What is the treatment for enlarged tonsils?

Treatment of Enlarged Tonsils

Adenotonsillectomy is the first-line treatment for enlarged tonsils causing obstructive sleep apnea (OSA) in children with adenotonsillar hypertrophy, and tonsillectomy is recommended for adults with OSA and tonsillar hypertrophy. 1

Clinical Assessment Required

Before proceeding with treatment, determine the underlying indication for addressing enlarged tonsils:

For Sleep-Disordered Breathing/OSA

• Document tonsillar size using the Brodsky grading scale (Grade 0-4+, with 3-4+ indicating significant obstruction) 1, 2
• Assess for symptoms beyond snoring: behavioral problems, poor school performance, enuresis, failure to thrive, daytime breathing difficulties, and witnessed apneas 1
• Polysomnography (PSG) is mandatory for children <2 years old, obese children, or those with comorbidities (Down syndrome, craniofacial abnormalities, neuromuscular disorders) 1, 3
• PSG is recommended but not always required for otherwise healthy children with clear clinical history of struggling to breathe during sleep, daytime symptoms, and enlarged tonsils on examination 1
• PSG should be obtained when there is discordance between tonsillar size and reported symptom severity 1, 2

For Recurrent Tonsillitis

• Surgery is indicated only if meeting Paradise criteria: ≥7 documented episodes in the past year, ≥5 episodes per year for 2 years, or ≥3 episodes per year for 3 years 3, 4, 5
• Watchful waiting is strongly recommended if episodes fall below these thresholds 4

Surgical Treatment Algorithm

Primary Surgical Approach

• Perform adenotonsillectomy (combined procedure) rather than tonsillectomy alone in children, as residual adenoid tissue contributes to persistent obstruction 1, 3
• Complete tonsillectomy is preferred over partial tonsillotomy, as residual lymphoid tissue may cause persistent symptoms 1, 3
• In adults with OSA and tonsillar hypertrophy, tonsillectomy alone is appropriate 1

Expected Outcomes by Patient Population

• Normal-weight, otherwise healthy children: 60-80% complete resolution of OSA 1, 2
• Obese children: Only 10-50% complete resolution of OSA; consider CPAP as alternative first-line therapy 1, 2
• Children with severe preoperative OSA: Higher rates of persistent sleep-disordered breathing (complete resolution as low as 25% in some studies) 1

Perioperative Management

• Administer intravenous dexamethasone (0.5 mg/kg, maximum 8-25 mg) intraoperatively to reduce postoperative pain, nausea, and vomiting 2, 3
• Plan inpatient observation for high-risk patients: oxygen saturation <80% on preoperative PSG, age <3 years with severe OSA, obesity, or significant comorbidities 3

Alternative Surgical Techniques

Radiofrequency tonsil reduction may be considered for patients who are poor surgical candidates or refuse traditional surgery, though it provides unpredictable tonsil volume reduction (53-71% reduction reported) and is not recommended as a standard technique 1, 2

Non-Surgical Management

Trial intranasal corticosteroids before surgery for adenoidal hypertrophy contributing to obstruction 6, 3

Critical Post-Treatment Monitoring

• Arrange postoperative PSG for patients with persistent symptoms (continued snoring, witnessed apneas), severe preoperative OSA, obesity, or syndromic conditions 1, 3
• Counsel families that additional interventions may be needed: weight loss, CPAP therapy, or further surgical procedures if OSA persists 1
• Expect improvements beyond respiratory parameters: growth acceleration, behavioral improvements, enhanced school performance, resolution of enuresis, and improved quality of life scores 1

Common Pitfalls to Avoid

• Never proceed to surgery for OSA without objective PSG documentation when polysomnography is indicated based on age or comorbidities 3
• Do not assume surgery will cure OSA in obese children—set realistic expectations and plan for possible adjunctive therapy 1
• Avoid relying solely on tonsillar size—small tonsils can still cause significant OSA, and large tonsils may be asymptomatic 1
• Do not perform tonsillectomy for recurrent infections unless Paradise criteria are met—most cases resolve with conservative management 4, 5
• Never skip concurrent adenoidectomy in children unless contraindicated, as combined surgery provides superior outcomes 1, 3