Tonsillectomy - when is it the right choice?

When deciding whether a tonsillectomy is indicated for a given patient, tailor your decision to the severity of symptoms and that patient's ongoing story, advised a specialist Saturday at the AAP's National Conference and Exhibition in Atlanta.

In a presentation designed as a primer for the generalist, David H. Darrow, MD, DDS, of the departments of otolaryngology and pediatrics at Eastern Virginia Medical School, Hampton Roads, reviewed the indications for tonsillectomy in children, including severe upper-airway obstruction, suspected malignancy, and recurrent tonsillitis.

In determining airway obstruction, Dr. Darrow reported that the gold standard is polysomnography - a procedure that is both expensive and difficult to schedule in a timely manner.

"Audiotaping or videotaping can be very practical," Darrow said. "Keep in mind that you won't get paid for your time, but it can enable you to see what parents may or may not be reporting."

When conducting a polysomnography test, Dr. Darrow advised pediatricians to look for apnea, hypopnea, the hypopnea index (events per hour), desaturation time, and arousal index.

"Cancer is one thing in patients that you never want to miss," said Dr. Darrow. "However, if you see asymmetry in tonsils, it is reasonable to observe the child over a period of weeks to see if further changes occur."According to Dr. Darrow, mild asymmetry is not unusual. Furthermore, the depth of the fossa can sometimes cause one tonsil to look significantly larger than the other-when, in fact, it is not.

Tonsillectomy for recurrent tonsillitis has been controversial for nearly a century, Dr. Darrow reported, because of the role tonsils play in the immune system. His advice - Consider whether the patient was at a point at which the degree of impairment of the local immune function because of the tonsillitis justifies the procedure. Also important to consider is that tonsillectomy removes some of the symptoms associated with infection but not necessarily the source of infection.Dr. Darrow urged all pediatricians to be familiar with the Paradise and colleagues' study of tonsillectomy, published in 1984 in the New England Journal of Medicine.

"This study is not without its flaws, but it provides one of the most comprehensive guides available to date," Dr. Darrow said. "A variety of entities, including insurance companies, use this [study] to make decisions regarding tonsillectomy."