Mr Elliot Benjamin BSc (Hons) MBChB (Hons) DLO FRCS (Orl-HNS) is an ear nose and throat surgeon at Bupa Cromwell Hospital, Charing Cross Hospital and Chelsea and Westminster Hospital.
Tonsils have been removed since antiquity; the operation has been reported in books of Hindu medicine as early as 1000BC and the first surgeon attributed to have performed the procedure was Aulus Cornelius Celsus in 25AD who used his finger nail and a hook to dissect the tonsil!!
The ancient indications for tonsillectomy are reported by West1 ; “When the phlegm and blood are deranged in the soft palate and tonsils, they become large and like a full bladder, accompanied with thirst, cough and difficulty in breathing.” This highlights the two main indications we have today - recurrent tonsillitis and obstructive sleep apnoea.
A five year old comes in to your surgery; mum reports that Chloe cannot breathe at night, she “snores like an old man” and then actually holds her breath. Mum has got so worried that Chloe now sleeps in bed with her. She tosses and turns all night long, sweats and often wets the bed.
Another mum comes to see you, yet again. It is now the fifth time in six months that Oliver has been off school with a high temperature, unable to eat or drink with “golf ball tonsils” in the back of his throat. Yet another course of antibiotics has been requested.
The debate for the justification of adenotonsillectomy has never been greater. In this world of commissioning and PPwt (planned procedures with a Threshold) we must justify the fulfilment of criteria before considering surgery on these children. I would hope that all surgeons carefully consider indications prior to embarking on any surgery.
Recurrent tonsillitis - remove or not?
This debate has been faught long and hard over the years and centres on various studies with differing definitions of severity, frequency of sore throat and tonsillitis symptoms. The general accepted opinion with strong evidence to support tonsillectomy is in children with clear documented episodes of tonsillitis; seven times in one year, five times per year over two years or three times a year over three year. This clearly defines a recurrent acute condition with implications for general health, time off school and more general health economic considerations or multiple consultations - medications, parents’ time off work etc.
In 1994-95 some 77,600 tonsillectomies were carried out in the UK. By 2009 this had dropped by 37% to 49,000. In 2000-01, there were 30,942 tonsil-related admissions for emergency medical treatment. By 2008-09, the figure had risen to 43,641, an increase of over 41% in eight years. The economic impact of tonsillitis is considerable. Overall, 35m days are lost from school or work each year due to sore throats in the UK. GP consultations for sore throats cost around £60m per year.
As with all conditions there may be other factors that one may need to take into account which will alter the indications for surgery, such as tonsillitis leading to nephritis, reactive arthritis, and failure to thrive. The case for surgery for chronic sore throats, tonsil “stones” and halitosis - is far harder to justify.
The sleep apnoea debate:
In the United States Obstructive Sleep Apnoea has become the most common indication for adenotonsillectomy. Children like Oliver are regularly seen and the prevalence is somewhere between 1% and 5%. There is a spectrum of symptoms going from simple heavy snoring (with no associated alteration in quality of sleep) to full Obstructive Sleep Apnoea. An intermediate status is also described of UARS - Upper Airway Resistance Syndrome - with less severe and less frequent apnoeic episodes. Children can move along this spectrum of severity, varying with age, obesity and presence of upper respiratory tract infections. The effects of long term and persistent apnoeic episodes are clear; the combination of hypoxaemia, hypercapnea, prolonged respiratory muscle effort all lead to cognitive and neuropsychological deficits. In very severe cases (which are rare) we see pulmonary oedema, pulmonary hypertension and right heart failure.
It should be stressed that a lot of the debate regarding the efficacy of adenotonsillectomy in curing OSA is due to the sometimes multiple factors that may be at play. Obesity can be a large factor; Charles Dickens describes Joe in the Pickwick Papers as a “fat and red faced boy in a state of somnolency”, and it may be likely that an adenotonsillectomy would not have helped him. In Down Syndrome macroglossia maybe be the predominant cause, in other syndromes a neuromuscular deficit or craniofacial abnormality may be a more important consideration than adenotonsilar hypertrophy. What is clear, even from “evidence based” meta analyses, is that adenotonsillectomy has a clear beneficial effect on children with OSA due to large tonsils and adenoids.
So what are the down sides?
As with all surgery one must consider the very small but still real risks of general anaesthesia, especially in small children or with other co-morbidities. Historically the greatest risk and concerns are for post operative bleeding. Only about 2% of children will get some form of post operative bleed, and less than 1% will need further surgery.
One of the most common questions is; “will my child suffer from not having their tonsils and adenoids anymore?”. Whilst it is true that these tissues are part of Waldeyers ring of lymphoid tissue and are responsible for the generation of B cells as part of the immune response, there is no evidence of a raised incidence of upper respiratory tract infections post surgery. In fact the opposite is true, obviously in the case of recurrent tonsillitis but often in the case of sleep apnoea as well.
To remove or not to remove?
The debate will continue and every child must be considered based on their particular symptoms. Meta analyses which include and discount randomised controlled trials will continue to present evidence to support both sides of the argument. What is perfectly clear however is that, almost on a daily basis, we hear parents like Oliver’s and Chloe’s report how their children have become transformed into healthy, responsive, well rested , infection-free children following adenotonsillectomy. This surgical intervention continues to be a useful and justifiable management in the treatment of appropriately selected children.
1. McNeil RA June 1960, A History of Tonsillectomy; Two millenia of Trauma, Ulster Medical Journal 29(1); 59-63.