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New Clinical Practice Guideline for Tonsillectomy in Children

Wednesday, January 5th, 2011

The American Academy of Otolaryngology €”Head and Neck Surgery has published a multidisciplinary, evidence-based clinical practice guideline, “Tonsillectomy in Children. ” The new guideline provides evidence-based recommendations on the preoperative, intraoperative, and postoperative care and management of children aged 1 to 18 years under consideration for tonsillectomy and is intended for all clinicians in any setting who care for these patients. This guideline also addresses practice variation in medicine and the significant public health implications of tonsillectomy.

Guideline Summary

  • Most children with frequent throat infection get better on their own; watchful waiting is best for most children with < 7 episodes in the past year, 5 per year in the past 2 years, or 3 per year in the past 3 years. Severe throat infections are those with fever ≥ 101, swollen or tender neck glands, coating on the tonsils, or a positive test for strep throat.
  • Tonsillectomy can improve quality of life and reduce the frequency of severe throat infection when there are at least 7 well-documented episodes in the past year, 5 per year in the past 2 years, or 3 per year in the past 3 years.
  • Children with less frequent or severe throat infections may still benefit from tonsillectomy if there are modifying factors, including antibiotic allergy/intolerance, a history of peritonsillar abscess, or PFAPA syndrome (periodic fever, aphthous stomatitis, pharyngitis, and adenitis).
  • Large tonsils can obstruct breathing at night, causing sleep-disordered breathing (SDB), with snoring, mouth breathing, pauses in breathing, and sometimes sleep apnea. Physicians should ask parents of children with SDB and large tonsils about problems that might improve after tonsillectomy, including growth delay, poor school performance, bedwetting, and behavioral problems. Although most children with SDB improve after tonsillectomy, some children, especially those who are obese or have syndromes affecting the head and neck, may require further management.
  • Physicians should give a single, intravenous dose of dexamethasone during tonsillectomy to reduce pain, nausea, and vomiting after surgery.
  • Physicians should not routinely prescribe antibiotics to improve recovery following tonsillectomy surgery since medical studies show no consistent benefits over placebo and there are associated risks and side effects.
  • Physicians should educate parents about the importance of managing and reassessing pain after tonsillectomy. Strategies include drinking plenty of fluids, using acetaminophen or ibuprofen for pain control, giving pain medicine early and regularly, and encouraging their child to tell them if their throat hurts.

The guideline pertains only to complete tonsillectomy, with or without adenoidectomy, and does not apply to tonsillotomy, intracapsular surgery, or any partial removal of a tonsil.

  1. Baugh RF, Archer SM, Mitchell RB, et al. Clinical practice guideline: tonsillectomy in children. Otolaryngol Head Neck Surg. 2010;144(Suppl 1):S1-S30. Abstract available at: http://oto.sagepub.com/content/144/1_suppl/S1.full. Accessed January 5, 2011.

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