Effect of monopolar diathermy power settings on postoperative pain, wound healing, and tissue damage after tonsillectomy: a randomized clinical trial

This study aimed to assess the impact of varying monopolar diathermy power settings on postoperative pain, hemorrhage, and wound healing following tonsillectomy. A single-center, prospective, randomized, double-blinded, controlled clinical study was conducted. During bilateral tonsillectomy procedures, one tonsil received low-power settings (15 W, cutting/blend) while the other tonsil received high-power settings (35 W, cutting/blend). Postoperative pain scores (0-10) and wound healing scores (0-3) were evaluated immediately after surgery and at 1, 2, and 4 weeks postoperatively using the visual analog scale. Additionally, histological analysis was performed on electrically resected tonsil tissues to assess tissue damage in the tonsil bed. The allocation of high and low power settings to each side was randomized. Results showed that 1 week after the surgery, the high-power group experienced significantly higher pain scores (mean ± standard deviation: 4.84 ± 2.21) compared to the low-power group (3.56 ± 2.24, p = 0.049). Moreover, the high-power side exhibited slower wound healing during the initial 1-2 weeks postoperatively, as indicated by lower wound scores at 2 weeks (high-power: 1.96 ± 0.64; low-power: 2.43 ± 0.59, p = 0.008). Furthermore, histological analysis revealed significantly deeper tissue degradation on the high-power side compared to the low-power side (p < 0.001), with mean depths of 565.2 ± 291.0 µm and 156.0 ± 36.8 µm, respectively. In conclusion, these findings suggest that when employing monopolar diathermy in tonsillectomy, lower power settings can lead to improved outcomes in terms of postoperative pain, wound healing, and tissue damage.Trial registration: CRIS identifier: KCT0005670 (cris.nih.go.kr, registration date: 11/12/2020).

Outcomes of coblation tonsillectomy versus bipolar electrocautery tonsillectomy in pediatric population

Background

Bipolar electrocautery tonsillectomy has been the preferred technique for many otolaryngologists, yet coblation tonsillectomy is gaining popularity in the current practice. This study aims at comparing both techniques in terms of pain, bleeding, and healing.

Results

A total of 120 patients were randomly divided into two equal groups. Overall mean pain score associated with coblation tonsillectomy was statistically less than that caused by bipolar electrocautery throughout the follow-up period (p < 0.001). The difference in pain duration was statistically longer for the bipolar group. The incidence of postoperative hemorrhage—both reactionary and secondary—was statistically higher in the bipolar group. Coblation tonsillectomy showed statistically shorter duration of healing (p < 0.001).

Conclusions

Coblation tonsillectomy is associated with less pain severity and shorter pain duration, fewer bleeding incidents, and more prompt healing.

Intrapatient Comparison of Coblation versus Electrocautery Tonsillectomy in Children: A Randomized, Controlled Trial

Many surgical instruments have been introduced and compared for safety and surgical efficiency in tonsillectomy. This study aimed to compare postoperative pain between coblation and conventional monopolar electrocautery tonsillectomy by intrapatient comparison in children. Thirty pediatric patients over six years of age undergoing tonsillectomies were enrolled. Coblation and electrocautery were used to remove both tonsils in one patient; one was removed by coblation and the other by electrocautery. The coblation side was randomly selected, and it was blinded to the patients. Each side’s daily pain scores were collected on the visual analogue scale (VAS) during ten postoperative days. On the day of surgery, 22 (73%) patients identified less pain on the coblation side, while others felt similar pain. The mean pain scores were significantly lower on the coblation side during the postoperative ten days (except for the 6th and 8th) than on the electrocautery side. The duration of severe pain (VAS > 5) was significantly shorter on the coblation side than on the electrocautery side (2.0 versus 3.7 days, respectively; p = 0.042). Coblation tonsillectomy induced less pain than electrocautery in pediatric patients; therefore, surgeons could choose the coblator as a surgical instrument for tonsillectomy to improve the pediatric postoperative quality of life.

Comparison of outcomes between thermal welding forceps, controlled ablation and monopolar electrosurgery for tonsillectomy in children

OBJECTIVE

To compare recovery from tonsillectomy using thermal welding forceps (TWF), controlled ablation (CA), and monopolar electrosurgery (MES) in children.

