What is the treatment protocol for tonsillar enlargement?

Treatment Protocol for Tonsillar Enlargement

The treatment approach for tonsillar enlargement depends critically on whether the patient has obstructive sleep-disordered breathing (SDB) or recurrent infections, with adenotonsillectomy serving as first-line surgical treatment when specific clinical criteria are met. 1, 2

Initial Assessment and Grading

Grade the tonsillar enlargement using the Brodsky scale to objectively document the degree of obstruction: Grade 0 (not visible), Grade 1+ (<25% of oropharyngeal space), Grade 2+ (25-49%), Grade 3+ (50-74%), or Grade 4+ (≥75% "kissing tonsils"). 1, 3

Assess for modifying factors through history and physical examination, including behavioral problems, poor school performance, decreased quality of life, failure to thrive, enuresis, nocturnal breathing difficulties, and daytime symptoms. 1 These factors significantly influence surgical decision-making and predict outcomes beyond simple tonsillar size. 1

Treatment Algorithm Based on Clinical Presentation

For Sleep-Disordered Breathing (Primary Indication)

Adenotonsillectomy is the first-line treatment for children with obstructive sleep apnea confirmed by polysomnography in the presence of adenotonsillar hypertrophy. 1, 2 Adenotonsillar hypertrophy represents the most common anatomical cause of pediatric OSA, with the highest correlations for disease severity found with tonsillar hypertrophy. 1

Polysomnography requirements vary by patient characteristics:

• Mandatory PSG for children <2 years old, obese patients, or those with comorbidities (Down syndrome, craniofacial abnormalities, neuromuscular disorders, sickle cell disease, mucopolysaccharidoses). 2
• PSG not necessary in otherwise healthy children with strong history of struggling to breathe, daytime symptoms, and enlarged tonsils on examination. 1
• Consider PSG when there is discordance between tonsillar size and reported symptom severity. 3

Complete tonsillectomy is preferred over partial tonsillotomy, as residual lymphoid tissue may contribute to persistent obstruction. 3, 2 However, tonsillotomy demonstrates substantially lower postoperative morbidity with comparable outcomes in pediatric populations and young adults. 4

Adenoidectomy should be performed concurrently in most pediatric cases, as combined adenotonsillectomy provides superior outcomes compared to tonsillectomy alone. 3, 2

For Recurrent Throat Infections

Tonsillectomy is indicated when meeting the Paradise criteria: ≥7 episodes in the past year, ≥5 episodes per year for 2 years, or ≥3 episodes per year for 3 years. 2

For patients with 3-5 episodes annually, implement a wait-and-see policy for 6 months to allow for potential spontaneous resolution before considering surgery. 4 Surgery is not indicated for patients with fewer than 3 episodes annually. 4

For Unilateral Tonsillar Enlargement

Unilateral enlargement requires heightened vigilance for malignancy, though most cases are benign. 5 The strongest risk factors for malignancy include enlarged cervical lymph nodes and suspicious tonsillar appearance. 5

Immediate tonsillectomy is indicated when: cervical lymphadenopathy is present, the tonsil has suspicious appearance, there is chronic pain or dysphagia, or mucosal abnormalities exist. 6 In one study, 45% of patients with these associated features had malignancy. 6

For isolated unilateral enlargement without suspicious features, a watch-and-wait approach is appropriate, as the prevalence of malignancy is very low (0% in some series). 7, 6 Many cases represent spurious asymmetry due to tonsillar pillar anatomy rather than true enlargement. 7

Medical Management Before Surgery

Trial intranasal corticosteroids for adenoidal hypertrophy before proceeding to surgical intervention. 8, 2 Recent clinical studies support this conservative approach. 8

Complete allergy evaluation and appropriate medical management should be performed before surgery, including adequate trials of antihistamines and intranasal steroids. 8

Perioperative Management

Administer intravenous dexamethasone (0.5 mg/kg, maximum 8-25 mg) intraoperatively to reduce postoperative pain, nausea, and vomiting. 3, 2

Plan for inpatient observation when patients have lowest oxygen saturation <80% on preoperative PSG, age <3 years with severe OSA, or significant comorbidities (obesity, Down syndrome, neuromuscular disorders). 2

Expected Outcomes and Counseling

Success rates vary significantly by patient characteristics:

• Normal-weight children: 60-80% complete resolution of OSA. 1, 3
• Obese children: Only 10-50% complete resolution of OSA. 1, 3
• African American children and those with severe preoperative OSA: Lower success rates. 1

Tonsillectomy produces significant improvements in respiratory parameters (mean AHI reduction from 18.2 to 6.4), sleep architecture, quality of life scores, behavioral outcomes, school performance, enuresis (61% resolution, 23% improvement), and growth parameters. 1 These improvements are maintained for at least 2 years postoperatively. 1

Potential complications include pain, bleeding, infection, postoperative respiratory difficulties, velopharyngeal incompetence, and rarely death. 3

Critical Pitfalls to Avoid

Never proceed to surgery without objective PSG documentation when the indication is sleep-disordered breathing, unless the patient meets criteria for clinical diagnosis (otherwise healthy child with strong obstructive history and enlarged tonsils). 2

Do not assume complete OSA resolution post-surgery in obese children, those with severe preoperative OSA, or syndromic patients—arrange postoperative PSG for persistent symptoms. 3, 2

Avoid unnecessary tonsillectomy for isolated unilateral enlargement without suspicious features, as apparent asymmetry is often spurious and malignancy rates are extremely low. 7, 6

Ensure adequate medical management trials before surgery, particularly for allergic rhinitis and adenoidal hypertrophy. 8, 2