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, as well as for documented obstructive sleep apnea. 1
Recurrent Throat Infections
- Strong recommendation for watchful waiting if the patient has experienced fewer than 7 episodes in the past year, fewer than 5 episodes per year in the past 2 years, or fewer than 3 episodes per year in the past 3 years 2, 1
- Each qualifying episode should be documented in the medical record 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, 3
- Even when frequency criteria are not met, tonsillectomy may be appropriate in patients with modifying factors including: 2, 1
- Multiple antibiotic allergies/intolerance
- PFAPA syndrome (Periodic Fever, Aphthous stomatitis, Pharyngitis, and Adenitis)
- History of more than one peritonsillar abscess
Obstructive Sleep-Disordered Breathing
- Tonsillectomy is recommended for children with obstructive sleep apnea documented by overnight polysomnography 1, 4
- Polysomnography should be performed prior to tonsillectomy for children with high-risk conditions: 1
- Age less than 2 years
- Down syndrome
- Neuromuscular disorders
- Sickle cell disease
- Mucopolysaccharidoses
- Clinicians should assess for comorbid conditions that may improve after tonsillectomy, including: 2, 1
- Growth retardation
- Poor school performance
- Enuresis
- Asthma
- Behavioral problems
Special Populations and Conditions
- Peritonsillar abscess: Tonsillectomy is not routinely indicated for a single episode but may be considered for recurrent cases not responding to other treatments 4, 5
- PFAPA syndrome: While tonsillectomy may benefit some patients, the condition is often self-limiting and responds well to steroid administration 4, 5
- Psoriasis: Limited evidence suggests potential benefit in select cases of psoriasis guttata or psoriasis vulgaris not responding to first-line therapy 5
- Renal diseases: Conflicting evidence exists regarding the role of tonsillectomy in IgA nephropathy 5
Perioperative Considerations
- A single intraoperative dose of intravenous dexamethasone is strongly recommended for children undergoing tonsillectomy 2, 1
- Ibuprofen, acetaminophen, or both are recommended for post-tonsillectomy pain control 2
- Perioperative antibiotics should not be administered or prescribed 1
- Overnight inpatient monitoring is recommended after tonsillectomy for children who are under 3 years old or have severe OSA 1
Clinical Pitfalls and Caveats
- Documentation of qualifying episodes is essential for justifying tonsillectomy for recurrent tonsillitis; poor documentation may lead to inappropriate surgical decisions 6
- Tonsillectomy for obstructive sleep-disordered breathing may not completely resolve symptoms in all patients; families should be counseled that symptoms may persist or recur 1
- The differentiation between sore throat and true tonsillitis episodes can be challenging but using scoring systems (Centor, McIssac, FeverPAIN) can help estimate the probability of bacterial tonsillitis 3
- When evaluating the need for tonsillectomy, quality of life measures should be considered alongside frequency of episodes 3, 7