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 Martn**, J. A. Gmez Campder**, J. R. Gras Albert*, B. Prez Piero*, 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 38C. - 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 recepcin: 15-11-2005 Fecha de aceptacin: 3-1-2006

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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 38C 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, pharyngeal exudate, 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. It remains raised for more than 6 months. High/Elevated > 10 High > 15,500 High > 60% High > 30 Viral pharyngitis Negative

Protein C Leucocytosis/ml Neutrophilia VSG/1st hour

<5 <10,000 <40% <30

2. Recurrent peritonsillar abscess/PTA/Quinsy Two consecutive cases of a peritonsillar abscess are considered to be an indication for surgery3. 2. Recurrent cervical adenitis The following set of symptoms is defined as cervical adenitis: Acute inflammation of multiple cervical adenopathies. - A temperature over 38 and general malaise. - Lasting more than 3 days. - No lower respiratory infection. - Higher respiratory infection and acute tonsillitis together. Recurrent cervical adenitis is defined as the clinical symptoms mentioned above being repeated with the same frequency as for recurrent tonsillitis. The considerations for assessing these cases are the same as those described above for recurrent tonsillitis4.

SCIENTIFIC EVIDENCE Tonsillectomy is a widely-used procedure for chronic or recurrent acute tonsillitis. 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. OBSTRUCTIVE SLEEP APNEA SYNDROME (OSAS) Definition OSAS is an alteration produced during sleep, characterized by a partial and prolonged obstruction of the upper airway and/or by a complete intermittent obstruction (obstructive apnea), that interrupts normal ventilation during sleep and alters normal sleep patterns6,7.

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Epidemiology OSAS affects 3% of children, of whom, 8-12% snore every night8,9. The peak prevalence is produced between the ages of 2 and 8, which is when the hypertrophy of the lymphoid tissue reaches its greatest size. However, the obstruction of the airway in the child during sleep should not only be attributed to the tonsil and adenoid hypertrophy. Complications: Untreated OSAS can lead to serious complications, such as slow development, learning difficulties and cor pulmonale10. Symptoms Night-time symptoms: Habitual nocturnal snoring Restless sleep, bed clothes disarranged. Ineffective respiratory efforts, with arousals during sleep. Periods without respiratory airflow (apnea/hypopnea) lasting more than 5 seconds. Enuresis. Daytime symptoms: Difficulty breathing. Closed rhinolalia. Nasal voice. Somnolence can occur, but is more common in adults. Hyperactivity. Repercussions on physical development affecting the childs height and weight. A noticeable decline in academic performance. Behavioral problems. Cor pulmonale in serious cases.

It is necessary to make an exact diagnosis, not only to be able to treat the patient correctly and to avoid unnecessary treatment (surgical or other), but also to determine which children are at risk from complications resulting from the treatment. Nighttime polysomnography is the only diagnostic technique that quantifies ventilatory and sleep anomalies associated with sleep respiratory disorders. It can be done at any age and is currently the Gold Standard of diagnostic techniques. PSM can distinguish between OSAS and PS. Nocturnal oximetry can be useful if it shows a pattern of cyclic desaturations, Brouillette12 conducted oximetry on a group of children with suspected OSAS and compared them with the PSM. Brouillette found positive predictive values of 97% and negative ones of 47%, which indicates that if the results are positive, oximetry is useful. If the oximetry is negative, it is necessary to carry out a PSM for an accurate diagnosis. 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, abnormalities in the gas exchange, and respiratory alterations (apnea/hypopnea index) (AHI)13. 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, it might not last all day. 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. Severe: drowsiness and/or somnolence on a daily basis during work-related activities or tasks that require a lot of attention. Also, when significant deterioration occurs in social and occupational activities. 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%. Moderate: The average oxygen saturation is equal to or greater than 90% with the minimum oxygen saturation being greater than or equal to 70%. Severe: The average oxygen saturation is less than 90% or the minimum oxygen saturation is less than 70% Slight: AHI 6 20. Moderate: AHI 21 40. Severe: AHI > 40. In children, daytime sleepiness and/or somnolence during school activities, 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, obesity, craneofacial anomalies, neuromuscular alterations and Down's Syndrome. It is necessary to distinguish between OSA and Primary Snoring (PS), the latter being defined as snoring without obstructive apnea, frequent arousals or alterations in oxygenation. Although Primary Snoring is normally considered benign, it has not been properly assessed because most studies on children who snore do not often distinguish between OSA and PS11. Methods of diagnosis Medical history. Physical examination. Pulsoximetry Polysomnography (PSM).

