decision for the adenoidectomy is taken by the ENT
doctor, taking into account the aforementioned
recommendations and studying and personalizing each
clinical case.
According to the consensus report by experts from
the Spanish ENT Societies (SEORL) and the Spanish
Pediatric Association (AEP)1 and the Tonsillectomy and
Adenoidectomy protocol of the Health Technology
Assessment Department of the Laín Entralgo Agency of
the Comunidad de Madrid, the indications for
Adenoidectomy are:
1) Adenoid hypertrophy that causes permanent
respiratory insufficiency, documented by a lateral
cranium x-ray to confirm the adenoidal mass and which
makes a marked reduction in the caliber of the airway
obvious.
This surgical indication should be established with
most emphasis when the adenoidal hypertrophy
coexists with:
- Craneofacial malformation.
- Acute recurrent otitis media, chronic otitis media
or persistent secretory otitis media.
63
J. CERVERA ESCARIO ET AL.
2) Adenoidal infection which, even without
marked respiratory difficulty, has repeated or persistent
otic repercussions.
According to this same report1, it is necessary to
carefully assess the indication of adenoidectomy and to
take precautions in the case of:
1. Palatine or uvula deformity as intervention can
cause open rhinolalia as a sequela.
2. Adenoidectomy in children under the age of 2
should be used in clinical situations that make it
necessary.
From our perspective, and according to
publications made in the last few years29-32,
adenoidectomy indications can be divided into:
1) Priorities:
- Hypertrophy of the adenoids with a clinical
history of severe OSAS
- Suspected malignant disease
2) Relatives
Adenoidal hypertrophy, (manifesting as buccal
breathing, persistent nighttime snoring, persistent
bilateral rhinorrhea, nasal respiratory insufficiency,
closed rhinolalia), which causes chronic nasal
respiratory insufficiency and that coexists with:
- OSA syndrome
- Craneofacial deformity
- Infections
1) Recurrent acute otitis media
2) Chronic otitis media.
3) Secretory otitis media.
4) Rhinosinusitis.
There are no clinical criteria or studies that assess
an adenoidectomy being performed with the objective
of improving the weight/height development of the
child, the child's appetite or treating halitosis.
ADENOIDECTOMY AND DENTOFACIAL
GROWTH
Some authors35,36 have postulated that a chronic
nasal obstruction provoked by adenoidal hypertrophy
could be the cause of altered dentofacial growth. On
account of this, numerous patients are referred to the
ENT department by the orthodontist for an
adenoidectomy.
The truth is, there are no studies which assess this
hypothesis and a clear improvement in dentofacial
growth following an adenoidectomy is not produced. It
is true, however, that children with nasal respiratory
obstruction usually have some characteristic craniofacial
features, described in Guilleminault’s clinical scale37.
Children with scores over 13 in the aforementioned
scale present a greater risk of suffering from OSAS
64
associated, beyond almost any doubt, with
developmental dentofacial problems.
Therefore, altered dentofacial growth is not per se an
indication for adenoidectomy if there is no adenoidal
hypertrophy with clinical symptoms of nasal
obstruction.
ADENOIDECTOMY AND CHRONIC
RHINOSINUSITIS
The relationship between adenoidal hypertrophy
and chronic sinus problems is not very clear. Despite
this, there are authors38,39 who propose carrying out an
adenoidectomy on children with recurrent sinus
infections before considering endoscopic sinus surgery.
According to these authors, an adenoidectomy
reduces the stasis of secretions in the nostrils and favors
sinus ventilation.
ADENOIDECTOMY AND MIDDLE EAR
PATHOLOGY
The close relationship between the Eustachian tube
and the adenoid tissue made us think of the possible
benefit that the adenoidectomy would produce in
patients with recurrent or chronic pathology in the
middle ear: recurrent acute otitis media, chronic or
persistent seromucous otitis.
This led to a number of studies that appeared to
show that the adenoidectomy improved the situation of
the middle ear in these patients40,41.
However, the latest studies conducted do not
support this theory and the recommendations of May
2004 from the “Subcommittee on otitis media with
effusion”, formed by members of the American
Academy of Family Physicians, the American Academy
of Pediatrics and the American Academy of
Otolaryngology-Head and Neck surgery are clear42:
1) In a child with chronic or recurring problems of
the middle ear who we are considering for surgery, the
insertion of transtympanic tubes is the ideal preliminary
treatment.
2) An adenoidectomy should not be performed
initially, unless there is a different indication to do so
(chronic nasal obstruction, OSAS, etc).
3) If the child needs a second operation for
seromucous
otitis,
an
adenoidectomy
plus
myringotomy is recommended (with or without the
insertion of tubes), as this reduces the need for future
interventions by 50%.
4) A tonsillectomy or myringotomy should not be
used in isolation in the treatment of seromucous otitis.
5) The benefits of adenoidectomy are observed in
children aged 2, but are clearer in children aged 3 or
over and are independent of adenoid size.
INDICATIONS FOR TOSILLECTOMY AND ADENOIDECTOMY
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