Article

ear-nose-throat

Tonsillectomy and Adenoidectomy and Myringotomy With Tube Insertion

Eric D. Baum, MD*

Objectives

After completing this article, readers should be able to:

Author Disclosure Dr Baum has disclosed no nancial relationships relevant to this article. This commentary does not contain a discussion of an unapproved/ investigative use of a commercial product/ device.

1. Recognize disease states associated with adenotonsillar hypertrophy and infection. 2. Understand the indications for, general surgical approach to, and complications of adenotonsillectomy. 3. Discuss the role of myringotomy and tube insertion in the management of middle ear disease. 4. Be familiar with common complications after myringotomy and tube insertion.

Introduction

A variety of head and neck problems are seen frequently in general pediatric practice, and issues related to adenotonsillar disease and middle ear disease are among the most common causes of these visits. Sleep-disordered breathing, a range of disorders that includes primary snoring and obstructive sleep apnea syndrome (OSAS), is strongly related to adenotonsillar hypertrophy. Recurrent and chronic pharyngitis are addressed less commonly surgically than in past decades but still are important causes of morbidity in children. Myringotomy with tube insertion is one of the most common surgical procedures performed on Americans and is an important tool in the management of chronic middle ear disease in the pediatric population.

The superior part of the pharynx contains a ring of lymphoid tissue roughly extending from the level of the skull base in the posterior portion of the nose down to the level of the larynx. Centered superiorly on the posterior wall of the nasopharynx are the pharyngeal tonsils, commonly known as the adenoids or adenoid pad. The two palatine tonsils (generally termed only tonsils) are situated on either side of the oropharynx. Inferiorly, near the base of the tongue and more inferior portions of the pharyngeal walls are the lingual tonsils. Disease states associated with these different aggregations of tissue often are affected by their precise anatomic location. The tonsils and adenoids are considered secondary lymphoid organs and are most active between the ages of 4 and 10 years. Before their involution, generally beginning at puberty, they are active immunologically and participate in B-cell proliferation as well as immunoglobulin (Ig) production and secretion. Unlike true lymph nodes, they also are capable of directly transporting antigens deposited on the surface to lymphoid cells on the Abbreviations interior. (1) A variety of studies have noted differences in immunoAOM: acute otitis media logic parameters between patients who have and have not EBV: Epstein-Barr virus undergone adenotonsillectomy, including minor changes in EEG: electroencephalography serum IgA concentrations. Despite this nding, evidence is GABHS: group A beta-hemolytic Streptococcus lacking that important immunologic function is comproIg: immunoglobulin mised in patients who have portions of the Waldeyer ring NSAID: nonsteroidal anti-inammatory drug removed. Although no surgical procedure should be recomOSAS: obstructive sleep apnea syndrome mended without consideration of all potential consequences, PET: pressure equalization tube parents and patients can be assured that no signicant longUARS: upper airway resistance syndrome term immunologic or infectious complications should be VPI: velopharyngeal insufciency anticipated as a result of tonsil or adenoid removal. (2)
*Clinical Instructor, Department of Surgery (Otolaryngology), Yale University School of Medicine, New Haven, Conn. Pediatrics in Review Vol.31 No.10 October 2010 417

