What are the indications for tonsillectomy in adults?

Indications for Tonsillectomy in Adults

Tonsillectomy is indicated in adults with recurrent acute tonsillitis who have experienced ≥7 adequately treated episodes in the preceding year, ≥5 episodes in each of the preceding 2 years, or ≥3 episodes in each of the preceding 3 years. 1, 2

Recurrent Throat Infections

• Tonsillectomy should be considered for adults with recurrent, disabling sore throat due to acute tonsillitis when episodes are well documented and meet the frequency criteria (≥7 episodes in the past year, ≥5 episodes per year for 2 years, or ≥3 episodes per year for 3 years) 1, 2
• Each episode should be documented with at least one of the following: temperature ≥38.3°C, cervical adenopathy, tonsillar exudate, or positive test for group A beta-hemolytic streptococcus 1
• Watchful waiting is strongly recommended if the frequency criteria are not met 1
• Recent evidence from the NATTINA trial (2023) shows that tonsillectomy in adults with recurrent tonsillitis results in fewer days with sore throat compared to conservative management (median 23 days vs 30 days over 24 months) 3

Special Considerations for Tonsillectomy

• Tonsillectomy may be appropriate even when frequency criteria aren't met in patients with:
  • Multiple antibiotic allergies/intolerance 1
  • PFAPA syndrome (Periodic Fever, Aphthous stomatitis, Pharyngitis, and Adenitis) 1
  • History of more than one peritonsillar abscess 1
• Quality of life assessment using validated tools (Tonsillectomy Outcome Inventory 14 or Tonsil and Adenoid Health Status Instrument) should be performed to help guide decision-making 2

Obstructive Sleep-Disordered Breathing

• Tonsillectomy is indicated for adults with obstructive sleep apnea documented by overnight polysomnography when tonsillar hypertrophy is present 1
• Assessment for comorbid conditions that may improve after tonsillectomy should be performed, including poor sleep quality, daytime fatigue, and cardiovascular complications 1

Perioperative Management

• A single intraoperative dose of intravenous dexamethasone is recommended for adults undergoing tonsillectomy 1
• Perioperative antibiotics should not be administered or prescribed to adults undergoing tonsillectomy 1
• Comprehensive pain management counseling should be provided before and after surgery 1, 2

Safety and Outcomes

• Adult tonsillectomy is generally a safe procedure with a 30-day mortality rate of 0.03%, complication rate of 1.2%, and reoperation rate of 3.2% 4
• The most common complications are infectious in nature, including pneumonia (27% of complications), urinary tract infections (27%), and superficial site infections (16%) 4
• Male sex, inpatient status, and postoperative complications are independent risk factors for reoperation 4
• Microdebrider-assisted intracapsular tonsillectomy may reduce postoperative pain and bleeding compared to conventional extracapsular tonsillectomy, but leaves tonsillar remnants in nearly half of patients 5

Clinical Decision Algorithm

1. Document frequency and severity of tonsillitis episodes over time
2. Confirm episodes meet diagnostic criteria (fever, exudate, adenopathy, or positive strep test)
3. Assess if frequency criteria are met (≥7/year, ≥5/year for 2 years, or ≥3/year for 3 years)
4. Evaluate impact on quality of life using validated instruments
5. Consider modifying factors (antibiotic allergies, PFAPA, peritonsillar abscess)
6. If criteria are met or significant modifying factors exist, recommend tonsillectomy
7. If criteria are not met and no significant modifying factors exist, recommend watchful waiting 1, 2