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TONSILS: SHOULD YOU HAVE THEM OUT?

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by Galen H. McGovern

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I thought that people didn’t get their tonsils out any more? I heard this frequently once we scheduled our son’s tonsillectomy. I told people that it still happens. About 500,000 tonsillectomy procedures are performed each year, “making it a pretty common operation — if not the most common operation that children undergo,” says Joseph Bernstein, M.D., director of pediatric otolaryngology at the New York University School of Medicine. The American Academy of Otolaryngology recommends that patients with three or more tonsil infections per year have them removed. It also cites tonsil enlargement causing upper airway obstruction, difficulty swallowing, and sleep disorders as reasons for removal. The University of Washington’s department of otolaryngology suggests that individuals with six to seven infections in one year, or two to three infections per year for more than a few years, would probably benefit from tonsillectomy. “Previously, the major need for a tonsillectomy was recurrent infection but in the last decade, doctors have learned to recognize the signs and symptoms of sleep obstruction in children and now we do just as many tonsillectomies for sleep obstruction as we do for recurrent infections,” Dr. Bernstein says. After two winters of several episodes of strep throat and chronically enlarged tonsils, I was still leery about putting my 4-year-old through a major operation. Besides, in the back of my mind I wondered: why have tonsils if they are not used for something? My searches of the web for sites extolling the virtues of keeping the tonsils turned up little, however. And I didn’t believe the doctors who told me “You don’t need your tonsils.” The truth is, the exact role played by tonsils in the body’s immune system is still an active area of research. According to University of Washington researchers, tonsils do play a role in fighting disease during early life.

The turning point in my son’s case came after two bouts of back-to-back strep throat infections. Six months prior to this, after two winters of infections and penicillin, our pediatrician suggested we consider having his tonsils removed. He explained that you really have to justify tonsil removal these days, and recommended a sleep study to document sleep disturbance and apnea. Now, he unequivocally stated: “I would have them out.” The ear, nose, and throat specialist agreed: “They should come out.” My husband and I became fully convinced when the pediatrician told us, “The tonsils don’t calm down until they are about 8.” Four more years of misery. Our son’s enlarged tonsils were affecting his sleep and behavior. He was grumpy 50 percent of the time. When an infection was approaching, he had night terrors where he woke up screaming bloody murder and pointing at intangible things around the room with great fear. The trance-like state is quite frightening. His tonsil doctor explained that he was waking up in this hysterical state because he couldn’t breathe. So we decided that the tonsils must come out. I encouraged our son by explaining that after the operation, he could only eat soft foods like ice cream. I told him he wouldn’t get sick so often, and would feel and sleep better. He seemed in perfect agreement and wanted to get them out that day! If only he knew. If only we knew. I didn’t know what the aftermath was going to be like until I was called into the recovery room to comfort my hysterical son. He kept trying to get out of the bed, crying beyond control. I couldn’t comfort him. After about 45 minutes of hysterics, he calmed down only after the nurse gave him some painkiller orally. Why didn’t they give this to him earlier? The doctor explained that they shoot the area of the tonsils with painkiller, but the scraping required to remove the adenoids causes a lot of pain.

