Acta Otorrinolaringol Esp 2006; 57: 59-65

REVIEW ARTICLE

Indications for tonsillectomy and adenoidectomy: consensus document by the Spanish Society of ORL and the Spanish Society of Pediatrics
J. Cervera Escario*, F. Del Castillo Martín**, J. A. Gómez Campderá**, J. R. Gras Albert*, B. Pérez Piñero*, M. A. Villafruela Sanz*
*Representante de la SEORL. **Representante de la AEP.

Abstract: Tonsillectomy and adenoidectomy are probably the most common as well as the most controversial operations performed within the ENT field. There are very few consensus documents available for these two types of surgery. One was published in 1997, written by the Spanish ENT Society, (SEORL), and the Spanish Pediatric Association, (AEP), on the indications for tonsillectomy and adenoidectomy in children and adolescents. In order to update that document, representatives from both scientific societies met again earlier this year and a new document was drawn up. The diagnostic criteria for pharyngotonsillitis and adenoiditis were described, as well as that of obstructive sleep apnea syndrome, with the aim of understanding these processes better when a decision needs to be taken regarding surgery. The indications and contraindications for tonsillectomy and adenoidectomy are given.

Acute phase reactants are proteins synthesized in the liver that increase their plasma concentration in different infectious or inflammatory processes and which, depending on the level reached -or rather on their presence or absence- would indicate infections of possible bacterial, viral or non-infectious origin, requiring different kinds of treatment. These are described in Table 2 depending on the values reached in each situation. INDICATIONS AND RECOMMENDATIONS FOR TONSILLECTOMY IN INFECTIOUS PROCESES 1. Recurrent tonsillitis The following clinical situations define recurrent tonsillitis - 7 or more episodes of acute tonsillitis a year in the last year, or, - 5 episodes a year in the last 2 years, or, - 3 episodes a year in the last 3 years. - Persistent symptoms for at least 1 year. Each episode should also meet at least one of the following criteria: - Purulent exudate on the tonsils. - A temperature over 38°C. - Anterior cervical lymphadenopathy. - Pharyngeal culture positive for group A betahemolytic streptococcus. These are the minimally acceptable criteria. However, each case should be evaluated individually, weighing up the following factors: - The episodes of tonsillitis are incapacitating and hinder the normal activities of the child. - Adequate treatment was administered during each episode. - The tonsillitis episodes disrupt family life and parents' work. - The child's growth curve does not advance and there is no other reason to explain it. - The episodes of tonsillitis should be documented in the patient's medical file, otherwise, if the medical history is unclear, the patient will need a check-up after 6 months to confirm the clinical pattern and to be able to assess the indication for surgery.

EVALUATION OF DIAGNOSTIC CRITERIA FOR PHARYNGOTONSILLITIS

Pharyngotonsillitis is described as the acute inflammation of the pharynx and/or of the palatine tonsils, which is generally caused by infectious agents, although it can also be caused by non-infectious processes. Around 80% of pharyngotonsillitis cases are due to viral infections, with viral etiology being the most common during infancy. There are a number of symptoms that allow us to opt for one diagnosis or another; these are described in Table 1. It is also important to consider the analytical alterations produced in the processes of tonsillitis that can make it possible to differentiate between streptococcal pharyngotonsillitis and other types of viral pharyngitis.
Fecha de recepción: 15-11-2005 Fecha de aceptación: 3-1-2006

