© Borgis - New Medicine 2/2002, s. 61-63
Mieczysław Chmielik, Anna Bielicka, Eliza Brożek
Tonsil operations in children – indications and contradictions
Department of Paediatric Otorhinolaryngology, The Medical University of Warsaw, Poland
Head: prof. Mieczysław Chmielik M.D.
Adenoidectomy, tonsillectomy and tonsillotomy were and still are the most common surgical procedures performed in Paediatric Otorhinolaryngology. The aim of this study is to justify the use of these methods in particular cases, and also specifying the complications that might occur in the postoperative period. The indications for the procedures are divided into definite and relative, while the complications are separated into two groups, early and late. The information given in the text is based on the experience of the Paediatric ENT Clinic of the Medical University of Warsaw, and the available literature.
The tonsil operations include adenotomy, tonsillotomy and tonsillectomy. The term adenotomy describes the removal of the adenoid tissue in the nasopharynx. Tonsillotomy signifies removing the palatine tonsil(s) in part. A type of tonsillotomy is wedge resection of the palatine tonsils. Tonsillectomy is the complete removal of the palatine tonsil(s) with their capsule. Considering the fact that tonsil operations are frequently a child´s first surgical experience, not only is an appropriate qualification for the operation important, but also the necessary preparation, considering coexisting diseases, especially haematological ones. It is necessary to perform these procedures under general anaesthesia in order to protect against blood and clot aspiration into the respiratory tract.
The characteristic symptoms of pharyngeal tonsil hypertrophy are: impaired breathing through the nose, resulting in mouth breathing either in daytime or during the night, snoring, the altered voice known as hyponasal speech, and in significant hypertrophy – the occurrence of sleep apnoea, causing daytime drowsiness in children and anxiety in parents. If the enlarged tonsil causes obstruction of the auditory tube, then it predis-poses to the incidence of otitis media and hearing deterioration. Nasal obstruction and mouth breathing impair physiological functioning of the nose, resulting in recurrent pharyngitis and lower respiratory tract infections. Long-term adenoid hypertrophy leads to anatomical changes of the face, described as "facies adenoidalis” (adenoidal face). This condition manifests by a protruding maxilla, constantly open mouth, lower lip muscle hypotonia, and a high palatine. Adenoid hypertrophy may occur before the first year of age. Nasal obstruction at this age may lead to life-threatening breaks in breathing, especially during upper airway infection. In such cases the age of the child is not a contraindication for adenotomy.
Direct indications for adenotomy are:
– Adenoid hypertrophy resulting in upper airway obturation and constant mouth breathing,
– Sleep apnoea symptoms,
– Adenoid hypertrophy complicated by otitis media with effusion.
Relative indications include situations in which the adenoid hypertrophy is accompanied by recurrent acute otitis media or chronic suppurative otitis media. In the last condition, unblocking the auditory tube by removing the adenoidal tissue is the first stage in preparation for further treatment. Other relative indications are dental malocclusion and orofacial growth abnormalities.
TONSILLECTOMY AND TONSILLOTOMY
More accurate knowledge concerning tonsillar physiology and specifying indications for tonsillectomy have significantly diminished the number of these among children. Only a few such procedures are performed in the Paediatric Otolaryngology Department in Warsaw in any one year. Tonsillotomy is performed if an enlarged palatine tonsil results in obturation of the upper airways. Due to the fact that tonsillectomy has negative aspects, such as influencing certain parameters of immunological response and altering the anatomical conditions in the oral part of the pharynx, this method is more often substituted with tonsillotomy or wedge resection of the palatine tonsils. Its advantage that it is a less radical way of in resecting the lymphoid tissue, which is an important part of the immunological system in a growing organism, and very fast and beneficial results connected with the abatement of obturative symptoms. Consequently, tonsillotomy is an effective and safe operating method. Recent years have shown its growing participation in surgical treatment of the palatine tonsils, and that it is particularly welcome by parents (1). Preserving part of the lymphoid tissue in a child´s body prevents the lack of an important part of the immunological barrier in the developing organism. Additionally, Swedish researchers have shown that tonsillotomy is a less traumatic procedure from the patient´s point of view, i.e. it gives less pain and anxiety (2, 3). Opponents think that scar formation in the crypts after the partial removal of a tonsil increases the risk of focal infection in the tonsils (1). However, papers based on wider material have not supported these suggestions (4).
