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QUESTION

  1. Top of page
  2. QUESTION
  3. BACKGROUND
  4. LITERATURE REVIEW
  5. BEST PRACTICE
  6. LEVEL OF EVIDENCE
  7. BIBLIOGRAPHY

In a child with enlarged adenoids and small tonsils, is adenoidectomy alone sufficient for the treatment of upper airway obstruction in children? What are the chances that this same child will someday require a tonsillectomy for similar symptoms?

BACKGROUND

  1. Top of page
  2. QUESTION
  3. BACKGROUND
  4. LITERATURE REVIEW
  5. BEST PRACTICE
  6. LEVEL OF EVIDENCE
  7. BIBLIOGRAPHY

Adenoidectomy is one of the most common surgical procedures performed in children in the United States. Indications for adenoidectomy include chronic or recurrent otitis media, as well as subjective upper airway obstructive symptoms such as nasal obstruction with chronic mouth breathing, snoring, chronic rhinitis, and chronic or recurrent sinusitis. When the indication includes obstructive symptoms, tonsillectomy is often considered. Parents often ask if the tonsillectomy can also be done, “since you are already in there.” However, adding a tonsillectomy can contribute significantly to surgical morbidity and mortality. Specifically, the risk of postoperative hemorrhage following adenoidectomy alone is less than 1%. The rate of hemorrhage follow tonsillectomy can be up to 3%. The return to normal activity and school occurs the day after the adenoidectomy in most children, whereas the recovery period after tonsillectomy can last up to 14 days, requiring parents to take extended periods off from their jobs. In order to adequately council patients on when to perform an adenoidectomy alone, one may want to consider and discuss with the family the likelihood of their child needing a tonsillectomy in the future.

LITERATURE REVIEW

  1. Top of page
  2. QUESTION
  3. BACKGROUND
  4. LITERATURE REVIEW
  5. BEST PRACTICE
  6. LEVEL OF EVIDENCE
  7. BIBLIOGRAPHY

Indications for when to perform an adenoidectomy versus a combined adenotonsillectomy are not universal. In a study by Kay et al., American Society of Pediatric Otolaryngology (ASPO) and American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS) members in New York were surveyed.[1] Two brief case presentations were included in the survey. The first case discussed a child with obstructive sleep apnea (OSA) and enlarged adenoids, but small tonsils. Most respondents reported they would perform adenoidectomy alone rather than adenotonsillectomy (T&A). But more than half of each group would “sometimes” perform a T&A. The second scenario described a child with symptomatically enlarged adenoids and incidentally large tonsils. Most respondents still would perform an adenoidectomy alone. This study demonstrates the variability within our specialty.

Although the AAO-HNS Clinical Practice Guidelines address the need for tonsillectomy for children with upper airway obstruction and sleep disordered breathing, they do not address the question of adenoidectomy alone for similar symptoms.[2]

There have been a few articles specifically evaluating the risk of subsequent tonsillectomy when adenoidectomy alone has been done in the past. Kay et al. found that several factors increased the odds of future tonsillectomy after adenoidectomy alone.[3] Based on their retrospective review of 2,462 patients, they found that the overall incidence rate for tonsillectomy was 2.0% per year. However, if the indication for surgery (upper airway obstruction, otitis media, or sinusitis) is included, a clear difference can be seen. If the adenoidectomy was done for upper airway obstruction, the patients were 1.9 times more likely to require subsequent tonsillectomy. It was also noted that children under the age of 2 at the time of adenoidectomy are more likely to undergo future tonsillectomy. They found 28.7% of children under the age of 2 required a tonsillectomy within 5 years. This number decreased to 14.8% for ages 2 to 4 years, and subsequent tonsillectomy was needed within 5 years in 6.1% for ages 5 to 7 and in 2% for ages older than 7 years. See Figure 1.

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Figure 1. Kaplan-Meier estimates demonstrating rates of tonsillectomy by age at time of initial adenoidectomy.6

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This study also noted that the odds of undergoing a future tonsillectomy significantly increased with increasing tonsil size at the time of adenoidectomy. The risk was increased by 1.6 times for each unit increase of tonsil size (0–4+).

