What is the treatment for enlarged tonsils?

Treatment for Enlarged Tonsils

Tonsillectomy is the first-line treatment for children with enlarged tonsils causing obstructive sleep-disordered breathing (oSDB), particularly when documented by polysomnography or when clinical presentation clearly indicates airway obstruction. 1, 2

Primary Indications for Surgical Treatment

Tonsillectomy should be performed when:

• Obstructive sleep apnea (OSA) is documented by overnight polysomnography in children with tonsillar hypertrophy 1
• Clinical examination shows significant adenotonsillar hypertrophy with symptoms of sleep-disordered breathing, making adenotonsillectomy the recommended first-line treatment 2
• Adults have significant tonsillar hypertrophy contributing to OSA 2

The decision should not rely solely on PSG findings but must incorporate clinical history, physical examination findings, and the likelihood that surgery will improve both sleep quality and daytime/nighttime symptoms 3.

When to Obtain Polysomnography

PSG is specifically recommended for children with oSDB who have:

• Age under 2 years 1
• Obesity, Down syndrome, craniofacial abnormalities, neuromuscular disorders, sickle cell disease, or mucopolysaccharidoses 1
• Discordance between physical examination findings (tonsillar size) and reported severity of symptoms 1, 2
• Uncertain need for tonsillectomy 1

Expected Outcomes and Success Rates

Effectiveness varies significantly by patient characteristics:

• Normal-weight children: 80% resolution of oSDB 3, 1
• Obese children: Only 20-30% complete resolution 3, with overall success rates of 10-25% in some studies 2
• Overall pediatric population: 60-70% complete resolution in normal-weight children 2

Tonsillectomy improves multiple comorbid conditions including growth retardation, poor school performance, enuresis, asthma, behavioral problems, quality of life, neurocognitive functioning, and parasomnias 1.

Perioperative Management

The following perioperative protocols are evidence-based:

• Do NOT administer perioperative antibiotics - they provide no demonstrable benefit for pain reduction, bleeding prevention, or recovery, while causing unnecessary adverse events including rash, allergy, gastrointestinal upset, and bacterial resistance 3, 1
• Administer a single intraoperative dose of intravenous dexamethasone 1
• Arrange overnight inpatient monitoring for children under 3 years old or those with severe OSA 1

Pain Management Strategy

Multimodal analgesia should include:

• Paracetamol (acetaminophen) and NSAIDs administered pre-operatively or intra-operatively and continued postoperatively unless contraindicated 3
• Pharmacologic interventions supplemented with nonpharmacologic methods including distraction, relaxation, cold/heat application, maintaining comfortable environment, and age-appropriate activities 3
• Validated age-appropriate pain scales for assessment: Wong-Baker FACES scale for children ≥3 years, FLACC scale for children 2 months to 7 years 3

Treatment for Recurrent Tonsillitis (Non-Obstructive Indication)

Watchful waiting is strongly recommended unless the patient meets Paradise criteria:

• ≥7 adequately treated episodes in the preceding year, OR
• ≥5 episodes per year for the preceding 2 years, OR
• ≥3 episodes per year for the preceding 3 years 4

For acute bacterial tonsillitis episodes, penicillin remains first-line antibiotic therapy when group A streptococcus is identified 5.

Critical Counseling Points

Patients and caregivers must understand:

• Enlarged tonsils are the most common cause of oSDB in children, but muscle tone and obesity also contribute 3
• Tonsillectomy is not curative in all cases, especially in obese children who may require additional interventions including weight loss, CPAP, or medications 3, 1
• Post-operative PSG should be considered for patients with persistent symptoms, severe preoperative OSA, obesity, or other risk factors for persistent sleep-disordered breathing 2