What is the treatment for unilateral tonsil hypertrophy?

Management of Unilateral Tonsillar Hypertrophy

Tonsillectomy is the recommended treatment for unilateral tonsillar hypertrophy, particularly when associated with concerning clinical features or obstructive symptoms. 1

Diagnostic Evaluation

• Assess tonsillar size using the Brodsky scale (grades 0-4) to objectively document the degree of asymmetry 1, 2
• Evaluate for concerning features that increase risk of malignancy:
  • Cervical lymphadenopathy 3, 4
  • Suspicious appearance of the tonsil 3, 4
  • History of malignancy or immunocompromise 3
  • Systemic symptoms (B symptoms: fever, night sweats, weight loss) 5

Treatment Algorithm

Indications for Tonsillectomy

• Unilateral tonsillar hypertrophy with ANY of the following:
  • Obstructive sleep apnea or sleep-disordered breathing 1, 6
  • Cervical lymphadenopathy 3, 4
  • Suspicious tonsillar appearance 3, 4
  • Progressive enlargement or symptoms 4
  • Systemic symptoms 5

Surgical Approach

• Complete tonsillectomy is preferred over partial tonsillectomy (tonsillotomy) for unilateral tonsillar hypertrophy 1
• Consider adenoidectomy concurrently if sleep-disordered breathing is present, as combined adenotonsillectomy provides better outcomes than tonsillectomy alone 1, 6
• Intraoperative administration of a single dose of intravenous dexamethasone (0.5 mg/kg, maximum 8-25 mg) is recommended to reduce postoperative pain, nausea, and vomiting 7

Alternative Management

• For asymptomatic unilateral tonsillar hypertrophy without concerning features:
  • Consider "watch and wait" approach with close follow-up 4
  • Proceed to tonsillectomy if symptoms develop or enlargement progresses 4
• For poor surgical candidates who require intervention:
  • Radiofrequency tonsil reduction may be considered, though it is less effective than traditional tonsillectomy 1

Special Considerations

Risk of Malignancy

• The risk of malignancy in unilateral tonsillar enlargement varies:
  • Low risk (0-20%) in patients with isolated unilateral enlargement 3, 4
  • Higher risk (up to 45%) when accompanied by concerning clinical features 4
• Most common malignancies include lymphoma and rarely chronic lymphocytic leukemia/small lymphocytic lymphoma 5, 8
• Non-malignant causes include actinomycosis and other infections 9

Postoperative Considerations

• Potential complications include pain, bleeding, infection, and respiratory difficulties 1, 6
• Complete resolution of obstructive symptoms occurs in 60-70% of normal-weight children but only 10-25% of obese children 7, 2
• Consider postoperative polysomnography in patients with persistent symptoms or risk factors for persistent sleep-disordered breathing 1, 2

Pitfalls to Avoid

• Failing to recognize concerning features that increase malignancy risk 3, 4
• Delaying tonsillectomy in patients with progressive symptoms or suspicious features 5
• Overlooking the need for histopathologic examination of all tonsil specimens removed for asymmetry 3, 4