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Recurrent peritonsillar abscess/PTA/Quinsy Two consecutive cases of a peritonsillar abscess are considered to be an indication for surgery3. The considerations for assessing these cases are the same as those described above for recurrent tonsillitis4. in the palate and retropharynx Table 2: Acute phase reactants Streptococcal pharyngitis ASLO It begins to go up a week into the infection from streptococcus.500 High > 60% High > 30 Viral pharyngitis Negative Protein C Leucocytosis/ml Neutrophilia VSG/1st hour <5 <10. SCIENTIFIC EVIDENCE Tonsillectomy is a widely-used procedure for chronic or recurrent acute tonsillitis. .J. OBSTRUCTIVE SLEEP APNEA SYNDROME (OSAS) Definition OSAS is an alteration produced during sleep. . that interrupts normal ventilation during sleep and alters normal sleep patterns6. . There are no controlled studies with random selection that could provide evidence that clinicians could use as a guide for formulating indications for surgery in adults or children5. characterized by a partial and prolonged obstruction of the upper airway and/or by a complete intermittent obstruction (obstructive apnea). Recurrent cervical adenitis is defined as the clinical symptoms mentioned above being repeated with the same frequency as for recurrent tonsillitis. CERVERA ESCARIO ET AL. . It remains raised for more than 6 months.Higher respiratory infection and acute tonsillitis together. 60 .Lasting more than 3 days. High/Elevated > 10 High > 15.No lower respiratory infection. Table 1: Differential epidemiological characteristics of streptococcal and non-streptococcal pharyngitis CAUSAL AGENT Season Age Onset Odynophagia Signs/symptoms Group A beta-hemolytic streptococcus Winter-spring >4 years (4-11 years of age) Sudden Intense Anterior cervical lymphadenopathies Difficulty swallowing Sore throat for at least 3 days General state affected Tonsillar purulent exudate Cephalea/headache Abdominal pain Nasal scabs Absence of cough Temperature over 38°C Pharyngeal culture (+) for SBHG A Exanthema Scarlatiniform Multiple Cough Diarrhea Virus/other bacteria All All Gradual Moderate-slight Lateral and retro cervical adenitis Affectation of multiple mucosas Conjunctivitis Rhinitis Can present tonsillar.A temperature over 38° and general malaise. 2. Recurrent cervical adenitis The following set of symptoms is defined as cervical adenitis: Acute inflammation of multiple cervical adenopathies.7.000 <40% <30 2. pharyngeal exudate.

and respiratory alterations (apnea/hypopnea index) (AHI)13. it might not last all day. Daytime symptoms: Difficulty breathing. craneofacial anomalies. However. which is when the hypertrophy of the lymphoid tissue reaches its greatest size. neuromuscular alterations and Down's Syndrome. the latter being defined as snoring without obstructive apnea. when significant deterioration occurs in social and occupational activities. Pulsoximetry Polysomnography (PSM). frequent arousals or alterations in oxygenation. 61 . but also to determine which children are at risk from complications resulting from the treatment. Somnolence can occur. abnormalities in the gas exchange. obesity. Methods of diagnosis Medical history. • Enuresis. daytime sleepiness and/or somnolence during school activities. Although Primary Snoring is normally considered benign. Physical examination. such as slow development. • Moderate: AHI 21 – 40. Symptoms Night-time symptoms: • Habitual nocturnal snoring • Restless sleep. The peak prevalence is produced between the ages of 2 and 8. 8-12% snore every night8. bed clothes disarranged.9. Also. Anomalies in the gas exchange: • Slight: The average oxygen saturation is equal to or greater than 90% and the minimum oxygen saturation is greater than or equal to 85%. It can be done at any age and is currently the Gold Standard of diagnostic techniques. Brouillette12 conducted oximetry on a group of children with suspected OSAS and compared them with the PSM. of whom. associated with a drop equal to or greater than 4% in oxygen saturation and/or associated with a change in the heartbeat equal to or The risk factors are adenotonsillar hypertrophy. but is more common in adults. It is necessary to distinguish between OSA and Primary Snoring (PS). • Behavioral problems. Nighttime polysomnography is the only diagnostic technique that quantifies ventilatory and sleep anomalies associated with sleep respiratory disorders. In children.INDICATIONS FOR TOSILLECTOMY AND ADENOIDECTOMY Epidemiology OSAS affects 3% of children. • Severe: The average oxygen saturation is less than 90% or the minimum oxygen saturation is less than 70% • Slight: AHI 6 – 20. with arousals during sleep. learning difficulties and cor pulmonale10. • • • • It is necessary to make an exact diagnosis. • Moderate: drowsiness and/or somnolence on a daily basis that occurs while carrying out minimal activity or activities that require a moderate level of attention. it is necessary to carry out a PSM for an accurate diagnosis. • Hyperactivity. Drowsiness and/or somnolence: • Slight: drowsiness and/or somnolence only while the patient is sitting down or carrying out an activity that requires little attention. • Repercussions on physical development affecting the child’s height and weight. OBSTRUCTIVE SLEEP APNEA DURING SLEEP The degree of severity is defined by the most severe degree of the 3 circumstances that are assessed: drowsiness and/or somnolence. Closed rhinolalia. • Periods without respiratory airflow (apnea/hypopnea) lasting more than 5 seconds. not only to be able to treat the patient correctly and to avoid unnecessary treatment (surgical or other). which indicates that if the results are positive. • Ineffective respiratory efforts. • Severe: AHI > 40. PSM can distinguish between OSAS and PS. • A noticeable decline in academic performance. Brouillette found positive predictive values of 97% and negative ones of 47%. • Severe: drowsiness and/or somnolence on a daily basis during work-related activities or tasks that require a lot of attention. Complications: Untreated OSAS can lead to serious complications. • Moderate: The average oxygen saturation is equal to or greater than 90% with the minimum oxygen saturation being greater than or equal to 70%. it has not been properly assessed because most studies on children who snore do not often distinguish between OSA and PS11. oximetry is useful. Nasal voice. Nocturnal oximetry can be useful if it shows a pattern of cyclic desaturations. If the oximetry is negative. • Cor pulmonale in serious cases. the obstruction of the airway in the child during sleep should not only be attributed to the tonsil and adenoid hypertrophy.

