What are the indications for surgery in patients with airway obstruction, Obstructive Sleep Apnea (OSA) symptoms, adenoidal hypertrophy, or tonsillar hypertrophy?

Surgical Indications for Adenotonsillectomy

Adenotonsillectomy is indicated for patients meeting specific criteria for recurrent throat infections (Paradise criteria) OR documented obstructive sleep apnea confirmed by polysomnography in the presence of adenotonsillar hypertrophy. 1, 2

Recurrent/Chronic Infection Criteria (Paradise Criteria)

Surgery is indicated when patients have documented episodes of:

• ≥7 episodes in the past year, OR 2
• ≥5 episodes per year for 2 consecutive years, OR 2
• ≥3 episodes per year for 3 consecutive years 2

These infections must be properly documented with clinical evidence, not just patient recall. 2

Obstructive Sleep Apnea and Airway Obstruction

Mandatory Polysomnography Requirements

Polysomnography must be performed BEFORE surgery to objectively document OSA—clinical symptoms and physical examination alone are insufficient for surgical decision-making. 1, 2

• PSG is mandatory for all children <2 years of age 2
• PSG is mandatory for patients with comorbidities including obesity, Down syndrome, craniofacial abnormalities, neuromuscular disorders, sickle cell disease, or mucopolysaccharidoses 2, 3
• Simple snoring without documented OSA is NOT an indication for surgery 1

Anatomical Indications

Surgery is indicated when PSG confirms OSA AND the following anatomical findings are present:

• Tonsillar hypertrophy (Grade 3-4 or "kissing tonsils") obstructing the pharyngeal airway 4, 5
• Adenoidal hypertrophy causing mouth breathing, hyponasal speech, and impaired olfaction 1
• Combined adenotonsillar hypertrophy provides superior outcomes when both are addressed 2

Special Consideration for Mild OSA

Patients with mild OSA who have severe obstructing anatomy that is surgically correctable (e.g., tonsillar hypertrophy obstructing the pharyngeal airway) can be considered for primary surgical treatment. 4

Critical Pre-Surgical Requirements

Medical Management Trial FIRST

Before proceeding to surgery, patients must undergo:

• Trial of intranasal corticosteroids for adenoidal hypertrophy 1, 2
• Complete allergy evaluation and appropriate management 1, 2
• Adequate trial of medical therapy including antihistamines and intranasal steroids 1

Failing to complete these conservative measures before surgery is a critical pitfall. 1, 2

When Surgery Becomes Secondary Treatment

Surgery may be considered as secondary treatment when: 4

• PAP therapy outcome is inadequate or patient is intolerant 4
• Oral appliance therapy provides inadequate improvement 4
• Obstructive anatomy compromises other therapies 4

Specific Clinical Scenarios

Adults with Tonsillar Hypertrophy and OSA

Tonsillectomy as a single intervention is recommended for adult OSA in the presence of tonsillar hypertrophy, with significant improvements in respiratory parameters consistently reported. 5, 6 However, residual sleep-disordered breathing may persist in some patients, requiring repeated sleep testing for those with persisting symptoms. 5

Pediatric Patients

Adenotonsillectomy represents first-line treatment for children with OSA confirmed by PSG in the presence of adenotonsillar hypertrophy, with 60-70% likelihood of complete OSA resolution. 1 Complete tonsillectomy is preferred over partial tonsillotomy, as residual lymphoid tissue may contribute to persistent obstruction. 2

Common Pitfalls to Avoid

• Never proceed to surgery without objective PSG documentation of OSA 1, 2
• Do not rely solely on physical examination findings or clinical symptoms 1, 2
• Always trial medical management before invasive procedures 1, 2
• Do not assume complete resolution post-surgery in obese children, those with severe preoperative OSA, or syndromic patients—arrange postoperative PSG 2
• Failing to evaluate and treat underlying allergies before surgical intervention 1