Background

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Infections

Although the normal ora of the upper aerodigestive tract is rich with a variety of aerobic and anaerobic organisms, including known pathogens such as Streptococcus pneumoniae and Moraxella catarrhalis, the presence of specic bacteria or viruses rarely is concerning unless overt signs and symptoms develop, either acutely or recurrently. Most infections in this part of the body are polymicrobial; when specic organisms are recovered or cultured from mucosal sampling (eg, by pharyngeal swab), it may not be possible to determine which are pathogenic during that episode and which are simply present as colonizers. Viral pharyngitis, which generally is mild and selflimited, can be due to any of a large number of respiratory pathogens, including adenovirus, respiratory syncytial virus, rhinovirus, inuenza virus, and parainuenza virus. Because these agents also are associated with other signs and symptoms, the patients additional clinical ndings may help point to a more specic diagnosis. Signs and symptoms of viral pharyngitis generally include sore throat and pain on swallowing. Herpes simplex infections also can present with classic cold sores or more generalized gingivostomatitis. Herpangina, associated with coxsackievirus, may present with an eruption of vesicles that ultimately ulcerate and are especially visible on the palate, tonsils, and posterior pharyngeal wall. Other viruses, particularly parainuenza and respiratory syncytial virus, may cause more severe lower respiratory symptoms that clinically overshadow pharyngitis and dysphagia. The triad of moderately high fever, pharyngitis, and generalized lymphadenopathy should prompt consideration of infectious mononucleosis, which usually is caused by acute infection with Epstein-Barr virus (EBV). Other signs of infectious mononucleosis include petechiae on the palate, palpable splenomegaly, and tonsillar enlargement with a gray exudate. About 85% of adolescent patients, and a somewhat lower percentage of younger children, have a positive heterophile antibody (monospot) test result. (3) Although the heterophile antibody test is very specic, its sensitivity is somewhat less, and up to 10% of patients who develop mononucleosis have persistently negative heterophile test results. Many such patients have detectable serum IgM antibodies against the viral capsid antigen. In addition, a signicant number of patients who appear clinically to have infectious mononucleosis from EBV actually have another viral infection. The most common alternative infectious agents are human herpesvirus 6, cytomegalovirus, and herpes simplex virus 1. (4)
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The most common bacterial cause of acute tonsillitis is group A beta-hemolytic Streptococcus (GABHS). Although the short-term morbidity of this disease is substantial, simply based on its frequency in the general population, particular concern is warranted because of two feared long-term complications: poststreptococcal glomerulonephritis and acute rheumatic fever. Bacterial pharyngitis presents similarly to viral pharyngitis. Patients complain of pain and difculty swallowing and of generalized malaise and fever; they often have enlarged, erythematous tonsils and surrounding tissues along with cervical lymphadenopathy. The physical examination cannot rule out GABHS reliably as the cause, and clinical suspicion should direct the decision to pursue laboratory conrmation of a streptococcal infection. For patients in whom the suspicion of a streptococcal infection is reasonably high (generally because of compatible presentation or a conrmatory history of similarly infected contacts), an ofce-based rapid strep test can be performed. These tests, generally based on enzymelinked immunosorbent assay methodology, are very specic, and a positive result is considered sufcient evidence of streptococcal infection. Sensitivity is not as high as with throat culture, which often is obtained immediately when rapid streptococcal tests yield negative results. Antibiotic therapy frequently is started empirically in anticipation of culture results, which may take up to 48 hours to obtain. Good evidence supports the consensus recommendation of a 10-day course of oral penicillin V, which is effective, safe, and inexpensive and has a narrow antimicrobial spectrum (benzathine penicillin G can be used in children who do not tolerate an oral course). The approach is less clear when considering alternative treatments, including shorter courses of macrolides (azithromycin, clarithromycin) or cephalosporins (cephalexin, cefuroxime, cefdinir). Such treatments are effective in reducing the duration of discomfort, especially when they are started within the rst 48 hours of symptom onset, but it should be noted that most symptoms of streptococcal pharyngitis resolve within 3 or 4 days even without treatment. More importantly, it is not completely clear that shorter courses of broader-spectrum antimicrobial agents have equivalent protective effects with respect to rheumatic fever. A full course of antibiotic therapy initiated within 9 days of the emergence of symptoms of streptococcal pharyngitis prevents development of rheumatic fever but has no effect on the risk for poststreptococcal glomerulonephritis. (5) Other microorganisms occasionally are implicated in pharyngitis. Immunocompromised patients or patients

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already receiving antimicrobial therapy are at higher risk for candidal pharyngitis, which generally presents with painful white plaques scattered throughout the oral cavity and pharynx that bleed with manipulation. Neisseria gonorrhoeae infection can present with an exudative pharyngitis and is transmitted via oral-genital contact. Exudative pharyngotonsillitis caused by Corynebacterium diphtheriae is rare, but it produces obstructive lesions and laryngeal inammation that can lead to life-threatening airway compromise. Rapid airway management, sometimes including tracheotomy, is imperative.

