What are the indications for tonsil and adenoid removal?

Indications for Tonsil and Adenoid Removal

Tonsillectomy and adenoidectomy should be performed for recurrent throat infections meeting specific frequency criteria or documented obstructive sleep apnea, with special considerations for high-risk populations requiring polysomnography before surgery. 1

Recurrent Throat Infections

• Tonsillectomy is indicated for recurrent throat infections with documented frequency of:

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

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

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

• Watchful waiting is strongly recommended if these frequency criteria are not met 2

• Modifying factors that may favor tonsillectomy even when frequency criteria aren't met include:

  • Multiple antibiotic allergies/intolerance
  • PFAPA syndrome (periodic fever, aphthous stomatitis, pharyngitis, adenitis)
  • History of more than one peritonsillar abscess 2, 1

Obstructive Sleep-Disordered Breathing (oSDB)

• Tonsillectomy is indicated for children with:

  • Documented obstructive sleep apnea (OSA) by overnight polysomnography 2, 1
  • Significant tonsillar hypertrophy causing upper airway obstruction 2

• Polysomnography should be performed before tonsillectomy in children with oSDB who:

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

• Assessment for comorbid conditions that may improve after tonsillectomy should include:

  • Growth retardation
  • Poor school performance
  • Enuresis
  • Asthma
  • Behavioral problems 2, 1

Special Considerations

• Adenoidectomy (without tonsillectomy) is indicated for:

  • Nasal airway obstruction due to adenoidal hypertrophy
  • Recurrent or chronic adenoiditis
  • Management of recurrent or chronic otitis media 3, 4

• Tonsillectomy and adenoidectomy should be performed as separate procedures with distinct indications, and only performed concurrently when indications for both exist 3

• Contraindications to tonsillectomy and adenoidectomy include:

  • Bleeding disorders
  • Familial anesthetic intolerance
  • Velopharyngeal insufficiency
  • Concurrent disease that may enhance operative risks 3

Perioperative Management

• A single intraoperative dose of intravenous dexamethasone should be administered to children undergoing tonsillectomy 2

• Ibuprofen, acetaminophen, or both should be recommended for pain control after tonsillectomy 2, 1

• Perioperative antibiotics should not be routinely administered 2, 1

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

  • Under 3 years old
  • Have severe OSA (AHI >10 or oxygen saturation nadir <80%) 2, 1

Clinical Pearls and Pitfalls

• Decisions regarding tonsillectomy should be made when the patient is clinically well, not during an acute episode of tonsillitis 5, 6

• Frequency of acute attacks alone should not be the sole indication for surgery; severity and impact on quality of life must also be considered 5, 7

• Patients and caregivers should be counseled that obstructive sleep-disordered breathing may persist or recur after tonsillectomy and may require further management 1

• Even with appropriate surgical indications, the risks, morbidity, and costs of surgery must be carefully weighed against the expected benefits, particularly in moderately affected children 7

• The most common complication of tonsillectomy is hemorrhage, with an overall mortality risk of approximately 0.006% 3