What is the treatment approach for tonsillar enlargement?

Treatment Approach for Tonsillar Enlargement

Tonsillectomy is the primary treatment for significant tonsillar enlargement, particularly when associated with obstructive sleep-disordered breathing (oSDB) or when there is concern for malignancy in unilateral cases. 1, 2

Assessment of Tonsillar Enlargement

Grading System

• Grade 0: Not visible (tonsils do not reach tonsillar pillars)
• Grade 1+: <25% of oropharyngeal space
• Grade 2+: 25-49% of oropharyngeal space
• Grade 3+: 50-74% of oropharyngeal space
• Grade 4+: 75% or more of oropharyngeal space 1

Clinical Presentation

• Bilateral Enlargement: Usually benign, commonly associated with oSDB
• Unilateral Enlargement: Requires careful evaluation for potential malignancy

Treatment Algorithm for Bilateral Tonsillar Enlargement

For Children with oSDB:

1. Surgical Intervention: Adenotonsillectomy is the first-line treatment for children with adenotonsillar hypertrophy causing oSDB 1, 2

   • Complete resolution occurs in approximately 75% of normal-weight children
   • Only 10-25% resolution in obese children 1

2. Polysomnography (PSG) Indications:

   • Not necessary in all cases of suspected oSDB
   • Recommended before surgery for high-risk children:
     • Obesity
     • Down syndrome
     • Craniofacial abnormalities
     • Neuromuscular disorders
     • Sickle cell disease
     • Mucopolysaccharidoses 2

3. Post-surgical Management:

   • Post-operative PSG recommended for:
     • Children with severe preoperative OSA
     • Persistent symptoms after surgery
     • High-risk patients (obesity, craniofacial abnormalities) 2
   • Avoid codeine for pain management in children under 12 years 2

For Adults with OSA:

• Tonsillectomy is recommended for adults with tonsillar hypertrophy and OSA 2, 3
• Success rates are variable; many adults benefit from tonsillectomy, but success may be transient in some cases 3

Treatment Algorithm for Unilateral Tonsillar Enlargement

Risk Assessment for Malignancy:

• High-Risk Features (warrant immediate tonsillectomy):

  • Cervical lymphadenopathy
  • Suspicious tonsillar appearance
  • History of malignancy
  • Immunocompromised state
  • Systemic symptoms (weight loss, night sweats, fever)
  • Progressive enlargement 4, 5, 6

• Low-Risk Features (observation may be appropriate):

  • Incidental finding without symptoms
  • No suspicious features
  • Normal appearance of tonsil
  • No cervical lymphadenopathy 5, 7

Management Approach:

• High-Risk Features Present: Proceed with tonsillectomy for histopathological examination
• Low-Risk Features Only: Consider "watch and wait" approach with regular follow-up
  • If symptoms or signs progress, tonsillectomy is then advised 5

Special Considerations

Medical Management Options:

• For Infectious Causes: Antibiotics may be appropriate for acute bacterial tonsillitis
  • Azithromycin has shown 95% bacteriologic eradication in streptococcal pharyngitis 8
  • Consider for patients who are not surgical candidates

Perioperative Management:

• Administer a single intraoperative dose of intravenous dexamethasone to children undergoing tonsillectomy to:
  • Decrease post-operative nausea and vomiting
  • Reduce throat pain
  • Improve time to resumption of oral intake 1

Cautions and Pitfalls

1. Unnecessary Tonsillectomies: Apparent unilateral tonsillar enlargement is often spurious; many unnecessary tonsillectomies are performed when UTE is the sole indication 7

2. Missed Malignancy: Despite low incidence of tonsillar lymphoma in children, most patients with tonsillar lymphoma present with unilateral enlargement, warranting careful follow-up 6

3. Incomplete Resolution of OSA: Caregivers should be counseled that tonsillectomy may not completely resolve OSA, particularly in:

   • Obese children (only 10-25% resolution)
   • Children with craniofacial or neuromuscular disorders 1, 2

4. Post-Operative Complications: Monitor for respiratory complications, especially in patients with severe OSA (AHI >10) 2