pediatric housecalls Robert R. Jarrett M.D. M.B.A. FAAP


[A mother asks for information about the guidelines for tonsillectomy in a six-year-old.]

My son is scheduled to have a tonsillectomy and adenoidectomy in 2 weeks. He is 6 yrs old. The reason why his primary physician referred him to a ENT specialist is because of recurring tonsillitis. He had 4 tonsillitis episodes last year. This year, he had 3 episodes. After the ENT specialist saw his X-Ray which showed a small airway passageway on his nose and throat, he immediately recommended surgery.
As a parent, I don’t want him to undergo any surgery right now. He is too young and I am afraid of the bleeding risk he might have. Is there any way to avoid this? Can we wait until he turns 8 or 9 yrs old? I badly need your advise and recommendation… Joanne
Thanks for your interest in my site. I must tell you that I receive nearly 3 questions about the tonsillectomy procedure for every one question about anything else. So there still seems to be a lot of confusion about the topic DESPITE the American Academy of Pediatrics and board of Otolaryngology having published fairly good “tonsillectomy guidelines” for physicians. You expressed great concern about your son’s upcoming surgery and asked if there was anything else that could be done and I also heard the unstated implication “does this really need to be done?” Your fears are telling you something – if only that you haven’t been given enough credible information. And, you are the one who would be in the best position to answer the questions.

First, ask yourself “what are we trying to improve or prevent” – i.e.. “why are we doing this?” What happens when your son gets a tonsil infection? Does he miss more than a couple days of school? is he otherwise healthy? How are the infections diagnosed? Was it by a “screen” or have actual “real cultures” been performed? If they were truly caused by Strep more than a few times, have any follow-up cultures after he was “well” been performed to make sure that he just isn’t “a carrier” for the strep. If he was, then even when he contracted a viral illness he would “magically” show “strep” because it’s always there?

Second, “Snoring” by itself is not an indication for tonsillectomy; nor are multiple ear infections an indication for adenoidectomy as long as they resolve by treatment. Has there been any hearing impairment demonstrated over 6-8 months? Is there any “emergency” reason to perform the surgery now – especially going into summer when the incidence of “colds” and infections go way down?

If you stand back and take a fresh look at the answers to these questions it should help you make a decision. You should know that there have been studies which have shown the incidence (frequency) of sore throats most frequently don’t get any less in number after the tonsils are removed (their severity may diminish somewhat.) Also, that x-rays are not the test for diagnosing soft tissue. Bone is what they show best, so someone looking for an air passage on an x-ray would most likely only be able to comment on the bony nasal passages with any accuracy – you didn’t mention him being scheduled for nose turbinate surgery. X-rays are not in the guidelines as diagnostic measures for a tonsillectomy.

It sounds like there are those pushing you faster than you feel comfortable in going. Ask yourself: what will happen if I wait? a month or a year? one or two more sore throats? or anything else? Then ask the same questions of physicians who have seen your child.

A Rand study showed that in the US there is much surgery (and many procedures) performed without adequate indication. I’m not sure whether your son’s would fall into that category or not; but, before you allow any incisions you should REQUIRE that your son’s physicians convince you with facts and logic. And also that the benefits (whatever they are) outweigh the risks.

Based on the limited information at my disposal, a second opinion may be in order from an unrelated physician.

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