Tonsillectomy and Tympanostomy: Historical Perspectives and Current Guidelines

Transcription

1 Tonsillectomy and Tympanostomy: Historical Perspectives and Current Guidelines Nathan Page, MD Division of Otolaryngology Phoenix Children s Hospital

2 I have no disclosures I do not plan to discuss unapproved or off label use of products

3 History of tonsillectomy Anatomy and physiology Health Care Burden Risks/Costs Guidelines Tympanostomy tubes Anatomy and physiology Guidelines Actually, it s more of a guideline than a rule.

4 Anatomy of the Tonsils and Adenoids

5 Size of the Tonsils

6 What do the tonsils do? Part of secondary immune system Exposed to ingested or inspired antigens passed through the epithelial layer Membrane cells and antigen presenting cells are involved in transport of antigen from the surface to the lymphoid follicle Antigen is presented to T-helper cells T-helper cells induce B cells in germinal center to produce antibody Secretory IgA is primary antibody produced

7 History of Tonsillectomy First description in 30 A.D. by Aulus Cornelius Celsus, a Roman encyclopedist. William Meyer in 1867 adenoidectomy performed through a ring forceps through the nasal cavity 1917 Samuel J. Crowe published his report on 1000 tonsillectomies, and popularized the use of the Crowe-Davis mouth gag and sharp dissection They ought to be disengaged all round by the finger and removed. If they are not separated by this method, it is necessary to take them up with a blunt hook and separate them with a scalpel; then to wash them with vinegar and anoint the wound with a styptic application. - Celsus McNeill RA. A history of tonsillectomy: two millennia of trauma, haemorrhage and controversy. Ulster Med J 1960;29: 59 63

8 The patient should be put in a sitting position toward the sunrise, facing east. The position must be in such a way that the sun s rays fall straight on the tonsils. If that is not possible, a smooth convex branch of myrtle, wrapped with wool, could be used for the straightening. - Paul of Aegina (c. 7 th century AD) Tsoucalas G, et al. Paul of Aegina (c. 7th Century AD): Introducing in the Surgical Operating Theatre of the Era an Innovative Tonsillectomy With a Forceps Under the Sunlight. Surgical Innovation 2016, Vol 23(1)

9 History of Tonsillectomy

10 History of Tonsillectomy

11 Incidence Tonsillectomies in U.S. From , the most common surgical procedure in the U.S. 1959: 1.4 million 1979: 500, : 340, : 287, : 530,000 (under 15yo)

12 Indications Recurrent or chronic tonsillitis Much more common during the teenage years Primary indication from 1950s-1980s Obstructive sleep apnea/sleep disordered breathing Most common age group 2-5 Primary indication from 1990s-2000

13 Microbiology of Tonsillitis

14 Health Care Burden Lower quality of life scores for children with tonsillar disease General health, physical functioning, behavior, bodily pain, caregiver impact Decrease in tonsillectomy rates in Wales correlated with increase in admissions for tonsillitis, peritonsillar abscess, and retropharyngeal abscess. Yap, D., Harris, A., & Clarke, J. (2017). Serious tonsil infections versus tonsillectomy rates in Wales: A 15-year analysis. Annals of The Royal College of Surgeons of England, 99(1),

15 Need for guidelines? Large variations in tonsillectomy between regions and countries Iran patients with recurrent tonsillitis T&A Recommended for Recurrent Tonsillitis Otolaryngologists 167 (84%) 187 (95%) Pediatricians 134 (68%) 162 (82%) T&A Recommended for any indication UK The reasons for the variation appear to be related to differences in local medical practice rather than differences in regional morbidity There appears to be no consistent clinical pathway by which children with recurrent tonsillitis are managed. E.H. Van Den Akker, A.W. Hoes, M.J. Burton, A.G. Schilder, Large international differences in T&A rates, Clin. Otolaryngol. Allied Sci. 29 (2004) A. Faramarzi et al. / International Journal of Pediatric Otorhinolaryngology 74 (2010) Capper R, Canter RJ. Is there agreement among general practitioners, paediatricians, and otolaryngologists about the management of children with recurrent tonsillitis? Clin Otolaryngol Allied Sci Oct; 26 (5):371-8

16 Recurrent Tonsillitis Paradise JL, Bluestone CD, Bachman RZ, et al: Efficacy of tonsillectomy for recurrent throat infection in severely affected children: results of parallel randomized and nonrandomized clinical trials, N Engl J Med. 310: , 1984.

