What are the indications for tonsillectomy?

From the Guidelines

Tonsillectomy is primarily indicated for recurrent tonsillitis, defined as seven or more episodes in one year, five episodes per year for two consecutive years, or three episodes per year for three consecutive years, as well as for obstructive sleep-disordered breathing, peritonsillar abscess, and other specific conditions. The indications for tonsillectomy can be broken down into several key areas, including:

• Recurrent throat infection with documentation, where clinicians may recommend tonsillectomy for recurrent throat infection 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 with documentation in the medical record for each episode of sore throat and 1 of the following: temperature >=38.3°C (101°F), cervical adenopathy, tonsillar exudate, or positive test for group A beta-hemolytic streptococcus 1
• Tonsillectomy for obstructive sleep-disordered breathing, where clinicians should ask caregivers of children with obstructive sleep-disordered breathing (oSDB) and tonsillar hypertrophy about comorbid conditions that may improve after tonsillectomy, including growth retardation, poor school performance, enuresis, asthma, and behavioral problems 1
• Tonsillectomy for peritonsillar abscess, which may be considered in cases of recurrent peritonsillar abscess or other modifying factors that may favor tonsillectomy, such as multiple antibiotic allergies or PFAPA (periodic fever, aphthous stomatitis, pharyngitis, and adenitis) 2
• Other indications, such as asymmetric tonsil enlargement concerning for malignancy, chronic tonsillitis unresponsive to antibiotics, and tonsillar hypertrophy causing dysphagia.

The procedure is typically performed under general anesthesia as an outpatient surgery, with a recovery period of 10-14 days. Patients should expect significant throat pain requiring analgesics like acetaminophen and ibuprofen, and should maintain hydration and soft diet during recovery. The rationale for tonsillectomy is to eliminate the chronically infected lymphoid tissue that serves as a reservoir for pathogens, or to remove obstructive tissue causing breathing or swallowing difficulties. While tonsils play a role in immune function, their removal doesn't significantly compromise immunity as other lymphoid tissues continue to function.

Some key considerations for clinicians include:

• Assessing the child with recurrent throat infection who does not meet criteria for tonsillectomy for modifying factors that may nonetheless favor tonsillectomy 1
• Referring children with obstructive sleep-disordered breathing (oSDB) for polysomnography (PSG) if they are <2 years of age or if they exhibit any of the following: obesity, Down syndrome, craniofacial abnormalities, neuromuscular disorders, sickle cell disease, or mucopolysaccharidoses 1
• Counseling patients and caregivers regarding the importance of managing posttonsillectomy pain as part of the perioperative education process 1

From the Research

Indications for Tonsillectomy

The indications for tonsillectomy include:

• Sleep apnea and other obstructive sleep-related breathing disorders 3
• Recurrent tonsillitis, with some benefit found when frequent infections are present for several years (>7 episodes/1 year, >5/2, >3/3) 3, 4
• Peritonsillar abscess, which tends to be treated with quinsy tonsillectomy 3
• Periodic fever, aphthous stomatitis, pharyngitis, adenitis (PFAPA), and other miscellaneous rare conditions 3
• Recurrent acute tonsillitis, with tonsillectomy indicated and highly effective if the patient has had ≥7 adequately treated episodes in the preceding year, ≥5 such episodes in each of the preceding 2 years, or ≥3 such episodes in each of the preceding 3 years 4, 5

Diagnostic Considerations

Diagnosis of tonsillitis/sore throat episodes should include a classification with a scoring system (Centor, McIssac, FeverPAIN score) to estimate the probability of a bacterial tonsillitis, mainly due to group A streptococcus (GAS) 4

• A point-of-care test GAS swab test is helpful in ambiguous cases 4
• Consecutive counting of the tonsillitis/sore throat episodes is important, along with a specific quality of life score (Tonsillectomy Outcome Inventory 14 or Tonsil and Adenoid Health Status Instrument) for each episode 4

Surgical Considerations

Tonsillectomy can be performed using total or subtotal (intracapsular/partial) techniques, with subtotal tonsillectomy potentially reducing perioperative morbidity 6, 7

• The choice of surgical technique may depend on the underlying condition, with subtotal tonsillectomy described for obstructive sleep apnea (OSA) 7
• Postoperative pain management is essential, as severe pain can be expected in most patients 4, 7