METHODS

This was a prospective single blinded observational study using data from electronic medical record (EMR) and caregiver completed patient diary, conducted at a community-based children's hospital within an academic program with tonsillectomy performed by attending surgeons. Children aged 3-17 years undergoing tonsillectomy or adenotonsillectomy by TWF, CA, or MES over a 4-year period were included. Demographics, intraoperative time for tonsillectomy, blood loss, patient diary documentation of pain levels, analgesic doses, diet type and events per day were recorded. In addition, EMR documentation of morbidity events (bleeding, visits for bleeding, return to operating room [OR], total visits or admissions, poor oral intake or dehydration) were noted. To assess for differences in baseline characteristics, we utilized analysis of variance and Pearson's χ² test. To determine primary outcomes, we used a multilevel mixed-effect linear regression model.

RESULTS

A total of 369 children were enrolled, and 346 who met inclusion criteria underwent tonsillectomy. The children were categorized by the instrument used by the surgeons: CA 32.4% (n = 112), MES 36.7% (n = 127), and TWF 30.9% (n = 107). Mean age overall was 6.8 ± 3.2 years, with 57.4% female and 42.6% male. Diary return rate was 52.3% (n = 181) overall, with CA at 48.2% (n = 54), MES at 44.8% (n = 57), and TWF at 65.4% (n = 70). Average pain on the day of surgery was different between instruments with CA having the lowest level of 2.0 compared to 2.7 for TWF and MES (p = 0.001). Maximum pain level for day of surgery were lowest for CA at 2.7 compared to 3.4 for MES and 3.5 for TWF (p = 0.003). Pain levels were lowest for TWF after postoperative day (POD) 6. Overall rate of bleeding was 9.3%, with 2.6% return to surgery for control of bleeding. TWF had the lowest rate of bleeds (4.7% versus CA 11.6% and MES 11.0%), return to surgery (0.0% versus CA 2.7% and MES 4.7%), the earliest and final return to regular diet at POD 5.8 and 8.1, respectively without reaching statistical significance.

CONCLUSION

CA had significantly lowest early pain levels on day 0-1 and trended lowest up to POD 6, after which TWF was lowest but did not reach statistical significance. TWF had the earliest return to regular diet. Children undergoing CA and MES are more likely to have a postoperative bleed and a return to the OR than TWF suggesting improved ability to seal vessels with the latter instrument. Further study with a larger sample is needed.

Radiofrequency Ablation vs Electrocautery Blinded Randomized Trial: Impact on Clinically Meaningful Outcomes

OBJECTIVE

To analyze patients' return to normal activity, pain scores, narcotic use, and adverse events after undergoing tonsillectomy or adenotonsillectomy with monopolar electrocautery or radiofrequency ablation.

STUDY DESIGN

Randomized double-blinded clinical trial based on prospective parallel design.

SETTING

Academic medical center and tertiary children's hospital between March 2018 and July 2019.

METHODS

Inclusion criteria included patients aged ≥3 years with surgical indication of recurrent tonsillitis or airway obstruction/sleep-disordered breathing. Patients were randomly assigned to monopolar electrocautery or radiofrequency ablation. Patients were blinded to treatment assignment. Survey questions answered via text or email were collected daily until postoperative day 15. The primary outcome was the patient's return to normal activity. Secondary outcomes included daily pain score, total amount of postoperative narcotic use, and adverse events.

RESULTS

Of the 236 patients who met inclusion criteria and were randomly assigned to radiofrequency ablation or monopolar electrocautery, 230 completed the study (radiofrequency ablation, n = 112; monopolar electrocautery, n = 118). There was no statistically significant difference between the groups in the number of days for return to normal activity (P = .89), daily pain scores over 15 postoperative days (P = .46), postoperative narcotic use (P = .61), or return to hospital for any reason (P = .60), including bleeding as an adverse event (P = .13).

CONCLUSIONS

As one of the largest randomized controlled trials examining instrumentation in tonsillectomy, our data do not show a difference between monopolar electrocautery and radiofrequency ablation with regard to return to normal activity, daily pain scores, total postoperative narcotic use, or adverse events.