17 Recurrent Tonsillitis Paradise conclusions Tonsillectomy was efficacious for 2 years and possibly a third in reducing frequency and severity of subsequent episodes Paradise criteria adopted by many otolaryngologists

18 Indications Three or more infections a year Tonsillar Hypertrophy Upper airway obstruction Sleep disorders Dental malocclusion Orofacial growth affected Dysphagia Cardiopulmonary complications Peritonsillar abscess (2 or more) Halitosis due to chronic tonsillitis (more than 3 months) Chronic/recurrent tonsillitis with Strep carrier state Unilateral hypertrophy, presumed neoplasm Tonsillar disease refractory to medical therapy American Academy of Otolaryngology-Head and Neck Surgery: 1995 Clinical indicators compendium, Alexandria, Virginia, 1995, American Academy of Otolaryngology-Head and Neck Surgery

19 Recurrent Tonsillitis Paradise JL, et al: Tonsillectomy and Adenotonsillectomy for Recurrent Throat Infection in Moderately Affected Children, Pediatrics 110(1):7, 2002.

20 Recurrent Tonsillitis Surgical criteria not as stringent as those in previous study Incidence of subsequent pharyngitis in surgical groups significantly lower than control group for 3 years postoperatively Overall incidence was low per year Overall, surgical complication risk was high 7.9% (unusually high malignant hyperthermia, intraop hemorrhage requiring packing and ligation, post-op hemorrhage 3.5%, transfusion, allergic rash and throat infection) Conclusion: modest benefit from surgery does not justify the inherent risks, morbidity and cost of surgery

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22 10 statements

23 Recurrent Tonsillitis Criteria 7+ episodes in last 1 year 5+ episodes in last 2 years 3+ episodes in last 3 years Clinical features of each episode Fever (38.5 C) Lymphadenopathy (tender, >2cm) Tonsillar/pharyngeal exudate and erythema Positive ß-hemolytic streptococcus test Medically treated

24 Recurrent Tonsillitis Criteria 7+ episodes in last 1 year 5+ episodes in last 2 years 3+ episodes in last 3 years Clinical features of each episode Fever (38.5 C) Lymphadenopathy (tender, >2cm) Tonsillar/pharyngeal exudate and erythema Positive ß-hemolytic streptococcus test Medically treated Each episode and its qualifying features had been substantiated by contemporaneous notation in a clinical record, OR

25 Recurrent Tonsillitis Criteria 7+ episodes in last 1 year 5+ episodes in last 2 years 3+ episodes in last 3 years Clinical features of each episode Fever (38.5 C) Lymphadenopathy (tender, >2cm) Tonsillar/pharyngeal exudate and erythema Positive ß-hemolytic streptococcus test Medically treated Each episode and its qualifying features had been substantiated by contemporaneous notation in a clinical record, OR If not fully documented, subsequent observance by the clinician of 2 episodes of throat infection with patterns of frequency and clinical features consistent with the initial history

26 Recurrent tonsillitis with modifying factors Antibiotic allergy/intolerance PFAPA History of peritonsillar abscess

27 Sleep-disordered breathing 4. Clinicians should ask caregivers of children with sleep-disordered breathing and tonsil hypertrophy about comorbid conditions that might improve after tonsillectomy, including growth retardation, poor school performance, enuresis, and behavioral problems. 5. Clinicians should counsel caregivers about tonsillectomy as a means to improve health in children with abnormal polysomnography who also have tonsil hypertrophy and sleep-disordered breathing. 6. Clinicians should counsel caregivers and explain that SDB may persist or recur after tonsillectomy and may require further management.

