When is a tonsillectomy recommended?

Tonsillectomy Indications: When to Recommend Surgical Intervention

Tonsillectomy is primarily recommended for children with documented recurrent throat infections meeting the Paradise criteria (≥7 episodes in the past year, ≥5 episodes per year for 2 years, or ≥3 episodes per year for 3 years) or for children with obstructive sleep apnea documented by polysomnography. 1, 2

Recurrent Throat Infections

Primary Indications

• Tonsillectomy may be recommended when the following Paradise criteria are met:
  • At least 7 episodes of throat infection 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, 2

Documentation Requirements

• Each episode must 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, 2

Modifying Factors

• Even if Paradise criteria are not met, tonsillectomy may be considered with these modifying factors:
  • Multiple antibiotic allergies/intolerance
  • PFAPA syndrome (periodic fever, aphthous stomatitis, pharyngitis, and adenitis)
  • History of >1 peritonsillar abscess 1

Watchful Waiting

• Strong recommendation for watchful waiting if criteria are not met (<7 episodes in past year, <5 episodes per year for 2 years, or <3 episodes per year for 3 years) 1, 2
• Many cases improve spontaneously over time (untreated children experienced only an average of 1.17 episodes in the first year after observation) 2

Obstructive Sleep-Disordered Breathing

Primary Indications

• Tonsillectomy is recommended for children with obstructive sleep apnea (OSA) documented by overnight polysomnography 1
• Presence of tonsillar hypertrophy with symptoms of obstructive sleep-disordered breathing 1, 3

Polysomnography Indications

• Polysomnography should be performed before tonsillectomy if the child:
  • Is <2 years of age
  • Has obesity
  • Has Down syndrome
  • Has craniofacial abnormalities
  • Has neuromuscular disorders
  • Has sickle cell disease
  • Has mucopolysaccharidoses 1
• Polysomnography should also be considered when:
  • The need for tonsillectomy is uncertain
  • There is discordance between physical examination and reported severity of symptoms 1

Comorbid Conditions

• Clinicians should assess for comorbid conditions that may improve after tonsillectomy:
  • Growth retardation
  • Poor school performance
  • Enuresis
  • Asthma
  • Behavioral problems 1

Other Indications

Peritonsillar Abscess

• Abscess tonsillectomy should be preferred if:
  • Complications have occurred
  • Alternative therapeutic procedures have failed
  • There is bilateral peritonsillar abscess 4
• Needle aspiration or incision and drainage are preferred if:
  • Comorbidities exist
  • There is increased surgical risk
  • Coagulation disorders are present 4

Infectious Mononucleosis

• Tonsillectomy is not recommended as a routine procedure for symptom control
• Only indicated in cases with clinically significant upper airway obstruction resulting from inflammatory tonsillar hyperplasia 4

Special Considerations

Adults with Recurrent Tonsillitis

• Recent evidence shows tonsillectomy is clinically effective and cost-effective in adults with recurrent acute tonsillitis compared to conservative management 5
• Adults who underwent tonsillectomy had fewer days of sore throat during 24 months than those with conservative management (median 23 days vs 30 days) 5

Perioperative Management

• Clinicians should not administer perioperative antibiotics 1
• A single intraoperative dose of intravenous dexamethasone should be administered 1
• Ibuprofen, acetaminophen, or both are recommended for post-operative pain control 1
• Codeine should not be administered to children younger than 12 years 1

Monitoring Requirements

• Overnight inpatient monitoring is recommended for:
  • Children <3 years old
  • Children with severe OSA (AHI ≥10 obstructive events/hour or oxygen saturation nadir <80%) 1

Common Pitfalls to Avoid

• Performing tonsillectomy without adequate documentation of recurrent infections 1, 2
• Failing to consider watchful waiting in cases that don't meet Paradise criteria 1
• Not obtaining polysomnography in high-risk children with suspected OSA 1
• Administering perioperative antibiotics, which is strongly recommended against 1
• Prescribing codeine for post-operative pain in children under 12 1
• Performing routine interval tonsillectomy after peritonsillar abscess without meeting criteria for elective tonsillectomy 4