For one week after the operation, he cried uncontrollably several times a day and woke up twice a night. Sometimes after taking Tylenol or codeine syrup, he would eat something soft or try to drink. For the most part, he didn’t eat at all and drank only water. Not even ice cream enticed him. A nurse suggested we double the doses of Tylenol. This didn’t seem to help. He was in so much pain and was losing a lot of weight. Not only did his mouth and throat hurt, he began holding his ears. That got me worried. “It’s not the ice cream that your kids don’t want,” Dr. Bernstein explains. “It simply hurts so much to swallow that you can't even bribe them with their favorite foods.” I made an appointment with the surgeon and he explained that what Michael was going through was all very normal. The pain in his ears was due to the nearby jaw joint (stretched during surgery) and referred pain from the high concentration of nerves in the disturbed tonsil area. He explained the only thing to worry about was bleeding. This made me feel a little better, but Michael was still in agony. The doctor prescribed steroids to reduce the swelling in his throat and a more potent painkiller. We could have used some of these drugs from day one. The recovery was rough — if only I’d known what to expect. After about three weeks, he really seemed better than he had been prior to the operation. Now, he has totally forgotten about the pain, and is glad they are out. As for my son’s overall health, the first winter following the tonsillectomy he wasn’t sick at all. He seemed to be sleeping better and he quickly gained back the lost weight — the 6-8 pounds was gained back within three months. I feel like we make the right decision — no more chronic strep throat, and a more rested, cheerful kid. Nevertheless, I do think the process could have gone more smoothly if I had known what to expect. Dr. Bernstein agrees: “Recovery can really throw you for a loop if you don’t know what to expect.” With a total tonsillectomy, recovery lasts seven to 10 days and narcotic or prescription painkillers are not unusual to control postoperative pain. But aside from sheer pain, children may not want to eat, drink or talk because it requires the use of certain scarred muscles. “Younger kids may not want to eat or drink or take medications and, therefore, their pain can’t be relieved and they get into a situation where they become dehydrated and need to be re-admitted to the hospital,” Dr. Bernstein says. Parents must also be psychologically prepared because 2 to 3 percent of children will have a post-operative bleeding episode. “This can be quite traumatic for a child and for parents because it rarely happens immediately after the operation,” Dr. Bernstein explains. “In fact, sometimes it occurs five to 10 days later when a scab sloughs off and blood vessels open up and cause bleeding,” he says. But don’t panic. “It is not related to the way the operation was performed; it can be a part of the healing process.” Some doctors opt for performing a subtotal tonsillectomy, which leaves some tonsil tissue behind in the hope of that tissue acting as a Band-Aid and protecting the throat (see sidebar). “Studies in the last couple of years suggest that the recovery is twice as fast and needs half the amount of pain medication with the subtotal procedure,” Dr. Bernstein says. ”With the subtotal procedure, there is a three- to four-day recovery period with less requirement for pain medication.” The downside to the subtotal procedure, Dr. Bernstein points out, is that, theoretically, doctors are leaving tonsil tissue behind and they don’t yet know if this tissue will develop infection in the future and need to be removed.

Denise Mann contributed to this report.

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Kids Recover Quicker from Partial Tonsillectomies An old procedure for removing tonsils is gaining new popularity. If your little one snores because his tonsils obstruct his airway, partial tonsillectomy might be just the ticket, according to the American Academy of Otolaryngology Head and Neck Surgery. Researchers at The Children's Hospital at the Cleveland Clinic Foundation studied over 550 children who needed a tonsillectomy because of enlarged tonsils. Half the group had a standard tonsillectomy that consists of removing all of the tonsillar tissue and the tonsillar capsule. The other half had a partial tonsillectomy, which included shaving away a portion of the tonsillar tissue and leaving the capsule, which encases the tonsils, in place. Afterwards, they interviewed the parents. They found that, compared to the standard operation, children who had partial tonsillectomies had less pain, fewer days of pain medication, and fewer days needed to return to normal activities and normal diet. The surgery was a success at relieving sleep apnea — a condition in which patients stop breathing for short periods repeatedly throughout the night — and for children with tonsil infections. Investigators said the two surgeries were similar when comparing blood loss and post-operative complications. They did not study the likelihood of possible tonsil re-growth after partial tonsillectomy.  Dale Mazer, M.D., M.P.H.

