Tonsillectomy

1. See Also
   1. Group A Streptococcal Pharyngitis
   2. Chronic Pharyngeal Carriage of Streptococcus pyogenes
   3. Pharyngitis
   4. Pharyngitis Causes
   5. Dysphagia
   6. Tonsillitis
   7. Peritonsillar Abscess
   8. Retropharyngeal Abscess
   9. Lemierre Syndrome
   10. Diphtheria
2. 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
3. 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
4. Management: Postoperative bleeding from Tonsillectomy
   1. Typically occurs at day 5-7 after Tonsillectomy
      1. Related to loss of eschar
   2. Secure airway if needed
      1. See Advanced Airway
   3. Consider Nebulized racemic epinephrine
      1. May Vasoconstrict Tonsillar region vessels
   4. Local Bleeding Control
      1. Insert bite block
      2. Anesthetize area (cetacaine or atomized Lidocaine)
      3. Apply pressure with finger to bleeding site
      4. Apply topical Tranexamic Acid (anecdotally, Tranexamic Acid has been nebulized for Tonsillar bleeding)
      5. Inject Epinephrine into bleeding site
   5. 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
5. Resources
   1. Clinical Practice Guideline for Tonsillectomy in Children
      1. http://oto.sagepub.com/content/144/1_suppl/S1.long
6. References
   1. Claudius, Behar and Stoner in Herbert (2015) EM:Rap 15(11):2-3
   2. Baugh (2011) Otolaryngol Head Neck Surg 144(1): S1-S30 [PubMed]
   3. Randel (2011) Am Fam Physician 84(5): 566-73 [PubMed]