What is the treatment for enlarged tonsils?

Treatment of Enlarged Tonsils

Adenotonsillectomy is the first-line treatment for enlarged tonsils causing obstructive sleep-disordered breathing (oSDB), with success rates of 60-80% in normal-weight children but only 10-30% in obese children. 1, 2

Initial Assessment and Diagnosis

• Grade tonsillar size using the Brodsky scale (Grade 1: <25% obstruction, Grade 2: 25-50%, Grade 3: 50-75%, Grade 4: >75% oropharyngeal obstruction) to objectively document the degree of enlargement 3

• Polysomnography (PSG) is the gold standard for confirming obstructive sleep apnea (OSA) when there is discordance between tonsillar size and severity of symptoms, though it is not required in all cases 1

• For otherwise healthy children with clear symptoms of struggling to breathe during sleep, daytime symptoms, and visibly enlarged tonsils, PSG is typically not performed unless parents want diagnostic confirmation 1

• Consider PSG mandatory in obese children, those with severe symptoms, or when comorbidities exist (craniofacial, neuromuscular, genetic, or metabolic disorders) 1

Treatment Algorithm Based on Clinical Presentation

For Obstructive Sleep-Disordered Breathing (Primary Indication)

Surgical Treatment:

• Adenotonsillectomy (combined procedure) is superior to tonsillectomy alone and should be performed in most cases, as adenoidal tissue contributes significantly to upper airway obstruction 2, 3

• Complete tonsillectomy is preferred over tonsillotomy because residual lymphoid tissue may contribute to persistent obstruction 2

• Tonsillectomy produces complete resolution of oSDB in approximately 80% of younger, normal-weight, non-African American children 1

• Success rates are substantially lower in obese children (10-25% complete resolution), and these patients may require additional interventions including weight loss, CPAP, or additional surgical procedures 1, 2, 3

Alternative Surgical Approach:

• Radiofrequency tonsil reduction may be considered for poor surgical candidates or those refusing traditional surgery, though it provides unpredictable amounts of tissue reduction and lacks polysomnographic outcome data 1, 2

• This technique has fewer side effects (less bleeding and postoperative pain) but is not recommended as a standard treatment 1

For Recurrent Acute Tonsillitis

Indications for tonsillectomy:

• ≥7 adequately treated episodes in the preceding year, OR

• ≥5 episodes in each of the preceding 2 years, OR

• ≥3 episodes in each of the preceding 3 years 4

• Wait-and-see policy for 6 months is justified when patients have 3-5 episodes, as spontaneous resolution may occur 5

• Surgery is not indicated with fewer than 3 episodes per year 5

For Unilateral Tonsillar Enlargement

• Tonsillectomy is mandatory when the tonsil has suspicious appearance or when cervical lymphadenopathy is present, as these are the strongest risk factors for malignancy 6

• Asymptomatic unilateral enlargement without suspicious features or lymphadenopathy can be managed with close observation initially, though some cases will ultimately require excision 7

• The prevalence of malignancy in isolated asymmetric tonsils without other clinical features is very low (0-5%), supporting initial observation in low-risk cases 7

For Adults with Tonsillar Hypertrophy and OSA

• Tonsillectomy as a single intervention is recommended for adult OSA in the presence of significant tonsillar hypertrophy 1, 3

• Success may be transient in some adults, requiring postoperative follow-up and possible additional interventions 8

Perioperative Management

Pain control:

• Administer intravenous dexamethasone (0.5 mg/kg, maximum 8-25 mg) intraoperatively to reduce postoperative pain, nausea, and vomiting 2

• Use validated age-appropriate pain scales (Wong-Baker FACES for children ≥3 years, FLACC for children 2 months to 7 years) 1

• Combine pharmacologic agents with nonpharmacologic interventions (distraction, cold/heat application, favorite activities) 1

Antibiotic therapy:

• Perioperative antibiotics are not recommended due to lack of demonstrable benefits and risks of adverse events including rash, allergy, gastrointestinal upset, and induced bacterial resistance 1

Postoperative Follow-Up

• Postoperative PSG should be considered in patients with persistent symptoms, severe preoperative OSA (AHI ≥10), obesity, or other risk factors for persistent sleep-disordered breathing 2, 3

• Repeated sleep testing is particularly important in children with moderate to severe OSA, as complete resolution may occur in as few as 25% of these cases 1

• Counsel families that additional interventions may be needed, including weight loss programs, CPAP therapy, or additional surgical procedures, particularly in obese children 1

Key Clinical Pitfalls

• Do not assume tonsillectomy will cure OSA in all patients—muscle tone, obesity, and craniofacial anatomy all contribute to the condition beyond tonsillar size alone 1

• Avoid performing tonsillectomy for infectious mononucleosis as routine symptom control—it is only indicated for clinically significant upper airway obstruction 5

• Do not perform interval tonsillectomy after peritonsillar abscess—this approach is not supported by contemporary evidence, as recurrence rates after drainage procedures are low 5

• Age and history of tonsillitis are not contraindications to intracapsular procedures (tonsillotomy), and abscess formation in tonsillar remnants is extremely rare 5