Suppurative Complications

Cellulitis and abscess in adjacent areas can result from tonsillar or pharyngeal infections; symptoms generally are related to the specic area that is inamed. Peritonsillar abscess typically is seen in older children and young adults and results from direct spread of a tonsillar infection from the superior pole of the tonsil into a space between the tonsil and the underside of the soft palate. Patients complain of severe pharyngitis symptoms and may have trismus (from adjacent inammation of the pterygoid muscles), referred otalgia, and very tender ipsilateral cervical adenopathy. On physical examination, the standard pharyngitis picture is supplemented by swelling and erythema of the uvula and soft palate. Often, the affected tonsil, as well as the immediately adjacent portion of the soft palate and the uvula itself, appear deviated toward the opposite side. Antibiotic therapy is indicated, and in cases where a true abscess has formed, needle drainage is effective. This may be attempted in appropriately selected patients while they are awake and offers immediate symptomatic relief, although antibiotic therapy still is indicated. For patients who require management under general anesthesia, consideration can be given to simultaneous tonsillectomy (the so-called Quinsy or hot tonsillectomy). Patients who have a history of peritonsillar abscess or chronic tonsillitis should be strongly considered for acute or delayed tonsillectomy, but most patients do not experience incomplete resolution or recurrence if drainage alone is performed. Quinsy tonsillectomy is not, as previously reported, associated with a higher postoperative bleeding risk. (6) Retropharyngeal space infections, seen most commonly in children younger than 2 years of age, also present with typical pharyngitis symptoms. A stiff neck and signs of impending airway obstruction also may be present. Intraoral examination often reveals obvious swelling or mass on the posterior pharyngeal wall. Transoral incision and drainage is indicated.

Parapharyngeal space infections may occur from direct lateral extension of tonsillitis or from a peritonsillar infection. Trismus is prominent because of inammation of the pterygoid musculature. On physical examination, medial displacement of the tonsil and uctuance of the upper neck may be present but can be hard to detect because of nearby muscle swelling. Transoral drainage in the operating room may be attempted in limited cases (generally after radiologic evaluation of the location of the abscess cavity with respect to the carotid sheath), but the standard approach is through the neck, with deep dissection proceeding just posterior to the submandibular gland when the abscess cavity is lateral to the carotid sheath.

Adenotonsillar Hypertrophy and Sleep-disordered Breathing

The term sleep-disordered breathing encompasses a range of respiratory abnormalities. The less severe manifestation is primary snoring, in which abnormally noisy air exchange occurs but changes in sleep architecture or gas exchange are not noted. Despite a lack of consistent sleep abnormalities, children who have primary snoring may not be sleeping normally. Patients who have upper airway resistance syndrome (UARS) experience airway obstruction while they sleep and may show sleep fragmentation and abnormal changes on electroencephalography (EEG). Patients who show a pattern of complete breathing blockage (obstructive apnea), often intermingled with partial obstruction (hypopnea), are diagnosed with OSAS. During the past few years, appreciation of the prevalence and importance of sleep-disordered breathing in children has increased, along with understanding of the marked differences between these disorders in children and adults, and this awareness has produced a number of controversial and unsettled issues. Although it has been well-shown that true OSAS is well-served by aggressive intervention, it is not clear if the more mild gradations of sleep-disordered breathing are worth the risk of treatment. In addition, basic denitions of certain parameters (eg, what constitutes hypopnea) and the interpretation of the enormous amounts of data produced by patient testing are not agreed on completely. Nonetheless, important strides have been made, and much research is ongoing. Sleep-disordered breathing is common and was found in 4% to 11% of children in one study. Commentators note that this gure probably underestimates the problem because many studies were performed before patients having UARS were included in the nal counts.
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Witnessed apnea occurs in 0.2% to 4% of children, although that range likely reects an underestimate because it was based primarily on casual observation. (7) Obstructive apnea and hypopnea lead to periods of hypercarbia, hypoxia, paradoxic respiratory motion, disrupted sleep architecture (fragmentation), and overall poor rest. These effects result in a wide variety of signs and symptoms during daily activities (Table 1). The pathophysiology involves a number of deranged pathways, all ultimately related to increased resistance to ow in the upper airway during sleep. Two major contributors to this phenomenon are the conguration of the facial skeleton and the space taken up by and dynamic behavior of the soft-tissue structures in the upper aerodigestive tract, including lymphoid tissue, the soft palate, and the tongue. A minimum level of obstruction required to cause a problem has not been established, but when ow is sufciently limited, a variety of breathing patterns can result, including obstructive cycling, increased respiratory effort, tachypnea, and gas exchange abnormalities. Any or all of these effects can lead to arousal, which can take the form of autonomic activation, obvious changes on EEG, and awakening. The vibratory nature of chronic snoring can lead to changes in neuromuscular activity and control, which feeds back to changes in collapsibility and static airway resistance. Chronic mouth-breathing and snoring can worsen abnormal craniofacial development, and studies have shown that effective treatment can normalize such changes. Most provocatively, a growing body of research has shown that respiratory arousals activate inammatory pathways, which can lead to changes in cerebral blood ow, increases in cytokine cascade activation, and structural changes in the brain. Many of these derangements can persist during waking hours. (8) A thorough history is the cornerstone of diagnosis in sleep-disordered breathing. Parents should be asked questions about what they observe while the child is sleeping, if there are behavioral abnormalities during waking hours, and if there are additional signs and symptoms suggestive of upper aerodigestive tract abnormalities (Table 2). Physical examination should concentrate on normalcy and patency of the entire upper aerodigestive tract: 1) Nose: size, shape, and patency of the nasal aperture; conguration and size of the septum and inferior turbinates; 2) Oral cavity: dentition, jaw excursion, hard palate shape, tongue size; and 3) Pharynx: tonsil size and space between them; signs of infection or inammation; shape and position of the soft palate. Other important
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Sequelae of Sleep-disordered Breathing

