Tonsillectomies and Adenoidectomies

[EAMom]

If anybody has access to the full-text, a link would be appreciated. Please note my comments were based on the abstract (since I couldn't find the full-text for free).

 

http://www.ncbi.nlm.nih.gov/pubmed/23518825

 

Tonsillectomies and Adenoidectomies Do Not Prevent the Onset of Pediatric Autoimmune Neuropsychiatric Disorder Associated with Group A Streptococcus.

 

Murphy TK, Lewin AB, Parker-Athill EC, Storch EA, Mutch PJ.

 

 

Source

 

1 Department of Pediatrics, University of South Florida, St. Petersburg, Florida 2 Department of Psychiatry & Behavioral Neurosciences, University of South Florida, Tampa, Florida.

 

 

Abstract

 

 

BACKGROUND:: In children presenting with obsessive compulsive disorder (OCD) and/or tics, especially those with a temporal association with streptococcal pharyngitis (e.g., PANDAS; Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcus), there is speculation about whether tonsillectomy/adenoidectomy might improve the child's neuropsychiatric course. Our objective was to examine whether removal of tonsils and/or adenoids impacted streptococcal antibody titers, the timing of onset of OCD and/or tics, and the clinical severity of these symptoms. METHODS:: Study participants (n = 112; average age = 9.2 ± 2.4; 44 female) were recruited as part of a prospective investigation of neuropsychiatric phenomena with temporal association to streptococcal pharyngitis and examined by family history, diagnostic interview, physical examination, medical record review, psychological testing, and streptococcal antibodies and divided into surgical or non-surgery groups. The surgical group consisted of children having previously had a tonsillectomy and/or adenoidectomy (n=32). The remaining children were categorized as non-surgery (N=76). Measures of OCD and tic severity, streptococcal antibody titers, and PANDAS classification were compared between both groups. RESULTS:: There were no significant differences as determined by streptococcal antibody titers, PANDAS classification, and OCD or tic severity between the surgical and non-surgery groups. Most participants had surgery before onset of neuropsychiatric symptoms and surgery did not affect symptomology. CONCLUSIONS:: Streptococcal antibodies and neuropsychiatric symptom severity did not differ on the basis of surgical status. From these data we cannot support that tonsillectomy and adenoidectomy are likely to impact positively the course of OCD/tics or streptococcal antibody concentrations

 

My thoughts on this study:

 

1) SELECTION BIAS IS A HUGE PROBLEM WITH THIS STUDY: There is probably a subset of pandas kids that do benefit from T/A, eg those with chronic infection lurking in their tonsils or those in which t/a actually do help prevent future strep.

 

The selection bias comes info play as the kids that benefit from an early T/a (before pandas starts, or with a recent pandas diagnosis) are unlikely to then travel to Florida to see a PANDAS specialist...since their pandas may have been nipped in the bud (so to speak).

 

In her study there were 32 pandas kids that had previous t/a . For all we know there might have been another 100 (or 1000!) kids (with either established pandas or kids that might have otherwise developed pandas) that were helped (or pandas totally prevented) by T/A that never made it to her door because their pandas was fixed by t/a and so they didn't need a top specialist.

 

2) ANTIBIOTICS (or lack thereof): since T/A was performed priot to the onset of PANDAS, these kids were presumeably NOT put on prophylactic antibiotics (or a "tonsil sterilizing protocol with clindamycin/rifampin).

 

Isn't this a be a bit like giving a kid (pre pandas) a single high dose IVIG, but NO antibiotics afterwards to prevent strep infections....how well would that work?? And then concluding that HD IVIG is an infective treatment for PANDAS???

 

3)IMHO T/A is a PIECE OF THE PUZZLE for treating pandas....not a ONE time cure all for all kids! What this study DOES show is that there are some kids (the 32) whose pandas was NOT cured (or prevented) by T/A alone. Doesn't say how many kids WERE cured or prevented with T/A or how useful T/A is when combined with other pandas treatments (eg IVIG and/or long term abs). From reading PANDAS boards over the years, it does seem that there are a subset of kids who benefit (some greatly) from T/A.

 

4)A MORE USEFUL STUDY: would be to see if prior T/A affects outcome of a single HD IVIG (eg does it "stick" better)? Of course kids would have to be "matched" for other things like type of antibiotics used (and duration of prophylaxis), age, years affected, severity and type (tics vs OCD) of symptoms...

 

5) ANTIBODY TITERS: it also bothers me that the study mentions using streptococcal antibody titers but NOT CULTURES. We all know that a many kids with cutlureable strep (and pandas)don't get elevated titers (or a titer rise). My own dd's ASO never got above 31 despite a Cunningham test in the high pandas range (when not in an exacerbation) and in the high SC range after H1N1, and titers drawn at the "right time" (2mo after fever/onset of beh change), AND positive cultures at the time.

 

"Trying to use titers to see if someone has been infected with strep is not very useful." --Dr. Sue Swedo IOCDF conf. 2012

Edited March 26, 2013 by EAMom

[EAMom]

I should add:

 

-My own PANDAS dd has NOT had a T/A (so I don't have personal experience on the matter).

 

-Both Dr. T. and Dr. Latimer are (in general) in favor of T/A prior to trying IVIG...so PANDAS docs are NOT in agreement of the benefit of T/A for the average PANDAS kid.

 

-Dr. Latimer said (at the IOCDF conf) that she is culturing a lot of antibiotic resistant staph from pandas tonsils.

 

-I think pretty much all PANDAS docs would agree that if the tonsils looks obviously diseased, they should come out.

[Mayzoo]

I do not think a T & A would have prevented my daughter from acquiring PANDAS, but I will never know of course. It seems she had been having asymptomatic strep for a while prior to our actual bout, that was also asymptomatic, that brought on the DX. I would have never known she had strep in January 2012 had I not been taking her in for blood work to see if she may have PANDAS. She had several mini-pandas flares that resolved themselves over a few days to a few weeks, but no one had a clue what was going on and the behaviour was always attributed to one of her other DXs.

 

I was always told kiddos tonsils "looked fine", even during the T & A evaluation. When they were removed, I was then told they were typical of chronically infected tonsils. The T & A has helped alleviate some of her symptoms. She had been running a low grade fever for 6-8 months prior to the T & A, and her pupils were dilated about 90% of the time prior. Now her temp is normal most the time and her pupils are dilated maybe 20% of the time. She has slept through the night a lot more since the T & A than the preceding 6 months or so as well. She is having fewer nightmares and they seem less severe when she does have them.

 

On the complicating side of things, I did add zithromax prior to the T & A and have not removed it either since she did culture bacteria in the tonsils. So some of the improvements maybe from adding low dose zith to her keflex. We are seeing Dr. Rao for the first time on the 4th so I am seeking his advice about the particular bacteria (actinomyces) we are dealing with from the tonsils then.

Edited March 27, 2013 by Mayzoo

[JPdad]

I can only speak from my personal experience, but the difference in my son has been night and day since his T&A and proph. antibiotics started. Then again, his primary trigger was recurring ear infections that wouldn't stop coming back month after month.