Considering the above statements, the direct indications for tonsillectomy are:
– Recurrent peritonsillar abscess (at least 2 episodes),
– Suspicion of malignancy,
– The necessity of reaching the retropharyngeal space.
In the case of tonsillotomy, the direct indication is the occurrence of obturative sleep apnoea, while relative indications include the presence of dysphagia or altered speech ("hot potato voice”) in children with palatine tonsil hypertrophy. Obturative sleep apnoea syndrome in children is not a universally defined problem as it is in adults. A simple method of estimating breathing impairment in children is the evaluation of night-time oxygen saturation. Its level should not decrease below 85%. Misdiagnosing the syndrome can lead to the impairment of the child´s development, as excessive breathing effort can result in short stature and poor growth, while chronic sleep disruption and hypoxygenation may contribute to behavioural abnormalities, including poor school performance, irritation, daytime hypersomnolence, learning disabilities, and problems with concentration. Sleep disturbance may also contribute to enuresis and night terrors.
COMPLICATIONS OF TONSIL OPERATIONS IN CHILDREN
Tonsil operations performed in children may be burdened with complications which can be divided into early and late. The early complications include:
– Minor and major bleeding,
– Acute impairment of airway patency,
– Anaesthesia and its complications,
– Wound infection,
– Iatrogenic injury of the uvula and palatine arches, with subsequent scar formation.
The frequency of postoperative bleeding mentioned by different authors ranges between 0.5% and 10% (5). A massive prolonging bleeding can occur directly after the operation, before the child wakes after anaesthesia. Such a situation can occur due to the presence of a bleeding disorder already revealed or not, due to an aberrant descending pharyngeal artery and its injury during the adenotomy (6), blood pressure elevation, or residual tonsil tissue in the nasopharynx. Unfortunately, these procedures are not infrequently connected with revealing a genetic disorder of the haemostatic system. Consequently, all children undergoing surgical treatment should be examined to estimate the number of thrombocytes, bleeding time, kaolin-kephalin time and prothrombin index. These parameters allow estimation of the endo- and exogenous coagulation pathway. Acetylosalicylic acid or ibuprofen should not be administered for two weeks before the operation because of their inhibitory influence on the aggregation of thrombocytes. The risk of bleeding is increased in children operated on during the course of infection or directly after its resolution, and also in allergy aggravation. All these situations are connected with blood vessel dilation, which impedes haemostasis. The risk of bleeding is also higher in excited children. Young children relatively often do not present bleeding directly; it is important to remember that there is a possibility of bleeding when a child swallows often, or presents "coffee-grounds” vomiting. Exacerbated postoperative bleeding can result in anaemia requiring blood transfusion, or even hypovolemic shock.
Acute impairment of airway patency can be connected with soft palate and base of the tongue oedema. In such cases it is obligatory to use an oropharyngeal tube, reintubate a patient, or administer corticosteroids. Wiatrak et al. observed a more frequent incidence of postoperative saturation decrease and transient airway obturation in patients under 3 years of age. Consequently, it is convenient to monitor oxygen saturation and pulse in younger children in the first postoperative hours (7). Acute respiratory failure can occur due to bronchospasm, especially in children with asthma or bronchial hypersensitivity. The safety requirements for these patients include an appropriate preparation for the operation.