28 Obstructive Sleep Apnea Clinical Practice Guideline: Diagnosis and Management of Childhood Obstructive Sleep Apnea Syndrome AMERICAN ACADEMY OF PEDIATRICS; Section on Pediatric Pulmonology, Subcommittee on Obstructive Sleep Apnea Syndrome Pediatrics 2002;109;

29 Definition OSA - disorder of breathing during sleep characterized by prolonged partial upper airway obstruction and/or intermittent complete obstruction (obstructive apnea) that disrupts normal ventilation during sleep and normal sleep patterns

30 Symptoms Habitual (nightly) snoring (often with intermittent pauses, snorts, or gasps) labored breathing during sleep, observed apnea, diaphoresis, enuresis, cyanosis Disturbed sleep - Restless sleeper Daytime neurobehavioral problems Daytime sleepiness may occur but is uncommon in young children

31 Sequelae of OSA Neurocognitive impairment Behavior problems (hyperactivity, aggression) Poor school performance Enuresis Anxiety/Depression/Somatization Failure to thrive Cor pulmonale in severe cases (very rare now due to the increased awareness)

32 Guideline Recommendations 1. All children should be screened for snoring; 2. Complex high-risk patients should be referred to a specialist; 3. Patients with cardiorespiratory failure cannot await elective evaluation; 4. Diagnostic evaluation is useful in discriminating between primary snoring and OSAS, the gold standard being polysomnography; 5. Adenotonsillectomy is the first line of treatment for most children, and continuous positive airway pressure is an option for those who are not candidates for surgery or do not respond to surgery; 6. High-risk patients should be monitored as inpatients postoperatively; 7. Patients should be reevaluated postoperatively to determine whether additional treatment is required.

33 Guideline Recommendations 1. All children should be screened for snoring; 2. Complex high-risk patients should be referred to a specialist; 3. Patients with cardiorespiratory failure cannot await elective evaluation; 4. Diagnostic evaluation is useful in discriminating between primary snoring and OSAS, the gold standard being polysomnography; 5. Adenotonsillectomy is the first line of treatment for most children, and continuous positive airway pressure is an option for those who are not candidates for surgery or do not respond to surgery; 6. High-risk patients should be monitored as inpatients postoperatively; 7. Patients should be reevaluated postoperatively to determine whether additional treatment is required.

34 Risk Factors for OSA Adenotonsillar hypertrophy Chronic nasal congestion/obstruction Obesity Craniofacial anomalies Neuromuscular disorders Down syndrome

35 Prevalence Most common among pre-school children adenoid and tonsil size largest relative to the size of the upper airway Primary snoring 10-12% OSA 2-3% Boys = Girls Slightly higher in African American children

36 Diagnosis History and Physical Size of the tonsil does NOT correlate well with OSA (plain film does not help for tonsils) Loudness of the snoring does NOT correlate well with OSA OSA most common during REM sleep early in the morning when parents are not watching Obstructive hypoventilation vs. cyclic apneas OSA scoring questionnaires not very successful at predicting OSA

37 Diagnosis Nocturnal polysomnography (sleep study) is currently the gold standard Age-appropriate criteria need to be used Severe shortage of pediatric facilities

38 Diagnosis other methods Audiotape or Videotape Nocturnal pulse oximetry Daytime nap polysomnography Reasonable PPV, but poor NPV when result is positive, it is very helpful

39 What to do in the real world? Rely on parental history Follow-up visit after parental monitoring Review symptoms/signs with parents Treat underlying allergic rhinitis or nasal obstruction Videotapes can help In selective patient, Sleep Study is appropriate Parental request Complicated high risk patients to assess severity and the need for post-op study Patient not a good candidate for T&A

40 PATS Trial Pediatric Adenotonsillectomy for Snoring patstrial.org

41 Perioperative care STRONG RECOMMENDATIONS: 7. Single dose of intraoperative dexamethasone 8. No perioperative antibiotics

42 Postoperative Care 9. The clinician should advocate for pain management after tonsillectomy and educate caregivers about the importance of managing and reassessing pain.