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greater than 25%, and a AHI equal to or greater than 5, should be considered a severe degree14. TREATMENT Tonsillectomy and adenoidectomy are the most appropriate forms of treatment for most children who suffer from OSA, and those that significantly reduce changes in behavior, learning, and other day- and nighttime symptoms15. An adenoidectomy alone may not be enough. In obese children, an adenotonsillectomy can produce less satisfactory results, but in general, it is the first line of treatment chosen for these patients16. TONSILLECTOMY CONTRAINDICATIONS Whether to perform a tonsillectomy or not is a difficult decision to make because medical, moral and economic factors are involved. Furthermore, it has been the subject of tremendous debate over time, and the theories on which the decision is based have changed over the years. Neither has this matter been a purely medical/scientific concern; it has reached public opinion with pressure of a more or less indirect nature coming from the press, literature and government health ministers. If we take a look back to different times, we can see how much the indications have changed. There are even cases of two different professionals maintaining the same line of reasoning, using the same argument, but one as an indication and the other as a contraindication. As a consequence of this, professionals have had a lot freedom when explaining why very few studies backed either one of these positions. At this point, criticisms relating to the lack of rationale behind the indications began to appear in the literature. An example is Bolandes an article entitled Ritualistic surgery: Circumcision and tonsillectomy17. Later, in 1976, Shaikh et al18, stressed the need to stop carrying out tonsillectomies until some clear scientific criteria verified the benefits of performing the operation. After that, Einhorn19 stated that there was no real indication that justified tonsillectomy. Tables have been established to facilitate the decision whether to perform the intervention or not20. We intend to reach an agreement, signaling the situations in which tonsillectomy is contraindicated. Patients whose episodes of tonsillitis are not clearly documented or confirmed should be excluded from the surgical option. A contraindication of surgery would also be an alteration in the functioning of the palate: an evident palatine fissure or submucosal lesion, neurological or

neuromuscular pathology affecting the functioning of the palate and/or the pharynx. Tonsillar surgery is usually bloody. The most common and most worrying complication is early and delayed hemorrhaging. This operation should be avoided in patients with hematological alterations such as anemia or a coagulation affectation. First, hemoglobin concentrations below 10gm/dl or when the hematocrit is less than 30% must be corrected. It is necessary to know the family medical history of frequent bleeding or blood diseases. The presence of hematological pathology is not a contraindication for this surgery, but the aforementioned alterations must be adequately treated. The respiratory state must be assessed. Lower airway diseases, such as asthma that has not been controlled for a long period of time, should be a contraindication until good respiratory functionality has once again been established21. Carrying out the intervention on patients who have recently had infections is not recommended; it is necessary to wait at least 3 weeks in order to reduce the risk of hemorrhaging, except when the vital situation of the patient means it is not possible to wait (respiratory obstruction). There is no connection between tonsillar disease and middle ear diseases, which is why there is no scientific justification for performing it in order to treat these processes22. More and more often an association is found between children with allergies and recurrent tonsillitis. It is necessary to treat the allergic process first as this can change the chances of the infection recurring in the future. EVALUATION OF THE DIAGNOSTIC CRITERIA OF ADENOIDITIS The adenoidal tissue, (adenoid vegetation), is made up of small lymphoid structures distributed throughout the posterior wall and roof, in particular, of the nasopharynx and which form part of the Waldeyer's ring. Adenoids cause disease when they become hypertrophic. Their hypertrophy is caused by the infection of the adenoid tissue itself or as a consequence of infection in the paranasal structures. The result of adenoid hypertrophy is nasal obstruction with retention of secretions, difficulty breathing through this airway and the facilitation of local infections. Intense hypertrophy causes serious obstruction of nasal breathing and causes Obstructive Sleep Apnea Syndrome (OSA)23. Lesser obstructive symptoms produce a great variety of symptoms in children, such as mouth breathing with the risk of palatine deformity,

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snoring, coughing, halitosis and a predisposition to chronic sinusitis. However, adenoid hypertrophy and chronic sinusitis have very similar symptoms; this means that, in many cases, it is difficult to know which is the main cause of chronic rhinosinusitis24. There are authors who maintain that bacterial infection of the adenoid tissue is the main cause and origin of chronic sinusitis25, although not all the findings confirm this hypothesis24. 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, can cause an obstructive symptom similar to that caused by adenoid hypotrophy26. The diagnosis of adenoid hypertrophy can be made by direct examination, lateral radiography of the pharynx, endoscopy, computed tomography (CT) or magnetic resonance. Direct exploration and conventional radiography have low diagnostic sensitivity compared with endoscopy27, but it is not always possible to carry out an endoscopy on a child due to a lack of sufficient collaboration. The CT is sensitive, but it has a high radiation index, magnetic resonance being preferable in this regard28. However, these two imaging techniques are expensive, and difficult to perform on a child, which is why they are restricted to special cases. Measuring the adenoid size It is clear that an adenoid hypertrophy that completely obstructs both choanae will benefit from an adenoidectomy. Now, 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. Paradise et al29 use a nasal obstruction index based on clinical data, 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, especially in extreme cases of no obstruction or of marked obstruction. In this way, other complementary explorations are avoided in a certain number of children. Other methods to measure adenoid size include the classic lateral skull radiograph30,31 or direct visualization by fibroscopy32, even acoustic rhinometry has been proposed in the last few years as a non-invasive method for measuring adenoid size33. In the bibliography consulted, the ideal method for measuring adenoid size appears to be direct visualization of the nasopharynx by means of fibroscopy32,34.

