Tonsillectomy is one of the most common surgical procedures undergone by children in Australia (ACSQHC 2021a) - but is it being performed more often than necessary?

What are the Tonsils?

The tonsils, which form part of the immune system, consist of two pads of lymphatic tissue at the back of the throat (one on each side) (Children’s Health Queensland 2020).

More lymph nodes known as adenoids sit behind the nose at the back of the throat, out of sight. Together, the tonsils and adenoids help to prevent infection by trapping pathogens that enter the nose and mouth and producing antibodies to kill them (Seladi-Schulman & Gill 2018).

Despite this, the tonsils and adenoids themselves are prone to infection and inflammation, particularly among children (ACSQHC 2021a; Healthdirect 2020a).

Why are Children Prone to Tonsil-related Issues?

Children naturally have large tonsils that grow rapidly between the ages of two and seven. This occurs because children are frequently exposed to infections, which cause the tonsils to enlarge (Healthdirect 2020b; RCHM 2018).

This is normal, and in fact, a person’s tonsils are generally at their largest during childhood (Better Health Channel 2013). The adenoids are also largest during childhood and may disappear altogether before adolescence (Healthdirect 2020a).

However, while enlarged tonsils and adenoids are common in young children, they can cause respiratory issues if they are large enough to block the airway (Better Health Channel 2019).

Children with large tonsils also tend to breathe through their mouth, which can lead to an increased risk of respiratory tract infections or jaw misalignment (InformedHealth.org 2019).

Common Tonsil-Related Issues Among Children

Tonsillitis

Read: Common Respiratory Tract Infections (RTI)

Tonsilitis is an infection that causes the tonsils to become inflamed and swollen. It is usually caused by one of many viruses, although about 15 to 30% of cases are bacterial. Often, it occurs after a cold. It can affect anyone but is most common in children (Healthdirect 2021; PCH 2020).

Symptoms in children may include:

• Sore throat
• Inflamed and painful tonsils, with white patches or pus in some cases
• Fever
• Swallowing difficulty, pain when swallowing or drooling
• Headache
• Swollen lymph nodes in the neck
• Nausea and vomiting
• Loss of appetite
• Hoarse or muffled voice
• Bad breath
• Stiff neck
• Ear pain
• Eye pain
• Abdominal pain
• Runny nose.

(Healthdirect 2021)

Obstructive Sleep Apnoea (OSA)

Read: Obstructive Sleep Apnoea: More Than Just a Bad Night's Sleep

Obstructive sleep apnoea (OSA) is a condition experienced by some children who have large tonsils and adenoids obstructing their airway.

OSA occurs when the upper airway muscles are partially or completely blocked during sleep. A person with OSA will stop breathing, wake up, open their airway and then immediately go back to sleep. This sequence may repeat hundreds of times in one night, impacting the person’s sleep quality (RCHM 2018; Better Health Channel 2019).

While large tonsils and adenoids are the primary cause of OSA in children, other contributing risk factors include obesity, Down syndrome, brain abnormalities and neuromuscular disorders (ACSQHC 2021a).

Symptoms of OSA in children include:

• Loud snoring, pauses in breathing or breathing difficulty during sleep
• Choking, gasping or snorting during sleep
• Restlessness and perspiration during sleep
• Unusual sleep positions (e.g. propped up high on pillows)
• Breathing through the mouth instead of the nose during sleep
• Headaches or fatigue in the morning
• Blocked nose, poor appetite or swallowing difficulties
• Concentration difficulties, behavioural issues or learning difficulties due to impaired sleep.

(RCHM 2018)

If left untreated, OSA may cause impaired growth, cognitive and behavioural issues, and even cardiovascular problems (ACSQHC 2021a).

What is a Tonsillectomy?

In some cases, children require surgical intervention in order to manage recurrent tonsillitis or OSA (ACSQHC 2021a).

This is achieved by performing a tonsillectomy - a procedure wherein the tonsils are surgically removed (Children’s Health Queensland 2020).

Despite the routine use of tonsillectomy in Australia to treat both recurrent tonsillitis and OSA, there is uncertainty surrounding the effectiveness of the procedure (ACSQHC 2021b).

Tonsillectomy in Australia

The Fourth Australian Atlas of Healthcare Variation identifies tonsillectomy in children as a key issue, stating that there is an ‘urgent need’ to determine the short and long-term outcomes of the procedure (ACSQHC 2021a).

What do we know so far?

Tonsillectomy for Tonsillitis

According to data compiled by the Atlas, tonsillectomy in children who experience recurrent tonsillitis has been found to reduce throat infections, doctor visits and school absences. However, these benefits only appear to last for the first year following surgery.

Furthermore, some children with recurrent tonsillitis recover on their own without the need for surgery (ACSQHC 2021a). While there are no Australian guidelines for tonsillectomy in children with recurrent tonsillitis, United States guidelines suggest the procedure be offered to children experiencing:

• Seven or more tonsillitis infections per year, or
• Five or more tonsillitis infections per year for two years, or
• Three or more tonsillitis infections per year for three years.