Table 1.

Behavioral problems Hyperactivity Inattention Oppositional behavior Anxiety Depression ADD/ADHD-like symptoms Lower intelligent quotient Abnormalities of executive function Autonomic dysfunction Poorer school performance Higher prevalence of neuropsychiatric diagnosis Poor quality of life for patient and caregivers Impaired growth/failure to thrive Abnormal dentofacial growth Cardiopulmonary abnormalities Right heart failure Pulmonary hypertension Higher health-care utilization
ADD/ADHD attention-decit (hyperactivity) disorder

factors to note are the patients weight, the presence of any voice abnormalities (nasality, articulation abnormalities), any craniofacial asymmetry or abnormalities, signs of hypotonia, and the presence of any cardiac or pulmonary disease. In most children who have sleep-disordered breathing, additional investigation is not needed to make an informed decision about proceeding with treatment. Both exible nasopharyngoscopy and lateral neck radiography are helpful in assessing the size of the adenoids and the severity of airway obstruction, but generally they are conrmatory. Overnight polysomnography has long been considered the gold standard for the diagnosis of sleepdisordered breathing, but it probably is not necessary in all patients. The procedure can be particularly helpful in selected cases (Table 3).

Tonsillectomy and Adenoidectomy

Tonsillectomy, adenoidectomy, or both are performed commonly in children, although the popularity of the procedures in general and for specic indications has shifted over time. (9) Commonly cited reasons for adenotonsillectomy include OSAS and recurrent or persistent pharyngitis. Studies support the role of adenotonsillectomy in OSAS, (10) but the picture is less clear in patients who have recurrent sore throats. A recent meta-

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Table 2.

Important Components of the History of Suspected Sleep-disordered Breathing

What happens during bedtime/sleeptime? Snoring Heavy breathing Mouth-breathing Stopping of breathing Followed by a big breath or gasp Paradoxic chest motion Restlessness Frequent awakenings Sleeping in odd positions Leg movements Enuresis Nocturnal perspiration What happens during the day? Upon awakening Difculty arousing Morning headache Dry mouth Behavioral problems and school performance issues Distracted easily Poor concentration Impulsive Organizational problems Fidgety ADD/ADHD-like symptoms Signs and symptoms during naps Mouth-breathing or audible breathing while awake Possible Related Issues Suggesting Other Causes or Other Adenotonsillar Problems Nasal obstruction Environmental allergies Difculty eating or poor oral intake Aversion to certain food textures Failure to thrive Obesity Halitosis Drooling Voice abnormalities