Other authors defend the use of Fujioka's adenoid to nasopharynx ratio (AN ratio)30,31, obtained from the lateral skull radiograph as a valid method which adequately correlates with adenoid hypertrophy that produces significant symptoms. This ratio expresses the relationship that exists between adenoid size and the nasopharynx, with values greater than 0.80 suggestive of adenoid hypertrophy which could benefit from surgery. Finally, 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, whether visualized by means of fibroscopy or calculated on the basis of Fujioka's AN ratio. Treatment for severe adenoidal hypertrophy is surgical (an adenoidectomy), but, given the overlap with chronic sinusitis, 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. INDICATIONS FOR AN ADENOIDECTOMY There are no strict surgical criteria for performing an adenoidectomy, but rather a series of recommendations inspired by scientific bases and supported in the international bibliography and by the experience of different work groups. To the present day the indication for an adenoidectomy is personal judgment, which will depend on the disease, clinical experience and the surgeon's personality. The final decision for the adenoidectomy is taken by the ENT doctor, taking into account the aforementioned recommendations and studying and personalizing each clinical case. 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 Lan Entralgo Agency of the Comunidad de Madrid, the indications for Adenoidectomy are: 1) Adenoid hypertrophy that causes permanent respiratory insufficiency, 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. This surgical indication should be established with most emphasis when the adenoidal hypertrophy coexists with: - Craneofacial malformation. - Acute recurrent otitis media, chronic otitis media or persistent secretory otitis media.

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2) Adenoidal infection which, even without marked respiratory difficulty, has repeated or persistent otic repercussions. According to this same report1, it is necessary to carefully assess the indication of adenoidectomy and to take precautions in the case of: 1. Palatine or uvula deformity as intervention can cause open rhinolalia as a sequela. 2. Adenoidectomy in children under the age of 2 should be used in clinical situations that make it necessary. From our perspective, and according to publications made in the last few years29-32, adenoidectomy indications can be divided into: 1) Priorities: - Hypertrophy of the adenoids with a clinical history of severe OSAS - Suspected malignant disease 2) Relatives Adenoidal hypertrophy, (manifesting as buccal breathing, persistent nighttime snoring, persistent bilateral rhinorrhea, nasal respiratory insufficiency, closed rhinolalia), which causes chronic nasal respiratory insufficiency and that coexists with: - OSA syndrome - Craneofacial deformity - Infections 1) Recurrent acute otitis media 2) Chronic otitis media. 3) Secretory otitis media. 4) Rhinosinusitis. 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, the child's appetite or treating halitosis. ADENOIDECTOMY AND DENTOFACIAL GROWTH Some authors35,36 have postulated that a chronic nasal obstruction provoked by adenoidal hypertrophy could be the cause of altered dentofacial growth. On account of this, numerous patients are referred to the ENT department by the orthodontist for an adenoidectomy. The truth is, there are no studies which assess this hypothesis and a clear improvement in dentofacial growth following an adenoidectomy is not produced. It is true, however, that children with nasal respiratory obstruction usually have some characteristic craniofacial features, described in Guilleminaults clinical scale37. Children with scores over 13 in the aforementioned scale present a greater risk of suffering from OSAS

associated, beyond almost any doubt, with developmental dentofacial problems. Therefore, altered dentofacial growth is not per se an indication for adenoidectomy if there is no adenoidal hypertrophy with clinical symptoms of nasal obstruction. ADENOIDECTOMY AND CHRONIC RHINOSINUSITIS The relationship between adenoidal hypertrophy and chronic sinus problems is not very clear. Despite this, there are authors38,39 who propose carrying out an adenoidectomy on children with recurrent sinus infections before considering endoscopic sinus surgery. According to these authors, an adenoidectomy reduces the stasis of secretions in the nostrils and favors sinus ventilation. 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, chronic or persistent seromucous otitis. This led to a number of studies that appeared to show that the adenoidectomy improved the situation of the middle ear in these patients40,41. However, the latest studies conducted do not support this theory and the recommendations of May 2004 from the Subcommittee on otitis media with effusion, formed by members of the American Academy of Family Physicians, 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, the insertion of transtympanic tubes is the ideal preliminary treatment. 2) An adenoidectomy should not be performed initially, unless there is a different indication to do so (chronic nasal obstruction, OSAS, etc). 3) If the child needs a second operation for seromucous otitis, an adenoidectomy plus myringotomy is recommended (with or without the insertion of tubes), as this reduces the need for future interventions by 50%. 4) A tonsillectomy or myringotomy should not be used in isolation in the treatment of seromucous otitis. 5) The benefits of adenoidectomy are observed in children aged 2, but are clearer in children aged 3 or over and are independent of adenoid size.

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