Lille, France – While progress in the techniques used to operate on children has made it possible to improve post-operative morbidity, the indications for tonsillectomy have changed little. the Congress of Pediatric Societieswhich was held in Lille from June 1 to 3, 2022, dedicated a session to updating the recommendations by the French Society of Oto-Rhino-Laryngology (SFORL) and Cervico-Facial Surgery (CCF).
Hypertrophy and sleep disorders
If the indications of infectious origin are well marked out (>7 infectious episodes over the last year, or >5/year over the last 2 years, or >3/year over the last 3 years), hypertrophy and sleep constitute the other part of the indications: it is necessary to look for the presence of nocturnal and/or diurnal signs evoking a sleep breathing disorder, and the questioning of the parents on this subject has an excellent predictive value. It is necessary to look for amygdala hypertrophy leading to an obstruction of the upper airways (VAS) and generating a syndrome of high resistance of the VAS or obstructive sleep apnea syndrome (SAHOS), knowing that these two disorders can also exist in l absence of hypertrophy (and vice versa). Nasofibroscopy is particularly useful in assessing nasal obstruction and the extent of enlargement in the cavity. Polysomnography is not essential to assess OSAHS except in special cases (discordance between the clinic and the pharyngeal examination, operative risk, morbid obesity, comorbidities, etc.). Finally, there are also a number of situations in which tonsillectomy is not recommended (unprogressive unilateral hypertrophy) or recommended on a case-by-case basis.
Partial excisions: less painful
Several surgical approaches are considered to perform tonsillectomy: however, most of the techniques used until now have relied on extracapsular dissections. Gradually, these total tonsillectomies have been replaced by partial resections which are less painful and have a lower risk of bleeding. Thus, intracapsular techniques such as microdebriders, radiofrequency devices or coblation offer the means to gradually remove the tissue and thereby allow reduced postoperative morbidity and an accelerated return to normal activity.
The management of tonsillectomy on an outpatient basis is possible provided that there are no medical contraindications (anaesthetic, surgical, etc.), that the social criteria are met and that the organization of the structure allows this support. Postoperative monitoring should ensure food intake, monitoring of the occurrence of bleeding, vomiting, or postoperative pain, and their treatment if necessary.
Despite the success of the treatment on the obstructive disorders, some children will not be improved: it is necessary to redo an assessment, consider a polysomnography and perform an endoscopy under induced sleep to look for an element that would persist. For the others, there is a risk of resumption of the disorders, in the medium or long term, in particular by adenoid or tonsillar regrowth. Regular monitoring over the following years is therefore recommended.
This article was originally published on Univadis.frmember of the Medscape network.
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