What are the absolute and relative indications for tonsillectomy?

Indications for Tonsillectomy

Tonsillectomy is indicated for recurrent throat infections meeting specific frequency criteria, obstructive sleep apnea documented by polysomnography, and certain absolute indications including peritonsillar abscess, suspicion of malignancy, and hemorrhagic tonsillitis. 1, 2

Absolute Indications

• Adenotonsillar hyperplasia with obstructive sleep apnea 2
• Suspicion of malignant disease 2
• Hemorrhagic tonsillitis 2
• Failure to thrive due to tonsillar obstruction 2
• Abnormal dentofacial growth due to chronic airway obstruction 2
• Peritonsillar abscess (especially recurrent or complicated cases) 3

Relative Indications

Recurrent Throat Infections

• Tonsillectomy is recommended when documented episodes meet frequency criteria of:
  • ≥7 episodes in the past year, OR
  • ≥5 episodes per year for 2 consecutive years, OR
  • ≥3 episodes per year for 3 consecutive years 1, 4
• Each episode should be documented with at least one of: temperature ≥38.3°C, cervical adenopathy, tonsillar exudate, or positive test for group A beta-hemolytic streptococcus 1
• Watchful waiting is strongly recommended if these frequency criteria are not met 4

Modifying Factors for Recurrent Infections

• Multiple antibiotic allergies/intolerance 4
• PFAPA syndrome (Periodic Fever, Aphthous stomatitis, Pharyngitis, and Adenitis) 4, 5
• History of >1 peritonsillar abscess 4, 1
• Chronic tonsillitis unresponsive to medical therapy 6

Obstructive Sleep-Disordered Breathing (oSDB)

• Tonsillectomy is recommended for children with obstructive sleep apnea documented by overnight polysomnography 1, 4
• Clinicians should assess for comorbid conditions that may improve after tonsillectomy, including:
  • Growth retardation
  • Poor school performance
  • Enuresis
  • Asthma
  • Behavioral problems 4, 1

Special Populations Requiring Polysomnography

Polysomnography should be performed prior to tonsillectomy for children with oSDB who have:

• Age <2 years 4
• Obesity 4
• Down syndrome 4
• Craniofacial abnormalities 4
• Neuromuscular disorders 4
• Sickle cell disease 4
• Mucopolysaccharidoses 4

Management Considerations

• In adults with OSA and tonsillar hypertrophy, tonsillectomy plays a role similar to nasal surgery in increasing the use of CPAP or when CPAP therapy is not possible 4
• For peritonsillar abscess, treatment options include needle aspiration, incision and drainage, or abscess tonsillectomy 3
• Abscess tonsillectomy should be preferred if complications have occurred or if alternative therapeutic procedures have failed 3
• For infectious mononucleosis, tonsillectomy is not recommended as a routine procedure but is indicated in cases with clinically significant upper airway obstruction 3
• Overnight inpatient monitoring is recommended after tonsillectomy for children <3 years old or with severe OSA 1

Efficacy and Outcomes

• In sleep apnea confirmed by polysomnography, tonsillectomy relieves symptoms in approximately 80% of patients 5
• The impact of tonsillectomy on the number of sore throat episodes per year in children is modest and conclusions are limited to 12 postoperative months 3
• Patients and caregivers should be counseled that obstructive sleep-disordered breathing may persist or recur after tonsillectomy and may require further management 1
• Tonsillotomy (partial removal) has substantially lower postoperative morbidity than complete tonsillectomy in terms of pain and bleeding, with similar efficacy for obstructive symptoms 3

Contraindications

• Bleeding disorders 6
• Familial anesthetic intolerance 6
• Velopharyngeal insufficiency 6
• Concurrent disease that may enhance operative risks 6