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by Samuel albert, mD T onSillectoMY iS a common surgical procedure, with more than 500,000 performed on children younger than 15 years old every year in the United States. The most common indications for tonsillectomy in children are sleep-disordered breathing and recurrent tonsillitis. In many cases, the adenoids are removed along with the tonsils. The lingual tonsils anteriorly, the palatine tonsils laterally and the pharyngeal tonsils (adenoids) posterosuperiorly form a ring of lymphoid tissue known as Waldeyer���s Ring. Tonsils and adenoids are predominantly B-cell organs and are involved in inducing secretory immunity and regulating secretory immunoglobulin production. Tonsil infections may be viral or bacterial. Group A streptococcus is the most common bacterial cause of acute pharyngitis with symptoms including throat pain, malaise, fever, odynophagia and headache. The tonsils may appear erythematous, enlarged and may have exudates. The diagnosis of acute tonsillitis is primarily made on clinical grounds. A throat culture is a simple and useful test to verify the diagnosis. Acute tonsillitis is commonly treated with antibiotics. Many children have recurrent episodes of tonsillitis requiring multiple courses of antibiotics. In severe cases, intramuscular or intravenous antibiotics are used. Often, children miss a significant amount of school due to tonsillitis. Today, sleep-disordered breathing is the most common indication for tonsillectomy. Sleep-disordered breathing includes a spectrum of obstructive disorders from primary snoring to obstructive sleep apnea syndrome and is usually associated with adenotonsillar hypertrophy. When the tonsil and adenoid tissue is large, it occupies a significant amount of space in the oropharynx and nasopharynx, which obstructs air flow. Common symptoms that occur during the sleep of children with obstructive sleep apnea syndrome are loud snoring, gasping, drooling, enuresis, mouth-breathing, restless sleep and diaphoresis. During the day, affected children may suffer from daytime sleepiness, morning headache, and behavioral difficulties such as hyperactivity, decreased academic performance and aggressive behavior. Polysomnographic testing can be performed in select children when the diagnosis is in question. Adenotonsillectomy has been shown to be an effective treatment for sleep-disordered breathing in children. Current recommendations for tonsillectomy in children include: children with sleep-disordered breathing, seven episodes of tonsillitis in the past year, five episodes per year for two years, or three episodes per year for three years. Less common indications include asymmetric tonsillar hypertrophy, peritonsillar abscess and tonsillar debris. Tonsillectomy is performed in the operating room under general anesthesia in which the tonsils and adenoids are removed through the mouth. A variety of techniques are currently used to remove tonsils and adenoids. A single dose of intra-operative steroids is recommended. In the vast majority of children, tonsillectomy is an outpatient procedure. But for children with significant sleep apnea, other health problems, who are younger than three years of age, or who live a great distance from the hospital, overnight observation is recommended. Following the procedure, children are discharged home on oral narcotic pain medications. Acetaminophen is used for mild pain, and a soft diet and light activity are recommended. Post-operative antibiotics were commonly prescribed in the past; however, the current guidelines do not recommend postoperative antibiotics. Potential post-operative complications after tonsillectomy include nausea, vomiting, pain and dehydration. Hemorrhage after tonsillectomy occurs in 2% to 3% of children and may result in readmission to the hospital or further surgery to control bleeding. Tonsillectomy is a very effective treatment for children with recurrent tonsillitis and sleep-disordered breathing. Using the recommended guidelines, tonsillectomy should continue to be performed in children who fail medical management. Dr. Samuel Albert is an Ear, Nose and Throat specialist at Akron Children���s Hospital. ��� MarcH -april 2013 ��� MDneWS.coM ��� MD News Cleveland/Akron/Canton | 25