TONSILLECTOMY AND ADENOIDECTOMY : Changing Indications - 11/09/11
Resumen |
Every pediatrician has wrestled with the question of appropriate criteria for recommending tonsillectomy, adenoidectomy, or both for an individual child, and each develops a personal algorithm for decision making. Multiple factors, both mundane and complex, influence this decision. Rigidly structured criteria are tempered by the anecdotal experiences of the physician and the family and a lack of universally accepted criteria. Both advocates and detractors make claims about the indications, efficacy, and risk of tonsillectomy, with lesser controversy surrounding adenoidectomy.
Tonsillectomy was described 3000 years ago in Hindu writings7, 45, 63 and again 2 millenia ago by Celsus and Paul of Aegina.45, 65 The procedure involved scraping the mucous membrane with a finger and enucleating the tonsil.45 Adenoidectomy may have first been performed in the late 1800s, when Meyer of Copenhagen suggested that adenoid vegetations were responsible for impaired hearing and nasal symptoms.65
In the first half of this century, great enthusiasm existed for tonsillectomies, which were considered by some to be a “public health measure,”63 and they were performed for minimal symptomatology. Baker4 describes an incident occurring in about 1920:
“…The doctors had coolly descended on the school, taken possession, lined the children up, marched them past, taken one look down each child's throat, and then two strong arms seized and held the child while the doctor used his instruments to reach down into the throat and rip out whatever came nearest to hand, leaving the boy or girl frightened out of a year's growth and bleeding savagely. No attempt at psychological preparation, no explanation to the child or warning to the parents…It was an outrage—as cruel and as stupid as an initiation ceremony in an African tribe.”
Skepticism about the appropriate indications for tonsillectomy developed in the next few decades. Paradise65 credits this to (1) the natural decline in the incidence of upper respiratory infections in children with age, (2) an increased risk for poliomyelitis after tonsillectomy prior to the availability of an effective vaccine, (3) the development of antimicrobial agents for treating upper respiratory infections, and (4) studies purporting that tonsil and adenoid surgery was ineffective. The number of tonsillectomies performed annually peaked at 1.4 million in 1959 and then declined.63
Although the total number of tonsillectomies has decreased, the percentage performed for upper airway obstruction has increased.81 In the 1960s, reports described patients with serious sequelae of upper airway obstruction caused by adenotonsillar hypertrophy.10, 11, 36, 48, 60, 63, 87 Most upper airway obstruction in children is caused by adenotonsillar hypertrophy, and most symptoms are reversible after relief of the upper airway obstruction, usually by tonsillectomy, adenoidectomy, or both.44, 63, 87, 98 Since then, the pendulum of public and professional opinion concerning tonsillectomy and adenoidectomy continues to swing between enthusiasm and condemnation.
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| Address reprint requests to Ellen S. Deutsch, MD, FAAP, FACS, Department of Pediatric Otolaryngology, St. Christopher's Hospital for Children, Erie Avenue at Front Street, Philadelphia, PA 19134–1095 |
Vol 43 - N° 6
P. 1319-1338 - décembre 1996 Regresar al número
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