AAO-HNS Issues New Clinical Practice Guidelines for Tonsillectomy
The American Academy of Otolaryngology -- Head and Neck Surgery (AAO-HNS) has issued new clinical practice guidelines which states most children with frequent throat infections do not need tonsillectomy surgery.
The AAO-HNS is the world's largest organization representing specialists who treat the ear, nose, throat, and related structures of the head and neck. The Academy represents more than 12,000 otolaryngologist—head and neck surgeons (ENTs) who diagnose and treat disorders of those areas.
The practice guidelines is published in the January issue of Otolaryngology -- Head and Neck Surgery. The guidelines was developed using a systematic literature search which was condensed into evidence-based statements with associated balance of benefit and harm. The guideline panel members were chosen to represent fields of sleep medicine, advanced practice nursing, anesthesiology, infectious disease, family medicine, otolaryngology–head and neck surgery, pediatrics, and consumers.
The panel notes “Guidelines are never intended to supersede professional judgment; rather, they may be viewed as a relative constraint on individual clinician discretion in a particular clinical circumstance.”
The guideline panel recommendations---
1. Watchful waiting for recurrent throat infection: Clinicians should recommend watchful waiting for recurrent throat infection if there have been fewer than 7 episodes in the past year or fewer than 5 episodes per year in the past 2 years or fewer than 3 episodes per year in the past 3 years.
2. Recurrent throat infection with documentation: Clinicians may recommend tonsillectomy for recurrent throat infection with a frequency of at least 7 episodes in the past year or at least 5 episodes per year for 2 years or at least 3 episodes per year for 3 years with documentation in the medical record for each episode of sore throat and one or more of the following: temperature >38.3°C, cervical adenopathy, tonsillar exudate, or positive test for Group A β-hemolytic streptococcus (GABHS).
3. Tonsillectomy for recurrent infection with modifying factors: Clinicians should assess the child with recurrent throat infection who does not meet criteria in Statement 2 for modifying factors that may nonetheless favor tonsillectomy, which may include but are not limited to multiple antibiotic allergy/intolerance, PFAPA (periodic fever, aphthous stomatitis, pharyngitis, and adenitis), or history of peritonsillar abscess.
4. Tonsillectomy for sleep-disordered breathing: Clinicians should ask caregivers of children with sleep-disordered breathing and tonsil hypertrophy about co-morbid conditions that might improve after tonsillectomy, including growth retardation, poor school performance, enuresis, and behavioral problems.
5. Tonsillectomy and polysomnography (sleep study): Clinicians should counsel caregivers about tonsillectomy as a means to improve health in children with abnormal polysomnography who also have tonsil hypertrophy and sleep-disordered breathing.
6. Outcome assessment for sleep-disordered breathing: Clinicians should counsel caregivers and explain that SDB may persist or recur after tonsillectomy and may require further management.
7. Intraoperative steriods: Clinicians should administer a single, intraoperative dose of intravenous dexamethasone to children undergoing tonsillectomy.
8. Perioperative antibiotics: Clinicians should not routinely administer or prescribe perioperative antibiotics to children undergoing tonsillectomy.
9. Postoperative pain control: The clinician should advocate for pain management after tonsillectomy and educate caregivers about the importance of managing and reassessing pain.
10. Posttonsillectomy hemorrhage (bleeding): Clinicians who perform tonsillectomy should determine their rate of primary and secondary posttonsillectomy hemorrhage at least annually.
Guideline co-author Richard Rosenfeld, MD, of SUNY Downstate Medical Center in Brooklyn, N.Y., said in a statement, "Over half a million tonsillectomies are done every year in the U.S. The tonsillectomy guideline will empower doctors and parents to make the best decisions, resulting in safer surgery and improved quality of life for children who suffer from large or infected tonsils."
Baugh RF, et al "Clinical practice guideline: Tonsillectomy in children" Otolaryngol Head Neck Surg 2011; DOI:10.1177/0194599810389949.