Indications for Tonsillectomy
Tonsillectomy is indicated for recurrent throat infections meeting specific frequency criteria (≥7 episodes in 1 year, ≥5 per year for 2 years, or ≥3 per year for 3 years with documented features) or for obstructive sleep-disordered breathing documented by polysomnography in children. 1
Recurrent Throat Infections
Standard Frequency Criteria
The American Academy of Otolaryngology-Head and Neck Surgery establishes clear thresholds for tonsillectomy in recurrent throat infections 1:
- At least 7 episodes in the past year, OR 1, 2
- At least 5 episodes per year for 2 consecutive years, OR 1, 2
- At least 3 episodes per year for 3 consecutive years 1, 2
Required Documentation
Each episode must be documented in the medical record with at least one of the following features 1:
- Temperature ≥38.3°C (101°F) 1
- Cervical lymphadenopathy 1
- Tonsillar exudate 1
- Positive test for group A beta-hemolytic streptococcus 1
When NOT to Operate
Watchful waiting is strongly recommended if frequency criteria are not met—fewer than 7 episodes in the past year, fewer than 5 episodes per year in the past 2 years, or fewer than 3 episodes per year in the past 3 years 1. This is a critical pitfall to avoid, as operating outside these criteria lacks evidence support and contributes to unnecessary surgical risk.
Special Circumstances for Recurrent Infections
Tonsillectomy may be appropriate even without meeting standard frequency criteria in 1:
- Patients with multiple antibiotic allergies or intolerance 1
- PFAPA syndrome (Periodic Fever, Aphthous stomatitis, Pharyngitis, Adenitis) 1
- History of more than one peritonsillar abscess 1, 3
Obstructive Sleep-Disordered Breathing
Primary Indication
The American Academy of Otolaryngology-Head and Neck Surgery recommends tonsillectomy for children with obstructive sleep apnea documented by overnight polysomnography 1. This has become the most common indication for tonsillectomy, accounting for approximately 67% of cases 4.
Mandatory Polysomnography
Polysomnography must be performed prior to tonsillectomy for high-risk children 1:
- Children <2 years of age 1
- Down syndrome 1
- Neuromuscular disorders 1
- Sickle cell disease 1
- Mucopolysaccharidoses 1
Associated Comorbidities to Assess
Clinicians should evaluate for conditions that may improve after tonsillectomy in children with obstructive sleep-disordered breathing and tonsillar hypertrophy 1:
Important Caveat
Patients and caregivers must be counseled that obstructive sleep-disordered breathing may persist or recur after tonsillectomy and may require further management 1. This is not a guaranteed cure, and postoperative monitoring is essential.
Perioperative Management Essentials
Medications
- Single intraoperative dose of intravenous dexamethasone should be administered to children undergoing tonsillectomy 1
- Perioperative antibiotics should NOT be administered or prescribed to children undergoing tonsillectomy 1, 3
Pain Management
Proper pain management counseling must be provided before and after surgery, as severe postoperative pain can be expected in most patients 1, 2.
Postoperative Monitoring
Overnight inpatient monitoring is recommended after tonsillectomy for 1:
Other Indications
Peritonsillar Abscess
A history of more than one peritonsillar abscess is an indication for tonsillectomy, even if standard frequency criteria for recurrent infections are not met 1, 3. However, a single peritonsillar abscess alone is not an indication unless the abscess cannot be drained otherwise 5.
Suspicion of Neoplasm
Tonsillectomy is obviously indicated if there is suspicion of malignancy 5.
NOT Standard Indications
Tonsillectomy plays no role in the standard management of 5: