What are the indications for tonsillectomy?

Indications for Tonsillectomy

Tonsillectomy is indicated for recurrent throat infections with a frequency of at least 7 episodes in the past year, at least 5 episodes per year for 2 years, or at least 3 episodes per year for 3 years, and for children with documented obstructive sleep apnea. 1

Recurrent Throat Infections

Primary Criteria

• Tonsillectomy should be performed when the following frequency criteria are met 2, 1:

  • ≥7 episodes of throat infection in the past year, OR
  • ≥5 episodes per year for 2 consecutive years, OR
  • ≥3 episodes per year for 3 consecutive years

• Each episode should be documented in the medical record with at least one of the following 1:

  • Temperature ≥38.3°C
  • Cervical adenopathy
  • Tonsillar exudate
  • Positive test for group A beta-hemolytic streptococcus

Watchful Waiting

• Clinicians should recommend watchful waiting for recurrent throat infection if there have been fewer episodes than the criteria above 2
• This is a strong recommendation from the American Academy of Otolaryngology-Head and Neck Surgery Foundation 1

Modifying Factors

• Even if frequency criteria are not met, tonsillectomy may be appropriate in patients with 2, 1, 3:
  • Multiple antibiotic allergies/intolerance
  • PFAPA syndrome (Periodic Fever, Aphthous stomatitis, Pharyngitis, and Adenitis)
  • History of >1 peritonsillar abscess

Obstructive Sleep-Disordered Breathing

Primary Indications

• Tonsillectomy is recommended for children with obstructive sleep apnea documented by overnight polysomnography 1, 4
• Tonsillectomy with or without adenoidectomy is effective in resolving sleep-related breathing disorders resulting from tonsillar hypertrophy in children 5

Special Populations Requiring Polysomnography

• Before performing tonsillectomy, clinicians should refer children with obstructive sleep-disordered breathing for polysomnography if they are 2, 1:
  • <2 years of age
  • Have Down syndrome
  • Have neuromuscular disorders
  • Have sickle cell disease
  • Have mucopolysaccharidoses

Associated Conditions

• Clinicians should assess for comorbid conditions that may improve after tonsillectomy in children with obstructive sleep-disordered breathing, including 2, 1:
  • Growth retardation
  • Poor school performance
  • Enuresis
  • Asthma
  • Behavioral problems

Other Indications

Peritonsillar Abscess

• Abscess tonsillectomy is not justified as a routine procedure 5
• It should be considered only for cases not responding to other treatments, evident complications, or with a significant history of tonsillitis 5

PFAPA Syndrome

• While PFAPA syndrome is often self-limiting and may respond to steroid administration, tonsillectomy may be beneficial in selected cases 1, 5

Potential Indications Requiring Further Research

• Psoriasis: Further trials are needed to evaluate the efficacy of tonsillectomy for psoriasis guttata and psoriasis vulgaris not responding to first-line therapy 5
• IgA Nephropathy: Conflicting results have been reported, requiring further clinical research 5

Perioperative Management

Medications

• Clinicians should administer a single intraoperative dose of intravenous dexamethasone to children undergoing tonsillectomy 2, 1
• Ibuprofen, acetaminophen, or both should be recommended for pain control after tonsillectomy 2, 1
• Perioperative antibiotics should not be administered or prescribed 1

Monitoring

• Overnight inpatient monitoring is recommended after tonsillectomy for children who are 1:
  • <3 years old
  • Have severe obstructive sleep apnea

Important Considerations

Documentation Requirements

• Proper documentation of indications for tonsillectomy is essential to justify the procedure 6
• All essential criteria should be documented in the surgical listing letter 6

Counseling

• Patients and caregivers should be informed that obstructive sleep-disordered breathing may persist or recur after tonsillectomy and may require further management 1
• Proper pain management counseling should be provided before and after surgery 1

Risk-Benefit Assessment

• The modest benefit of tonsillectomy in children only moderately affected with recurrent throat infections (not meeting the strict frequency criteria) may not justify the inherent risks, morbidity, and cost of the operation 7
• Surgery-related complications occur in approximately 7.9% of children treated with tonsillectomy or adenotonsillectomy 7