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    Tonsillectomy in Children (beta)

    Based on guidelines from the American Academy of Otolaryngology-Head and Neck Surgery Foundation.

    Strength
    Strong recommendation
    Recommendation
    Option
    Strong recommendation against

    Care and Management

    Watchful Waiting for Recurrent Throat Infection
    1. Clinicians should recommend watchful waiting for recurrent throat infection if there have been <7 episodes in the past year, <5 episodes per year in the past 2 years, or <3 episodes per year in the past 3 years.
    Recurrent Throat Infection with Documentation
    1. Clinicians may recommend tonsillectomy for recurrent throat infection with a frequency of at least 7 episodes in the past year, at least 5 episodes per year for 2 years, or at least 3 episodes per year for 3 years with documentation in the medical record for each episode of sore throat and ≥1 of the following: temperature >101°F (38.3°C), cervical adenopathy, tonsillar exudate, or positive test for group A beta-hemolytic streptococcus.
    Tonsillectomy for Recurrent Infection with Modifying Factors
    1. Clinicians should assess the child with recurrent throat infection who does not meet the criteria (a frequency of at least 7 episodes in the past year, at least 5 episodes per year for 2 years, or at least 3 episodes per year for 3 years with documentation in the medical record for each episode of sore throat and ≥1 of the following: temperature >101°F (38.3°C), cervical adenopathy, tonsillar exudate, or positive test for group A beta-hemolytic streptococcus) for modifying factors that may nonetheless favor tonsillectomy, which may include but are not limited to: multiple antibiotic allergies/intolerance, PFAPA (periodic fever, aphthous stomatitis, pharyngitis, and adenitis), or history of >1 peritonsillar abscess.
    Tonsillectomy for Obstructive Sleep-Disordered Breathing
    1. Clinicians should ask caregivers of children with obstructive sleep-disordered breathing and tonsillar hypertrophy about comorbid conditions that may improve after tonsillectomy, including growth retardation, poor school performance, enuresis, asthma, and behavioral problems.
    Indications for Polysomnography
    1. Before performing tonsillectomy, the clinician should refer children with obstructive sleep-disordered breathing for polysomnography if they are <2 years of age or if they exhibit any of the following: obesity, Down syndrome, craniofacial abnormalities, neuromuscular disorders, sickle cell disease, or mucopolysaccharidoses.
    Additional Recommendations for Polysomnography
    1. The clinician should advocate for polysomnography prior to tonsillectomy for obstructive sleep-disordered breathing (oSDB) in children without any of the comorbidities listed (obesity, Down syndrome, craniofacial abnormalities, neuromuscular disorders, sickle cell disease, or mucopolysaccharidoses) for whom the need for tonsillectomy is uncertain or when there is discordance between the physical examination and the reported severity of oSDB.
    Tonsillectomy for Obstructive Sleep Apnea
    1. Clinicians should recommend tonsillectomy for children with obstructive sleep apnea documented by overnight polysomnography.
    Education Regarding Persistent or Recurrent Obstructive Sleep-Disordered Breathing
    1. Clinicians should counsel patients and caregivers and explain that obstructive sleep-disordered breathing may persist or recur after tonsillectomy and may require further management.
    Perioperative Pain Counseling
    1. The clinician should counsel patients and caregivers regarding the importance of managing posttonsillectomy pain as part of the perioperative education process and should reinforce this counseling at the time of surgery with reminders about the need to anticipate, reassess, and adequately treat pain after surgery.
    Perioperative Antibiotics
    1. Clinicians should not administer or prescribe perioperative antibiotics to children undergoing tonsillectomy.
    Intraoperative Steroids
    1. Clinicians should administer a single intraoperative dose of intravenous dexamethasone to children undergoing tonsillectomy.
    Inpatient Monitoring for Children After Tonsillectomy
    1. Clinicians should arrange for overnight, inpatient monitoring of children after tonsillectomy if they are <3 years old or have severe obstructive sleep apnea (apnea-hypopnea index ≥10 obstructive events/hour, oxygen saturation nadir <80%, or both).
    Postoperative Ibuprofen and Acetaminophen
    1. Clinicians should recommend ibuprofen, acetaminophen, or both for pain control after tonsillectomy.
    Postoperative Codeine
    1. Clinicians must not administer or prescribe codeine, or any medication containing codeine, after tonsillectomy in children younger than 12 years.
    Outcome Assessment for Bleeding
    1. Clinicians should follow up with patients and/or caregivers after tonsillectomy and document in the medical record the presence or absence of bleeding within 24 hours of surgery (primary bleeding) and bleeding occurring later than 24 hours after surgery (secondary bleeding).
    Posttonsillectomy Bleeding Rate
    1. Clinicians should determine their rate of primary and secondary posttonsillectomy bleeding at least annually.
    What do the icons mean?  
    Research PaperMitchell RB, Archer SM, Ishman SL, et al. Clinical Practice Guideline: Tonsillectomy in Children (Update). Otolaryngol Head Neck Surg. 2019;160(1_suppl):S1-S42.