Northeast Florida Medicine
Vol. 66, No. 1 2015
15
Otolaryngology
readily available smart phones and correlated sleep question-
naires are simple tests to help document thresholds of clinical
findings and indications for surgery.
Adenotonsillectomy (T/A)
There are more than 500,000 adenotonsillectomies per-
formed in children each year in the United States (US).
1
It
is the second most common surgical procedure performed
in children after myringotomy and tube placement.
1
T/A
remains the gold standard procedure for the treatment of
OSA and recurrent chronic upper respiratory illness. More
T/A are performed for SDB than upper respiratory illness by
a widemargin.Themean age ofT/A has declined significantly
during the last 20 years.
5
A variety of newer surgical and anesthesia techniques have
improvedpatient safety andoutcomes. Inpatient admission for
T/Ahas sharply declined. A50percent reduction in admission
was seen from 1977 to 1989 and rates continue to decline as
perioperativemanagement techniques continue to improve.
4,5
Despite this evolution in care, several children die each year
from “routine” adenotonsillectomy. Exact data is very diffi-
cult to verify, but highly publicized case reports, malpractice
claims and anecdotal information should alert professionals
and the public to the fact that T/A is not a simple or minor
procedure. Mortality is due to failure to recognize potential
airway, respiratory,medication and comorbid conditions such
as OSA.
5
Patient selection and family education are critical
in the management of children undergoing T/A. Dedicated
pediatric professionals and facilities improve safety and care.
Though newer surgical techniques are often touted as
minimally invasive or less painful, T/A remains a painful,
anxiety-provoking and unpredictable procedure during the
important postoperative period. Limited use of narcotics, due
an FDA “black box” warning about codeine, and increased
use of nonsteroidal anti-inflammatory medications are recent
changes in postoperative care intended to meet individual
patient needs. Some increases in postoperative bleeding rates
have been noted as these changes have emerged.
6
Bleeding
after T/A is a well known adverse event and may occur in as
many as three percent of patients.
1
Clinical practice guidelines for adenotonsillectomy have
been developed by several interested specialties individually
or as part of OSA, PSG or other management protocols.
2,3,7
These evidence basedparadigms create discordance across spe-
cialties, but help add needed perspective on having dedicated
care protocols to improve safety and care in this common and
still controversial procedure.
TheAmericanAcademyofOtolaryngology (AAO) guideline
made several important recommendations including
1
:
1) The importance of watchful waiting for recurrent but
not chronic illness;
2) The utility of surgery for other conditions including anti-
biotic allergy or intolerance, periodic fever and abscess;
3) The importance of other conditions associated with
SDB/OSA such as growth retardation, poor school
performance and behavioral problems;
4) Improvement in overall health after T/A for OSA/SDB;
5) Important perioperative management needs including
the use of steroids and pain medications;
6) Requirement for quality reporting such as bleeding rates.
Otitis media
Tympanostomy tube insertion is the most common
outpatient surgical procedure requiring general anesthesia
performed in the US.
8
In an era of increasing attention to
the cost of healthcare and access to medical resources, it
is not a surprise that there is increasing attention on the
treatment of otitis media with effusion and recurrent acute
otitis media. The last two years saw the publication of two
important reviews of surgical treatment of otitis media with
effusion (OME) in children:
• The clinical practice guideline for tympanostomy tubes
in children. Published by a multispecialty panel for the
American Academy of Otolaryngology – Head and Neck
Surgery in July, 2013.
9
• Surgical treatments for otitis media with effusion: a
systematic review. Published by a multi-specialty group
in the journal Pediatrics in January, 2014.
10
Surprisingly until 2013 therewas no clinical practice guide-
line for tympanostomy tube insertion in the US. There have
been various recommendations that were followed based on
the best available literature.Many of these established practice
recommendations have found their way to the guidelines with
a fewnotable exceptions. In summary, the question of “to tube
or not to tube” is answered by the guidelines is as follows
9,10
:
• Tympanostomy tubes should be recommended if:
o Chronic (three months or longer) bilateral OME
with hearing difficulty (documented)
o Chronic OME with symptoms
o Recurrent (three episodes in six months or four in 12
months with at least one in the last six months) acute
otitis media (AOM) with middle ear effusion (MEE)
at the time of evaluation by the Otolaryngologist.