Intense hypertrophy causes serious obstruction of nasal breathing and causes Obstructive Sleep Apnea Syndrome (OSA)23. The respiratory state must be assessed. More and more often an association is found between children with allergies and recurrent tonsillitis. it has reached public opinion with pressure of a more or less indirect nature coming from the press. It is necessary to know the family medical history of frequent bleeding or blood diseases. Lower airway diseases. There is no connection between tonsillar disease and middle ear diseases. Tonsillar surgery is usually bloody. criticisms relating to the lack of rationale behind the indications began to appear in the literature.J. (adenoid vegetation). It is necessary to treat the allergic process first as this can change the chances of the infection recurring in the future. professionals have had a lot freedom when explaining why very few studies backed either one of these positions. A contraindication of surgery would also be an alteration in the functioning of the palate: an evident palatine fissure or submucosal lesion. stressed the need to stop carrying out tonsillectomies until some clear scientific criteria verified the benefits of performing the operation. an adenotonsillectomy can produce less satisfactory results. it has been the subject of tremendous debate over time. The result of adenoid hypertrophy is nasal obstruction with retention of secretions. Patients whose episodes of tonsillitis are not clearly documented or confirmed should be excluded from the surgical option. and a AHI equal to or greater than 5. using the same argument. signaling the situations in which tonsillectomy is contraindicated. we can see how much the indications have changed. Carrying out the intervention on patients who have recently had infections is not recommended. literature and government health ministers.and nighttime symptoms15. The presence of hematological pathology is not a contraindication for this surgery. Their hypertrophy is caused by the infection of the adenoid tissue itself or as a consequence of infection in the paranasal structures. learning. EVALUATION OF THE DIAGNOSTIC CRITERIA OF ADENOIDITIS The adenoidal tissue. in particular. 62 . of the nasopharynx and which form part of the Waldeyer's ring. There are even cases of two different professionals maintaining the same line of reasoning. neurological or neuromuscular pathology affecting the functioning of the palate and/or the pharynx. An example is Bolande’s an article entitled “Ritualistic surgery: Circumcision and tonsillectomy”17. Shaikh et al18. The most common and most worrying complication is early and delayed hemorrhaging. moral and economic factors are involved. If we take a look back to different times. and other day. TREATMENT Tonsillectomy and adenoidectomy are the most appropriate forms of treatment for most children who suffer from OSA. difficulty breathing through this airway and the facilitation of local infections. hemoglobin concentrations below 10gm/dl or when the hematocrit is less than 30% must be corrected. We intend to reach an agreement. Adenoids cause disease when they become hypertrophic. and those that significantly reduce changes in behavior. Tables have been established to facilitate the decision whether to perform the intervention or not20. which is why there is no scientific justification for performing it in order to treat these processes22. After that. An adenoidectomy alone may not be enough. and the theories on which the decision is based have changed over the years. should be a contraindication until good respiratory functionality has once again been established21. TONSILLECTOMY CONTRAINDICATIONS Whether to perform a tonsillectomy or not is a difficult decision to make because medical. As a consequence of this. such as asthma that has not been controlled for a long period of time. Later. is made up of small lymphoid structures distributed throughout the posterior wall and roof. but in general. Einhorn19 stated that there was no real indication that justified tonsillectomy. First. Lesser obstructive symptoms produce a great variety of symptoms in children. Neither has this matter been a purely medical/scientific concern. should be considered a severe degree14. but one as an indication and the other as a contraindication. This operation should be avoided in patients with hematological alterations such as anemia or a coagulation affectation. such as mouth breathing with the risk of palatine deformity. At this point. Furthermore. except when the vital situation of the patient means it is not possible to wait (respiratory obstruction). but the aforementioned alterations must be adequately treated. CERVERA ESCARIO ET AL greater than 25%. In obese children. in 1976. it is necessary to wait at least 3 weeks in order to reduce the risk of hemorrhaging. it is the first line of treatment chosen for these patients16.

