Tonsillectomy is Indicated for This Patient
This patient should undergo tonsillectomy based on the presence of obstructive sleep-disordered breathing (oSDB) with grade 3 tonsillar hypertrophy, which alone constitutes a primary surgical indication, with the recurrent tonsillitis serving as an additional supporting factor. 1, 2
Primary Indication: Obstructive Sleep-Disordered Breathing
The combination of snoring, mouth breathing during sleep, and grade 3 tonsils represents clinically significant oSDB that warrants surgical intervention. 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. 1
Grade 3 tonsils with clinical symptoms of airway obstruction provide sufficient clinical evidence for surgical intervention without mandatory polysomnography in otherwise healthy children. 2
The presence of snoring and mouth breathing constitutes sufficient clinical evidence for proceeding with surgery. 2, 3
Secondary Supporting Indication: Recurrent Tonsillitis
While the patient has 6 episodes of tonsillitis in the past year (one episode short of the strict Paradise criteria of ≥7 episodes/year), this serves as a modifying factor that further supports the surgical decision. 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 nonetheless favor tonsillectomy. 1
The concurrent presence of oSDB with tonsillar hypertrophy qualifies as a significant modifying factor. 2, 3
Polysomnography Considerations
Polysomnography is NOT required before proceeding with surgery in this case. 2, 3
PSG should only be obtained if the patient is <2 years of age, obese, has Down syndrome, craniofacial abnormalities, neuromuscular disorders, sickle cell disease, or mucopolysaccharidoses. 1
For otherwise healthy children with strong clinical history and enlarged tonsils, PSG is typically not performed unless parents want diagnostic confirmation. 2
Critical Preoperative Counseling Points
Families must understand that oSDB may persist or recur after tonsillectomy and may require further management. 1, 2
Overall success rate for resolving OSA is approximately 79%, varying based on age, weight, ethnicity, and OSA severity. 2
Younger, normal-weight children may have resolution rates of 80%, while obese children have complete resolution <50% of the time. 2
Additional interventions may be needed including weight loss, medications, or CPAP if symptoms persist. 2
Repeated sleep testing is recommended if symptoms persist postoperatively. 2
Perioperative Management Requirements
Administer a single intraoperative dose of intravenous dexamethasone. 1, 3
Do NOT administer or prescribe perioperative antibiotics. 1, 3
Recommend ibuprofen, acetaminophen, or both for postoperative pain control. 1
Do NOT prescribe codeine or any medication containing codeine if the patient is younger than 12 years. 1
Common Pitfalls to Avoid
Do not delay surgery for "watchful waiting" in this patient. 2, 4
Watchful waiting is only appropriate when Paradise criteria are not met AND there are no obstructive symptoms. 2, 4
The presence of oSDB symptoms with grade 3 tonsils overrides any consideration of observation. 2
Do not require PSG before proceeding unless high-risk comorbidities are present. 2, 3
- The clinical presentation is sufficient for surgical decision-making. 2
Document all episodes thoroughly in the medical record including symptoms, physical findings, test results (temperature ≥38.3°C, cervical adenopathy, tonsillar exudate, or positive strep test), and quality of life impacts. 1, 4