Current perspectives on the role of tonsillectomy.

Abstract

Tonsillectomy is one of the most common paediatric surgical procedures performed in Australasia. The aim of this paper is to provide an up-to-date review of the indications for the procedure (and the evidence base for each of these indications), as well as describe the surgical technique and perioperative management and risks for a non-surgical audience. The primary indications for tonsillectomy are obstructive sleep apnoea (OSA) (where it is most commonly performed in association with adenoidectomy) and recurrent pharyngotonsillitis. There is now high-quality evidence that tonsillectomy improves objective measures of OSA on sleep studies, as well as quality of life and child behaviour. The impact of surgery on cognitive function is less well delineated. For recurrent pharyngotonsillitis, tonsillectomy has a modest impact on recurrent sore throat symptoms - clinicians should ensure an appropriate pre-operative observation period and adequately discuss the potential benefits with parents prior to surgery. Traditional approaches to tonsillectomy involve surgically dissecting the entire tonsil from the underlying pharyngeal muscle. Subtotal tonsillectomy (intracapsular tonsillectomy or tonsillotomy) is described for OSA and may reduce perioperative morbidity. Children younger than 3 years and those with moderate to severe OSA or significant comorbidities should be admitted for overnight observation. Simple analgesia is adequate for most patients postoperatively. Codeine is contraindicated due to reports of postoperative death due to respiratory suppression. Overall, tonsillectomy is a well-tolerated procedure, with pain and postoperative haemorrhage (2-4%) being the most common complications. Haemorrhage can be life threatening; however, the mortality rate remains very small at approximately 1:30 000.