What is the treatment for unilateral tonsil hypertrophy?

Management of Unilateral Tonsillar Hypertrophy

Adenotonsillectomy is recommended as the first-line treatment for unilateral tonsillar hypertrophy when associated with obstructive sleep apnea or when malignancy is suspected. 1

Diagnostic Evaluation

• Assess tonsillar size using the Brodsky scale (grades 0-4 based on percentage of oropharyngeal airway obstruction) to objectively document the degree of asymmetry 2
• Evaluate for concerning features that suggest malignancy:
  • Cervical lymphadenopathy (strongest risk factor for malignancy) 3, 4
  • Suspicious appearance of the tonsil 3, 5
  • Systemic symptoms (B symptoms: fever, weight loss, night sweats) 4
  • History of malignancy or immunocompromise 3
• Consider polysomnography (PSG) when there is discordance between tonsillar size and reported severity of sleep-disordered breathing symptoms 1, 2

Treatment Algorithm

For Unilateral Tonsillar Hypertrophy with OSA:

• Adenotonsillectomy is recommended as first-line treatment when clinical examination is consistent with tonsillar hypertrophy causing OSA 1
• Complete tonsillectomy is preferred over tonsillotomy (partial removal) as residual lymphoid tissue may contribute to persistent obstruction 1
• Adenoidectomy should be performed concurrently in most cases, as combined adenotonsillectomy provides better outcomes than tonsillectomy alone 1

For Unilateral Tonsillar Hypertrophy without OSA:

• When malignancy is suspected (presence of cervical lymphadenopathy, suspicious appearance, systemic symptoms), tonsillectomy for histopathologic examination is mandatory 3, 4
• For asymptomatic unilateral tonsillar enlargement without concerning features, close observation may be appropriate initially 5, 6
• If symptoms progress or new concerning features develop during observation, proceed with tonsillectomy 5

Special Considerations

• Tonsillar asymmetry is often the presenting sign in patients with tonsillar lymphoma, even when B symptoms are absent 4
• The prevalence of malignancy in tonsils with asymmetry but no other concerning clinical features is low (0-5%) 3, 5, 6
• Non-malignant causes of unilateral tonsillar hypertrophy include:
  • Anatomical variation in tonsillar fossa size 6
  • Infections such as actinomycosis (rare) 7
• In obese children with tonsillar hypertrophy, clinical judgment is required to determine the benefits of adenotonsillectomy compared with other treatments, as surgical outcomes may be less satisfactory 1, 2

Postoperative Considerations

• Potential complications of adenotonsillectomy include pain, bleeding, infection, postoperative respiratory difficulties, velopharyngeal incompetence, and rarely death 1, 8
• Complete resolution of OSA after adenotonsillectomy occurs in 60-70% of normal-weight children but only 10-25% of obese children 2
• Consider postoperative polysomnography in patients with persistent symptoms, severe preoperative OSA, or risk factors for persistent sleep-disordered breathing 2

Surgical Alternatives

• For patients who are poor surgical candidates or refuse surgery, radiofrequency tonsil reduction may be considered, though it is less effective than traditional tonsillectomy 1
• Radiofrequency tonsil reduction appears to have fewer side effects such as bleeding and postoperative pain but provides unpredictable amounts of tonsil reduction 1