Another complication can be dehydration. After an uncomplicated operation, a child is allowed to drink no sooner than in 3-4 hours´ time. In the early postoperative stage, oral fluid supplementation may appear insufficient due to pain and dysphagia. Consequently, it is important to control the fluid intake in the postoperative period and control pain with the administration of appropriate analgesics. In severe cases intravenous fluid supplementation is required. Coexisting vomiting increases the risk of dehydration. Such a situation in the postoperative period may be connected with certain general anaesthetics or with retention of blood in the stomach or further parts of alimentary tract. If bleeding during the operation is severe, it is convenient to insert a stomach tube and aspirate the retained contents before the child´s awakening.
The most common reason for fever or a feverish state in the first postoperative days is infection around the wound or respiratory tract infection.
Bleeding can also occur as a late postoperative complication. It may appear 7-10 days after the operation. Apart from examination of the nasopharynx post adenoidectomy and the site of tonsil post tonsillotomy or tonsillectomy, and control of bleeding, we should repeat examination of the coagulation parameters. An intraoperative bleeding in patients with von Willebrand disease may increase deficits of factor VIII and thrombocyte function disturbances. In clinical practice these deficits may manifest several days later as late bleeding. However, von Willebrand disease does not disqualify a patient from an operation; in these cases an appropriate haematological preparation is recommended. Some authors suggest that administration of desmopressin in the preoperative period in some forms of von Willebrand disease diminishes the risk of bleeding (8). Desmopressin releases von Willebrand factor and its cofactor from tissue reservoirs.
Irritating the posterior nasal wall muscles during thea tonsil operation may cause nuchal rigidity and torticollis. Another late complication a after tonsil operation is palatopharyngeal dysfunction. This problem usually appears in children with an unrecognised palate anomaly, for example with submucosal palatoschisis or with general decreased muscle tone. In these cases speech rehabilitation with a speech therapist usually results in regular muscular occlusion during phonation.
Operations on the tonsils – the most common operations in children – have an important place in medical practice. Therefore an appropriate diagnosis and plan for a child with a tonsillar problem, and individual determination of the indications for operation is very important. If the laryngologist suggests that tonsil removal or tonsil resection is the best method of treatment, then we should remember that preventing postoperative complications begins in the preoperative period (9). This can be accomplished through an accurate anamnesis concerning perinatal period, coexisting diseases, and tendency to prolonged bleedings.
1. Jordan J. et al.: Trendy w operacjach migdałków u dzieci. Nowa Pediatria 1999, 17(6):93-4. 2. Densert O, Desai H, Eliasson A. et al.: Tonsillotomy in children with tonsillar hypertrophy. Acta Otolaryngol 2001, 121(7):854-8. 3. Hultcrantz E. et al.: Tonsillectomy or tonsillotomy? – A randomized study comparing postoperative pain and long-term effects. Int. J. Pediatr. Otorhinolaryngol. 1999, 51(3):171-6. 4. Chmielik M. et al.: Tonsillotomia a występowanie ropni okołomigdałkowych. Otolaryng. Pol., 1995, 53 (30):295-297. 5. Rak J. i wsp.: Częściowa resekcja migdałków – tonsylotomia; analiza wskazań i ocena wyników leczenia tą metodą dzieci w Klinice Laryngologicznej Akademii Medycznej we Wrocławiu w okresie od 1989-1998. N. Ped. 1999, 17(6):152-6. 6. Windfuhr J.P.: An aberrant artery as a cause of massive bleeding following adenoidectomy. J. Laryngol. Otol. 2002, 116(4):299-300. 7. Wiatrak B.J. et al.: Complications of adenotonsillectomy in children under 3 years of age. Am. J. Otolaryngol. 1991, 12(3):170-2. 8. Allen G.C. et al.: Adenotonsillectomy in children with von Willebrand disease. Arch. Otolaryngol. Head Neck Surg. 1999, 125(5):547-51. 9. Bolger W.E. et al.: Preoperative hemostatic assessment of the adenotonsillectomy patient. Otolaryngol. Head Neck Surg. 1990, 103(3):396-405. 10. Kossowska E.: Otolaryngologia wieku rozwojowego. Warszawa, PZWL 1979.