AHRQ Studies: Tonsillectomy Provides Some Benefit to Children With Throat Infections, Sleep-Disordered Breathing

Two articles recently published in Pediatrics found tonsillectomy to be of short-term benefit to children with recurrent throat infections or sleep-disordered breathing. The articles are based on an AHRQ-funded systematic review. In the first article, authors compared tonsillectomy with watchful waiting and found that throat infections and school absences declined in the year following surgery, as did the number of health care visits for sore throat and throat infections. In the first year post-surgical year, children who had tonsillectomies had an average 1.7 episodes of sore throat or throat infection compared with 2.9 episodes for those who did not undergo surgery. However, the benefits of surgery waned over time and information on long-term outcomes was limited. Access the abstract of the article. In the second article, authors found that among children with sleep-disordered breathing, those who had tonsillectomies had better sleep outcomes than those who engaged in watchful waiting. Researchers cautioned, however, that less is known about longer-term outcomes or treatment effects in specific subpopulations. Access the abstract of that article. Two additional articles on tonsillectomy based on the systematic review, one on postoperative bleeding, the other comparing full vs. partial tonsillectomy, were published in the journal Otolaryngology-Head and Neck Surgery.

Executive Summary – Jan. 17, 2017

Tonsillectomy for Obstructive Sleep-Disordered Breathing or Recurrent Throat Infection in Children

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Purpose of Review

To assess the effectiveness of tonsillectomy for treating children with obstructive sleep-disordered breathing or recurrent throat infections.

Key Messages

Tonsillectomy compared with watchful waiting can modestly improve sleep and reduce throat infections in the short term, which must be weighed against a relatively low risk of postoperative bleeding.
Different surgical techniques had little effect on either outcomes or bleeding risk.
Perioperative use of dexamethasone may improve pain, and pre-emptive 5-HT receptor antagonist antiemetics may reduce vomiting in the immediate postoperative period.
Future research should address long-term outcomes and include enough detail to allow better identification of which children benefit most from surgery and which children benefit most from watchful waiting.

Introduction

Tonsillectomy or adenotonsillectomy ("tonsillectomy") represent more than 15 percent of all surgical procedures in children under the age of 15 years.1,2 The primary indication for tonsillectomy has shifted over the last 20 years from recurrent throat infections to obstructive sleep-disordered breathing (OSDB) and obstructive sleep apnea (OSA).3,4 Widely variable national and small area tonsillectomy rates are well-documented. In their seminal study, Wennberg and Gittlesohn found rates of tonsillectomy varied almost 12-fold across adjacent counties in rural Vermont with similar populations.5 Variation in rates continue despite improved evidence and dissemination about indications.1

Indications for Tonsillectomy

Tonsillectomy has two primary indications: recurrent tonsillitis and OSDB recurrent or severe tonsillitis has been defined as seven or more episodes of sore throat in the preceding year OR five or more episodes in the each of the preceding 2 years OR 3 or more episodes in each of the preceding 3 years.6 No gold standard diagnostic test exists to etiologically implicate or predictably attribute symptoms to tonsillitis. In fact, consensus is lacking on what symptoms attributable to tonsillitis are considered "disabling." Surrogates often used for tonsillitis include sore throat and pharyngitis. However, the degree to which either of these terms reflects true tonsillitis is not known. Bacterial pharyngitis can be diagnosed via rapid testing or culture. It is not possible, however, to determine whether the tonsil represents the infectious nidus or whether the suspected pathogen represents normal bacterial flora for a particular child's pharynx.

Currently, the most common indication for tonsillectomy is OSDB (i.e., breathing difficulties during sleep including OSA and upper airway resistance syndrome [UARS]). OSDB results from obstruction from or dynamic collapse due to upper airway soft tissue during sleep resulting in snoring, hypopnea, apnea, and restless sleep. Adenotonsillar hypertrophy can cause oropharyngeal crowding, thereby increasing the likelihood of symptomatic airway collapse during sleep. OSDB includes disorders ranging from simple snoring to OSA and can result in significant effects on quality of life and health consequences. It has been associated with a five-point decrease in IQ, hypersomnolence, emotional lability, decreased attention, small stature, enuresis, cardiopulmonary morbidity, and missed school.7 Evidence of the relationship is reinforced by the effectiveness of OSDB treatment in improving behavior, attention, quality of life, neurocognitive functioning, enuresis, parasomnias, and restless sleep, and reversal of associated cardiovascular sequelae.8,9 Moreover, OSDB occurs at especially high rates in subsets of children with developmental disorders and craniofacial syndromes, including Down syndrome.