II. Indications: Paradise Criteria for Tonsillectomy in Children
- Frequency Criteria: Minimum number of Pharyngitis episodes
- Past 1 year: 7 episodes
- Past 2 years: 5 episodes per year for both years
- Past 3 years: 3 episodes per year for all three years
- Episode Criteria: Each Pharyngitis episode must include at least ONE of the following criteria in addition to Sore Throat
- Temperature >100.9 F (38.3 C)
- Tender cervical adenopathy or cervical Lymph Nodes >2 cm in size
- Tonsillar exudate
- Group A Beta Hemolytic Streptococcus Culture positive
- Treatment Criteria: Each Pharyngitis episode must have been treated with standard protocol
- Antibiotics at conventional dosing for suspected or proven Streptococcal Pharyngitis
- Documentation Criteria
- Medical record documents each Pharyngitis episode including above criteria or
- Observation by clinician for at least 2 subsequent episodes that meet above criteria, typically over a 12 month period
III. Indications: Modifying Factors which may indicate Tonsillectomy (if Paradise criteria not met)
-
Sleep disordered breathing (e.g. pediatric Sleep Apnea)
- Witnessed snoring, apneas or gasping for air
- Obstructive Sleep Apnea by Polysomnogram
- Difficult management of frequent Pharyngitis
- Multiple drug allergies
- Intolerance to medications
- Complicated Pharyngitis cases
- Miscellaneous unproven indications
- Based on clinical judgement and Informed Consent regarding risks versus benefits
- Halitosis
- Febrile Seizures
- Malocclusion
-
Tonsillar size is not an indication for surgery
- Exception: Related complication such as sleep disordered breathing
- Size diminishes naturally in early adolescence
IV. Management: Postoperative bleeding from Tonsillectomy
- Typically occurs at day 5-7 (up to day 10) after Tonsillectomy
- Related to sloughing of eschar (Fibrin clot)
- Occurs in 2-7% of post-Tonsillectomy cases
- Newer intracapsular techniques have bleeding rates <1%
- Of those with mild Tonsillar bleeding, 40% may go on to have major bleeding in next 24 hours
- Teenagers and adults are more likely than younger children to require surgical intervention
- Secure airway if needed
- See Advanced Airway
- Consider gargled Tranexamic Acid (TXA) 5% Mouthwash
- https://rebelem.com/topical-tranexamic-acid-epistaxis-oral-bleeds/
- Prepare Tranexamic Acid (TXA) 5% Mouthwash
- Tranexamic Acid (TXA) is available in 1000 mg/10 ml vials that contain 10 ml
- Prepare 2 small cups each of 5 ml TXA (500 mg) and 5 ml cold water (10 ml of diluted TXA per cup)
- Alternatively a 500 mg TXA tablet may be dissolved in 10-15 ml water
- Have patient gargle 10 ml for 1-2 minutes and then gently spit out solution
- May repeat again in 10-15 minutes
- Consider nebulized Tranexamic Acid (TXA)
- Nebulize 500 mg (children) or 1000 mg adults (case reports)
- Hankerson (2015) J Palliat Med 18(12): 1060-2 [PubMed]
- Consider Nebulized racemic epinephrine
- May Vasoconstrict Tonsillar region vessels
- Anecdotally, Tranexamic Acid may be more effective
- Local Bleeding Control
- Insert bite block
- Anesthetize area (cetacaine or atomized Lidocaine via MADD)
- Apply pressure with finger to bleeding site
- Apply Tranexamic Acid or Epinephrine soaked gauze directly against bleeding site with McGill forceps
- Inject Epinephrine into bleeding site
- Disposition
- Bleeding continues
- Transfer emergently to otolaryngology
- Secure airway as needed
- Replace Blood Products as needed
- Bleeding stops
- Consult otolaryngology
- Typically transfer to otolaryngology for evaluation, management and observation
- Bleeding continues
V. Management: Postoperative Pain
- Liquid Analgesics
- Ibuprofen 10 mg/kg up to 600 mg orally every 6 hours
- Does NOT appear to increase Hemorrhage risk and very effective for postoperative pain
- However, unlike Ibuprofen, Toradol does increase Hemorrhage risk (esp. in age >18 years old, see below)
- Acetaminophen 15 mg/kg up to 650 mg orally every 6 hours
- Oxycodone or Morphine for breakthrough pain
- Risk of apnea in patients with history of Obstructive Sleep Apnea (Brainstem tolerance for CO2 retention)
- Ibuprofen 10 mg/kg up to 600 mg orally every 6 hours
- Other measures
- Maluka honey lozenges or popsicles (OTC)
- Dexamethasone
- Dexamethasone 0.5 mg/kg (up to 10 mg) scheduled on day 3 post-operatively (consider repeat dose on day 5)
- Greenwell (2021) Otolaryngol Head Neck Surg 165(1):83-8 +PMID: 33228459 [PubMed]
- Emergency department
- Consider Dexamethasone if not already dosed (see above)
- Intravenous Fluids
- Avoid Toradol
- Unlike Ibuprofen, Toradol increases the risk of Hemorrhage up to 5-fold (esp. in age >18 years old)
- Mixed results in study
VI. Resources
- Clinical Practice Guideline for Tonsillectomy in Children
VII. References
- Claudius, Behar and Hofmann, Santillanes, Bowman in Herbert (1018) EM:Rap 18(6):13-4
- Claudius, Behar and Stoner in Herbert (2015) EM:Rap 15(11):2-3
- Wiedermann (2024) Mayo Clinic Pediatric Days, attended lecture 1/18/2024
- Baugh (2011) Otolaryngol Head Neck Surg 144(1): S1-S30 [PubMed]
- Randel (2011) Am Fam Physician 84(5): 566-73 [PubMed]