X-From_: Sun May 2 18:37:11 1999
From: "Dogwood Ridge" <>
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Subject: indications for tonsilectomies
Date: Sun, 2 May 1999 17:35:13 -0500
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Reply-To: "Dogwood Ridge" <>
I hope Mike Rothschild, pedi ENT is listening. In training I was taught that the most common indications for a tonsillectomy were 6 strep throats in a year, or four strep throats in two consecutive years or tonsils that were so big they caused sleep apnea. I've used this criteria for all these years without really ever really updating my knowledge. Do these indications still hold? What would you do with a 13 year old that has gotten four or five strep throats this year but whose tonsils are quite small? Thanks- Kim Burlingham, MD Rural Pediatrics, somewhere in Texas
Mike Rothschild is here, listening, and flattered that you are asking for his opinion!
The numbers that you quote are the inclusion criteria for one of the largest tonsillectomy studies ever (the Pittsburgh study).
When designing such a study, you generally want to pick the sickest kids so as to more easily demonstrate a statistically and clinically significant difference with a given sample size. Does this mean that kids who DON'T fit that criteria should never get surgery? No, all the results can mean is that kids who DO fit the criteria show a benefit. The matter is complicated by the fact that the typical outcome measures (e.g. days without illness) in any such study are generally quality of life issues. If you were testing a new chemotherapy protocol, it would be a "simple" matter to compare survival curves, but in this case, you may be comparing apples and oranges...
What is the "cost" of one more eposode of strep pharyngitis? Lost school/work time? The remote risk of cardiac or renal complications? More antibiotic usage? What if the child has multiple severe antibiotic sensitivities? What if there is concomitant sleep disordered breathing? What if there has been a history of peritonsillar abscess? What if there are cardiac valvular lesions?
What are the risks of tonsillectomy? What if the child has malignant hyperthermia, and is at serious risk for undergoing any kind of surgery? What if he or she has a significant coagulation disorder?
All of you who practice clinical medicine know that many scenarios do NOT fit neatly into a calculus of risks versus benefits, and many intangibles must be weighed. Do not take this as a case for more tonsillectomies... I like to think that I am EXTREMELY conservative when it comes to T&A for recurrent pharyngitis. All I am saying is that the Pittsburgh criteria are a good place to start, but for some children they are unnecessarily strict, while for others, they may be unnecessarily lenient! Bottom line is, you have to treat the patient in front of you, and you should use evidence based medicine as a powerful tool for clinical decision support, not as a "mandatory sentencing guideline". Unfortunately, this is frequently the approach taken with managed care...
NOW that I have given you the long answer to a simple question.. here is the short answer!
I use the Pittsburgh criteria myself, but remain farily flexible one way or the other with regard to special circumstances. I consider sleep disordered breathing (and its most severe form, sleep apnea) as a separate issue, but there is clearly evidence that daytime (behavioral) problems can come from disturbance of sleep architecture even in the absence of complete apnea (i.e. hypopnea or the "upper airway resistance syndrome").
Best Wishes,
Michael Rothschild, MD, FAAP, FACS
Associate Professor and Chief
Pediatric Otolaryngology
Mount Sinai Medical Center
New York, NY USA
http://www.kids-ent.com