ADD/ADHD attention-decit (hyperactivity) disorder

analysis concluded that surgery is effective, but the overall improvement in the treated group was not dramatic. (11) Part of the difculty involves inconsistency in reporting and diagnosis of episodes, and clinicians may nd it useful to concentrate on questions of frequency, severity, and interference with regular activities (especially missed school). Although rare, surgical removal also is indicated in

cases of suspected malignancy. It may be appropriate to consider surgery in cases of chronic halitosis, dysphagia, sialorrhea, and dysarthria. Adenoidectomy alone has been shown to be effective in the treatment of chronic middle ear disease (generally in conjunction with myringotomy and tube insertion) and chronic sinusitis. Preoperative evaluation of patients undergoing adenotonsillar surgery requires a history and physical examination, with emphasis on any risk factors for anesthesia or perioperative problems. A personal or family history of abnormal reactions to anesthetic agents (including malignant hyperthermia), excessive bleeding, or hematologic disorder always must be excluded. Patients who have reactive airways disease or other pulmonary problems should be well controlled and on a stable medical regimen before surgery. Routine laboratory studies are not indicated in otherwise healthy patients. Although the level of severity of sleep apnea that constitutes a clear cutoff point is not clear, patients who have more pronounced disease are at higher risk for cardiopulmonary sequelae, and chest radiography, electrocardiography, and electrocardiography may be appropriate. Special mention should be made of velopharyngeal insufciency (VPI), which is of particular concern in patients undergoing adenoidectomy. Patients who have VPI do not completely close the soft palate and related structures against the posterior and lateral pharyngeal walls, and the resulting abnormalities of airow are most obvious during speech production and deglutition. VPI is a postoperative complication of approximately 1 in every 1,500 adenoidectomies, but certain patients are at higher risk preoperatively. Patients who have pre-existing VPI, especially children who have had a repaired cleft palate, are at risk for more severe problems postoperatively. Other higher-risk groups include patients who have a personal history of infantile nasal regurgitation, hypernasal speech, or velocardiofacial syndrome or a family history of VPI. On physical examination, the presence of a bid uvula or submucous cleft palate (an abnormally thin midline connection between the right and left halves of the palate) are important clues. The surgeon generally can avoid causing or worsening the problem with a limitedremoval technique, although VPI sometimes occurs even in patients who undergo partial adenoidectomy and in patients who have no identiable preoperative risk factors. Initial management is conservative, with observation and speech therapy, but a small number of patients require corrective surgery. (12) Numerous techniques for surgical extirpation of tonsil and adenoid tissue exist, and no single procedure has
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Table 3.

Selected Situations for Overnight Polysomnography

Reason Help decide risk/benet of intervention Can provide a useful pretreatment baseline because patient is likely to have residual disease after treatment Objective data to clarify/conrm diagnosis To rule out alternate or additional diagnoses (eg, other sleep disorders)

Clinical Scenario Severe symptomatology Craniofacial abnormality Severe obesity Down syndrome Parental or clinical uncertainty Atypical presentation

emerged as clearly superior. Benchmarks used to compare different operative methods include intraoperative blood loss, rate of postoperative bleeding, length and severity of postoperative pain, and delay until resumption of normal diet and activity. Initial studies of a variety of techniques, most notably, partial tonsil removal and coblation tonsillectomy, were very promising, but later conrmatory studies failed to show any clinically important advantages. (13) Postoperative complications in adenotonsillar surgery include bleeding, airway problems, and dehydration. High-risk patients are more likely to require hospital admission after surgery. Even if there are no identiable risk factors (Table 4), patients routinely are kept in the recovery room for 2 to 4 hours, which nearly always is enough time to assess whether they will be safe going home or will require more time in the hospital under close nursing supervision. (14) Postoperative bleeding rates after tonsillectomy range from 1.5% to 5%, although the higher end of the range probably encompasses a disproportionate number of adults. Most bleeding is classied as late, meaning more than 24 hours after the surgery; hemorrhage within 1 day of surgery often is attributed to technical failure. Aspirin has been shown to increase the incidence of bleeding, but nonsteroidal anti-inammatory drugs (NSAIDs) have

Patients at Higher Risk for Postadenotonsillectomy Complications

Table 4.

