What are the treatment options for tonsil issues?

Treatment Options for Tonsil Issues

For recurrent tonsil infections, watchful waiting is strongly recommended unless you meet specific criteria: fewer than 7 episodes in the past year, fewer than 5 episodes per year for 2 years, or fewer than 3 episodes per year for 3 years—if you don't meet these thresholds, surgery should be considered. 1

Recurrent Tonsillitis Management

When to Watch and Wait (Non-Surgical Approach)

• Watchful waiting is the appropriate first-line approach if your throat infections are less frequent than the Paradise criteria: <7 episodes in the past year, <5 episodes per year in the past 2 years, or <3 episodes per year in the past 3 years 1
• Many patients improve spontaneously without surgery—control groups in clinical trials showed dramatic reductions from expected infection rates to only 0.3-1.17 episodes per year without intervention 1, 2
• During watchful waiting, supportive care includes adequate analgesia (acetaminophen is recommended) and hydration 1, 3

When Surgery (Tonsillectomy) Is Indicated

Tonsillectomy should be considered when you meet the Paradise criteria for frequency AND have documentation of each episode including: 1

• Temperature >38.3°C (101°F)
• Cervical lymph node enlargement
• Tonsillar exudate (pus on tonsils)
• Positive test for Group A beta-hemolytic streptococcus (GABHS)

Additional modifying factors that may favor earlier surgery even without meeting strict Paradise criteria include: 1

• Multiple antibiotic allergies or intolerances
• PFAPA syndrome (periodic fever, aphthous stomatitis, pharyngitis, and adenitis)
• History of more than one peritonsillar abscess
• Complications requiring hospitalization 1

Bacterial Tonsillitis Treatment

If Group A streptococcal infection is confirmed, antibiotic treatment is indicated: 3

• Penicillin remains the first-line antibiotic for documented streptococcal pharyngitis/tonsillitis 3
• Azithromycin (12 mg/kg once daily for 5 days in children) showed 98% clinical success at Day 14 and 94% at Day 30, superior to penicillin V 4
• Treatment prevents progression to systemic complications including acute rheumatic fever, post-streptococcal glomerulonephritis, and scarlet fever 3

Obstructive Sleep-Disordered Breathing (oSDB)

When Tonsillectomy Is Recommended for Breathing Issues

Tonsillectomy should be recommended for children with obstructive sleep apnea documented by polysomnography 1

Ask about these comorbid conditions that improve after tonsillectomy: 1

• Growth retardation or failure to thrive
• Poor school performance or behavioral problems
• Nighttime bed wetting (enuresis)
• Asthma exacerbations

Important Caveats About Surgery for Sleep Issues

Counsel patients that tonsillectomy is NOT curative in all cases: 1

• Success rate is approximately 79-80% in normal-weight children with tonsillar hypertrophy 1
• In obese children, complete resolution occurs in only 20-50% of cases 1
• Obesity, certain ethnicities, and severe baseline sleep apnea (AHI >4.7) predict lower cure rates 1
• Additional interventions may be needed including weight loss, CPAP, or further surgery 1

Polysomnography (sleep study) should be advocated when: 1

• The need for tonsillectomy is uncertain
• There is discordance between physical exam findings and reported symptom severity
• High-risk comorbidities exist (obesity, Down syndrome, craniofacial abnormalities) 1

Perioperative Management for Tonsillectomy

Pain Control

Counsel patients and caregivers about pain management as part of perioperative education: 1

• Anticipate, reassess, and adequately treat pain after surgery 1
• Use validated age-appropriate pain scales (Wong-Baker FACES for ages ≥3 years, FLACC for ages 2 months to 7 years) 1
• Acetaminophen is recommended before and after surgery 1

Medications During Surgery

A single intraoperative dose of intravenous dexamethasone should be administered (typically 0.5 mg/kg, maximum varies 8-25 mg) 1

• Decreases postoperative nausea/vomiting up to 24 hours 1
• Reduces throat pain and time to first oral intake 1
• No adverse events in randomized trials except one uncontrolled report 1

Perioperative antibiotics should NOT be administered or prescribed 1

• Cochrane review shows no reduction in pain, need for pain medication, or bleeding rates 1
• Avoids adverse events including rash, allergy, gastrointestinal upset, and antibiotic resistance 1

Tonsil Stones (Tonsilloliths)

Tonsilloliths are managed expectantly with watchful waiting 3

• Small tonsil stones are common clinical findings and typically pass spontaneously 3
• Surgical intervention (stone removal or tonsillectomy) is rarely required only if stones become too large to pass on their own 3, 5
• They are a known cause of halitosis (bad breath) 5

Surgical Risks to Discuss

Tonsillectomy carries these risks that must be weighed against benefits: 6

• Bleeding: 0.2-3% incidence 6
• Pain: inevitable postoperative pain lasting several days 2
• Dehydration risk 6
• Anesthetic risks 6

The trade-off: Surgery provides one predictable episode of postoperative pain in exchange for preventing 2-3 unpredictable episodes of sore throat in the following year for severely affected patients 2