What are the indications for a tonsillectomy?

Indications for Tonsillectomy

Tonsillectomy is indicated for recurrent throat infections meeting the Paradise criteria (≥7 episodes in the past year, ≥5 episodes per year in the past 2 years, or ≥3 episodes per year in the past 3 years) or for obstructive sleep-disordered breathing with significant impact on quality of life and health. 1

Primary Indications

1. Recurrent Throat Infections

The American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS) provides clear criteria for tonsillectomy based on infection frequency:

• Paradise Criteria (Strong recommendation) 1:

  • ≥7 episodes in the past year, OR
  • ≥5 episodes per year in the past 2 years, OR
  • ≥3 episodes per year in the past 3 years

• Documentation requirements:

  • Temperature >38.3°C (100.9°F)
  • Cervical lymphadenopathy (tender nodes or >2 cm)
  • Tonsillar exudate
  • Positive culture for group A β-hemolytic streptococcus
  • Appropriate antibiotic treatment for suspected streptococcal episodes

2. Obstructive Sleep-Disordered Breathing (oSDB)

• First-line treatment for children with adenotonsillar hypertrophy and OSA 2
• Particularly indicated when comorbid conditions are present:
  • Growth retardation
  • Poor school performance
  • Enuresis
  • Behavioral problems

Secondary Indications (Modifying Factors)

Even when Paradise criteria aren't fully met, tonsillectomy may be indicated with these modifying factors 1:

1. Multiple antibiotic allergies/intolerance limiting treatment options
2. PFAPA syndrome (Periodic Fever, Aphthous stomatitis, Pharyngitis, and Adenitis) 3
3. History of peritonsillar abscess, especially with prior recurrent tonsillitis (40% recurrence rate vs. 9.6% without prior history) 4
4. Severe episodes with significant impact on quality of life
5. Family history of rheumatic heart disease
6. "Ping-pong" spread (multiple infections within household)

Special Considerations

Polysomnography Requirements

Polysomnography is essential before tonsillectomy in high-risk patients 2:

• Obesity
• Down syndrome
• Craniofacial abnormalities
• Neuromuscular disorders
• Sickle cell disease
• Mucopolysaccharidoses

Age Considerations

• Children under 2 years: Tonsillectomy should only be performed for obstructive sleep-disordered breathing with polysomnography confirmation 2
• Adults: Tonsillectomy shows benefit for recurrent pharyngitis with reduced episodes and days with symptoms, though evidence quality is moderate 5, 6, 7

Watchful Waiting Recommendations

Watchful waiting is strongly recommended when infection frequency is below Paradise criteria 1. This is supported by evidence showing:

• Natural improvement over time in control groups
• Average of only 1.17 episodes in the first year after observation
• Continued reduction to 0.45 episodes by third year

Clinical Pitfalls to Avoid

1. Inadequate documentation: Ensure episodes are properly documented with clinical features and treatment
2. Premature intervention: Remember many cases resolve without surgery
3. Overlooking modifying factors: Consider the full clinical picture beyond just frequency counts
4. Ignoring comorbidities: Assess for conditions that might increase surgical risk
5. Inappropriate pain management: Codeine must not be used in children under 12 years 2

Postoperative Monitoring Requirements

• Overnight observation for all children under 3 years
• PICU monitoring for severe OSA (AHI >10 or oxygen saturation nadir <80%)
• Post-operative polysomnography for children with severe preoperative OSA or persistent symptoms

Tonsillectomy provides modest but meaningful benefits when properly indicated, with the greatest benefit seen in severely affected patients with recurrent infections or significant obstructive symptoms.