Younger than 36 months of age Craniofacial abnormalities Down syndrome Other craniofacial syndromes Former preterm babies who had bronchopulmonary dysplasia History of severe obstructive sleep apnea syndrome Morbid obesity

been shown not to in multiple studies. Nonetheless, many American otolaryngologists advise against NSAID use for a few weeks after adenotonsillectomy and prescribe acetaminophen-narcotic combinations as the mainstay of the analgesic regimen. (15) Dehydration is predominantly due to odynophagia but is exacerbated by postanesthesia vomiting and fever and is treated best with aggressive and consistent pain control. Studies have shown that fewer than 1% of patients require postoperative overnight admission because of refusal to drink sufciently, but this gure likely underestimates the problem. Edema and discomfort peak a few days after surgery, and parents should be counseled to watch for important signs, such as decreased urine output, dry mucous membranes, and thickened secretions. Because of the anatomic proximity of the adenoids to the transverse spinal ligaments, postoperative inammation from the use of monopolar cautery (or simply from postoperative or infectious inammation) can cause laxity in those ligaments and, rarely, lead to subluxation of the atlantoaxial joint, a condition known as Grisel syndrome. Patients complain of posterior neck pain and, on examination, have marked, xed torticollis, with tenderness to palpation over the C1 and C2 vertebral bodies. Although the condition is rare, frank neurologic signs can be seen. In suspected cases, cervical spine computed tomography scan is obtained. Most cases are treated conservatively, with muscle relaxants and analgesics used in conjunction with a soft cervical collar. (16) Brief mention should be made of other postadenotonsillectomy complications. Voice changes can be multifactorial and generally are self-limited, although they can take months to resolve. Concern about postoperative VPI should prompt evaluation by a speech-language pathologist. Nasopharyngeal stenosis is a rare but feared complication of adenotonsillectomy and presumably is due to circumferential cicatrix formation because of extensive raw areas of tissue removal. Deglutition and speech can be severely affected, and complex surgical

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procedures are indicated for relief. Finally, parents should be counseled on the possibility of adenoid regrowth. Although the risk of radiologic or physical evidence of regrowth is as high as 5.5%, most cases are asymptomatic. (17) Evidence is emerging that the rate of regrowth may be partially technique-dependent; other patient risk factors likely also affect the rate of this complication.

Myringotomy and Tube Placement

In recent years, treatment for serous otitis media (more properly called middle ear effusion) and acute otitis media (AOM) (true infections, most of which are bacterial) has shifted toward less aggressive use of antibiotics, largely due to increasing concerns about bacterial resistance and growing awareness that acute middle ear problems in children are often self-limited. Surgical pressure equalization tube (PET) placement is indicated for recurrent AOM, AOM with concurrent complication, and chronic middle ear effusion. The timing of surgery in the disease process is controversial, primarily because many factors in each patient must be carefully weighed to determine the risk-benet ratio of surgery in relation to observation or continued medical treatment.

alone, thereby eliminating issues of systemic antibiotic adverse effects and resistance. Tubes generally stay in place for approximately 1 year, although there is much variability among patients and various tube designs. Most children do not require reinsertion for recurrent or ongoing middle ear disease. Up to one third of patients who have undergone PET placement have recurrent disease after tube extrusion that qualies them for surgical reinsertion. In these cases, concurrent adenoidectomy should be considered because it has been shown that such patients have a marked decrease in the need for future surgery. Tonsillectomy is not an effective treatment for chronic middle ear disease and should be considered in this group of patients only if a separate indication is apparent. Parents must be counseled about the increase in morbidity associated with adenoidectomy compared with tube reinsertion alone, including a longer surgical procedure, more postoperative discomfort, and postsurgical risks.

In the case of persistent middle ear effusion, guidelines state that it is reasonable to observe the patient for 3 months before contemplating surgery, but only if the child is not at risk for speech-language development or learning problems and is not experiencing signicant hearing loss. Strong consideration for surgery should be given to the patient who has experienced four episodes of recurrent AOM within a 6-month period or six within 1 year. In addition to the childs speech-language and learning development and hearing status, other factors to consider include the severity of the infections, presence of complications, tolerance of antibiotics, visible structural changes to the eardrum or middle ear, and comorbidities (immunodeciency, craniofacial abnormalities, general developmental delay, other sensory decits). (18)

Indications

PET placement is performed safely in all age groups and nearly always is quick and well-tolerated. Patients generally are anesthetized with an inhalational agent and usually continue to breathe spontaneously by mask throughout the 5- to 10-minute procedure. In healthy children, intravenous access often is not obtained, although such decisions are made by the anesthesiologist. Recovery room observation usually lasts no more than 1 hour, and parents are instructed on proper postoperative use of ear drops (primarily to ensure tube patency).