(ACSQHC 2021a)

Tonsillectomy for Obstructive Sleep Apnoea (OSA)

First-line treatment for moderate or severe OSA and enlarged tonsils is generally adenotonsillectomy (removal of the tonsils and the adenoids). However, the benefits of adenotonsillectomy for mild to moderate OSA compared with watchful waiting are inconclusive, though some studies have suggested that it may improve sleep study scores, symptoms, behaviour and quality of life. It is also possible that some children will recover on their own without surgery (ACSQHC 2021a).

Potential Complications of Tonsillectomy

In addition to determining the potential benefits of undergoing a tonsillectomy, it is also important to understand the possible consequences of the procedure.

Compared to all childhood surgical procedures, tonsillectomy has the highest risk of postoperative complications (ACSQHC 2021a). These may include:

• Respiratory compromise
• Pain
• Bleeding
• Dehydration
• Nausea and vomiting
• Speech disorders
• Unplanned hospital readmission
• Death (rarely).

(ACSQHC 2021a)

Among these potential complications, the most common is postoperative bleeding, which can be fatal in some cases (ACSQHC 2021a).

What Recommendations Have Been Made?

Based on the information compiled by the Atlas, the Australian Commission on Safety and Quality in Health Care recommends that the Australian and New Zealand Society of Paediatric Otorhinolaryngology develops clinical guidelines for tonsillectomy in children. From there, the Commission will develop a clinical care standard with safety and quality indicators (ACSQHC 2021b).

Until then, clinicians and parents are left to weigh up the potential risks and benefits of tonsillectomy and make difficult treatment decisions amidst this uncertainty (ACSQHC 2021a).

Additional Resources

• The Fourth Australian Atlas of Healthcare Variation 2021 | ACSQHC
• Common Respiratory Tract Infections (RTI) | Ausmed Article
• Obstructive Sleep Apnoea: More Than Just a Bad Night's Sleep | Ausmed Article

References

• Australian Commission on Safety and Quality in Health Care 2021b, 3.1 Tonsillectomy Hospitalisations, 17 Years and Under, ACSQHC, viewed 3 May 2021, https://www.safetyandquality.gov.au/our-work/healthcare-variation/fourth-atlas-2021/ear-nose-and-throat-surgery-children-and-young-people/31-tonsillectomy-hospitalisations-17-years-and-under
• Australian Commission on Safety and Quality in Health Care 2021a, Fourth Australian Atlas of Healthcare Variation 2021: 3.1 Tonsillectomy Hospitalisations, 17 Years and Under, ACSQHC, viewed 3 May 2021, https://www.safetyandquality.gov.au/sites/default/files/2021-04/fourth_atlas_2021_-_3.1_tonsillectomy_hospitalisations_17_yeras_and_under.pdf
• Better Health Channel 2019, Sleep Apnoea, Better Health Channel, viewed 3 May 2021, https://www.betterhealth.vic.gov.au/health/ConditionsAndTreatments/sleep-apnoea
• Better Health Channel 2013, Tonsillitis, Better Health Channel, https://www.betterhealth.vic.gov.au/health/ConditionsAndTreatments/tonsillitis
• Children’s Health Queensland Hospital and Health Service 2020, Tonsillectomy, Queensland Government, viewed 3 May 2021, https://www.childrens.health.qld.gov.au/fact-sheet-tonsillectomy/
• Healthdirect 2020a, Adenoids, Healthdirect, viewed 5 May 2021, https://www.healthdirect.gov.au/adenoids
• Healthdirect 2020b, Adeno-tonsillectomy (Child), Healthdirect, viewed 3 May 2021, https://www.healthdirect.gov.au/surgery/adeno-tonsillectomy-child
• Healthdirect 2021, Tonsillitis, Healthdirect, viewed 3 May 2021, https://www.healthdirect.gov.au/tonsillitis
• InformedHealth.org 2019, Enlarged Tonsils and Adenoids: Overview, Institute for Quality and Efficiency in Health Care, viewed 3 May 2021, https://www.ncbi.nlm.nih.gov/books/NBK536881/
• Perth Children’s Hospital 2020, Tonsillitis, Government of Western Australia Child and Adolescent Health Service, viewed 3 May 2021, https://pch.health.wa.gov.au/For-health-professionals/Emergency-Department-Guidelines/Tonsillitis
• The Royal Children's Hospital Melbourne 2018, Obstructive Sleep Apnoea (OSA), RCHM, viewed 3 May 2021, https://www.rch.org.au/kidsinfo/fact_sheets/Childhood_obstructive_sleep_apnoea_OSA/
• Seladi-Schulman, J & Gill, K 2018, Tonsils and Adenoids Overview, Healthline, viewed 3 May 2021, https://www.healthline.com/health/tonsils-and-adenoids