• AAFP Endorses AAO-HNS Tonsillectomy in Children Guideline

    February 27, 2019, 03:10 pm Chris Crawford – The AAFP has endorsed an updated guideline on tonsillectomy in children that was developed by the American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS).

    Published Feb. 5 in Otolaryngology-Head and Neck Surgery, the AAFP endorsed the guideline when it was first reviewed in November.

    This clinical practice guideline is intended for all clinicians in any setting, including family physicians, who interact with children ages 1-18 who may be candidates for tonsillectomy.

    The guideline updates and replaces the AAO-HNS' 2011 guideline on the topic and includes 15 key action statements and new information that applies to children for whom tonsillectomy is being considered.

    "The purpose of this multidisciplinary guideline is to identify quality improvement opportunities in managing children, 18 years of age or less, who are under consideration for tonsillectomy and to create explicit and actionable recommendations," said Ron Mitchell, M.D., chair of the AAO-HNS' guideline update group, in a news release.

    physician examining young girl's throat

    Mitchell added that there is an emphasis on the need for evaluation and intervention in special populations -- highlighting the need for counseling and education of families.

    Family physician Sarah Coles, M.D., of Phoenix, participated as a member of the guideline update group. Coles is an assistant professor of family, community and preventive medicine in the University of Arizona College of Medicine.

    Story Highlights

    Coles told AAFP News that she believed the Academy's Commission on Health of the Public and Science chose to endorse this guideline for several reasons.

    Tonsillectomy in children is an important and relevant issue for family physicians because they are frequently asked to evaluate whether tonsillectomy is indicated for recurrent throat infections and obstructive sleep-disordered breathing, she said. Additionally, family physicians often see these children in the postoperative period and may be asked to assist in management of post-tonsillectomy pain.

    "This guideline gave clear, actionable and sound recommendations that are valuable in the primary care setting," Coles said. "The guideline panel was multidisciplinary and, importantly, included consumer representatives to ensure that patient preferences were sought and addressed throughout the process."

    Updates Since 2011 Guideline

    The AAO-HNS said in its news release that since its 2011 guideline, changes in practice have included fewer clinicians using routine postoperative antibiotics and the FDA's addition of a black box warning on the use of codeine in children. (That drug safety communication has since been updated.)

    The revised guideline incorporates input from the two new consumer advocates who joined the guideline update group and includes evidence from one new clinical practice guideline, 26 new systematic reviews and 13 new randomized controlled trials, among other changes.

    According to Coles, major updates from the previous guideline included adding evidence profiles for each of the 15 key action statements (seven of which are new).

    "These profiles include aggregate evidence quality, confidence in the evidence, benefits and harms of the recommendations, role for patient preferences, value judgments made by the panel, and a description of any differences of opinion expressed by panel members," she said. "This is intended to increase clarity and transparency for physicians utilizing this guideline."

    Additionally, Coles said the AAO-HNS updated five of its previous key action statements, including changing the strength of a recommendation for watchful waiting for recurrent throat infection if there have been fewer than seven episodes in the past year, fewer than five episodes per year in the past two years, or fewer than three episodes per year in the past three years. That is now a strong recommendation, she noted.

    "Tonsillectomy in children who do not meet these criteria (known as the Paradise Criteria) does not provide clinically meaningful improvements in outcomes, is not cost-effective and exposes children to unnecessary risks of surgery," Coles said.

    Notes on Key Action Statements

    Coles said there are a number of key action statements she thinks are especially important for family physicians to know about.

    First, the AAO-HNS added a new action statement that suggests physicians recommend tonsillectomy for children with obstructive sleep apnea (OSA) documented by overnight polysomnography.

    "The prior guideline stated that physicians should counsel caregivers about tonsillectomy to improve health in children with abnormal polysomnography," Coles said. "The results of the Childhood Adenotonsillectomy Trial (CHAT) demonstrated that tonsillectomy improved symptoms, behavior and quality of life outcomes for children with OSA treated with tonsillectomy compared with watchful waiting."

    Another new key action statement specifically recommends that clinicians not administer or prescribe codeine, or any medication containing codeine, after tonsillectomy in children younger than age 12.

    "This is in line with the FDA's black-box warning," Coles said. "Patients and caregivers are likely to look to their family physician for assistance in postoperative pain control. Family physicians should feel comfortable recommending pain control measures."

    Instead, said a closely related key action statement, physicians should recommend ibuprofen, acetaminophen or both for pain control after tonsillectomy.

    "Ibuprofen is safe and effective and is not associated with significant increased bleeding risk," Coles said.

    Finally, Coles highlighted a key action statement that said tonsillectomy may be considered for recurrent throat infection with a frequency of seven or more episodes in the past year, five or more episodes per year in the past two years, or three or more episodes per year in the past three years with documentation in the medical record for each episode of sore throat and one or more of the following: temperature greater than 38.3°C, or 101°F; cervical adenopathy; tonsillar exudate; or a positive test for group A beta-hemolytic streptococcus.

    "In severely affected children, tonsillectomy results in a small improvement in the first year following tonsillectomy," she said. "However, those benefits do not persist after one year. Watchful waiting is an appropriate option for these children, as well."

    More From AAFP
    Familydoctor.org: Tonsillitis

    Additional Resource
    Choosing Wisely: Perioperative antibiotics for elective tonsillectomy in children