A more recent study by Gov-Ari et al. sought to find predictors of tonsillectomy after previous adenoidectomy for upper airway obstruction.[4] This study included a retrospective cohort study of 1,291 patients who underwent adenoidectomy. Using a nested case-control study, they determined predictors of subsequent tonsillectomy. Overall rate of tonsillectomy after previous adenoidectomy was 7.8 %. Age younger than 3 years, female, tonsil size, and upper airway obstruction were found to be significant predictors of subsequent tonsillectomy. Patients younger than 3 years had a higher rate of subsequent tonsillectomy than those children who were 3 years or older (8% vs. 1%). Within the group with airway obstruction, girls younger than age 3 had the highest rate of subsequent tonsillectomy (28% vs. 5%). With each increase of tonsil size by 1 unit, the odds of tonsillectomy increased by 2.5 (95% CI, 1.2–5.2 P = .01).

Other studies have noted similar trends. Brietzke et al. performed a retrospective review of 100 patients undergoing adenoidectomy.[5] In this study, 21% of 100 children underwent subsequent tonsillectomy. When the group was divided into obstructive symptoms (OS) versus nonobstructive symptoms (NOS), there was a significant difference. Children in the OS group had a 27% rate of subsequent tonsillectomy versus 14% of the NOS group. Overall, the OS group were three times more likely to require a second surgery, either tonsillectomy or revision adenoidectomy. They also noted that a greater proportion of children in the youngest age group (<2 years old) required revision surgery, with 22% requiring tonsillectomy.

BEST PRACTICE

  1. Top of page
  2. QUESTION
  3. BACKGROUND
  4. LITERATURE REVIEW
  5. BEST PRACTICE
  6. LEVEL OF EVIDENCE
  7. BIBLIOGRAPHY

The majority of children undergoing adenoidectomy alone will not require subsequent tonsillectomy. However, there is the potential risk for further surgery that includes a tonsillectomy, particularly if the adenoidectomy was done for treatment of airway obstruction. Two to 29% of children undergoing adenoidectomy alone for airway obstruction will require subsequent tonsillectomy. Risk factors for subsequent tonsillectomy include age <2 years old, girls less than 3 years of age (28%), and tonsillar hypertrophy. Knowledge of these risk factors can improve preoperative family/patient counseling and surgical planning.

LEVEL OF EVIDENCE

  1. Top of page
  2. QUESTION
  3. BACKGROUND
  4. LITERATURE REVIEW
  5. BEST PRACTICE
  6. LEVEL OF EVIDENCE
  7. BIBLIOGRAPHY

There were no level 1 or 2 studies available for this review. Two studies reviewed were level 3 studies (retrospective case-controlled studies with internal comparison group) and two level 4 studies (case series without an internal control group). Since there are no level 1 or level 2 studies, the evidence could be improved by future prospective studies.

BIBLIOGRAPHY

  1. Top of page
  2. QUESTION
  3. BACKGROUND
  4. LITERATURE REVIEW
  5. BEST PRACTICE
  6. LEVEL OF EVIDENCE
  7. BIBLIOGRAPHY
  • 1
    Kay DJ, Mahta V, Goldsmith AJ. Perioperative adenotonsillectomy management in children: current practices. Laryngoscope 2003;113:592597.
  • 2
    Baugh RF, Archer SM, Mitchell RB, et al. American Academy of Otolaryngology-Head and Neck Surgery Foundation. Clinical practice guideline: tonsillectomy in children. Otolaryngol Head Neck Surg 2011;144(suppl 1):S130.
  • 3
    Kay DJ, Bryson PC, Casselbrant M. Rates and risk factors for subsequent tonsillectomy after prior adenoidectomy. Arch Otolaryngol Head and Neck Surg. 2005;131:252255.
  • 4
    Gov-Ari E, Mills JC, Basler KJ. Predictors of tonsillectomy after previous adenotonsillectomy for upper airway obstruction. Otolaryngology Head and Neck Surgery 2012;146:647652. Epub 2011.
  • 5
    Brietzke SE, Kenna M, Katz ES, Mitchell E, Roberson D. Pediatric adenoidectomy: What is the effect of obstructive symptoms on the likelihood of future surgery? Int J Pediatr Otorhinolaryngol 2006;70:14671472. Epub 2006.