II. Indications: Paradise Criteria for Tonsillectomy in Children

  1. Frequency Criteria: Minimum number of Pharyngitis episodes
    1. Past 1 year: 7 episodes
    2. Past 2 years: 5 episodes per year for both years
    3. Past 3 years: 3 episodes per year for all three years
  2. Episode Criteria: Each Pharyngitis episode must include at least ONE of the following criteria in addition to Sore Throat
    1. Temperature >100.9 F (38.3 C)
    2. Tender cervical adenopathy or cervical Lymph Nodes >2 cm in size
    3. Tonsillar exudate
    4. Group A Beta Hemolytic Streptococcus Culture positive
  3. Treatment Criteria: Each Pharyngitis episode must have been treated with standard protocol
    1. Antibiotics at conventional dosing for suspected or proven Streptococcal Pharyngitis
  4. Documentation Criteria
    1. Medical record documents each Pharyngitis episode including above criteria or
    2. Observation by clinician for at least 2 subsequent episodes that meet above criteria, typically over a 12 month period

III. Indications: Modifying Factors which may indicate Tonsillectomy (if Paradise criteria not met)

  1. Sleep disordered breathing (e.g. pediatric Sleep Apnea)
    1. Witnessed snoring, apneas or gasping for air
    2. Obstructive Sleep Apnea by Polysomnogram
  2. Difficult management of frequent Pharyngitis
    1. Multiple drug allergies
    2. Intolerance to medications
  3. Complicated Pharyngitis cases
    1. Peritonsillar Abscess
    2. PFAPA Syndrome
  4. Miscellaneous unproven indications
    1. Based on clinical judgement and Informed Consent regarding risks versus benefits
    2. Halitosis
    3. Febrile Seizures
    4. Malocclusion
  5. Tonsillar size is not an indication for surgery
    1. Exception: Related complication such as sleep disordered breathing
    2. Size diminishes naturally in early adolescence

IV. Management: Postoperative bleeding from Tonsillectomy

  1. Typically occurs at day 5-7 (up to day 10) after Tonsillectomy
    1. Related to sloughing of eschar (Fibrin clot)
    2. Occurs in 2-7% of post-Tonsillectomy cases
      1. Newer intracapsular techniques have bleeding rates <1%
    3. Of those with mild Tonsillar bleeding, 40% may go on to have major bleeding in next 24 hours
      1. Teenagers and adults are more likely than younger children to require surgical intervention
  2. Secure airway if needed
    1. See Advanced Airway
  3. Consider gargled Tranexamic Acid (TXA) 5% Mouthwash
    1. https://rebelem.com/topical-tranexamic-acid-epistaxis-oral-bleeds/
    2. Prepare Tranexamic Acid (TXA) 5% Mouthwash
      1. Tranexamic Acid (TXA) is available in 1000 mg/10 ml vials that contain 10 ml
      2. Prepare 2 small cups each of 5 ml TXA (500 mg) and 5 ml cold water (10 ml of diluted TXA per cup)
      3. Alternatively a 500 mg TXA tablet may be dissolved in 10-15 ml water
    3. Have patient gargle 10 ml for 1-2 minutes and then gently spit out solution
    4. May repeat again in 10-15 minutes
  4. Consider nebulized Tranexamic Acid (TXA)
    1. Nebulize 500 mg (children) or 1000 mg adults (case reports)
    2. Hankerson (2015) J Palliat Med 18(12): 1060-2 [PubMed]
  5. Consider Nebulized racemic epinephrine
    1. May Vasoconstrict Tonsillar region vessels
    2. Anecdotally, Tranexamic Acid may be more effective
  6. Local Bleeding Control
    1. Insert bite block
    2. Anesthetize area (cetacaine or atomized Lidocaine via MADD)
    3. Apply pressure with finger to bleeding site
    4. Apply Tranexamic Acid or Epinephrine soaked gauze directly against bleeding site with McGill forceps
    5. Inject Epinephrine into bleeding site
  7. Disposition
    1. Bleeding continues
      1. Transfer emergently to otolaryngology
      2. Secure airway as needed
      3. Replace Blood Products as needed
    2. Bleeding stops
      1. Consult otolaryngology
      2. Typically transfer to otolaryngology for evaluation, management and observation

V. Management: Postoperative Pain

  1. Liquid Analgesics
    1. Ibuprofen 10 mg/kg up to 600 mg orally every 6 hours
      1. Does NOT appear to increase Hemorrhage risk and very effective for postoperative pain
      2. However, unlike Ibuprofen, Toradol does increase Hemorrhage risk (esp. in age >18 years old, see below)
    2. Acetaminophen 15 mg/kg up to 650 mg orally every 6 hours
    3. Oxycodone or Morphine for breakthrough pain
      1. Risk of apnea in patients with history of Obstructive Sleep Apnea (Brainstem tolerance for CO2 retention)
  2. Other measures
    1. Maluka honey lozenges or popsicles (OTC)
    2. Dexamethasone
      1. Dexamethasone 0.5 mg/kg (up to 10 mg) scheduled on day 3 post-operatively (consider repeat dose on day 5)
      2. Greenwell (2021) Otolaryngol Head Neck Surg 165(1):83-8 +PMID: 33228459 [PubMed]
  3. Emergency department
    1. Consider Dexamethasone if not already dosed (see above)
    2. Intravenous Fluids
    3. Avoid Toradol
      1. Unlike Ibuprofen, Toradol increases the risk of Hemorrhage up to 5-fold (esp. in age >18 years old)
      2. Mixed results in study
        1. Rabbani (2020) Int J Pediatr Otorhinolaryngol 138:110341 +PMID: 32891944 [PubMed]
        2. Chan (2014) Laryngoscope 124(8):1789-93 +PMID: 24338331 [PubMed]

VII. References

  1. Claudius, Behar and Hofmann, Santillanes, Bowman in Herbert (1018) EM:Rap 18(6):13-4
  2. Claudius, Behar and Stoner in Herbert (2015) EM:Rap 15(11):2-3
  3. Wiedermann (2024) Mayo Clinic Pediatric Days, attended lecture 1/18/2024
  4. Baugh (2011) Otolaryngol Head Neck Surg 144(1): S1-S30 [PubMed]
  5. Randel (2011) Am Fam Physician 84(5): 566-73 [PubMed]

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