Tonsillectomy, Adenoidectomy and Down Syndrome
Dr. Eli Grunstein, MD
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Background:
Tonsillectomy (with or without adenoidectomy) is one of the most commonly performed surgical operations in children. More than 500,000 cases are performed per year in children younger than 15 years of age.
Tonsils and adenoids are lymphoid tissue. They are part of a ring of lymphoid tissue in the throat comprised of the tonsils in the back of the throat, the adenoids behind the nasal cavity, and lingual tonsils on the back of the tongue.
Lymphoid tissue is responsible for generating immunity and fighting infections. Thankfully, there hasn’t been any conclusive data that shows a significant risk of extra infections or immune issues if someone has their tonsils (with or without adenoids) removed.
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What are the indications for tonsillectomy:
The most common indication for tonsillectomy (with or without adenoidectomy) is enlargement leading to sleep disordered breathing (SDB), which includes obstructive sleep apnea (OSA). SDB and OSA have been previously discussed in previous issues of this magazine. The second most common indication is recurrent throat infections. Less common indications include a disease commonly known as periodic fevers, or concern for a growth in the tonsil.
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How is tonsillectomy performed?
For the general population, when performing tonsillectomy (with or without adenoidectomy) for SDB, options could include complete removal of the tonsils or reducing the tonsils (also known as a partial tonsillectomy or tonsil shaving). However, for patients with Down syndrome, most surgeons will typically perform complete tonsil removal and will not perform tonsil reduction, since residual tonsils have a higher risk of collapse and blocking the throat in patients with Down syndrome, as a result of the narrow anatomy and low muscle tone. Similarly, when performed tonsillectomy for recurrent throat infections, periodic fevers, or concern for a growth in the tonsils, complete tonsillectomy is recommended and not partial tonsillectomy. The adenoids are difficult to remove completely, so when people say adenoidectomy, they are typically referring to a reduction of the adenoids.
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Are there any special precautions that are taken for Down syndrome patients who are undergoing tonsillectomy?
Patients with Down syndrome will typically undergo a cardiac clearance and anesthesia consult prior to the surgery. If there is any personal or family history of bleeding or bruising, then a hematology consult is indicated.
Patients with Down syndrome have a high risk of spine instability, and special precautions must be taken in the operating room to avoid spine dislocation.
After surgery, patients with Down syndrome are monitored in the hospital, often in the intensive care unit or step-down unit. It is prudent for the procedure to be done with a surgeon and at a hospital that has experience caring for children with Down syndrome.
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What are the risks or potential complications of tonsillectomy (with or without adenoidectomy)?
The risk of a complication after surgery is higher for patients with Down syndrome than for the general population.
All patients have pain after tonsillectomy (with or without adenoidectomy). This is typically treated with Acetaminophen or Ibuprofen as needed. Narcotics are typically avoided given their side effects and risk of suppressing breathing. Care must be taken to ensure that the patient drinks adequately to avoid dehydration.
The most common complication after tonsillectomy (with or without adenoidectomy) is bleeding. The chance of bleeding is reported to be 1-3%, although it is more common in older children and adults, as well as patients who have a history of frequent throat infections. Bleeding can occur anytime up to 2 weeks after surgery, and requires a return to the hospital, and sometimes even a return to the operating room to stop the bleeding.
Patients with Down syndrome are at higher risk for respiratory issues after surgery, which is the main reason they are admitted to the hospital for observation after tonsillectomy (with or without adenoidectomy). There are also potential anesthesia-related complications which the anesthesiologists will typically discuss with the family in advance of the procedure.
Other less common risks include infection at the surgery site, unusual scarring, a change in the resonance of speech, injury to the lips/teeth/gums/tongue/throat, or taste change.
According to the American Academy of Pediatrics, tonsillectomy (with or without adenoidectomy) has an approximately 80% success rate in treating otherwise healthy children with OSA. However, this success rate is lower in children with Down syndrome.
Tonsillectomy is not known to cause weight gain in Down syndrome patients.
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Eli Grunstein, M.D. is the John and De Graaf Woodman Associate Professor of Clinical Otolaryngology—Head & Neck Surgery at the Columbia University College of Physicians and Surgeons and Assistant Attending physician at New York-Presbyterian/ Morgan Stanley Children’s Hospital. He specializes in general Pediatric Otolaryngology, with specific clinical interest in pediatric throat and airway diseases, hyper nasality, and pediatric sinonasal diseases