QUESTIONS What are the appropriate indications for tonsillectomy Recurrent infections how many Sleep disordered breathingShould clinicians administer or prescribe perioperative antibiotics to children undergoing tonsillectomyRELEVANT PATIENT GROUPChildren 1 to 18 years of age who may be candidates for tonsillectomyBENEFITS The 2 most common indications for tonsillectomy are recurrent throat infections and sleep disordered breathing SDB. Throat infections are a common reason to see a primary care physician and often result in antibiotic treatment.1 The cost of outpatient visits and the medications prescribed for sore throats including antibiotics are substantial. Indirect costs associated with throat infections and SDB are substantial due to missed school and loss of time from work for caregivers.Treatment of SDB is associated with an increase in health care utilization and cost. Children with SDB compared with controls have a significantly higher rate of antibiotic use 40 more hospital visits and an overall elevation of 215 in health care usage mostly from increased respiratory tract infections.2 Children with tonsillar disease including children with throat infections and SDB also showed significantly lower scores on several quality of Life QoL subscales including general health physical functioning behavior bodily pain and caregiver impact when compared with healthy children.3SDB represents a spectrum of disorders ranging in severity from primary snoring to obstructive sleep apnea OSA. The prevalence of OSA in the pediatric population is 1 to 44 as many as 10 of children have primary snoring.5 Up to 30 to 40 of children with clinically diagnosed SDB exhibit behavioral problems that include enuresis6 hyperactivity aggression anxiety depression and somatization.7 OSA is also associated with poor school performance and a decrease in QoL.8 The QoL of children with OSA is similar to children with chronic conditions such as asthma and juvenile rheumatoid arthritis.9Controversy persists about the actual benefits of tonsillectomy as compared with observation and medical treatment of throat infections. Although tonsillectomy for recurrent throat infections in severely affected children has been shown in a randomized controlled trial to reduce the frequency and severity of infections in the 2 years following surgery10 the same cannot be shown for less severe cases or for a period greater than 2 years after surgery.1112 Observational studies however show improved diseasespecific and global QoL after tonsillectomy for recurrent or chronic sore throat as measured by validated instruments.12 These children suffered fewer infections after surgery resulting in fewer antibiotics and physician visits.A growing body of evidence indicates that tonsillectomy is an effective treatment for SDB13 based on the idea that tonsillar hypertrophy is a principal cause. A metaanalysis of case series14 and a recent study15 showed that tonsillectomy was effective at improving or resolving SDB in most children. There is also evidence that behavioral parameters school performance and QoL improve after resolution of this sleep disorder.8HARMS AND ADVERSE EVENTS OF TONSILLECTOMY Tonsillectomy is a surgical procedure with an associated morbidity that includes possible hospitalization risks of anesthesia prolonged throat pain and financial costs. A common complication of tonsillectomy is bleeding during or after the surgery. In published reports the rate of primary hemorrhage within 24 hours of surgery has ranged from 0.2 to 2.2 and the rate of secondary hemorrhage more than 24 hours after surgery from 0.1 to 3.16 Hemorrhage after tonsillectomy may result in readmission for observation or in further surgery to control bleeding. Other complications of tonsillectomy are diverse and have been well described.17 Operative complications include trauma to the teeth larynx pharyngeal wall or soft palate difficult intubation laryngospasm laryngeal edema aspiration respiratory compromise endotracheal tube ignition and cardiac arrest. Injury to nearby structures has been reported including lip burn eye injury and fracture of the mandibular condyle. Postoperative complications include nausea vomiting pain dehydration referred otalgia postobstructive pulmonary edema velopharyngeal insufficiency and nasopharyngeal stenosis. Complications are more common in patients with craniofacial disorders Down syndrome cerebral palsy major heart disease or bleeding diatheses and in children younger than 3 years with polysomnography PSGproven OSA.1822After tonsillectomy about 1.3 of patients experience delayed discharge during the initial hospital stay and up to 3.9 have secondary complications requiring readmission.23 The primary reasons for readmission or prolonged initial stay included pain vomiting fever and tonsillar hemorrhage. In addition to these common causes of morbidity many unusual and rare complications of tonsillectomy have also been described.24 Among these are reports of vascular injury subcutaneous emphysema jugular vein thrombosis atlantoaxial subluxation Grisel syndrome taste disorders hypogeusia ageusia dysgeusia and phantogeusia and persistent neck pain Eagle syndrome.Mortality rates for tonsillectomy have been estimated at between 1 in 16000 to 1 in 35000 based on data from the 1970s.25 There are no current estimates of tonsillectomy mortality but a prospective audit reported only 1 postoperative death after 33921 procedures in England and Northern Ireland.23 About onethird of deaths are attributable to bleeding while the remainder are related to aspiration cardiopulmonary failure electrolyte imbalance or anesthetic complications.1626 Similarly airway compromise is the major cause of death ormajor injury in malpractice claims after tonsillectomy.

Tonsillectomy is one of the most common surgical procedures in the United States with more than 530 000 procedures performed annually in children younger than 15 years.28 Indications for surgery include recurrent throat infections and sleepdisordered breathing SDB29 both of which can substantially affect child health status and QoL.

The AAOHNSF published a clinical practice guideline CPG on Tonsillectomy in 2011. This CPG will need to be updated in 2016 therefore a systematic review would inform the update.

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Research Quality Improvement at the American Academy ofOtolaryngology Head and Neck Surgery Foundation AAOHNSF

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Stephanie Chang MD MPH