Snore and sore
Tonsillectomies are on the rise, as children fight airway restriction — and antibiotic resistance

Ask Kim Burrell and she might say that she and her children came with some extra parts.

Tonsils, according to the Pacolet resident and nurse at Spartanburg ENT, caused them nothing but problems.

According to the American Academy of Otolaryngology/Head and Neck Surgery, the first reported tonsillectomy occurred in A.D. 30. After becoming quite common 75 years ago, the number of tonsillectomies dropped dramatically with the advent of antibiotics. The procedure is again on the rise, according to the AAO/HNS, due in part to antibiotic resistance and the more common removal of enlarged tonsils.

Burrell had her tonsils removed at age 25 after chronic problems that resulted in difficulty breathing and swallowing. Her daughter Annabelle, now age 7, had a tonsillectomy at 22 months of age.

“She was having chronic tonsillitis,” Burrell said. “Every month she was having to be treated with antibiotics. With Annabelle, we had been treated numerous times and they are hesitant to do (surgery) so early, but she had so many infections, fever and multiple antibiotics.”

For Burrell’s son, Connor, now age 2, the surgery became necessary when he was just 18 months old.

“We would have to prop him up to sleep,” Burrell said. “I was hesitant at his age to have it done, but he was so tired during the day and not as active. I also noticed speech problems with him, a real muffled voice. He’s a typical little boy now, full of energy.”

Christopher Rucker, an otolaryngologist with Spartanburg ENT who practices in Spartanburg, Greer and Gaffney, said guidelines assist doctors and parents to help them know when a tonsillectomy is indicated, but the decision must be made based on each individual’s circumstances.

“I prefer to think of each person I see as a person, not a number,” Rucker said. “It’s entirely a quality-of-life issue for the patient and the family.”

Rucker said tonsils, much like the appendix, aren’t missed by the patient once removed.

“The tonsils themselves are lymphatic tissue and lymphatic tissue is there as part of our immune system,” he said. “You take it out and the patient is better. Children are not less healthy, they are healthier.”

According to Rucker, there are two common situations when a tonsillectomy may be indicated.

“The first reason is when a child is having multiple infections, causing a child to miss school or take a lot of oral antibiotics,” Rucker said. “The other child is the one whose tissue is just too large,” which may cause sleep apnea, a change in voice, or malformation of the palate or facial bones.

David Parsons, a pediatric otolaryngologist with Charlotte Eye, Ear, Nose and Throat, is an internationally renowned physician who has designed more than 40 medical instruments and has taught worldwide. Parsons recently moved his practice to Charlotte, N.C., from Upstate South Carolina to devote more time to medical missions. He said obstructive sleep apnea, also known as upper airway resistance syndrome and sleep disordered breathing, is responsible for approximately 70 percent of tonsillectomies.

“These kids are snorers,” Parsons said. “If they are not snorers, they don’t have this problem. If they are snorers and have this, they stop breathing for typically three to five seconds in length. This typically occurs in children who are old enough that you don’t watch them sleep anymore. The next thing, when they resume breathing, it will be a bigger than average breath and it meets resistance,” resulting in a gasping sound.

While they’re still asleep, he said, these children awaken slightly and reposition their body. In the morning, “they wake up like they got a bad night’s sleep,” he said.

Such obstructive episodes occur as often as 250 times per night, he said, which may result in a variety of fatigue-related problems.

Rucker agreed.

“If you don’t sleep well, you are going to have problems the next day,” he said. “(Following a tonsillectomy) they can have a remarkable change in behavior if they have been chronically sleep deprived.”

If a tonsillectomy is indicated, a variety of techniques are available for removal. The type used depends on the doctor performing the surgery. Parsons said tonsillectomies can be total or partial. Partial removal is used only for upper airway resistance syndrome.

“It is en vogue right now,” Parsons said. “If a child has sleep disordered breathing, we can take out part of the tonsil and it ends up being less pain and the postoperative complication of bleeding rarely occurs — but the tonsil can grow back.”

He said when armed with the knowledge their child may regrow tonsils, “100 percent of the parents want the total tonsillectomy.”

For total tonsillectomy, “there are multiple ways,” Parsons said. “None of them are bad.”

Rucker agreed.

“There are as many ways to take tonsils out as there are ENT specialists, which shows there is no one way to do it,” Rucker said.

Methods include cold steel, or scalpel, dissection; electrocautery; coblation; high-speed microdebrider; lasers; and harmonic scalpel, Parsons’ method of choice.

“It is a vibrating scalpel that takes the tonsil out with vibrations of 55,000 per second,” Parsons said. “It closes blood vessels and turns the tissue to butter. The kids do well from a pain standpoint and I have had a very low incidence of postoperative bleeding.”

Risks from tonsillectomies are generally low and include the possibility of bleeding, as well as dehydration if children do not consume enough liquids after surgery.

But the child who is looking forward to an all-ice cream diet may be disappointed.

“Wonderful, big studies have been done to show that is completely wrong,” Parsons said. “Kids who eat a regular diet with lots of chewing and lots of liquid do best. It’s critical on day one to start chewing aggressively.”

In fact, Parsons is so adamant about chewing to reduce muscle stiffness, that he commonly gives patients gum and gummy bears as they leave the recovery room.

“If they are chewing well, there are essentially no restrictions on what they eat,” Parsons said.