Tonsillar Hypertrophy: in and of itself and indication for tonsillectomy in kids?

[DrMetal]

Hi, quick question:

Do you guys generally recommend tonsillectomy in kids with very large---say kissing tonsils, almost obscuring the airway---who are completely asymptomatic? (no recurrent infections, no known OSA, no known airway difficulties? In other words, is severe tonsillar hypertrophy in and of itself (in the absence of anything else) and indication for a tonsillectomy in kids?

Thanks,

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[OtoHNS]

No, but I would send the kid for a sleep study (and recommend surgery if it is positive for OSA). It would be unusual to see a true 4+ tonsillar hypertrophy with no symptoms though.

If the sleep study was normal and there was no history of recurrent or chronic tonsillitis, I would not recommend tonsillectomy no matter how big the tonsils are.

 

[DrMetal]

It would be unusual to see a true 4+ tonsillar hypertrophy with no symptoms though.

And I'd imagine most parents aren't that astute at catching/reporting OSA symptoms in their 3-yo, right? (kid goes to bed, sleeps, wakes up next day, runs around, must be fine). Also with 4+ hypertrophy, sooner or later they'd have to come out, you'd rather do the surgery at age 3 than 10, right? (anes for a 3-yo is just gas?).

 

[OtoHNS]

No, in my experience, most parents are very aware of what’s going on with their kid’s breathing overnight. I typically proceed directly to surgery if the parent is reporting apneas, gasping, etc overnight. No need for a sleep study in that case.

And no, big tonsils alone (without any OSA or infection issues) is not an indication for tonsillectomy. They will not need to be removed “sooner or later” unless an actual reason for tonsillectomy develops. That being said, most (all?) patients with 4+ tonsils will have sleep disordered breathing or some other indication for surgery.

 

[DrMetal]

No, in my experience, most parents are very aware of what’s going on with their kid’s breathing overnight. I typically proceed directly to surgery if the parent is reporting apneas, gasping, etc overnight. No need for a sleep study in that case.

And no, big tonsils alone (without any OSA or infection issues) is not an indication for tonsillectomy. They will not need to be removed “sooner or later” unless an actual reason for tonsillectomy develops. That being said, most (all?) patients with 4+ tonsils will have sleep disordered breathing or some other indication for surgery.

Got it, thank you!

 

[HighPriest]

Surprising how often the parents are very aware of symptoms of OSA if you just run down a list. The only time I get any waffling is when it’s a somewhat “older” kid (sleeps in their own room) and the parents sometimes don’t know if there are apneic pauses.

Agree with everything above. At least a couple times every month I tell a parent that you don’t have to take out a set of tonsils just because they’re big. Lots of consults for that. And yeah, usually if they’re 4+ and you ask the right questions you’ll figure out that they’re causing trouble somehow.

 

[DrMetal]

And yeah, usually if they’re 4+ and you ask the right questions you’ll figure out that they’re causing trouble somehow.

Yeah this is what prompted my question. Saw a kid with 4+ (so big, no daylight between them), ENT took one look at em, said they have to come out. parents claim the kid is asymptomatic. ENT didn't believe them, and said they should come out (almost suggested it as a prophylactic measure...he was convinced they would be problematic in the future). Parents didn't seem reliable.

 

[HighPriest]

Well, lots of possible explanations.

He may have found a real problem, and the parents just weren't following the rationale.

He may just be one of those guys who will operate on anything you send him. Always be wary of that, of course.

He may just be old AF. We used to take tonsils out of everyone for any reason. I have two older partners who will take any big tonsil out and call it chronic tonsillitis. They've even had a conversation with me about how big tonsils are chronic tonsillitis, and they should come out. It's antiquated thinking, and not really appropriate (which I've told them.)

I tell parents that you don't need to take out tonsils just because they're there. If they cause OSA, infections, pain, tonsil stones, etc., etc., then I think it's reasonable. If they're that big, it's hard to believe that they won't cause a problem at some point. That being said, I've seen it happen. Kid has a growth spurt and the tonsils don't. The other classic one is the 17 year old girl with massive kissing tonsils because she has EBV or CMV. People freak right out when they see them, and we get consulted emergently for this kid who is now in the ICU on observation. And you put her on steroids and fluids and in 2 weeks she's fine and more often than not her tonsils are back down.

But, again, if you ask the right questions and someone has tonsils that big, you can usually find a reason to take them out if you want to.