Cost benefit of coblation versus electrocautery adenotonsillectomy for pediatric patients

INTRODUCTION

Coblation and electrocautery are two common techniques used for adenotonsillectomy (T&A). Numerous studies have assessed surgical outcomes of coblation versus electrocautery and overall, postoperative complications are similar with the exception of a decrease in patient reported postoperative pain for coblation. Instrumentation required for coblation is significantly more expensive than that required for electrocautery. With minimal outcome differences, justification for the additional instrumentation costs is difficult. We performed this study to assess if there is a difference between operative & postoperative costs of electrocautery and coblation.

METHODS

300 patient medical records were reviewed from 2015 to 2017 with equal numbers of electrocautery and coblation surgeries. Outcome measures included finance information, duration and cost of OR and Phase I and Phase II post-anesthesia care unit (PACU), in-hospital pharmacy costs, and postoperative complications. Logistic regression was used for analysis.

RESULTS

The median patient age for each surgical technique was 6 years old. Electrocautery resulted in more time in the OR compared to coblation, (OR:1.11,95%CI:1.07-1.15, p < .001), with greater associated costs, p < .001. Electrocautery patients were under anesthesia longer and had a longer surgical duration, p < .001. These same patients had longer duration in Phase II PACU, p = .028, and were given pain medications an increased number of times, p < .001. Total costs including operative expense, physician charges, OR and anesthesia times, pharmacy, and instrument were significantly higher for electrocautery patients, p = .003. There were no differences in ED visits, post-tonsillectomy bleed, or additional surgery between techniques, p > .05.

CONCLUSION

T&A electrocautery technique was found to have increased overall indirect costs. Costs of instrumentation in addition to increased operative time, use of analgesics and post-operative care contribute to costs associated with electrocautery and coblation should be used when assessing surgical costs.

Postoperative Pain and 14-Day Recovery in Children Undergoing Adenotonsillectomy: Low Thermal Damage Device Versus Electrosurgery

This was a randomized controlled trial of low thermal damage device versus traditional electrosurgery in children 3 to 17 years old with a clinical diagnosis of sleep disordered breathing, obstructive sleep apnea with adenotonsillar hypertrophy, or recurrent adenotonsillitis. Pain score (Wong-Baker FACES pain scale) was recorded each morning before eating, drinking, or administering pain medication for 14 days postoperatively. Seventy-five children were enrolled. There was no difference in the rate of decrease in pain scores. A significant interaction between rate of pain decrease and number of pain medication doses was present ( P < .0001). Median number of pain medication doses was greater with electrosurgery (36, range: 7-49) versus low thermal device (21, range: 2-124; P = .001). Pain scores reached 0 after a median of 7 days (95% confidence interval [CI], 5.2-8.6) for low thermal device and 9 days (95% CI, 8.0-10.0) for electrosurgery ( P = .67). One child randomized to electrosurgery was withdrawn due to hospitalization for postoperative bleed. In children, low thermal device results in significantly less pain medication used during the postoperative period than electrosurgery.

Impact of coblation versus electrocautery on acute post-operative outcomes in pediatric tonsillectomy

Objective

Based on previous studies in the pediatric population, it remains unclear whether there is a difference in postoperative pain between two widely used tonsillectomy techniques: coblation and bovie electrocautery. This large prospective study investigates whether postoperative pain scores differ between these two surgical techniques for tonsillectomy.

Methods

Prospective, non‐randomized study of children aged 2–8 enrolled in a randomized controlled trial of single‐dose intravenous acetaminophen for pain associated with adenotonsillectomy. Included procedures occurred between October 2012 and June 2015 at a tertiary referral center. Only patients whose operations exclusively used coblation or electrocautery and who required postoperative admission for extended observation were included. Follow‐up period was the length of inpatient stay. Patients and nurses who recorded the pain scores were blinded to the tonsillectomy technique.

Results

A total of 183 patients were included: 117 coblation cases and 66 electrocautery cases. Pain scores in the surgical recovery unit and pain scores after admission to the floor unit were not significantly different between coblation and electrocautery, either before or after adjustment for patient age, body mass index, intravenous acetaminophen use, and surgeon. There was also no difference in length of stay, readmission rate, or post‐tonsillectomy hemorrhage.

Conclusions

Coblation and electrocautery tonsillectomy are associated with similar post‐operative pain scores in the recovery and inpatient units in the pediatric population. As coblation is costlier, the results of this study may affect which tool is used by otolaryngologists from a cost–benefit perspective.

