What is the appropriate treatment for a patient with enlarged tonsils, possibly due to recurrent tonsillitis or bacterial infection?

Management of Enlarged Tonsils

For enlarged tonsils with recurrent tonsillitis, watchful waiting is strongly recommended unless the patient meets specific surgical criteria: ≥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 properly documented and accompanied by qualifying clinical features. 1, 2

Initial Assessment and Documentation Requirements

When evaluating a patient with enlarged tonsils and possible recurrent tonsillitis, each episode must be documented with specific clinical features to determine if surgical intervention is warranted 1, 2:

• Temperature >38.3°C (100.9°F) 1, 2
• Cervical lymphadenopathy 1, 2
• Tonsillar exudate 1, 2
• Positive test for group A beta-hemolytic streptococcus 1, 2

Additional documentation should include days of school absence, quality of life impacts, and family history of rheumatic heart disease or glomerulonephritis 1.

Medical Management for Bacterial Tonsillitis

If group A beta-hemolytic streptococcus is identified, penicillin remains the first-line antibiotic 3. However, bacterial tonsillitis only accounts for 5-15% of adult cases and 15-30% of pediatric cases aged 5-15 years 3. The majority (70-95%) of tonsillitis cases are viral and do not require antibiotics 3.

For confirmed bacterial tonsillitis, amoxicillin dosing for adults and children ≥40 kg is 500 mg every 12 hours or 250 mg every 8 hours for mild/moderate infections, and 875 mg every 12 hours or 500 mg every 8 hours for severe infections 4. Treatment should continue for at least 10 days for streptococcal infections to prevent acute rheumatic fever 4.

Surgical Indications: The Paradise Criteria

Tonsillectomy is indicated when the patient meets the Paradise criteria 1, 2:

• ≥7 documented episodes in the preceding year, OR
• ≥5 documented episodes per year in each of the preceding 2 years, OR
• ≥3 documented episodes per year in each of the preceding 3 years 1, 2

At least 12 months of observation is recommended before considering tonsillectomy in patients who do not meet these criteria 1, 2. This recommendation is based on evidence showing that untreated children experienced only an average of 1.17 episodes in the first year after observation, 1.03 in the second year, and 0.45 in the third year 2.

Modifying Factors That May Favor Earlier Surgery

Even when Paradise criteria are not fully met, assess for modifying factors that may nonetheless favor tonsillectomy 1:

• Multiple antibiotic allergies or intolerance 1
• PFAPA syndrome (periodic fever, aphthous stomatitis, pharyngitis, and adenitis) 1
• History of >1 peritonsillar abscess 1, 2

Special Consideration: Obstructive Sleep-Disordered Breathing

If the patient has enlarged tonsils with symptoms of obstructive sleep-disordered breathing (snoring, mouth breathing, witnessed apneas), this alone justifies surgical intervention 1, 5, 6. The presence of tonsillar hypertrophy causing airway obstruction is a separate and independent indication for tonsillectomy 1, 5.

Adenotonsillectomy is recommended for childhood obstructive sleep apnea in the presence of adenotonsillar hypertrophy 1. Before surgery, assess for comorbid conditions that may improve after tonsillectomy, including growth retardation, poor school performance, enuresis, asthma, and behavioral problems 1, 5.

Polysomnography should be obtained before tonsillectomy if the patient is <2 years of age, obese, has Down syndrome, craniofacial abnormalities, neuromuscular disorders, sickle cell disease, or mucopolysaccharidoses 1, 5, 6. For otherwise healthy children with strong clinical history and enlarged tonsils, polysomnography is typically not required 5, 6.

Critical Counseling Points

Families must understand that obstructive sleep-disordered breathing may persist or recur after tonsillectomy 5, 6. The overall success rate for resolving obstructive sleep apnea is approximately 79%, but varies significantly: younger, normal-weight, non-African American children may have resolution rates of 80%, while obese children have complete resolution <50% of the time 5.

For recurrent tonsillitis, the benefits of tonsillectomy are modest and do not persist beyond the first year in many cases 2. Many children awaiting tonsillectomy no longer meet criteria by the time of surgery, highlighting the importance of observation and documentation 2.

Perioperative Management (If Surgery Proceeds)

Administer a single intraoperative dose of intravenous dexamethasone 1, 6. Recommend ibuprofen, acetaminophen, or both for postoperative pain control 1, 6. Do not administer or prescribe perioperative antibiotics 1, 6. Do not prescribe codeine or any medication containing codeine if the patient is younger than 12 years 6.

Common Pitfalls to Avoid

• Do not proceed with tonsillectomy without proper documentation of episodes meeting Paradise criteria, unless obstructive symptoms or other modifying factors are present 1, 2
• Do not delay surgery for "watchful waiting" if the patient has obstructive sleep-disordered breathing with tonsillar hypertrophy 5, 6
• Do not require polysomnography before proceeding unless high-risk comorbidities are present 5, 6
• Do not use radiofrequency tonsil reduction as a single procedure for treatment, as the amount of tonsil reduction is unpredictable and tonsil re-growth may occur 1