Tonsillectomy is Indicated for This Patient
This patient should undergo tonsillectomy based on the presence of obstructive sleep-disordered breathing (oSDB) symptoms with grade 3 tonsillar hypertrophy, which alone constitutes a primary indication for surgery. 1 The recurrent tonsillitis (6 episodes) serves as an additional supporting factor, even though it falls one episode short of strict Paradise criteria. 1
Primary Surgical Indication: Obstructive Sleep-Disordered Breathing
The combination of snoring, mouth breathing during sleep, and grade 3 tonsils provides sufficient clinical evidence for surgical intervention without requiring polysomnography in otherwise healthy patients. 1 The American Academy of Otolaryngology-Head and Neck Surgery recommends tonsillectomy for patients with oSDB and tonsillar hypertrophy, particularly when accompanied by comorbid conditions that may improve after surgery. 1
Do not delay surgery for "watchful waiting" in this case - watchful waiting is only appropriate when Paradise criteria are not met AND there are no obstructive symptoms. 1 This patient has clear obstructive symptoms that justify immediate surgical intervention.
Secondary Supporting Factor: Recurrent Tonsillitis
While the patient has 6 episodes of tonsillitis in the past year (one short of the Paradise threshold of ≥7 episodes), the American Academy of Otolaryngology-Head and Neck Surgery recommends assessing for modifying factors that may favor tonsillectomy even when Paradise criteria are not fully met. 1 The presence of oSDB symptoms serves as this modifying factor.
Polysomnography Considerations
PSG is typically not required before proceeding in this case. 1 Polysomnography should only be obtained if the patient is <2 years of age, obese, has Down syndrome, craniofacial abnormalities, neuromuscular disorders, sickle cell disease, or mucopolysaccharidoses. 1 For otherwise healthy patients with strong clinical history of struggling to breathe, daytime symptoms, and enlarged tonsils, PSG is not performed unless parents want diagnostic confirmation. 1
Surgical Approach: Complete vs. Partial Tonsillectomy
Complete tonsillectomy is preferred over tonsillotomy (partial removal) in this patient due to the history of recurrent tonsillitis. 2, 3 While tonsillotomy has lower postoperative morbidity in terms of pain and bleeding, it is primarily indicated for tonsillar hypertrophy causing obstructive sleep apnea without a significant history of recurrent infections. 2
In patients with chronic or recurrent tonsillitis, complete tonsillectomy is the preferable surgical modality because scarring and persistent inflammation in tonsillar remnants may require revision surgery. 2 Age and a history of tonsillitis are not contraindications to tonsillotomy, but the recurrent infectious component makes complete removal more appropriate. 3
Critical Counseling Points Before Surgery
oSDB may persist or recur after tonsillectomy and may require further management. 1 Overall success rate for resolving OSA is approximately 79%, but varies based on age, weight, ethnicity, and OSA severity. 1
Younger, normal-weight, non-African American children may have resolution rates of 80%, while obese children have complete resolution <50% of the time. 1 Additional interventions may be needed including weight loss, medications, or CPAP if symptoms persist. 1
Adenotonsillectomy is recommended for childhood OSA in the presence of adenotonsillar hypertrophy. 4 Consider evaluating for adenoid hypertrophy as well, particularly in pediatric patients.
Document all episodes thoroughly in the medical record including symptoms, physical findings, test results, and quality of life impacts. 1
Expected Outcomes
In children, adenotonsillectomy shows significant postoperative improvements in respiratory parameters, with evidence of improved sleep architecture, quality of life scores, OSA symptom scores, and child behavioral scores. 4 Additional benefits include rapid increase in growth rate, improvement in insulin-like growth factor-I levels, and improvements in systemic inflammation, lipid profiles, and endothelial function. 4
However, most studies investigating children with moderate to severe OSA observed persistent sleep disordered breathing in a clinically relevant proportion of children, with complete resolution reported as low as 25% in some studies. 4 Repeated sleep testing has been recommended, particularly in those with persisting symptoms of upper airway obstruction (such as snoring) and/or in those with severely abnormal preoperative polysomnography results. 4