Letter to the Editor Regarding the Updated American Academy of Otolaryngology-Head and Neck Surgery Foundation Clinical Practice Guideline on Tonsillectomy in Children

摘要

The American Academy of Sleep Medicine (AASM) appreciates being invited to participate in the development of the updated clinical practice guideline on tonsillectomy in children by the American Academy of Otolaryngology-Head and Neck Surgery Foundation (AAO-HNSF).1 We realize this was a tremendous undertaking and are pleased to endorse the AAO-HNSF guideline. This letter provides an overview of the guideline, focusing on areas of most interest to sleep medicine providers, and outlines areas in which it differs from the recommendations established by the AASM.2PURPOSE OF A AO -HNSF CLINICAL PR ACTICE GUIDELINETonsillectomy is one of the most common surgical procedures in the United States with almost 300,000 ambulatory procedures performed annually in children under 15 years of age.3 The indications for tonsillectomy have changed with time. Thirty years ago, approximately 90% of tonsillectomies in children were done for recurrent infection. According to the AAO-HNSF guideline, the primary indication for tonsillectomy currently is obstructive sleep-disordered breathing in two-thirds of patients.1The AAO-HNSF published its original clinical practice guideline on tonsillectomy in children in 2011 and the updated guideline was published in February 2019 as a supplemental issue of the journal OtolaryngologyHead and Neck Surgery. The guideline is intended for clinicians in any setting who interact with children ages 1 to 18 years old who are under consideration for tonsillectomy. The purpose of the guideline is to educate clinicians, patients and/or their caregivers regarding the indications for tonsillectomy and optimize perioperative management, reducing variations in care and enhancing patient outcomes. It strives to emphasize the need for evaluation and intervention in special populations and improve counseling and education of families who are considering tonsillectomy for their child.The guideline update group included members from various specialties: advanced practice nursing, family medicine, otolaryngology-head and neck surgery, pediatrics, anesthesia, sleep medicine, and infectious disease. With the addition of two consumer advocates on the guideline update group, there was enhanced emphasis on patient education and shared decision-making.There were 15 key action statements identified in the updated guideline which were expanded from 10 in the original guideline including 2 new statements related to polysomnography (PSG) indications. Throughout the guideline, sleep-disordered breathing was changed to obstructive sleep-disordered breathing (oSDB) to clarify that tonsillectomy should be done for obstructive breathing in sleep. The key action statements of most interest to sleep medicine providers are numbers 48 and 12, since they relate directly to tonsillectomy for oSDB, indications for PSG, education regarding persistent or recurrent oSDB after tonsillectomy, and inpatient monitoring after tonsillectomy in high-risk patients. The other key action statements are also important clinically as they relate to tonsillectomy recommendations for infection, perioperative pain counseling and management, perioperative antibiotics, intraoperative steroids, and monitoring of post-tonsillectomy bleeding. The key action statements of most interest to the readership of the Journal of Clinical Sleep Medicine will be reviewed here.KEY ACTION STATEMENTS (K AS) FOCUSED ON SLEEPKAS 4. Tonsillectomy for oSDB: Clinicians should ask caregivers of children with oSDB and tonsillar hypertrophy about comorbid conditions that may improve after tonsillectomy, including growth retardation, poor school performance, enuresis, asthma and behavioral problems.The above statement is important for helping clinicians and caregivers make informed decisions about tonsillectomy in children with clinically diagnosed oSDB. It highlights the importance of considering comorbid conditions that may be overlooked but could affect the decision to proceed with surgery.The AASM practice parameters for the respiratory indications for PSG in children states that PSG is indicated when the clinical assessment suggests the diagnosis of obstructive sleep apnea syndrome (OSAS) and in children being considered for adenotonsillectomy to treat OSAS.2 The AASM task force found, after extensive literature review, that clinical evaluation alone does not have sufficient sensitivity or specificity to establish the diagnosis of OSAS. While the comorbid conditions should be a consideration, the gold standard for making the diagnosis of OSAS is overnight PSG.KAS 5. Indications for PSG: Before performing the tonsillectomy, the clinician should refer children with oSDB for PSG if they are 2 years of age or if they exhibit any of the following: obesity, Down syndrome, craniofacial abnormalities, neuromuscular disorders, sickle cell disease, or mucopolysaccharidoses.This statement highlights that information gained through PSG can assist in diagnosing and quantifying OSA in