New tonsillectomy guidelines call for fewer surgeries

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Removing tonsils is probably not necessary for most children who get recurrent throat infections, according to the first set of official guidelines issued on a procedure that was once a rite of passage for many kids.

Rather, with careful monitoring, the infections will get better over time.

The recommendations published Monday by the American Academy of Otolaryngology-Head and Neck Surgery set several new standards based on seminal studies done at Children's Hospital of Pittsburgh of UPMC beginning in 1971.

The guidelines also cover tonsillectomies for sleep-disordered breathing, which is now the larger reason more than 530,000 tonsillectomies are performed on children under 15 each year. The surgery is the second-most performed on children in that age group annually in the United States, ranking behind surgery for ear tubes.

Farrel Buchinsky, pediatric otolaryngologist at Allegheny General Hospital who supports the new guidelines, expects there will be some resistance by the public on the changes regarding throat infections.

"A lot of people won't like it both from people who want to have large clinical volume and parents who believe it's right," he said. "They don't like data messing with their beliefs."

The tonsils, two glands located in the back of the throat, consist of lymph tissue and help fight off infections. Tonsillectomies carry risks and side effects; in addition to infections, up to 3 percent of patients have bleeding and an estimated 1 in 35,000 patients die. Post-recovery is painful.

Under the new guidelines, children who are candidates for surgery for recurrent throat infections should have at least seven documented infections in one year, five infections in each of two consecutive years or three infections in each of three consecutive years.

Moreover, to be diagnosed with a bona fide throat infection, the child should have a temperature of 100.9 degrees Fahrenheit, a white covering over the tonsils, enlarged lymph nodes in the neck or a positive test for a strep throat.

The tonsillectomy guidelines covering recurrent throat infections often cite the research done between 1971 and 1994 by a Children's Hospital team led by Jack L. Paradise, former chief of the Division of General Academic Pediatrics at Children's and currently a professor emeritus in the University of Pittsburgh School of Medicine. Dr. Paradise said the last study from the research was published in 2002.

Children's "looked at severe cases and less severe cases. They were the best studies done in the field and [provide] the evidence by which people created these guidelines," said Dr. Buchinsky, who attended a 90-minute academy briefing on the guidelines in September.

"Given the frequency of the surgery it's actually quite embarrassing there are only two or three good studies to point to. It should be 10," he said.

The numerical criteria in the academy guidelines "are word for word taken from our report," Dr. Paradise acknowledged Wednesday.

"We arbitrarily established certain minimum criteria for children with histories of throat infection that would serve as the absolute minimum for children being eligible for surgery," Dr. Paradise said.

Dr. Buchinsky and Children's pediatric otolaryngologist Deepak Mehta both stressed that the guidelines are just that.

"It's not a set of rules to go by," Dr. Mehta said. "It's important [for parents] to discuss either with an ear, nose and throat specialist or a primary care doctor."

In the case of sleep-disordered breathing, which can range from snoring to obstructive sleep apnea, the guidelines rely on input from caregivers and others.

Dr. Paradise's team did not include children with sleep-disordered breathing in its studies.

Dr. Paradise said he was "gratified" to see his work end up as the basis for official guidelines "because I think they're still perfectly sensible."

Pohla Smith: or 412-263-1228.


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