What is the recommended treatment for a patient with enlarged tonsils and recurrent tonsillitis?

Treatment of Enlarged Tonsils with Recurrent Tonsillitis

For patients with enlarged tonsils and recurrent tonsillitis, tonsillectomy is indicated when there are ≥7 documented episodes in the past year, ≥5 episodes per year for 2 years, or ≥3 episodes per year for 3 years, with each episode meeting specific clinical criteria. 1, 2

Documentation Requirements Before Surgery

Each episode must be documented with:

• Sore throat PLUS at least one of the following: 1, 3
  • Temperature >38.3°C (101°F)
  • Cervical lymphadenopathy
  • Tonsillar exudate
  • Positive test for group A beta-hemolytic streptococcus

If episodes do not meet these frequency thresholds (<7 in past year, <5/year for 2 years, or <3/year for 3 years), watchful waiting is strongly recommended to avoid unnecessary surgery. 1, 2

Surgical Decision Algorithm

When Surgery is Indicated:

• Tonsillectomy (complete removal) is the preferred procedure for recurrent tonsillitis meeting the above criteria 1, 2
• Tonsillectomy reduces sore throat days by approximately 47% (incident rate ratio 0.53) over 24 months compared to conservative management 4
• The procedure is clinically effective and cost-effective in adults with recurrent acute tonsillitis 4

Alternative Surgical Option:

• Tonsillotomy (partial removal) may be considered in pediatric patients and young adults with tonsillar hypertrophy graded >1 on the Brodsky scale 5
• Tonsillotomy has substantially lower postoperative morbidity (less pain and bleeding) compared to complete tonsillectomy 5
• Tonsillar tissue remains along the capsule, but outcomes appear similar to complete tonsillectomy in children and young adults 5
• Abscess formation in tonsillar remnants after tonsillotomy is extremely rare 5

Conservative Management Period

A 6-month wait-and-see policy is justified before surgery when patients have 3-5 episodes per year to allow for potential spontaneous resolution 5. During this period:

• Continue symptomatic treatment with paracetamol and/or NSAIDs 2
• Use antibiotics only when bacterial infection (particularly group A streptococcus) is confirmed or highly probable 2
• Document each episode with quality of life assessment using validated instruments 1, 2

Critical Red Flags Requiring Urgent Evaluation

Drooling during tonsillitis mandates immediate evaluation for life-threatening complications: 6

• Peritonsillar abscess (unilateral throat pain, trismus, "hot potato" voice, uvular deviation)
• Parapharyngeal abscess (neck swelling, systemic toxicity)
• Epiglottitis (stridor, tripod positioning, respiratory distress)
• Lemierre syndrome (severe pharyngitis with neck pain/swelling in adolescents/young adults)

These require same-day ENT consultation, possible CT imaging with contrast, and potential surgical drainage 6.

Special Considerations

Asymmetric Tonsillar Enlargement:

Routine excision is recommended for abnormally large asymmetric tonsils due to 2.3% malignancy risk, particularly in patients >50 years without recurrent tonsillitis history 7. This represents concern for neoplasm and is a distinct indication for surgery 1.

Obstructive Sleep-Disordered Breathing:

Tonsillectomy is indicated for obstructive sleep-disordered breathing with tonsillar hypertrophy, which is a separate indication from recurrent infection 1. Adenotonsillectomy is recommended for childhood obstructive sleep apnea with adenotonsillar hypertrophy 8.

Contraindications:

Tonsillectomy is NOT indicated for recurrent tonsilloliths alone, as this is not an established surgical indication 1. Small tonsilloliths are managed expectantly 3.

Postoperative Pain Management

Multimodal analgesia is essential: 8

• Paracetamol (acetaminophen) and NSAIDs combined pre-operatively, intra-operatively, and postoperatively
• Single intra-operative dose of IV dexamethasone
• Avoid codeine as routine addition to acetaminophen (no benefit over acetaminophen alone with known adverse events including nausea/vomiting) 8

Common Pitfalls to Avoid

• Do not perform tonsillectomy for episodes that don't meet documentation criteria (fever, adenopathy, exudate, or positive strep test) 1
• Do not add adenoidectomy to initial tonsillectomy unless distinct indication exists (adenoiditis, postnasal obstruction, chronic sinusitis) 8
• Do not perform tonsillectomy alone for otitis media with effusion 8
• Hemorrhage risk is approximately 19% with tonsillectomy, with most being minor 4