43 Postoperative Care 10. Clinicians who perform tonsillectomy should determine their rate of primary and secondary posttonsillectomy hemorrhage at least annually.

44 Technique

45 Risk for Post-op Complications Age younger than 3 years Severe OSAS on polysomnography Cardiac complications of OSAS (eg, right ventricular hypertrophy) Failure to thrive Obesity Prematurity Recent respiratory infection Craniofacial anomalies* Neuromuscular disorders*

46 Post-op Complications Anesthesia complications Respiratory problems Post-obstructive pulmonary edema Chronic lung disease transient worsening of OSA Pain and poor PO intake dehydration Post-tonsillectomy hemorrhage 1-2%

47 Results from T&A % resolution of symptoms* Additional treatment Weight management result is less optimal in obese children CPAP severe OSA Other surgical procedures in high risk patients tongue reduction, tongue base suspension, maxillomandibular advancement, etc.

48 Adenoidectomy alone? OSA: very small tonsils, but prominent adenoids with significant daytime nasal congestion symptoms Chronic mouth breathing without significant apnea component Chronic otitis media with effusions: adenoidectomy generally at the second set of tubes Recurrent sinusitis Complications: 1:1500 VPI

49 Review Tonsillectomy and Adenoidectomy Gigante Pediatrics in Review.2005; 26:

50 Tympanostomy

51 Tympanostomy - Incidence ,000

52 Diagnose AOM in children with: moderate to severe bulging of the TM OR new onset otorrhea not due to acute otitis externa Mild bulging of TM AND recent (less than 48 hrs) onset of ear pain (holding, tugging, rubbing), or intense erythema of TM Assess pain and recommend treatment to reduce pain Do not diagnose AOM in children who do not have MEE.

53 Treatment Treat with antibiotics: children 6 months and older with unilateral or bilateral AOM and severe signs or symptoms (moderate or severe otalgia for at least 48 hrs OR temp 39C (102.2) or higher Bilateral AOM in children 6 mo 23 mo without severe signs or symptoms (mild otalgia for less than 48 hrs and temp less than 39C Antibiotic therapy OR observation with close follow-up: Unilateral AOM in children 6 mo 23 mo without severe signs of symptoms Unilateral or bilateral AOM in children 24 mo or older without severe signs or symptoms If observing, ensure follow-up and begin antibiotics if child worsens or fails to improve within 48 hrs Clinicians should prescribe amoxicillin for AOM if using abx Use augmentin if amoxicillin in past 30 days, has concurrent purulent conjunctivitis, or history of AOM unresponsive to amoxicillin. Reassess therapy if worsening or no response in hrs

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55 Additional Considerations Do not prescribe prophylactic antibiotics to reduce frequency of AOM. Recommend pneumococcal conjugate vaccine Annual influenza vaccine Encourage avoidance of tobacco smoke

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58 Definitions Otitis media with effusion (OME): presence of fluid in the middle ear without signs of symptoms of acute ear infection Chronic otitis media: OME persisting for 3 months or longer from date of onset or diagnosis Acute otitis media (AOM): Rapid onset of signs and symptoms of inflammation of the middle ear Recurrent AOM: 3 or more welldocumented and separate AOM episodes in the past 6 months OR at least 4 well-documented and separate AOM in the past 12 months with at least 1 in the past 6 months

59 OME Guidelines 1. Document presence of middle ear effusion with pneumatic otoscopy 2. Perform pneumatic otoscopy to assess for OME in a child with otalgia, hearing loss, or both. 3. Obtain tympanometry in children with suspected OME for whom the diagnosis is uncertain after performing (or attemptimg) pneumatic otoscopy 4. Manage OME who are not at risk with watchful waiting for 3 months from onset 5. DO NOT use systemic or intranasal steroids, systemic antibiotics, antihistamines, decongestants, or any combination!

