ISSN: 2574-1241 Volume 5- Issue 4: 2018 DOI: 10.26717/BJSTR.2018.07.001440 Evans Paul Kwame Ameade. Biomed J Sci & Tech Res Review Article Open Access Adenotonsillectomy in Children with Recurrent Acute Tonsillitis: Review and Implications for Practice Adenotonsillectomy in Recurrent Acute Tonsillitis Lorenzo Pignataro1, Tullio Ibba1, Paola Marchisio2 and Sara Torretta1* 1Department of Clinical Sciences and Community Health, University of Milan, Otolaryngology Unit, Italy 2Paediatric Highly Intensive Care Unit, Department of Patophysiology and Transplantation, Università degli Studi Milano, Italy Received: July 11, 2018; Published: July 18, 2018 *Corresponding author: Sara Torretta, Department of Clinical Sciences and Community Health, University of Milan, Otolaryngology Unit, Italy. Abstract This paper aims at defining the therapeutic role of (adeno)tonsillectomy in children affected by recurrent acute tonsillitis (RAT), and at drawing some practical implications based on the current evidence. A literature search was performed to find pertinent study accessible by means of a MEDLINE search (accessed via PubMed). 15 papers were selected for literature analysis. The evidence suggests that although significant, the effect of tonsillectomy in children with moderate to severe RAT is modest and limited to 12 months post-operatively. In the case of patients with mild symptoms, it seems that the benefits are not sufficient to balance the disadvantages of the procedure. This can be explained by the fact that the generallyprocedure limited is intrinsically and relatively characterised transient. by pharyngeal pain and that the surgical removal of a palatine tonsil does not exclude the subsequent onset of successive episodes of pharyngitis. An analysis of the literature indicates that the efficacy of (adeno)tonsillectomy in treating pediatric RAT is Keywords: Tonsillectomy; Children; Tonsillitis; Pharynx; Tonsils Introduction therapeutic role of (adeno)tonsillectomy such patients to draw Acute pediatric pharyngotonsillary inflammation is very Sectionpractical recommendations 1: Pathogenesis for clinicaland Surgical practice (Section Treatment 2). of frequently encountered in clinical practice, and its symptoms often limit children’s everyday activities. Furthermore, a number of Pediatric Rat children have recurrent or persistent symptoms characterised by Defining acute tonsillitis pain, general malaise and, respiratory sleep disorders, and the a succession of acute infections associated with fever, pharyngeal limitations on their everyday activities cause them to miss school Pharyngeal pain may be due to infection of the pharynx and/or tonsils but, as there are no specific diagnostic criteria, it is difficult (if and prevent their parents from going to work. In such cases, practice and the literature often refers generically to “sore throat” (adeno)tonsillectomy can be considered, although it is necessary to not impossible) to distinguish pharyngitis and tonsillitis in clinical consider the possible risks of surgery, including those related to the use of general anesthesia [1-3]. [4]. Since the publication of the paper by Paradise et al. in the New certainly play a major role in the genesis of episodes of recurrent England Journal of Medicine [5], many authors have differentiated Although probably not the only cause, the palatine tonsils tonsillar infections into severe, moderate or mild, but without specifying whether they are bacterial or viral, and so neither their acute pharyngeal inflammation, which means that, even if it episodes of acute purulent tonsillitis as those that are medically further episodes of pharyngeal pain and/or reduce the severity site nor their etiology is defined. Nowadays, most authors define cannot eliminate the risk, tonsillectomy could theoretically prevent documented as being characterised by the presence of pyrexia of subsequent infections, thus improving the patient’s quality (>38.3 °C), tonsillary exudate, and jugodigastric adenopathy, and of life [4]. However, it is still not clear whether an accompanying requiringFurthermore, antibiotic the treatment nosological [5,6]. terms “recurrent acute tonsillitis” adenoidectomy can lead to a further clinical benefit in terms of the number and/or severity of infections [4]. This paper will provide an overview on pathogenesis and surgical treatment of recurrent (RAT) and “chronic tonsillitis” (CT) are usually used as synonyms, acute tonsillitis (RAT) in children (Section 1) and it will review the thus making it difficult to compare different trials. Burton [4] has Biomedical Journal of Scientific & Technical Research (BJSTR) 5640 Biomedical Journal of Scientific & Technical Research Volume 7- Issue 1: 2018 in the preceding 12 months, and CT as the