—————————————————————— Local doc tries “cool burn” method

By Kristen J. Gough

Susan Friedlaender recalls June 19, 2002 as one of the longest days of her life. The New Rochelle mother waited and worried as both of her children, Jason, age five, and Greg, age eight, had their tonsils removed. While she didn’t relish the idea of surgery for her children, it was better than the alternative — countless visits to the doctor’s office and throat infections so frequent that her boys had a tough time making it to birthday parties, soccer practices and even school. Friedlaender’s doctor, Stephen Jablon, M.D., of ENT and Allergy Associates in Rye Brook, suggested a new procedure for Jason and Greg — a coblation tonsillectomy. After surgery, both boys were sore but within a couple of days they had returned to their normal diets and by the end of the week they were back at summer camp. When asked if she would have the surgery for her children again, Friedlaender responded enthusiastically. “Yes, we’ve had no sick days this year,” she said, “but I might not do them both on the same day.” Friedlaender’s sons were two of nearly 700,000 children in the U.S. to undergo tonsillectomies last year. As previously stated, while tonsillectomies are common, the method of performing the surgery is not uniform. And method of tonsillectomy is an ongoing debate within the medical community, specifically among Ear, Nose and Throat (ENT) specialists, or otolaryngologists. Although coblation tonsillectomy holds promise for easing the pain of the procedure, many doctors question its effectiveness. “I understand doctors’ concerns about the technique,” explains Dr. Kelvin Lee of Rye, associate professor of clinical otolaryngology at New York University Medical Center and associate director of otolaryngology at Bellevue Hospital Center. Dr. Lee developed the coblation procedure because, he says, “The traditional approach to tonsillectomy, using a scalpel to cut or an electrocautery to burn the tissue and then remove the tonsil, continues to be associated with a high level of postoperative pain and significant incidence of postoperative bleeding.” To address both of these concerns, Dr. Lee used coblation technology, which had previously been effective in orthopedic surgery. Coblation tonsillectomy is often described as a “cool burn”. By passing a wand-like instrument over the infected tonsil, low-temperature radio frequency energy breaks down the tissue, essentially dissolving it. The doctor is then able to take out the tonsil with minimal damage to the surrounding tissue. A study of pediatric coblation tonsillectomy, appearing in the International Journal of Pediatric Otorhinolayrngology, concluded, “This new technique using tissue coblation for tonsil removal offers significant advantages in the post-operative period, with rapid return to a normal diet and a drastic reduction in analgesic requirements (pain medication) following the surgery.” “These studies have been limited,” says Dr. R.J. Ruben, distinguished university professor at the Albert Einstein College of Medicine and the Montefiore Medical Center. Dr. Ruben has performed coblation tonsillectomies, but prefers more traditional techniques. “It’s very simple,” he explains. “There’s a very small incidence of complication with tonsillectomy but there are risks. You are working in the middle of a child’s airway. Tonsillectomies are performed on relatively healthy children. And I would rather use a traditional approach, which I have found effective, rather than risk the patient’s health for the possibility of less post-operative morbidity (pain).” Along with lack of significant studies, Dr. Stephen Salzer, an instructor in surgery at the Yale University School of Medicine, points out that the coblation procedure is a slower technique than a traditional tonsillectomy. The time of surgery is significant because the longer the procedure takes, the greater likelihood that the tongue will be more swollen and the pain after surgery more severe. “No one wants to inflict more pain in a patient, especially a child,” says Dr. Sylvan Stool, former chief of pediatric otolaryngology at Philadelphia Children’s Hospital. “Every [new tonsillectomy] procedure has come out and said that it causes less pain than another. The bottom line is that you can’t do surgery in the mouth in an area that is involved with activities such as swallowing and eating without pain until healing occurs. It just doesn’t make sense.” Dr. Stool suggests a more old-fashioned approach to easing children’s post-surgery pain. “There is a great individual variation among children concerning their perception of pain and how they handle it,” he says. “Some of that perception is in reaction to their parent’s anxiety. If parents continually ask the child, ‘Are you hurting?’, they’ll be hurting.” While the debate continues over how to improve tonsillectomies, experts point out that parents need to discuss with their doctor the most effective surgery for their child. “With each patient,” Dr. Lee says, “you have to evaluate their circumstances and present parents with their options so that they can make an informed decision.” For more information on tonsillectomy, visit www.snoreinfo.com, www.kids-ent.com, and www.entandallergy.com.

 


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