63 . The CT is sensitive.Craneofacial malformation. According to the consensus report by experts from the Spanish ENT Societies (SEORL) and the Spanish Pediatric Association (AEP)1 and the Tonsillectomy and Adenoidectomy protocol of the Health Technology Assessment Department of the Laín Entralgo Agency of the Comunidad de Madrid. Finally. This ratio expresses the relationship that exists between adenoid size and the nasopharynx. In the bibliography consulted. There are authors who maintain that bacterial infection of the adenoid tissue is the main cause and origin of chronic sinusitis25. in many cases. The diagnosis of adenoid hypertrophy can be made by direct examination. some authors26 propose treatment with antibiotics and anti-inflammatories prior to surgery in unclear cases in order to rule out the possibility of an infectious origin. and difficult to perform on a child. .80 suggestive of adenoid hypertrophy which could benefit from surgery. but it is not always possible to carry out an endoscopy on a child due to a lack of sufficient collaboration. taking into account the aforementioned recommendations and studying and personalizing each clinical case.31. obtained from the lateral skull radiograph as a valid method which adequately correlates with adenoid hypertrophy that produces significant symptoms. The final decision for the adenoidectomy is taken by the ENT doctor. Measuring the adenoid size It is clear that an adenoid hypertrophy that completely obstructs both choanae will benefit from an adenoidectomy. the most recent studies33 have used acoustic rhinometry to measure the cross-sectional nasopharynx area with a good clinical correlation between the data obtained by acoustic rhinometry and adenoid size. but it has a high radiation index. but rather a series of recommendations inspired by scientific bases and supported in the international bibliography and by the experience of different work groups. can cause an obstructive symptom similar to that caused by adenoid hypotrophy26. computed tomography (CT) or magnetic resonance. clinical experience and the surgeon's personality. Now. documented by a lateral cranium x-ray to confirm the adenoidal mass and which makes a marked reduction in the caliber of the airway obvious. halitosis and a predisposition to chronic sinusitis. but. Direct exploration and conventional radiography have low diagnostic sensitivity compared with endoscopy27. chronic otitis media or persistent secretory otitis media.INDICATIONS FOR TOSILLECTOMY AND ADENOIDECTOMY snoring. even acoustic rhinometry has been proposed in the last few years as a non-invasive method for measuring adenoid size33. these two imaging techniques are expensive. However. adenoid hypertrophy and chronic sinusitis have very similar symptoms.Acute recurrent otitis media. lateral radiography of the pharynx. which will depend on the disease. whether visualized by means of fibroscopy or calculated on the basis of Fujioka's AN ratio. which is why they are restricted to special cases. Paradise et al29 use a nasal obstruction index based on clinical data. although not all the findings confirm this hypothesis24. In this way. it is difficult to know which is the main cause of chronic rhinosinusitis24. Other authors defend the use of Fujioka's adenoid to nasopharynx ratio (AN ratio)30. magnetic resonance being preferable in this regard28. However. Treatment for severe adenoidal hypertrophy is surgical (an adenoidectomy). INDICATIONS FOR AN ADENOIDECTOMY There are no strict surgical criteria for performing an adenoidectomy.31 or direct visualization by fibroscopy32. coughing. the ideal method for measuring adenoid size appears to be direct visualization of the nasopharynx by means of fibroscopy32. this means that. Other methods to measure adenoid size include the classic lateral skull radiograph30. with values greater than 0. Other authors believe that inflammation of the nasal mucosa by extension of the sinus inflammation and drainage of its secretions. especially if this occurs in the large space of the middle meatus in which the maxillary and ethmoidal sinuses open. given the overlap with chronic sinusitis. the indications for Adenoidectomy are: 1) Adenoid hypertrophy that causes permanent respiratory insufficiency. To the present day the indication for an adenoidectomy is personal judgment. depending on the degree of mouth breathing and the changes in the voice when the nose is blocked They state that this index provides an important degree of reliability regarding the existence of adenoid hypertrophy.34. either the patient's symptoms are sufficient to be able to diagnose adenoid hypertrophy or other methods are required to measure the size of the adenoids. especially in extreme cases of no obstruction or of marked obstruction. endoscopy. other complementary explorations are avoided in a certain number of children. This surgical indication should be established with most emphasis when the adenoidal hypertrophy coexists with: .