60 2016 Update to 2004 Guidelines: Counsel parents of infants with OME who fail newborn screening regarding the importance of follow-up to ensure that hearing is normal when OME resolves and to exclude underlying SNHL Determine if a child with OME is at risk for speech, language, or learning problems from middle ear effusion because of baseline sensory, physical, cognitive, or behavioral factors Evaluate at-risk children for OME at time of diagnosis of at-risk condition AND at months of age Obtain an age-appropriate hearing test if OME persists for 3 months or longer OR OME of any duration in an at-risk child

61 Who are at risk? Risk factors for developmental difficulties: Permanent hearing loss, independent of otitis media with effusion Suspected of confirmed speech and language delay or disorder Autism-spectrum disorder and other pervasive developmental disorders Syndromes (Trisomy 21) or craniofacial disorders that include cognitive, speech, or language delays Blindness or uncorrectable visual impairment Cleft palate Developmental delay

62 Counsel families with bilateral OME and documented hearing loss about impact on speech and language development Re-evaluate at 3-6 month intervals until OME is not present, hearing loss is identified, or structural abnormalities of eardrum or middle ear are suspected. Tympanostomy tubes should be performed in children less than 4 years of age (No adenoids unless specific indication exists (nasal obstruction, adenoiditis)) In children over 4 years, surgery should include adenoidectomy, tympanostomy tubes, or both.

63 Hearing Loss with MEE Ask Parents: How would you describe your child s hearing? Has he/she misheard words when not looking at you? Has he/she had difficulty hearing when with a group of people? If no/rarely = PASS If often/always=fail

64 Tympanometry

65 BMT Guidelines

66 Tympanostomy tubes Most common ambulatory surgery performed in the US Significantly improves hearing, reduces effusion prevalence, reduce incidence of RAOM (~3 episodes/year), and provides a mechanism for drainage and administration of topical antibiotic therapy, improves QOL, reduced pain with infection Sequelae of ear tubes are common, but typically transient or not clinically signficant: otorrhea, tympanosclerosis, focal atrophy, shallow retraction pocket TM perforations, which may require repair, are seen in about 2% of children

67 COME Guidelines: 1. Clinicians should not perform BMT in children with a single episode of OME of less than 3 month duration 2. Clinicians should obtain an age-appropriate hearing test if OME persists for 3 months or longer OR prior to surgery 3. Clinicians should offer BMT to children with bilateral COME AND documented hearing difficulties. 4. Clinicians may perform BMT in children with unilateral or bilateral COME AND symptoms (balance/vestibular problems, poor school performance, behavioral problems, ear discomfort, or reduced QOL) 5. If you DON T do BMT for COME, reevaluate effusions at 3- to 6- month intervals until effusion is no longer present, significant hearing loss is detected, or structural abnormalities of the TM or middle ear are suspected

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69 RAOM Guidelines Clinicians should not perform BMT for RAOM when children do not have a MEE in either ear at the time of assessment for candidacy. Clinicians should offer BMT to children with RAOM with unilateral or bilateral MEE at time of assessment Clinicians should determine if a child with RAOM or OME of ANY duration is at increased risk for speech, language, or learning problems from OM because of baseline sensory, physical, cognitive, or behavioral factors. Clinicians may perform BMT in at-risk children with unilateral or bilateral OME that is unlikely to resolve quickly, as reflected by type B tympanogram or persistence of effusion

70 Tympanostomy Tube Otorrhea Guidelines: Clinicians should prescribe topical antibiotic eardrops only, without oral antibiotics, for children with uncomplicated acute tympanostomy tube otorrhea Clinicians should NOT encourage routine, prophylactic water precautions (use of earplugs, headbands, avoidance of water sports or swimming) for children with tympanostomy tubes