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Pediatric Tonsillectomy an Evidence-Based Approach

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Pediatric Tonsillectomy an Evidence-Based Approach Pediatric Tonsillectomy An Evidence-Based Approach a, Glenn Isaacson, MD * KEYWORDS Adenotonsillectomy Complications Pain management Tonsillectomy Wound healing KEY POINTS Tonsillectomy decreases the frequency of severe recurrent sore throats in children who meet the “Paradise criteria.” Adenotonsillectomy improves symptoms of sleep disordered breathing in children with adenotonsillar hypertrophy. Polysomnography is a useful adjunct in selecting children for surgery, especially when the diagnosis is in doubt or risks of surgery are increased because of young age or comorbid conditions. Obese children with sleep disordered breathing may not be cured by surgery. Ibuprofen is safe after tonsillectomy and provides good pain relief with fewer side effects than narcotics. INTRODUCTION The tonsillectomy operation has changed in recent years. More children are operated on for sleep disordered breathing and fewer for recurrent pharyngitis. New instruments now permit less invasive surgery. Systematic reviews by the Cochrane Collaboration and others have helped to define best practices for preoperative assessment and postoperative care. Approximate 100 million tonsillectomies have been performed worldwide in the cen- tury since the procedure was popularized. Pediatric tonsillectomy with or without adenoidectomy is an effective operation for obstructive sleep apnea and sleep Funding: None. Financial Disclosures: None. Conflicts of Interest: None. a Departments of Otolaryngology – Head & Neck Surgery and Pediatric, Temple University School of Medicine, 3400 North Broad Street, Philadelphia, PA 19140, USA * Department of Otolaryngology – Head & Neck Surgery, Temple University School of Medicine, 1077 Rydal Road, Suite 201, Rydal, PA 19046. E-mail address: [email protected] Otolaryngol Clin N Am 47 (2014) 673–690 http://dx.doi.org/10.1016/j.otc.2014.06.011 oto.theclinics.com 0030-6665/14/$ – see front matter Ó 2014 Elsevier Inc. All rights reserved. Downloaded for Anonymous User (n/a) at Kaiser Permanente from ClinicalKey.com by Elsevier on January 24, 2019. For personal use only. No other uses without permission. Copyright ©2019. Elsevier Inc. All rights reserved. 674 Isaacson Abbreviations AAO-HSN American Academy of Otolaryngology – Head and Neck Surgery Foundation IL Interleukin PANDAS Pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections disorder breathing. It can decrease the incidence of sore throat in children who have frequent throat infections and may be effective for children who suffer from peritonsil- lar cellulitis or abscess, pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections (PANDAS), “chronic” tonsillitis, febrile seizures, halitosis, dental malocclusion, cryptic tonsils, or hemorrhagic tonsillitis. It has a role in the pre- vention of recurrences of rheumatic fever, and in controlling chronic pharyngeal car- riage of group A beta-hemolytic streptococci. Yet despite a century of experience with this operation, tonsillectomy remains a traumatic experience for children and their families. In the best of hands, tonsillectomy has a 1% to 5% risk of immediate or delayed hemorrhage1 and a 1:35,000 death rate.2 The surgery produces separation anxiety, postoperative edema, dysphagia, weight loss, and night terrors. Nausea and vomiting remain common despite pharmacologic advances and everyone suffers from pain. Even when well-treated with opioid and nonopioid analgesics, most chil- dren still rate their pain as moderate to severe. This article reviews current knowledge of the science of pediatric tonsillectomy— developmental anatomy of the tonsil, physiology of the operation, and wound healing after surgery. It outlines indications for surgery and best practices for intraoperative and postoperative care as described in the American Academy of Otolaryngology– Head and Neck Surgery Foundation (AAO-HSN) clinical practice guideline: Tonsillec- tomy in Children. Finally, it discusses areas of uncertainty in the field and opportunity for future improvement. DEVELOPMENTAL ANATOMY Developmental anatomy describes when the tonsil becomes immunologically active, how its structure changes, when it enlarges, and when it involutes. An appreciation of the fetal development of the tonsil and the changes it undergoes in the first decade of life can aid in surgical decision making (Table 1). Intrauterine Development The epithelium that covers the tonsil’s medial surface and lines the tonsillar crypts arises from the second branchial (pharyngeal) pouch. The outer edges of this out- pouching go on to form the faucial arches and mucosa plicae. In the embryo, solid epithelial cores form in the lateral walls