Level of evidence

III

The debate continues: a prospective, randomised, single-blind study comparing Coblation and bipolar tonsillectomy techniques

OBJECTIVES

Tonsillectomy is a common procedure with significant post-operative pain. This study was designed to compare post-operative pain, returns to a normal diet and normal activity, and duration of regular analgesic use in Coblation and bipolar tonsillectomy patients.

METHODS

A total of 137 patients, aged 2-50 years, presenting to a single institution for tonsillectomy or adenotonsillectomy were recruited. Pain level, diet, analgesic use, return to normal activity and haemorrhage data were collected.

RESULTS

Coblation tonsillectomy was associated with significantly less pain than bipolar tonsillectomy on post-operative days 1 (p = 0.005), 2 (p = 0.006) and 3 (p = 0.010). Mean pain scores were also significantly lower in the Coblation group (p = 0.039). Coblation patients had a significantly faster return to normal activity than bipolar tonsillectomy patients (p < 0.001).

CONCLUSION

Coblation tonsillectomy is a less painful technique compared to bipolar tonsillectomy in the immediate post-operative period and in the overall post-operative period. This allows a faster return to normal activity and decreased analgesic requirements.

Use of intranasal corticosteroids in adenotonsillar hypertrophy

Objectives:

This review examined the efficacy of intranasal corticosteroids for improving adenotonsillar hypertrophy.

Method:

The related literature was searched using PubMed and Proquest Central databases.

Results:

Adenotonsillar hypertrophy causes mouth breathing, nasal congestion, hyponasal speech, snoring, obstructive sleep apnoea, chronic sinusitis and recurrent otitis media. Adenoidal hypertrophy results in the obstruction of nasal passages and Eustachian tubes, and blocks the clearance of nasal mucus. Adenotonsillar hypertrophy and obstructive sleep apnoea are associated with increased expression of various mediators of inflammatory responses in the tonsils, and respond to anti-inflammatory agents such as corticosteroids. Topical nasal steroids most likely affect the anatomical component by decreasing inspiratory upper airway resistance at the nasal, adenoidal or tonsillar levels. Corticosteroids, by their lympholytic or anti-inflammatory effects, might reduce adenotonsillar hypertrophy. Intranasal corticosteroids reduce cellular proliferation and the production of pro-inflammatory cytokines in a tonsil and adenoid mixed-cell culture system.

Conclusion:

Intranasal corticosteroids have been used in adenoidal hypertrophy and adenotonsillar hypertrophy patients, decreasing rates of surgery for adenotonsillar hypertrophy.

Primary Caregiver Perception of Pain Control following Pediatric Adenotonsillectomy

Objectives

To (1) review pain medications prescribed following pediatric adenotonsillectomy (T&A), (2) identify pain medications reported to be helpful, and (3) compare parent-reported outcomes among various combinations of pain medications.

Study Design

Case series with planned data collection.

Setting

Multihospital network.

Subjects and Methods

The primary caregivers of children aged 1 to 18 years who underwent isolated T&A from June to December 2014 were contacted 14 to 21 days after surgery. Data collected included pain medications prescribed, medications most helpful in controlling pain, and duration that pain medication was required. Parents rated their children’s pain on postoperative days 2, 3, 7, and 14 and reported the time to resumption of normal diet/activity, as well as any hospital return visits.

Results

The study cohort included 672 subjects of 1444 potential participants (46% response rate). The mean age of the patients was 7.9 ± 3.6 years. Narcotics were prescribed in 71.9%, and 70.4% were told to use ibuprofen. Children who took ibuprofen alone were significantly younger ( P < .001). Pain was significantly less on postoperative days 2 and 3 in the ibuprofen-only group as compared with the groups taking narcotics only ( P < .001) and ibuprofen with narcotics ( P = .002). Those taking ibuprofen alone returned to normal activity ( P < .001) and diet ( P = .026) sooner than those taking ibuprofen with narcotics. No difference was seen in pain control on subgroup analysis comparing oxycodone and hydrocodone.

Conclusions

For pediatric T&A, significant variation exists in the management of postoperative pain. Parents of children given ibuprofen reported less pain than those given narcotics with and without ibuprofen. Further studies are needed to identify the optimal pain regimen for children after T&A.

Postoperative tonsillectomy bleeding complications in children: A comparison of three surgical techniques

OBJECTIVE & HYPOTHESIS

Stated in the Null form: There will be no difference in primary or secondary hemorrhage rate in children undergoing tonsillectomy or adenotonsillectomy across three surgical techniques: PEAK Plasmablade, electric monopolar cautery, coblation.

