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)
  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. Of those with mild Tonsillar bleeding, 40% may go on to have major bleeding in next 24 hours
    3. Occurs in 2-7% of post-Tonsillectomy cases
  2. Secure airway if needed
    1. See Advanced Airway
  3. Consider nebulized Tranexamic Acid
    1. Nebulize 500 mg (children) or 1000 mg adults (case reports)
    2. Hankerson (2015) J Palliat Med 18(12): 1060-2 [PubMed]
  4. Consider Nebulized racemic epinephrine
    1. May Vasoconstrict Tonsillar region vessels
    2. Anecdotally, Tranexamic Acid may be more effective
  5. 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
  6. 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. Resources

  1. Clinical Practice Guideline for Tonsillectomy in Children
    1. http://oto.sagepub.com/content/144/1_suppl/S1.long

VI. 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. Baugh (2011) Otolaryngol Head Neck Surg 144(1): S1-S30 [PubMed]
  4. Randel (2011) Am Fam Physician 84(5): 566-73 [PubMed]

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Ontology: Tonsillectomy (C0040423)

Definition (MSHCZE) Chirurgické odstranění krčních (patrových) mandlí nebo mandle. (Dorland, 28th ed)
Definition (NCI) Surgical removal of the tonsils.
Definition (MSH) Surgical removal of a tonsil or tonsils. (Dorland, 28th ed)
Concepts Therapeutic or Preventive Procedure (T061)
MSH D014068
ICD9 28.2
ICD10 41789-00
SnomedCT 367426008, 26789009, 173435000, 149063005, 173422009
English Tonsillectomies, Tonsillectomy, Excision of tonsil NOS, Tonsillectomy without adenoidectomy, tonsillectomy (treatment), tonsillectomy, Tonsillectomy [dup], surgical removal of the tonsil, tonsillectomies, procedures tonsillectomy, tonsillectomy procedure, Excision of tonsil NOS (procedure), Ts - Tonsillectomy, Excision of tonsil, Tonsillectomy (procedure), Tonsillectomy, NOS, Excision of tonsil, NOS, Tonsillectomy (procedure) [Ambiguous], Tonsillectomy [dup] (procedure)
Japanese 扁桃摘出, ヘントウテキシュツ
Swedish Tonsillektomi
Czech tonzilektomie, Tonzilektomie, odstranění krčních mandlí, tonsilektomie
Finnish Tonsillektomia
Russian TONZILLEKTOMIIA, ТОНЗИЛЛЭКТОМИЯ
Croatian TONZILEKTOMIJA
Polish Tonsylektomia, Wycięcie migdałków podniebiennych
Hungarian Mandulaműtét
Norwegian Fjerning av mandler, Tonsillektomi
Spanish amigdalectomía, SAI, resección de amígdala, SAI, resección de amígdala, SAI (procedimiento), Amigdalectomía, amigdalectomía (concepto no activo), amigdalectomía (procedimiento), amigdalectomía, resección de amígdala palatina, Tonsilectomía
Portuguese Amigdalectomia, Tonsilectomia
Dutch tonsillectomie, Tonsillectomie
French Amygdalectomie, Tonsillectomie
German Tonsillektomie
Italian Tonsillectomia

Ontology: Control of hemorrhage after tonsillectomy or adenoidectomy (C0810382)

Concepts Therapeutic or Preventive Procedure (T061)
English Control of hemorrhage after tonsillectomy or adenoidectomy