Tonsillectomy is Strongly Indicated
This patient requires tonsillectomy based on obstructive sleep-disordered breathing (oSDB) symptoms with grade 3 tonsillar hypertrophy, which alone constitutes a primary surgical indication regardless of the recurrent tonsillitis history. 1, 2
Primary Indication: Obstructive Sleep-Disordered Breathing
The presence of snoring, mouth breathing during sleep, and grade 3 tonsils provides sufficient clinical evidence for surgical intervention without requiring polysomnography in an otherwise healthy patient. 1, 2 The American Academy of Otolaryngology-Head and Neck Surgery recommends tonsillectomy for children with oSDB and tonsillar hypertrophy, particularly when accompanied by symptoms of airway obstruction. 3, 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, 4 This patient has clear obstructive symptoms that independently justify surgery. 1, 2
Secondary Supporting Indication: Recurrent Tonsillitis
While the patient has 6 episodes of tonsillitis in the past year (one episode short of the strict Paradise criterion of ≥7 episodes), this serves as an additional modifying factor supporting surgery. 1, 4 The American Academy of Otolaryngology-Head and Neck Surgery recommends assessing children with recurrent throat infection who do not meet strict Paradise criteria for modifying factors that may favor tonsillectomy, such as concurrent oSDB with tonsillar hypertrophy. 3, 4, 2
The combination of near-threshold recurrent infections plus obstructive symptoms creates a compelling dual indication. 1, 2
Polysomnography Considerations
PSG is not required before proceeding to surgery in this case. 1, 2 Polysomnography should only be obtained if the patient has high-risk comorbidities including: age <2 years, obesity, Down syndrome, craniofacial abnormalities, neuromuscular disorders, sickle cell disease, or mucopolysaccharidoses. 1 For otherwise healthy children with strong clinical history of struggling to breathe, daytime symptoms, and enlarged tonsils, PSG is typically not performed unless parents want diagnostic confirmation. 1
Expected Outcomes and Critical Counseling
Adenotonsillectomy shows significant postoperative improvements in respiratory parameters, sleep architecture, quality of life scores, OSA symptom scores, and behavioral scores. 1 Additional benefits include rapid increase in growth rate, improvement in insulin-like growth factor-I levels, and improvements in systemic inflammation and lipid profiles. 1
However, families must understand that oSDB may persist or recur after tonsillectomy and may require further management. 1, 2 The 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, 2 Repeated sleep testing is recommended if symptoms persist postoperatively, particularly in those with severely abnormal preoperative polysomnography results. 1
Perioperative Management
Administer a single intraoperative dose of intravenous dexamethasone. 2 Do not routinely administer or prescribe perioperative antibiotics unless there is a specific indication. 3, 2
Documentation Requirements
Document all episodes thoroughly in the medical record including symptoms, physical findings, test results, and quality of life impacts. 1, 4 This documentation supports the surgical decision and provides baseline data for postoperative comparison.