STUDY DESIGN

Retrospective chart analysis.

SETTING

Academic Medical Center: Children's Hospital.

SUBJECTS & METHODS

Electronic chart data were collected from patient's age 2-18 years who underwent tonsillectomy, with or without adenoidectomy, at a tertiary pediatric hospital between June 2011 to May 2013 by electric monopolar cautery, coblation, or PEAK PlasmaBlade. Treatment outcomes following each of these surgical approaches, relative to rate of post-operative primary and secondary bleeding, hospital admission, and emergency department visits were compared.

RESULTS

A total of 1780 patients that had tonsillectomy or adenotonsillectomy were evaluated. There was a significant difference in bleed rate by age with older patients having more bleeding post-procedure than their younger counterparts. There was also a difference in bleeding frequency by diagnosis. Patients with a diagnosis of OSA were less likely to experience a postoperative bleed than children with either recurrent tonsillitis or both. Significance was evident between post-op hemorrhage rate and instrumentation (χ(2) = 11.17, df = 2, p = 0.004). The majority of bleeds occurred with coblation (58.9%), while PEAK had only 17.8% and cautery 23%.

CONCLUSION

The null hypothesis was rejected. That is, PEAK PlasmaBlade was safe and effective, with statistically less postoperative bleeding and ED visits, especially when compared to coblation techniques. Coblation patients had the highest rates of postoperative bleeding.

Coblation tonsillectomy under surgical microscopy: A retrospective study

Objective

A retrospective study to compare surgical parameters and postoperative pain in patients undergoing coblation tonsillectomy with or without microscopic guidance.

Methods

Data regarding duration of surgery and hospital stay, intraoperative blood loss, incidence of haemorrhage and postoperative pain scores were retrieved from the medical records of adult patients undergoing coblation tonsillectomy under direct vision or with microscopic guidance.

Results

The incidence of secondary haemorrhage (>24 h postoperatively) was significantly lower and the duration of hospital stay was significantly shorter in the microscope group (n = 92) than the direct vision group (n = 76). Pain scores both at rest and while swallowing reached ≤3 (no significant impact on quality-of-life) significantly faster in the microscope group than the direct vision group.

Conclusions

Microscope-assisted coblation tonsillectomy decreases the duration of hospital stay and the incidence of postoperative secondary haemorrhage, and results in an early improvement in postoperative pain scores.

Surgical treatment for childhood obstructive sleep apnoea: Cold-knife tonsillar dissection versus bipolar radiofrequency thermal ablation

INTRODUCTION AND OBJECTIVE

Adenotonsillectomy for treatment of childhood obstructive sleep apnoea is effective. The uncomfortable postoperative period and possible complications have significantly increased the use of partial techniques, seeking to improve these aspects while achieving the same results in resolving sleep apnoea. The aim was to present the experience with 2 consecutive groups of patients, comparing total tonsillectomy to bipolar radiofrequency ablation (RFA).

METHOD

A group of 96 children that underwent total tonsilloadenoidectomy using cold dissection were compared to another group of 101 children that underwent RFA. In all cases, polysomnography was performed before and 1 year after surgery. The percentage of cases with persistent disease (apnea-hypopnea index ≥ 3) and the improvement of clinical symptoms at one year were evaluated. The percentages of surgical and anaesthetic complications in both groups were also compared.

RESULT

The persistence of the syndrome was comparable in both groups: 25% in the cold dissection and 22.77% in the radiofrequency ablation group. Anaesthetic complications (5% in the group where cold dissection was used and 4.2% in the radiofrequency ablation group) and postoperative bleeding rates were very low and statistically comparable with both techniques.

CONCLUSION

In the treatment of childhood obstructive sleep apnoea syndrome, both extracapsular surgery using cold scalpel and bipolar radiofrequency tunnelling techniques are safe. Likewise, results as to resolution of the syndrome show no statistically significant differences.

