Paediatric (Adeno)Tonsillectomy Pre-Assessment Pathway

Absolute exclusion criteria for paeds (adeno)tonsillectomy surgery within NHSL include: 

• Age under 3 years.
• Severe cerebral palsy.
• Achondroplasia.
• Down’s syndrome.
• Neuromuscular disorders.
• Significant craniofacial anomalies.
• Mucopolysaccharidosis.
• Severe comorbidity (e.g. complex or uncorrected congenital heart disease, home oxygen or CPAP, severe cystic fibrosis).
• When onsite support from tertiary medical specialties is needed e.g. metabolic, haematology (anaemias, clotting disorders).
• Obesity (equal to or over 99th centile).

Such patients should be referred directly from ENT clinic to the RHC and not be referred to PA within NHSL. 

For children whose BMI is equal to or over the 99th centile, please consider referring to NHSL paediatrics team for an obesity assessment, alongside their referral to the RHC.

For day-case patients at UHM the following additional criteria apply: 

• Child must be ≥ 3 years.
• Weight must be ≥14 kg.
• BMI must be <98th centile.
• Minimal comorbidities. 
  • Patients with poorly controlled respiratory disease, safeguarding concerns, or Type 1 diabetes should not undergo surgery at UHM.

The decision over whether to proceed with sleep studies generally lies with the ENT team who will screen for OSA symptoms at their clinic review. 

A BMI should be calculated from height and weight measurements of the child and plotted on the iGrow centile chart on clinical portal.  Ideally this should be done at the ENT clinic review. 

All NHSL patients should have a routine pre-assessment referral.  This is likely to take the form of a nurse-led telephone consultation with a parent or guardian.   

Any patients with comorbidities or a documented Hx of sleep apnoea should be submitted by the PA nurses for an anaesthetic consultant case notes review.   Any PA consultant should be able to review the case notes by applying the following exclusion criteria:  

• Significant co-morbidities e.g. poorly controlled asthma, epilepsy or T1DM, any concerning or untreated cardiac history (including arrhythmias).
• SEVERE OSA - Sats nadir < 80% on good quality pulse oximetry study if this has been done, low mean saturations (< 94%) or > 10 dips/hr of >4% .

Other criteria for anaesthetic consultant case note review include: 

• Previous GA complications, a family history of anaesthetic complications (MH, sux apnoea) as these may also necessitate a tertiary referral.
• Children under the care / supervision of Social Work services.
• Children who have had a recent LRTI (wheeze, SoB, cough, fever but not specifically requiring antibiotics) should have their surgery delayed for 6 weeks.   
• Elective surgery in children should be deferred for 14 days following the onset of symptoms or diagnosis in children with mild or asymptomatic COVID-19 infection (as per RCPCH guidelines).

For cases where the decision to proceed locally remains unclear – the case should be discussed with the list anaesthetist or Dr L Young (PA consultant, UHW) 

If the child is decided to be unsuitable for surgery at UHW, the PA consultant must inform the referring ENT consultant by letter or email to be printed for the notes explaining their rationale for this for ongoing clarity for the clinical team, parents and GP.  The ENT surgeon should then refer to the case onwards to the RHC.