What are the indications for tonsillectomy in adults?

Indications for Tonsillectomy in Adults

Tonsillectomy in adults is primarily 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. 1

Recurrent Throat Infections

The primary indications for tonsillectomy in adults with recurrent throat infections include:

1. Frequency criteria (Paradise criteria):

   • ≥7 documented episodes of throat infection in the previous year, OR
   • ≥5 documented episodes per year in the previous 2 years, OR
   • ≥3 documented episodes per year in the previous 3 years 2, 1

2. Documentation requirements for each episode:

   • Temperature >38.3°C (100.9°F)
   • Cervical lymphadenopathy
   • Tonsillar exudate or erythema
   • Positive culture for group A β-hemolytic streptococcus (when available)
   • Appropriate antibiotic treatment for suspected streptococcal episodes 1

3. Modifying factors that may justify tonsillectomy even when Paradise criteria aren't fully met:

   • Multiple antibiotic allergies/intolerance
   • PFAPA syndrome (Periodic Fever, Aphthous stomatitis, Pharyngitis, Adenitis)
   • History of peritonsillar abscess
   • Exceptionally severe episodes
   • Family history of rheumatic heart disease
   • "Ping-pong" spread (multiple infections within household) 2, 1

Obstructive Sleep-Disordered Breathing

Tonsillectomy is indicated for adults with:

• Obstructive sleep-disordered breathing (oSDB) with tonsillar hypertrophy
• Significant impact on quality of life and health
• Polysomnography confirmation of obstructive sleep apnea (OSA), particularly in high-risk patients 1

Clinical Effectiveness

Recent research demonstrates that tonsillectomy is clinically effective for adults with recurrent tonsillitis:

• Significantly reduces the number of sore throat days (median 23 vs 30 days over 24 months compared to conservative management)
• Decreases physician visits for pharyngitis (4% vs 43% in conservative management)
• Reduces episodes of pharyngitis (39% vs 80% in conservative management) 3
• Improves quality of life scores on standardized measures 4
• Reduces analgesic use (7% vs 65% pre-operatively) and antibiotic consumption (22% vs 95% pre-operatively) 4

Watchful Waiting Recommendations

Watchful waiting rather than tonsillectomy is strongly recommended when:

• Infection frequency is below Paradise criteria
• Patient has had fewer than 7 episodes in the previous year
• Patient has had fewer than 5 episodes in each of the previous 2 years
• Patient has had fewer than 3 episodes in each of the previous 3 years 2, 1

Pre-Operative Evaluation

For adults with suspected OSA:

• Polysomnography is essential before proceeding with tonsillectomy, particularly in high-risk patients
• Risk factors requiring polysomnography include obesity, craniofacial abnormalities, and neuromuscular disorders 1

Potential Complications

The most common adverse events related to tonsillectomy include:

• Post-operative bleeding (occurs in approximately 19% of patients)
• Pain requiring analgesic management
• Potential for dehydration 3

Summary

Tonsillectomy provides significant benefits for carefully selected adult patients with recurrent tonsillitis or obstructive sleep-disordered breathing. The decision to perform tonsillectomy should be based on documented frequency and severity of episodes, impact on quality of life, and presence of modifying factors. For recurrent infections, the Paradise criteria remain the gold standard for surgical decision-making.