What is the treatment for tonsil growth?

Treatment for Tonsil Growth

Tonsillectomy is the recommended treatment for significant tonsillar hypertrophy causing obstructive sleep-disordered breathing (oSDB), while watchful waiting is appropriate for mild cases without significant symptoms. 1

Evaluation and Indications for Surgical Intervention

Obstructive Sleep-Disordered Breathing (oSDB)

• Tonsillectomy is indicated when tonsillar hypertrophy causes obstructive sleep-disordered breathing with significant symptoms 1
• Clinicians should assess for comorbid conditions that may improve after tonsillectomy, including:
  • Growth retardation
  • Poor school performance
  • Enuresis
  • Asthma
  • Behavioral problems 1

Recurrent Throat Infections

• Watchful waiting is strongly recommended if throat infections are:
  • <7 episodes in the past year, OR
  • <5 episodes per year in the past 2 years, OR
  • <3 episodes per year in the past 3 years 1
• Tonsillectomy may be considered if infections meet or exceed:
  • ≥7 documented episodes in the past year, OR
  • ≥5 documented episodes per year for 2 years, OR
  • ≥3 documented episodes per year for 3 years 1
• Each episode should be documented with:
  • Temperature ≥38.3°C (101°F)
  • Cervical adenopathy
  • Tonsillar exudate
  • Positive test for Group A beta-hemolytic streptococcus 1

Modifying Factors

• Tonsillectomy may be appropriate even if frequency criteria aren't met when there are:
  • Multiple antibiotic allergies/intolerances
  • PFAPA syndrome (Periodic Fever, Aphthous stomatitis, Pharyngitis, and Adenitis)
  • History of >1 peritonsillar abscess 1

Surgical Approaches

Complete Tonsillectomy vs. Partial Tonsillectomy (Tonsillotomy)

• For children under 6 years with tonsillar hypertrophy without recurrent infections:
  • Partial tonsillectomy (tonsillotomy) is preferred as first-line therapy 2, 3
  • Benefits include lower risk of hemorrhage and reduced postoperative pain 2
• Total extracapsular tonsillectomy remains indicated for:
  • Recurrent bacterial tonsillitis
  • Antibiotic allergies
  • PFAPA syndrome
  • Peritonsillar abscess 3

Surgical Techniques

• Cold dissection with ligature or suturing has the lowest risk of hemorrhage 3
• "Hot" techniques (laser, radiofrequency, coblation, monopolar or bipolar forceps) carry higher risk of late hemorrhage 3
• For tonsillotomy, various methods can be used (laser, radiofrequency, shaver, coblation, bipolar scissor) as long as the crypts remain open and some tonsil tissue is preserved 2

Perioperative Management

Polysomnography Considerations

• Polysomnography (sleep study) should be performed before tonsillectomy if the child:
  • Is <2 years of age
  • Has obesity, Down syndrome, craniofacial abnormalities, neuromuscular disorders, sickle cell disease, or mucopolysaccharidoses 1
• Polysomnography should be considered when:
  • Need for tonsillectomy is uncertain
  • There is discordance between physical examination and reported severity of oSDB 1

Perioperative Care

• Perioperative antibiotics should NOT be administered or prescribed to children undergoing tonsillectomy 1
• A single intraoperative dose of intravenous dexamethasone should be administered 1
• Comprehensive pain management counseling should be provided to patients and caregivers 1
• Patients and caregivers should be informed that oSDB may persist or recur after tonsillectomy 1

Complications and Follow-up

Hemorrhage Risk

• Primary hemorrhage (within 24 hours) occurs in 0.2-2.2% of cases 1
• Secondary hemorrhage (after 24 hours) occurs in 0.1-3% of cases 1
• Bleeding can occur until complete wound healing (approximately 3 weeks) 3
• Even small hemorrhages require proper treatment and inpatient observation 3

Other Complications

• Pain management is crucial as inadequate pain control is a common cause of morbidity 1
• Potential complications include nausea, vomiting, dehydration, and referred otalgia 1
• In children with oSDB, complete resolution occurs in as few as 25% of cases, highlighting the importance of follow-up 1

Special Considerations

• Tonsillectomy is the second most common ambulatory surgical procedure in children in the United States 1
• Preoperative screening for coagulation disorders using a standardized questionnaire is more effective than routine blood tests 3
• Children with hereditary coagulopathy have higher risk of hemorrhage 3