Is adenoidectomy alone sufficient for the treatment of airway obstruction in children?

BACKGROUND Adenoidectomy is one of the most common surgical procedures performed in children in the United States. Indications for adenoidectomy include chronic or recurrent otitis media, as well as subjective upper airway obstructive symptoms such as nasal obstruction with chronic mouth breathing, snoring, chronic rhinitis, and chronic or recurrent sinusitis. When the indication includes obstructive symptoms, tonsillectomy is often considered. Parents often ask if the tonsillectomy can also be done, ‘‘since you are already in there.’’ However, adding a tonsillectomy can contribute significantly to surgical morbidity and mortality. Specifically, the risk of postoperative hemorrhage following adenoidectomy alone is less than 1%. The rate of hemorrhage follow tonsillectomy can be up to 3%. The return to normal activity and school occurs the day after the adenoidectomy in most children, whereas the recovery period after tonsillectomy can last up to 14 days, requiring parents to take extended periods off from their jobs. In order to adequately council patients on when to perform an adenoidectomy alone, one may want to consider and discuss with the family the likelihood of their child needing a tonsillectomy in the future. LITERATURE REVIEW Indications for when to perform an adenoidectomy versus a combined adenotonsillectomy are not universal. In a study by Kay et al., American Society of Pediatric Otolaryngology (ASPO) and American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS) members in New York were surveyed. Two brief case presentations were included in the survey. The first case discussed a child with obstructive sleep apnea (OSA) and enlarged adenoids, but small tonsils. Most respondents reported they would perform adenoidectomy alone rather than adenotonsillectomy (T&A). But more than half of each group would ‘‘sometimes’’ perform a T&A. The second scenario described a child with symptomatically enlarged adenoids and incidentally large tonsils. Most respondents still would perform an adenoidectomy alone. This study demonstrates the variability within our specialty. Although the AAO-HNS Clinical Practice Guidelines address the need for tonsillectomy for children with upper airway obstruction and sleep disordered breathing, they do not address the question of adenoidectomy alone for similar symptoms. There have been a few articles specifically evaluating the risk of subsequent tonsillectomy when adenoidectomy alone has been done in the past. Kay et al. found that several factors increased the odds of future tonsillectomy after adenoidectomy alone. Based on their retrospective review of 2,462 patients, they found that the overall incidence rate for tonsillectomy was 2.0% per year. However, if the indication for surgery (upper airway obstruction, otitis media, or sinusitis) is included, a clear difference can be seen. If the adenoidectomy was done for upper airway obstruction, the patients were 1.9 times more likely to require subsequent tonsillectomy. It was also noted that children under the age of 2 at the time of adenoidectomy are more likely to undergo future tonsillectomy. They found 28.7% of children under the age of 2 required a tonsillectomy within 5 years. This number decreased to 14.8% for ages 2 to 4 years, and subsequent tonsillectomy was needed within 5 years in 6.1% for ages 5 to 7 and in 2% for ages older than 7 years. See Figure 1. From the Department of Otolaryngology Head Neck Surgery (S.S.), University of Cincinnati; and the Cincinnati Children’s Hospital Medical Center (A.B., S.S.), Cincinnati, Ohio, U.S.A. Editor’s Note: This Manuscript was accepted for publication November 1, 2012. The authors have no funding, financial relationships, or conflicts of interest to disclose. Send correspondence to Sally R. Shott, MD, Department of Pediatric Otolaryngology, Cincinnati Children’s Hospital Medical Center, 3333 Burnet Avenue, Cincinnati, OH 4529. E-mail: [email protected]