of each pouch and grow outward into the sur- rounding mesenchymal tissue. These epithelial cores branch and subsequently canalize. The branches ultimately become the primary and secondary tonsillar crypts (Fig. 1A).3 Transmission electron microscopy has demonstrated that the mature crypt epithelium is porous and allows the protrusion of lymphocytes that mediate the immune response.4 The mucosa of the tonsillar fossa is similar in microscopic structure to the lining of the oropharynx. Its surface is nonkeratinizing squamous epithelium with an underlying lamina propria. The pharyngeal tonsils are a part of the mucosa-associated lymphatic tissue system and develop their monocellular populations in a fashion much like the Downloaded for Anonymous User (n/a) at Kaiser Permanente from ClinicalKey.com by Elsevier on January 24, 2019. For personal use only. No other uses without permission. Copyright ©2019. Elsevier Inc. All rights reserved. Pediatric Tonsillectomy 675 Table 1 Fetal development of the tonsil and the changes it undergoes Observation Implications for Intracapsular Tonsillectomy The tonsil epithelium arises before the The crypt epithelium runs full thickness lymphoid component. Lymphoid cells through the tonsil; thus, superficial infiltrate the lamina propria then treatment of the crypts is unlikely to be proliferate. effective. The tonsil is arranged in lymphoepithelial Crypt epithelium and lymphoid elements are fronds. Lymphoid elements are arranged intimately associated and cannot be around a fibrovascular core in each frond. treated independently. The fronds are surrounded by crypt epithelium. Germinal center activation occurs after birth The tonsil is an immunologically active when the immune system is exposed to structure. It is insignificant in mass in most stimulating antigens. infants. Rapid germinal center proliferation is the Surgery that leaves significant amounts of most conspicuous event of the first decade residual lymphoid tissue may lead to of tonsil development and accounts for recurrent hyperplasia. most of tonsillar enlargement. The tonsil has no core. It is not possible to perform a tonsil “core” biopsy without contamination by epithelial elements. The concept of bacterial sequestration in the tonsil “core” is not valid. The tonsil capsule is contiguous with the There is no natural surgical plane between trabeculae and frond fibrovascular cores. the tonsil parenchyma and the capsule. The tonsil capsule surrounds the tonsil Powered intracapsular tonsillectomy, except on the medial crypt surface. proceeding outward from the crypt area, can remove all of the lymphoid and epithelial elements. The appearance of thick trabeculae signals the approach of the capsule. Marginal incisions around the crypt area are made in intracapsular tonsillectomy with bipolar electrosurgical scissors or plasma excision. Such incisions will encompass all tonsil epithelial elements. The tonsil expands, rather than invades, Removal of the parenchyma of the tonsil surrounding structures as it grows. allows collapse of expanded normal tissues, minimize wound surface area. The tonsillar pillars and plicae do not The tonsil pillars and all plica mucosa can be contain bulky lymphoid elements or crypt preserved for healing without epithelium. compromising surgical goals. Involution of lymphoid elements is More conservative tonsil resection (or characteristic of the second decade of life. avoidance of surgery) may be preferable in older children. Prominent fibrosis of the capsule and Techniques applicable to young children trabeculae is typical of the third decade may work less well in the fibrotic tonsils of and beyond. adults. From Isaacson G, Parikh T. Developmental anatomy of the tonsil and its implications for intracap- sular tonsillectomy. Int J Pediatr Otorhinolaryngol 2008;72(1):89–96; with permission. Downloaded for Anonymous User (n/a) at Kaiser Permanente from ClinicalKey.com by Elsevier on January 24, 2019. For personal use only. No other uses without permission. Copyright ©2019. Elsevier Inc. All rights reserved. 676 Isaacson Fig. 1. Development of the tonsil (A) epithelial evagination, (B) lymphoid infiltration of the lamina propria, (C) primary germinal centers develop before birth, and (D) hyperplastic tonsil of childhood. (From Isaacson G, Parikh T. Developmental anatomy of the tonsil and its impli- cations for intracapsular tonsillectomy. Int J Pediatr Otorhinolaryngol 2008;72(1):89–96; with permission.) Peyer’s patches in the gut.5 Around the 16th week postconception, the lamina propria is invaded by wandering lymphocytes and lymphoid stem cells of bone marrow origin (see Fig. 1B).6 The lymphatic tissue surrounding the crypts becomes organized into a cellular architecture resembling that of lymph nodes and includes B-cell follicles, pri- mary
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