The paediatric approach to tonsillectomy

Abstract

As paediatricians our approach to tonsillectomy should be cautious and should take into account the following consideations, 1. Despite criticism, the incidence of tonsillectomy, the most frequent cause of hospital admission, imrains excessive, particularly in children between five and seven years of age. 2. This age distribution suggts that many tonsillectomies are done because of enlargements which are either physiological, associated with the great chang in development during this critical period, or immunological respon to the unaccustomed infections met with on entry to schooL or to the sepsis resulting from the decay of the primary teeth. 3. Tonsils cannot be determined as 'sdis d' or 'infected' by clinical examination; as their function includes the arrest of pathogenic organisMs, the fact that these can be found in them after removal forms no justifiction for the operation. 4. Tonsilletomy should command all the respect due to a major operation. In a proportion of cases it is followed by umplasant sequeae, and it has a mortality which, though small, is larger than is generally Moreover, tonSillar remnants are often left, which may be more harmful than the original tonsis 5. The most reliable indication is the occurrnce of firquently repeated attacks of acute tonsillitis which cannot be explained by extraneous infection 6. Some indiations still often held to justify the operation, particularly frequent colds, chronic nasal catarrh, and otitis media are misleading. To emove the tonsils to cure sinusitis is to put the cart before the horse. Certain other conditions, including bronchitis, asthma, and nephritis, are definitely contra-indictons. The value of the operation in benefiting acute rheumatism is doubtful. 7. The operation has no value as a prophylactic against common infectious dis, with the possible exception of diphtheria. In residential schools with high tonsilectomy rates, while the incidence of recurrent sore throats may be somewhat diminished, that of firquent colds is slightly increased. The incidence of otitis and mastoid disease is the same, or perhaps slightly increased, in the tonsillectomized, while their liability to bronchitis and pneumonia is also increased. 8. The operation is never urgent, and should always be preceded by a period of observation of six months after the completion of any necessary treatment of teeth or sinuses. It should not be done in winter or early spring, or during the prevalence of infectious diseases, especially of measles or influeza, and most of all when poliomyelitis is epidemic. 9. Further critical and controlled investigation of the indications for and after-results of tonsillectomy are needed, with further study of the optimum age; probably these could best be carried out at the type of clinic resembling the 'Upper Respiratory Clinic for Children' suggested by Mr.Capps, or the pre-tonsillectomy clinic at Mount Sinai Hospital described by Denzer. 10. It is well to remind ourselves that in 1885 that great paediatrician, Goodhart, said of tonsillar enlargement, 'It is comparatively seldom that an operation is necessary . . . children generally grow out of it and at fourteen or fifteen years of age the condition ceases to be a disease of any importance.