This article is more than 5 years old. Information may no longer be current.
Pediatricians play key role in tonsillectomy
Click Here to Manage Email Alerts
With 80% of tonsillectomies being performed on an outpatient basis, pediatricians bear more of the responsibility for perioperative care, according to a review article published online.
Glenn Isaacson, MD, of the department of otolaryngology-head and neck surgery and pediatrics at Temple University, discussed his review in an interview with Infectious Diseases in Children. He said it is important for pediatricians to familiarize themselves with recently issued guidelines about tonsillectomy, which recommend limiting the procedure to only those children who meet certain criteria, including but not limited to seven episodes of sore throats in a year.
In the review, Isaacson also discussed bleeding episodes, noting that bleeding occurs in 5% of tonsillectomies, about 7 to 10 days after the procedure. He said children who have bleeding should be managed in the hospital, rather than a clinic.
Isaacson said the guidelines also stress the use of ibuprofen over narcotics, adding that “a single dose of intraoperative dexamethasone decreases nausea and vomiting after tonsillectomy.”
Although this procedure is not as effective in children with obesity and sleep-disordered breathing, it has been shown effective for other populations. He said tonsillectomy has been shown to decrease recurrent sore throats in children who meet certain criteria.
Isaacson also noted advancements in technology, such as lasers and molecular resonance technologies, which have made tonsillectomy less invasive.
Isaacson also listed in his review several things that must be resolved regarding tonsillectomy, including: 1) whether some children with recurrent sore throats benefit more from tonsillectomy than the general population; and 2) whether partial tonsillectomy is as effective as total tonsillectomy for long-term control for sore throat.
Disclosure: Dr. Isaacson reports no relevant financial disclosures.
Perspective
Back to Top
William T. Gerson, MD
Isaacson provides a timely state-of-the-art review of current tonsillectomy care and practice. Issues of the tonsils and upper airways are common in practice and can be troubling to both practitioner and parent — not to mention the affected patient. Some difficulties reflect recent changes in care. Over the past 25 years, more patients are being operated on for obstructive sleep apnea and less for recurrent pharyngitis. The vast majority receive all their care as outpatients; hospitalized patients are those more at risk for complications, the very young and those with significant comorbidities (severely disordered breathing, obesity, bleeding diatheses, craniofacial disorders, neuromuscular diseases and sickle cell disease).
Directed to the concerns of the office-based general pediatrician, the review focuses on postoperative medical management and refers often to the 2011 American Academy of Otolaryngology – Head and Neck Surgery Foundation clinical practice guideline “Tonsillectomy in Children.” Isaacson describes the current indications for tonsillectomy, as well as the technical variations available for the procedure. He carefully describes postoperative healing, as well as pain and bleeding complications.
How involved with perioperative care one is as the pediatrician varies considerably by training and practice location. The office-based practitioner may be far more involved in the care leading up to the actual surgery, but have few pre- and postoperative calls. Hospitalists will not be involved in preoperative medical decision making, but may be called on to direct in-hospital and postoperative emergent care. Some otolaryngologists might supervise all perioperative questions and care. No one model is likely to emerge, as local issues will always trump national guidelines.
Most impressive about Isaacson’s review is its overall form. Clearly an expert in the field, he is adept at summarizing the clinical care issues. I will place him in the group of critical thinkers in pediatrics, otolaryngology, infectious disease and public health who over the past 5 years have worked to improve tonsillectomy care. Basing their work on better evidence and practice models, utilizing systematic reviews to assess the quality of available evidence, this group has endeavored to put into place evidence-based suggestions for care.
Isaacson concludes his review with what I believe is the critical feature of our early attempts at true quality initiatives. He ends with three headings and numerical sub-listings that underscore the following points: 1) Things We Know (or are pretty sure we know); 2) Things We Believe (and may well be true); and 3) Things We Don’t Know (and really should). Even for tonsillectomies, a very common and long-standing procedure, we still do not have the evidence to satisfactorily generate a practice guideline. For a myriad of clinical areas, we can and should have experts in the field, along with general pediatricians, evaluate the state-of-the-art evidence and arrive at the listings to follow the above headers, as has been done in this review, to then drive clinical studies that are well designed and statistically powered to answer the needed clinical questions so generated. Without this we are left with guidelines that are no better than current practice and that do not drive future research.
Click Here to Manage Email Alerts