What are the indications for tonsillectomy?

Indications for Tonsillectomy

Tonsillectomy is indicated for recurrent throat infections meeting specific frequency criteria or for obstructive sleep apnea documented by polysomnography, with additional considerations for certain modifying factors that may favor surgery even when standard criteria aren't met. 1

Recurrent Throat Infections

Primary Criteria

• Tonsillectomy may be recommended for recurrent throat infections with a frequency of:

  • At least 7 episodes in the past year, OR
  • At least 5 episodes per year for 2 years, OR
  • At least 3 episodes per year for 3 years 1

• Each episode should be documented in the medical record with at least one of the following:

  • Temperature ≥38.3°C (101°F)
  • Cervical adenopathy
  • Tonsillar exudate
  • Positive test for group A beta-hemolytic streptococcus 1

• Watchful waiting is strongly recommended if the frequency criteria are not met (fewer than 7 episodes in past year, fewer than 5 episodes per year in past 2 years, or fewer than 3 episodes per year in past 3 years) 1

Modifying Factors

• Even when frequency criteria aren't met, tonsillectomy may be appropriate in patients with:
  • Multiple antibiotic allergies/intolerance
  • PFAPA syndrome (Periodic Fever, Aphthous stomatitis, Pharyngitis, and Adenitis)
  • History of >1 peritonsillar abscess 1
  • Severe impact on quality of life 2

Obstructive Sleep-Disordered Breathing

Primary Indications

• Tonsillectomy is recommended for children with obstructive sleep apnea (OSA) documented by overnight polysomnography 1

• Polysomnography should be performed prior to tonsillectomy for children with obstructive sleep-disordered breathing (oSDB) if they:

  • Are <2 years of age
  • Have obesity
  • Have Down syndrome
  • Have craniofacial abnormalities
  • Have neuromuscular disorders
  • Have sickle cell disease
  • Have mucopolysaccharidoses 1

• Polysomnography should also be considered when:

  • The need for tonsillectomy is uncertain
  • There is discordance between physical examination and reported severity of oSDB 1

Associated Conditions

• Clinicians should assess for comorbid conditions that may improve after tonsillectomy in children with oSDB and tonsillar hypertrophy:
  • Growth retardation
  • Poor school performance
  • Enuresis
  • Asthma
  • Behavioral problems 1

Other Indications

• Absolute indications for tonsillectomy include:

  • Suspicion of malignancy
  • Hemorrhagic tonsillitis 3

• Relative indications include:

  • Tonsillar hypertrophy with dysphagia or speech impairment
  • Halitosis
  • Peritonsillar abscess 1, 3

Special Considerations

• Overnight inpatient monitoring is recommended after tonsillectomy for children who are:

  • <3 years old
  • Have severe OSA (apnea-hypopnea index ≥10 obstructive events/hour, oxygen saturation nadir <80%, or both) 1

• Recent evidence suggests tonsillectomy is clinically effective and cost-effective in adults with recurrent acute tonsillitis compared to conservative management 4

• Patients and caregivers should be counseled that oSDB may persist or recur after tonsillectomy and may require further management 1

Perioperative Management

• A single intraoperative dose of intravenous dexamethasone should be administered to children undergoing tonsillectomy 1

• Perioperative antibiotics should not be administered or prescribed to children undergoing tonsillectomy 1

• Proper pain management counseling should be provided before and after surgery 1