What are the recent guidelines for adenotonsillectomy that I should be aware of?

Recent Guidelines on Adenotonsillectomy

The 2019 American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS) Clinical Practice Guideline for tonsillectomy in children provides the most comprehensive and recent evidence-based recommendations for adenotonsillectomy management, with specific criteria for surgical indications, perioperative care, and postoperative monitoring to reduce morbidity and mortality.

Indications for Adenotonsillectomy

Recurrent Throat Infections

• Tonsillectomy may be recommended for recurrent throat infections with:
  • At least 7 episodes in the past year, OR
  • At least 5 episodes per year for 2 years, OR
  • At least 3 episodes per year for 3 years 1
• Each episode must be documented with:
  • Temperature ≥38.3°C (101°F)
  • Cervical adenopathy
  • Tonsillar exudate
  • Positive test for group A beta-hemolytic streptococcus 1

Obstructive Sleep-Disordered Breathing (oSDB)

• Strong recommendation for tonsillectomy in children with obstructive sleep apnea documented by polysomnography 1
• Clinicians should assess for comorbid conditions that may improve after tonsillectomy:
  • Growth retardation
  • Poor school performance
  • Enuresis
  • Asthma
  • Behavioral problems 1

Preoperative Evaluation

Polysomnography Recommendations

• Mandatory polysomnography referral before tonsillectomy for children with oSDB who:

  • Are <2 years of age
  • Have obesity
  • Have Down syndrome
  • Have craniofacial abnormalities
  • Have neuromuscular disorders
  • Have sickle cell disease
  • Have mucopolysaccharidoses 1

• Polysomnography should be advocated for children with oSDB when:

  • Need for tonsillectomy is uncertain
  • Discordance exists between physical examination and reported severity 1

Special Populations

• Children with sickle cell disease:
  • Require pre-operative transfusion as per standard guidance
  • Need special attention for those with high transcranial Doppler flows (stroke risk)
  • May need nasopharyngeal airway placement during surgery 1

Perioperative Management

Medication Recommendations

• Strong recommendation for a single intraoperative dose of intravenous dexamethasone (0.5 mg/kg) to reduce pain and postoperative nausea 1, 2
• Strong recommendation against routine perioperative antibiotics 1
• Strong recommendation against codeine or any medication containing codeine after tonsillectomy in children younger than 12 years 1
• Postoperative pain management should include:
  • Ibuprofen and acetaminophen without routine use of opiates 1
  • Pre-operative or intra-operative administration continued postoperatively 2

Postoperative Care

Monitoring Requirements

• Arrange for overnight inpatient monitoring for children who are:
  • <3 years old
  • Have severe OSA (AHI ≥10 obstructive events/hour)
  • Have oxygen saturation nadir <80% 1

Bleeding Assessment

• Clinicians should:
  • Follow up with patients/caregivers after tonsillectomy
  • Document presence/absence of bleeding within 24 hours (primary bleeding)
  • Document bleeding occurring later than 24 hours (secondary bleeding)
  • Determine their rate of primary and secondary post-tonsillectomy bleeding at least annually 1

Patient Education

• Counsel patients and caregivers that:
  • oSDB may persist or recur after tonsillectomy and may require further management
  • Postoperative pain management is crucial and requires anticipation, reassessment, and adequate treatment 1

Potential Complications

Common Complications

• Postoperative hemorrhage (primary and secondary)
• Pain, otalgia, fever, dehydration
• Velopharyngeal incompetence
• Airway risks and aspiration 3, 4

Rare Complications

• Atlantoaxial subluxation (Grisel syndrome)
• Nasopharyngeal stenosis
• Taste disorders
• Persistent neck pain (Eagle syndrome) 3, 4

Special Considerations

High-Risk Patients

• Children with hematologic disorders require:
  • Proper preoperative screening
  • Specialized perioperative management 5
• Children with Prader-Willi syndrome:
  • Higher risk of postoperative residual OSA
  • Higher complication rates 6

Quality Improvement Opportunities

• Implement shared decision-making with patients/caregivers
• Document outcomes assessment for bleeding
• Avoid routine use of antibiotics and codeine
• Ensure appropriate pain management strategies 1

The 2019 AAO-HNS guideline represents a significant update from the 2011 version, with seven new key action statements and modifications to five existing statements, reflecting the evolution of evidence-based practice in adenotonsillectomy management 1.