Surgery

Studies have shown that PETs eliminate middle ear effusions and markedly reduce the incidence of AOM. In addition, functioning tubes convert ear infections to a milder clinical manifestation (less pain, hearing loss, and disturbed sleep), and episodes of otorrhea through the tube nearly always can be treated with topical drops

Efcacy

Nearly all patients who are given PETs experience an occasional episode of otorrhea through the tube, which is especially common within a few weeks of surgery, particularly if there is active middle ear inammation at the time of the procedure. At other times, episodes are related temporally to a viral upper respiratory tract infection and can be considered an extension of that illness. (19) Most patients are bothered less by such episodes of AOM than before they had tubes in place because the purulent drainage, however dramatic and upsetting it appears to the parent, is not under pressure in a closed middle ear cavity. A few days of uoroquinolone ear drops (with or without corticosteroid) generally (although not always) clear the drainage. Treatment may fail because of antibiotic resistance, although the concentration of antimicrobial agents in topical preparations
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usually is high enough to obviate that concern. More commonly, the outward ow of infected uid blocks access to the tube and middle ear space, and in-ofce suctioning can be a valuable adjunct treatment to help drops get to the appropriate site of action. Some patients benet from the addition of an oral antibiotic, and in rare cases, culture of the middle ear uid (not of the contaminated drainage already in the canal) from the patent tube can help guide therapy. Intravenous antibiotics and hospital admission are mentioned in various protocols for refractory otorrhea, but in practice, such extreme measures should be employed rarely. Patients often are advised to wear ear protection or avoid water exposure when functioning PETs are in place, but numerous studies show no statistically signicant protective effect. Patients who swim deeply underwater or in natural bodies of water (eg, lakes, ponds) or who have a particular propensity to develop otorrhea after such activities may be advised to wear ear protection or avoid such activities. Otorrhea that is believed to have been caused by ingress of water through a patent tube should be treated similarly to otorrhea that is presumed to be related to an upper respiratory tract infection or other cause. (20) Although otorrhea is the most common complication of PETs, other problems can arise as well. Patients can develop blockage of the tube, rendering it nonfunctional. Such blockage can be due to a polyp or granulation tissue or from desiccated otorrhea clogging the lumen. In either of these cases, topical therapy or microscopic manipulation may clear and salvage the tube. Tubes also can extrude prematurely, necessitating repeated insertion, and certain tube designs seem to be more prone to extrusion than others. On occasion, a tube can become dislodged from the tympanic membrane and become trapped in the middle ear. Although this condition may not always be detected, when it is, repeat myringotomy with foreign body removal is indicated. Tubes also may fail to extrude, and patients who no longer need them may be served best by removal and simple patching of the drum. A nal category of tube-related complications may be more related to the disease process, although it can be affected by the surgery or presence of PETs. These complications include persistent perforation after tube extrusion (which requires operative closure), scarring of the tympanic membrane (myringosclerosis) or middle ear structures (tympanosclerosis), and atrophy of the previously incised area of the tympanic membrane. The
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risk of cholesteatoma is higher in children who have had PETs placed, but the overall risk has dropped substantially since PET placement became commonplace. This nding suggests that much of the chronic middle ear and mastoid disease seen in patients who have a history of PET placement is related more to the underlying disease process and that the appropriate treatment does, in fact, improve long-term outcomes. (21)

Summary
Adenotonsillar disease in children is common and manifests primarily as either recurrent or persistent infection or sleep-disordered breathing. Studies have shown that adenotonsillectomy is an effective treatment in appropriately selected patients. (10) It is important to recognize postoperative complications and issues related to recovery in adenotonsillectomy; some patients require hospital admission. Myringotomy with tube insertion has been shown in studies to be an effective treatment for children who have middle ear disease. Strict criteria for surgical intervention have not been established. (22) Most patients who have pressure equalization tubes inserted experience otorrhea, which generally can be treated without systemic antibiotics.