Confronting the challenges of effective pain management in children following tonsillectomy

Tonsillectomy is an extremely common surgical procedure associated with significant morbidity and mortality. The post-operative challenges include: respiratory complications, post-tonsillectomy hemorrhage, nausea, vomiting and significant pain. The present model of care demands that most of these children are managed in an ambulatory setting. The recent Federal Drug Agency (FDA) warning contraindicating the use of codeine after tonsillectomy in children represents a significant change of practice for many pediatric otolaryngological surgeons. This introduces a number of other safety concerns when deciding on a safe alternative to codeine, especially since most tonsillectomy patients are managed by lay primary caregiver's at home. This review outlines the safety issues and proposes, based on currently available evidence, a preventative multi-modal strategy to manage pain, nausea and vomiting without increasing the risk of post-tonsillectomy bleeding.

Variation in pediatric outpatient adenotonsillectomy costs in a multihospital network

OBJECTIVES/HYPOTHESIS

Identify hospital costs for same-day pediatric adenotonsillectomy (T&A) surgery, and evaluate surgeon, hospital, and patient factors influencing variation in costs, and compare relationship of costs to complications for T&A.

STUDY DESIGN

Observational retrospective cohort study.

METHODS

A multihospital network's standardized activity-based accounting system was used to determine hospital costs per T&A from 1998 to 2012. Children 1 to 18 years old who underwent same-day T&A surgery were included. Subjects with additional procedures were excluded. Mixed effects analyses were performed to identify variation in mean costs due to surgeon, hospital, and patient factors. Surgeons' mean cost/case was related to subsequent complications, defined as any unplanned visit within 21 days in the healthcare system.

RESULTS

The study cohort included 26,626 T&As performed by 66 surgeons at 18 hospitals. Mean cost per T&A was $1,355 ± $505. Mixed effects analysis using patient factors as fixed effects and surgeon and hospital as a random effect identified significant variation in mean costs per surgeon, with 95% of surgeons having a mean cost/case between 67% and 150% of the overall mean (range, $874-$2,232/case). Similar variability was found among hospitals, with 95% of the facilities having mean costs between 64% to 156% of the mean (range, $1,029-$2,385/case). Severity of illness and several other patient factors exhibited small but statistically significant associations with cost. Surgeons' mean cost/case was moderately associated with an increased complication rate.

CONCLUSIONS

Significant variation in same-day pediatric T&A surgery costs exists among different surgeons and hospitals within a multihospital network. Reducing variation in costs while maintaining outcomes may improve healthcare value and eliminate waste.

LEVEL OF EVIDENCE

4.

Surgeon Dependent Variation in Adenotonsillectomy Costs in Children

Objectives

To (1) identify the major expenses for same-day adenotonsillectomy (T&A) and the costs for postoperative complication encounters in a children’s hospital and (2) compare differences for variations in costs by surgeon.

Study Design

Observational cohort study.

Setting

Tertiary children’s hospital.

Subjects and Methods

A standardized activity-based hospital accounting system was used to determine total hospital costs per encounter (not including professional fees for surgeons or anesthetists) for T&A cases at a tertiary children’s hospital from 2007 to 2012. Hospital costs were subdivided into categories, including operating room (OR), OR supplies, postanesthesia care unit (PACU), same-day services (SDS), anesthesia, pharmacy, and other. Costs for postoperative complication encounters were included to identify a mean total cost per case per surgeon.

Results

The study cohort included 4824 T&As performed by 14 different surgeons. The mean cost per T&A was $1506 (95% confidence interval, $1492-$1519, with a range of $1156-$1828 for the lowest and highest cost per case per surgeon; P < .01). Including the cost for postoperative complications, the mean cost increased to $1599 ($1570-$1629). The largest cost categories included OR (31.9%), SDS (28.1%), and OR supplies (15.6%).

Conclusion

A large portion of T&A expenses are due to OR and supply costs. Significant differences in costs between surgeons for outpatient T&A were identified. Studies to understand the reasons for this variation and the impact on outcomes are needed. If this variation does not affect patient outcomes, then reducing this variation may improve health care value by limiting waste.

Tonsillectomy and adenoidectomy

Adenotonsillectomy (AT) is one of the most common pediatric surgical procedures performed in the United States; more than 530,000 are performed annually in children younger than 15 years of age. AT was traditionally performed for recurrent tonsillitis and its sequelae but in recent times, sleep-disordered breathing/obstructive sleep apnea in children has emerged as the primary indication for surgical removal of adenoids and tonsils. The new guidelines used by clinicians to identify children who are appropriate candidates for AT address indications based primarily on obstructive and infectious causes.