What is the treatment approach for a pediatric or young adult patient with no significant medical history presenting with either enlarged or swollen tonsils?

Treatment Approach for Enlarged vs Swollen Tonsils

The treatment approach fundamentally depends on whether the patient has obstructive sleep-disordered breathing (oSDB) versus recurrent acute tonsillitis—enlarged tonsils causing airway obstruction warrant tonsillectomy as first-line treatment, while acutely swollen tonsils from infection require conservative management with antibiotics only when bacterial infection is confirmed. 1, 2

Initial Clinical Assessment

Distinguish between two distinct clinical scenarios:

• Enlarged tonsils (tonsillar hypertrophy): Chronically large tonsils causing mechanical airway obstruction, typically presenting with snoring, witnessed apneas, mouth breathing, and daytime symptoms 3

• Swollen tonsils (acute tonsillitis): Acutely inflamed tonsils with sore throat, fever, dysphagia, and often tonsillar exudate 4

Grade tonsillar size using the Brodsky scale (0-4 based on percentage of oropharyngeal obstruction: Grade 1 <25%, Grade 2: 25-50%, Grade 3: 50-75%, Grade 4: >75%) to objectively document the degree of enlargement 1

Management Algorithm for Enlarged Tonsils (Tonsillar Hypertrophy)

When Obstructive Sleep-Disordered Breathing is Present

Adenotonsillectomy is first-line treatment for children with clinical examination consistent with adenotonsillar hypertrophy and symptoms of obstructive sleep apnea 1, 2

Key decision points:

• For otherwise healthy children with strong history of struggling to breathe, daytime symptoms, and enlarged tonsils: Proceed directly to surgery without polysomnography (PSG) unless parents want diagnostic confirmation 3

• PSG is mandatory before surgery if the patient has: Age <2 years, obesity, Down syndrome, craniofacial abnormalities, neuromuscular disorders, sickle cell disease, or mucopolysaccharidoses 2

• PSG should be obtained when: There is discordance between tonsillar size on examination and reported severity of symptoms 1, 2

Expected Surgical Outcomes

Success rates vary significantly by patient characteristics 3:

• Younger, normal-weight, non-African American children: 80% resolution of oSDB 3, 2
• Obese children: Only 10-25% complete resolution (compared to 60-70% in normal-weight children) 1, 5
• Adults with significant tonsillar hypertrophy and OSA: Tonsillectomy as single intervention is recommended 1

Counsel families that tonsillectomy may not completely resolve oSDB and additional interventions may be needed, including weight loss, CPAP, or additional surgery 3

Perioperative Management

• Do NOT administer perioperative antibiotics 2
• Give single intraoperative dose of IV dexamethasone (0.5 mg/kg, maximum 8-25 mg) to reduce pain, nausea, and vomiting 2, 5
• Arrange overnight inpatient monitoring for: Children <3 years old or those with severe OSA 2

Post-operative Follow-up

Consider post-operative PSG in patients with: Persistent symptoms after surgery, severe preoperative OSA, obesity, or other risk factors for persistent sleep-disordered breathing 1, 5

Management Algorithm for Swollen Tonsils (Acute Tonsillitis)

Diagnostic Approach

Use a clinical scoring system (Centor, McIsaac, or FeverPAIN score) to estimate probability of bacterial tonsillitis, primarily group A streptococcus (GAS) 6

In ambiguous cases, perform point-of-care GAS rapid antigen test 6

Conservative Treatment

Most tonsillitis is viral and requires only supportive care 4:

• Analgesia: Combination of acetaminophen and/or NSAIDs 6
• Hydration 4

Initiate antibiotic therapy ONLY when:

• High probability of bacterial tonsillitis based on scoring system 6
• Positive GAS testing 6
• Patient is at risk for complications (e.g., rheumatic fever) 4

When antibiotics are indicated, use amoxicillin 7:

• Adults and children >40 kg: 500 mg every 12 hours or 250 mg every 8 hours for mild/moderate; 875 mg every 12 hours or 500 mg every 8 hours for severe 7
• Children <40 kg: 25 mg/kg/day divided every 12 hours or 20 mg/kg/day divided every 8 hours for mild/moderate; 45 mg/kg/day divided every 12 hours or 40 mg/kg/day divided every 8 hours for severe 7
• Treatment duration: Minimum 10 days for GAS to prevent acute rheumatic fever 7

Indications for Tonsillectomy in Recurrent Acute Tonsillitis

Tonsillectomy is indicated when the patient has had 6, 8:

• ≥7 adequately treated episodes in the preceding year, OR
• ≥5 episodes in each of the preceding 2 years, OR
• ≥3 episodes in each of the preceding 3 years

For patients with 3-5 episodes in 12 months: Implement a wait-and-see policy for 6 months to allow for potential spontaneous resolution before considering surgery 8

Surgery is NOT indicated with <3 episodes 8

Important caveat: The quality of evidence for tonsillectomy in recurrent tonsillitis is moderate for children and low for adults, with modest impact on reducing sore throat episodes 8. The benefit is primarily seen within the first 12 postoperative months in children and only 5-6 months in adults 8.

Critical Pitfalls to Avoid

Unilateral tonsillar enlargement requires heightened vigilance: While rare, non-Hodgkin lymphoma can present as persistent tonsillar hypertrophy that fails to respond to antibiotics 9. Consider histologic analysis of excised tissue in cases of asymmetric, persistent enlargement 9.

Do not perform interval tonsillectomy after peritonsillar abscess: This approach is not supported by contemporary evidence, as recurrences after needle aspiration or incision/drainage are rare 8

Avoid routine tonsillectomy for infectious mononucleosis: Surgery should only be performed for clinically significant upper airway obstruction from inflammatory tonsillar hyperplasia 8

Document quality of life impact: Use specific validated instruments (Tonsillectomy Outcome Inventory 14 or Tonsil and Adenoid Health Status Instrument) when tracking recurrent episodes to support surgical decision-making 6