What is the treatment for enlarged tonsils in adults?

Treatment of Enlarged Tonsils in Adults

The treatment of enlarged tonsils in adults depends entirely on the underlying cause: if associated with obstructive sleep apnea (OSA) and significant tonsillar hypertrophy, tonsillectomy is recommended; if associated with recurrent bacterial tonsillitis meeting Paradise criteria (≥7 episodes/year, ≥5 episodes/year for 2 years, or ≥3 episodes/year for 3 years), tonsillectomy is indicated; otherwise, conservative management with observation is appropriate. 1

Initial Diagnostic Approach

The first step is determining whether the enlarged tonsils are causing functional problems or represent an infectious/inflammatory process:

• Assess for obstructive symptoms: Ask specifically about witnessed apneas, gasping during sleep, excessive daytime sleepiness, morning headaches, and snoring. These symptoms suggest OSA, which is the primary indication for tonsillectomy in adults with tonsillar hypertrophy. 2, 1

• Document infectious episodes: Count the number of documented tonsillitis episodes over the past 1-3 years. Each episode should meet clinical criteria (fever, tonsillar exudates, anterior cervical adenopathy) and ideally have microbiologic confirmation. 1, 3

• Evaluate for malignancy: Unilateral tonsillar enlargement, especially with associated symptoms like dysphagia, odynophagia, otalgia, weight loss, or neck mass, requires urgent evaluation for malignancy. Asymmetric tonsils are particularly concerning. 2

Management Based on Clinical Scenario

Scenario 1: Tonsillar Hypertrophy with OSA

Tonsillectomy is recommended for adult OSA in the presence of tonsillar hypertrophy (Grade 3-4 tonsils obstructing the pharyngeal airway). 2, 1

• Objective documentation with polysomnography is mandatory before proceeding to surgery when OSA is suspected. 1

• Surgery may be considered as primary treatment when severe obstructing anatomy is present, or as secondary treatment when CPAP therapy is inadequate or not tolerated. 1

• Patients should be counseled that tonsillectomy for OSA in adults provides improvement in respiratory parameters and quality of life, though complete resolution may not occur in all cases. 2

Scenario 2: Recurrent Acute Tonsillitis

Tonsillectomy is indicated when patients meet Paradise criteria: ≥7 adequately treated episodes in the preceding year, ≥5 episodes per year for 2 consecutive years, or ≥3 episodes per year for 3 consecutive years. 1, 3

• Each episode must be adequately documented and treated. "Adequately treated" means episodes were evaluated by a clinician and managed with appropriate antibiotics when bacterial infection was confirmed. 3

• Tonsillectomy solely to reduce the frequency of group A streptococcal pharyngitis in adults is NOT recommended if Paradise criteria are not met. 2

• For patients with fewer episodes than Paradise criteria, watchful waiting is strongly recommended, as the modest benefit of surgery does not outweigh the risks. 4, 3

• Quality-adjusted life-year (QALY) analysis demonstrates that adults sustaining more than 3 annual bouts of tonsillitis over at least 2 years will gain meaningful QALY after tonsillectomy, with gains increasing proportionally to the number of yearly events. 5

Scenario 3: Acute Bacterial Tonsillitis

When enlarged tonsils are associated with acute infection:

• Test for group A Streptococcus using rapid antigen detection test and/or culture in patients with symptoms suggestive of bacterial pharyngitis (persistent fevers, anterior cervical adenitis, tonsillopharyngeal exudates). 2

• Treat with antibiotics ONLY if group A Streptococcus is confirmed. Penicillin V 250-500mg twice or three times daily for 10 days remains first-line treatment. 6, 4

• Antibiotics shorten symptom duration by only 1-2 days, with number needed to treat of 6 at 3 days and 21 at 1 week. The primary benefit is prevention of complications (peritonsillar abscess, rheumatic fever) rather than symptom relief. 2

• Alternative antibiotics (cephalosporins, amoxicillin-clavulanate, macrolides) may be more effective in patients who failed previous penicillin therapy, particularly when beta-lactamase-producing bacteria are suspected. 7

Scenario 4: Asymptomatic Tonsillar Enlargement

For adults with enlarged tonsils but no obstructive symptoms, recurrent infections, or concerning features:

• Observation is appropriate. No intervention is needed for asymptomatic tonsillar hypertrophy. 2

• Provide symptomatic management if mild throat discomfort is present: acetaminophen, NSAIDs (with caution in elderly due to cardiovascular and renal risks), or throat lozenges. 2, 6

Surgical Considerations When Tonsillectomy Is Indicated

• Complete tonsillectomy is preferred over partial tonsillotomy, as residual lymphoid tissue may contribute to persistent symptoms. 1

• Coblation techniques result in slightly less postoperative pain during the first day compared with cold dissection or electrocautery, though differences are modest. 2

• Perioperative management should include: intravenous dexamethasone (0.5 mg/kg, maximum 8-25mg) to reduce postoperative pain, nausea, and vomiting. 1

• Postoperative pain management should combine paracetamol and NSAIDs (unless contraindicated), continued for several days postoperatively. 2

Critical Pitfalls to Avoid

• Never perform tonsillectomy for recurrent pharyngitis without documenting that episodes meet Paradise criteria. The surgery carries significant morbidity (severe postoperative pain in most patients) and should only be performed when clear benefit is established. 2, 3

• Do not prescribe antibiotics for sore throat without confirming bacterial infection. Over 60% of adults with sore throat receive unnecessary antibiotics, contributing to resistance and adverse effects without meaningful benefit. 2

• Always evaluate unilateral tonsillar enlargement for malignancy before attributing it to benign causes. Asymmetric tonsils, especially with associated red flag symptoms (dysphagia, odynophagia, weight loss, otalgia with normal ear exam), require urgent specialist referral. 2

• Do not assume OSA based on symptoms alone. Polysomnography is mandatory for surgical decision-making when OSA is the indication for tonsillectomy. 1

• Recognize that persistent sore throat beyond 2 weeks is atypical and demands evaluation for serious complications and non-infectious causes (malignancy, GERD), not empiric antibiotic therapy. 6