New Guidelines for Children's Tonsillectomies

The Problem with Tonsils

Everyone is born with three tonsils (or four, if you count the adenoids, which are in the same ring of tissue). The tonsils that are visible when you say "Aaaaah" are the palatine tonsils, but there is tonsil tissue around the tongue and the throat as well.

However, if a child has regular high fevers, if the child tests positive for strep throat, or if tonsillitis is causing mouth sores or sleep apnea, the child may be fast-tracked for surgery to remove the tonsils.

If tonsil surgery is indicated, the child still will be evaluated through several rounds of testing.

1.    Children are not given tonsillectomies if there are indications that bleeding will be a problem. In the era when children were often treated with surgery, it was not unusual for bleeding to require an emergency run back to the hospital almost as soon as children were discharged to go home. Now doctors recognize that about 4 percent of children who are given standard coagulation tests may have blood clotting problems that the old tests did not pick up. Pre-operative testing now usually includes an activated partial thromboplastin time (aPTT) and a platelet count. Doctors will make sure that children do not have undiagnosed hemophilia or other blood clotting disorders before they receive a tonsillectomy.

2.    Doctors now recognize that "throbbing tonsils" usually indicate an unusual placement of the carotid artery — which cannot be nicked during surgery. Doctors look for unusual pressures around the tonsils that may suggest that the carotid artery is closer than expected to the tonsils, and do magnetic resonance arteriography (MRA) to locate blood vessels. MRA is a procedure very similar to MRI, only intended to locate circulation.

3.    Antibody testing is used to determine if the problem might be that the child simply has not been given the right antibiotic. Antibodies to streptolysin indicate that the child has had previous infection with group A beta-hemolytic streptococcus (GABHS). These are the bacteria that cause "strep throat" instead of just "sore throat." If they have not been treated properly, it may be better from a medical standpoint to treat with antibiotics than with surgery, as this less invasive option could solve their syptoms just as well.

4.    Sometimes tonsillitis is made worse by allergies, including seasonal allergies and perennial allergies like to cats or house mites. Children who suffer from frequent infections of the adenoids and tonsils tend also to have allergies. If treating the allergy makes the tonsillitis more bearable, surgery to remove the tonsils may not be needed.

5.     When tonsillectomies are carried out because a child has frequent episodes of sore throat, the up to date guidelines suggest that at least seven episodes should have occurred within the last 12 months, accompanied by high fever, swollen lymph nodes, and the episodes should have been listed in the child's medical records.

6.    Tonsillitis usually causes the same amount of swelling on both sides of the mouth. When swelling is asymmetrical, meaning that one tonsil is more inflamed than the other, doctors may do a biopsy just to make sure that there is no cancer before they do an operation to remove the tonsils. Cancer of the tonsils in children, however, is very, very rare.

Children who have Down syndrome often also have "loose" vertebra at the base of the brain, which also must be evaluated before tonsillectomy surgery.

Insurance companies usually try to make tonsillectomy an out-patient procedure. Some children should go into the hospital when they have their tonsils taken out. These include children who have sleep apnea (cessation of breath for a few seconds up to a minute repeatedly through the night, due to swelling of the tonsils), children who are on medications for ADHD or seizures, children who have other breathing disorders, and children of parents who object to blood transfusions on religious grounds. Children who live far away from a medical treatment center usually should also stay close by for about a week.

The pain of tonsillitis goes away immediately after surgery, and then is even worse about 3 days later. Giving pain medication on a regular schedule is usually better than giving it only when the child cries or complains of pain. The new guidelines recommend giving a shot of steroids to minimize pain and swelling after tonsil surgery. Antibiotics, however, are discouraged.

Laser ablation or radiofrequency surgery is sometimes used for tonsils that are just too large, rather than large and inflamed. There is good evidence that tonsillectomy will stop recurrent sore throats and make nighttime breathing easier, but there are no good medical studies that show that it treats halitosis, or it does not.