References

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of the pharyngeal lymphoid tissue. Otolaryngol Clin North Am. 1987;20:219 228 2. Siegel G. The inuence of tonsillectomy on cell-mediated immune response. Arch Otorhinolaryngol. 1984;239:205209 3. Alcaide ML, Bisno AL. Pharyngitis and epiglottitis. Infect Dis Clin North Am. 2007;21:449 469 4. Hurt C, Tammaro D. Diagnostic evaluation of mononucleosislike illnesses. Am J Med. 2007;120:e911 e918 5. Altamimi S, Khalil A, Khalaiwi KA, et al. Short versus standard duration antibiotic therapy for acute streptococcal pharyngitis in children. Cochrane Database Syst Rev. 2009;1:CD004872 6. Lehnerdt G, Senska K, Jahnke K, Fischer M. Post-tonsillectomy haemorrhage: a retrospective comparison of abscess- and elective tonsillectomy. Acta Otolaryngol. 2005;125:13121317 7. Lumeng JC, Chervin RD. Epidemiology of pediatric obstructive sleep apnea. Proc Am Thorac Soc. 2008;5:242252 8. Katz ES, DAmbrosio CM. Pathophysiology of pediatric obstructive sleep apnea. Proc Am Thorac Soc. 2008;5:253262 9. Darrow DH, Siemens C. Indications for tonsillectomy and adenoidectomy. Laryngoscope. 2002;112:6 10 10. Mitchell RB. Adenotonsillectomy for obstructive sleep apnea in children: outcome evaluated by pre- and postoperative polysomnography. Laryngoscope. 2007;117:1844 1854 11. Blakley BW, Magit AE. The role of tonsillectomy in reducing

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ear-nose-throat

tonsillectomy/adenoidectomy

recurrent pharyngitis: a systematic review. Otolaryngol Head Neck Surg. 2009;140:291297 12. Abdel-Aziz M, Dewidar H, El-Hoshy H, Aziz AA. Treatment of persistent post-adenoidectomy velopharyngeal insufciency by sphincter pharyngoplasty. Int J Pediatr Otorhinolaryngol. 2009. Epub ahead of print 13. Sobol SE, Wetmore RF, Marsh RR, et al. Postoperative recovery after microdebrider intracapsular or monopolar electrocautery tonsillectomy: a prospective, randomized, single-blinded study. Arch Otolaryngol Head Neck Surg. 2006;132:270 274 14. Ross AT, Kazahaya K, Tom LW. Revisiting outpatient tonsillectomy in young children. Otolaryngol Head Neck Surg. 2003;128: 326 331 15. Krishna S, Hughes LF, Lin SY. Postoperative hemorrhage with nonsteroidal anti-inammatory drug use after tonsillectomy: a meta-analysis. Arch Otolaryngol Head Neck Surg. 2003;129: 1086 1089 16. Karkos PD, Benton J, Leong SC, et al. Grisels syndrome in otolaryngology: a systematic review. Int J Pediatr Otorhinolaryngol. 2007;71:18231827 17. Reed J, Sridhara S, Brietzke SE. Electrocautery adenoidectomy

outcomes: a meta-analysis. Otolaryngol Head Neck Surg. 2009;140: 148 153 18. Schraff SA. Contemporary indications for ventilation tube placement. Curr Opin Otolaryngol Head Neck Surg. 2008;16: 406 411 19. Heikkinen T. Post-tympanostomy tube otorrhea. In: Alper CB, Casselbrant ML, Dohar JE, Mandel EM, eds. Advanced Therapy of Otitis Media. Hamilton, Ontario, Canada: BC Decker; 2004: 238 241 20. Goldstein N. Water precautions with tympanostomy tubes. In: Alper CB, Casselbrant ML, Dohar JE, Mandel EM, ed. Advanced Therapy of Otitis Media. Hamilton, Ontario, Canada: BC Decker; 2004:242245 21. Rakover Y, Keywan K, Rosen G. Comparison of the incidence of cholesteatoma surgery before and after using ventilation tubes for secretory otitis media. Int J Pediatr Otorhinolaryngol. 2000;56: 41 44 22. McDonald S, Langton Hewer CD, Nunez DA. Grommets (ventilation tubes) for recurrent acute otitis media in children. Cochrane Database Syst Rev. 2008;4:CD004741

HealthyChildren.org Parent Resources from AAP

Tonsillitis (includes info on adenoidectomy) http://www.healthychildren.org/English/health-issues/conditions/ear-nose-throat/ Pages/Tonsillitis.aspx

Downloaded from http://pedsinreview.aappublications.org by Giordano Perez-Gaxiola on October 4, 2010

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