39 who propose carrying out an adenoidectomy on children with recurrent sinus infections before considering endoscopic sinus surgery. 4) Rhinosinusitis.J. According to this same report1. as this reduces the need for future interventions by 50%. Children with scores over 13 in the aforementioned scale present a greater risk of suffering from OSAS associated.Suspected malignant disease 2) Relatives Adenoidal hypertrophy. Adenoidectomy in children under the age of 2 should be used in clinical situations that make it necessary. it is necessary to carefully assess the indication of adenoidectomy and to take precautions in the case of: 1. an adenoidectomy plus myringotomy is recommended (with or without the insertion of tubes). but are clearer in children aged 3 or over and are independent of adenoid size. 3) Secretory otitis media. etc). persistent nighttime snoring. 2. the latest studies conducted do not support this theory and the recommendations of May 2004 from the “Subcommittee on otitis media with effusion”.41. It is true.36 have postulated that a chronic nasal obstruction provoked by adenoidal hypertrophy could be the cause of altered dentofacial growth. ADENOIDECTOMY AND MIDDLE EAR PATHOLOGY The close relationship between the Eustachian tube and the adenoid tissue made us think of the possible benefit that the adenoidectomy would produce in patients with recurrent or chronic pathology in the middle ear: recurrent acute otitis media.Infections 1) Recurrent acute otitis media 2) Chronic otitis media. the American Academy of Pediatrics and the American Academy of Otolaryngology-Head and Neck surgery are clear42: 1) In a child with chronic or recurring problems of the middle ear who we are considering for surgery. formed by members of the American Academy of Family Physicians. The truth is. From our perspective. described in Guilleminault’s clinical scale37. closed rhinolalia). ADENOIDECTOMY AND DENTOFACIAL GROWTH Some authors35. However. 2) Adenoidal infection which. 3) If the child needs a second operation for seromucous otitis. Palatine or uvula deformity as intervention can cause open rhinolalia as a sequela. Therefore. 5) The benefits of adenoidectomy are observed in children aged 2. OSAS. with developmental dentofacial problems. According to these authors. altered dentofacial growth is not per se an indication for adenoidectomy if there is no adenoidal hypertrophy with clinical symptoms of nasal obstruction. There are no clinical criteria or studies that assess an adenoidectomy being performed with the objective of improving the weight/height development of the child.Craneofacial deformity . the child's appetite or treating halitosis. (manifesting as buccal breathing. CERVERA ESCARIO ET AL. Despite this. 64 . the insertion of transtympanic tubes is the ideal preliminary treatment. an adenoidectomy reduces the stasis of secretions in the nostrils and favors sinus ventilation. there are authors38. however. 2) An adenoidectomy should not be performed initially. which causes chronic nasal respiratory insufficiency and that coexists with: . there are no studies which assess this hypothesis and a clear improvement in dentofacial growth following an adenoidectomy is not produced. unless there is a different indication to do so (chronic nasal obstruction. chronic or persistent seromucous otitis.OSA syndrome . even without marked respiratory difficulty. that children with nasal respiratory obstruction usually have some characteristic craniofacial features. 4) A tonsillectomy or myringotomy should not be used in isolation in the treatment of seromucous otitis. numerous patients are referred to the ENT department by the orthodontist for an adenoidectomy. and according to publications made in the last few years29-32. beyond almost any doubt. This led to a number of studies that appeared to show that the adenoidectomy improved the situation of the middle ear in these patients40. adenoidectomy indications can be divided into: 1) Priorities: . has repeated or persistent otic repercussions. persistent bilateral rhinorrhea.Hypertrophy of the adenoids with a clinical history of severe OSAS . nasal respiratory insufficiency. On account of this. ADENOIDECTOMY AND CHRONIC RHINOSINUSITIS The relationship between adenoidal hypertrophy and chronic sinus problems is not very clear.

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