Ultrasonographic assessment of tonsillar volume in children

Sir, we read with great interest the recent article by Asimakopoulos et Al. entitled “Ultrasonographic assessment of tonsillar volume in children”1. The study has been well planned and we would like to appreciate the effort made by the Authors to shed light on this topic. However there are few points regarding the methodology with which we have some reservations and would like to highlight these through your prestigious journal . First, the clinical utility of tonsillar volume as a predictor of OSAS severity has not been clearly demonstrated despite its widespread use. The etiologies of pediatric OSAS are diverse. Tonsil size is not the sole factor and this could explain why tonsillectomy is not 100 % curative2. Because the tonsils are larger relative to the airway size a better way to assess tonsil size clinically is to evaluate the tonsils within a more 3-dimensional/volumetric framework to capture the impact of the tonsils on the upper airway. Second, since in the paper by Asimakopoulos et Al indication for tonsillectomy was recurrent tonsillitis in about 70% of the patients, it could be hasty to conclude that “Preoperative ultrasound assessment of tonsillar anatomy and size may be an additional and suitable, objective method in the development of a risk stratification system in children with obstructive sleep apnoea undergoing tonsillar surgery”. Certainly, as supposed by the Authors, tonsillar ultrasound may have a role to assess for tonsillar asymmetry and potentially prevent patients from undergoing unnecessary diagnostic tonsillectomies. Finally, even if assessment of tonsils size is an effective screening tool for the clinical diagnosis of paediatric OSA , the true effect of tonsils volume on sleep disordered breathing requires further exploration. Particularly, in the case of a child who may be at higher risk for complications during surgery only a PSG may have real value in firmly establishing the risk of postoperative respiratory compromise potentially needing for ICU overnight observation3.