presence of persistent recently defined RAT as the presence of at least two acute episodes c) Regardless of the technique used, most authors agree that the ability of tonsillectomy to reduce the number of episodes symptoms lasting more than three months; however, most authors of RAT is limited to the first 12 post-operative months [3-6,13- define severe RAT as five episodes of acute tonsillitis a year, the Extra-capsular16]. tonsillectomy (ET) presence of symptoms for at least a year, disabling episodes and limitations on everyday activities [7], whereas others continue to use Paradise’s definition of at least five episodes a year in the This refers to the complete removal of tonsillar tissue, which two preceding years, or at least three a year in the three preceding may be done using ‘hot’ electro-surgical instruments (mono- or years [5,6]. It should also be pointed out that, unlike in the case bipolar electro cauters, lasers or radiofrequency instruments) for of acute rhinosinusitis, the term “CT” or “CT with recurrent acute both dissection and hemostasis, or ‘cold’ dissection with a scalpel exacerbations”, which suggest the presence of chronic structural followed by electro-surgical hemostasis [17-21]. ET generally changes in tonsillar tissue with periodic acute episodes [8], involves identifying the larger calibre afferent vessels during should be avoided because of the absence of real chronic tonsillar dissection and closing them outside the capsule by means of inflammation associated with symptoms lasting for more than four sutures or electro-surgical methods. This means that, regardless weeksEtiopathogenesis and permanent of structural Recurrent alterations Acute Tonsillitis[3]. of the technique used, the peri-tonsillar pharyngeal musculature undergoes a substantial trauma that may expose the adjacent nervous and vascular structures to direct contact with saliva, thus Most episodes of acute tonsillitis are caused by viral leading to a bacterial super-infection that favours the development infections (i.e. adenovirus, Epstein- Barr virus, bocaviruses, of some of the main morbidities associated with the procedure influenza and para-influenza viruses, rhinovirus, enteroviruses such as post-operative pain and bleeding (4.5% of cases) [12]. including coxsackievirus, coronavirus, respiratory syncytial virus, Furthermore, the findings of some meta-analyses suggest that hemolytic Streptococcus Pyogenes metapneumovirus and HIV) or bacterial infections (group A beta- ‘cold’ techniques are associated with an increased risk of intra- mainly transmitted by means and early post-operative bleeding (i.e. within 24 hours according of Flügge droplets from infected subjects or, more rarely, healthy to the classification of Sarny et al.) [22], whereas ‘hot’ techniques encountered include group C and G streptococci, Haemophilus carriers) [1]. Other bacterial species that have been less frequently are more subject to the risk of delayed post-operative bleeding (i.e. influenzae, Nocardia, Coriobacteriia, Neisseria gonorrhoeae, and afterTonsillotomy >24 hours) (TT) [22] and severe post-operative pain [23,24]. Fusobacteria and Borrelia members of the families responsible for Vincent’s angina, which is characterised by the onset of a unilateral This procedure, which can be performed using many kinds ulcerous and necrotising form of tonsillitis [1]. Finally, some recent of instruments (a CO2 laser, ultrasound scalpel, hot knife, bipolar studies of children with RAT have highlighted the role played by scissors, bipolar radiofrequency coblator, microdebrider, or bacterial biofilms: i.e. metabolically quiescent polymicrobial monopolar argon laser) [25-29], reduces the volume of tonsillar tissue medially up to the palatine arches, thus allowing the removal bacterial colonies inside a polysaccharide matrix that makes them preserving the residual and immunologically active lateral tissue. extremely resistant to the action of the immune system and the of the excess tissue extending into the oropharyngeal cavity while administrationTonsillar Surgery of antibiotics [8-10]. It has been reported that, in comparison with ET, this procedure reduces post-operative pain and the risk of post-operative bleeding pediatric procedures and is generally performed from the age Tonsillar surgery has always been one of the most frequent [30,31] insofar as the extra-capsular vascular and nervous afferents areIntra-capsular not exposed. tonsillectomy (IT) of three years [4]. It is estimated that about 530,000 pediatric procedures were performed in the United States in 2006 [11], but an analysis of the published data shows that: The methods described above can also be used for an intra- capsular tonsillectomy (the sub-total [90%] removal of the tonsillar a)