Indications for Tonsillectomy
Tonsillectomy is indicated when a patient meets the Paradise criteria: ≥7 documented episodes of tonsillitis in the past year, ≥5 episodes per year for 2 consecutive years, or ≥3 episodes per year for 3 consecutive years, with each episode properly documented and meeting specific clinical criteria. 1
Documentation Requirements for Each Episode
Each episode must be documented in the medical record with the following:
- Sore throat PLUS at least one of: 1, 2
- Antibiotics administered in conventional dosage for proven or suspected streptococcal episodes 2
Obstructive Sleep-Disordered Breathing as Primary Indication
Tonsillectomy is strongly indicated for children with obstructive sleep-disordered breathing (oSDB) and tonsillar hypertrophy, regardless of infection frequency. 3
Key clinical features justifying surgery:
- Grade 3 tonsillar hypertrophy with snoring and mouth breathing 3
- Struggling to breathe during sleep 3
- Associated comorbidities: growth retardation, poor school performance, enuresis, asthma, behavioral problems 3
- Polysomnography is NOT mandatory in otherwise healthy children with clear clinical symptoms 3
Expected outcomes for oSDB:
- Overall OSA resolution rate approximately 79% 3
- Higher success in younger, normal-weight, non-African American children (80%) 3
- Lower success in obese children (<50% complete resolution) 3
- Significant improvements in growth rate, insulin-like growth factor-I levels, systemic inflammation, and endothelial function 3
Modifying Factors That Lower the Threshold
Consider tonsillectomy even when Paradise criteria are not fully met if the following modifying factors are present: 1, 2
- Multiple antibiotic allergies or intolerance 1, 2
- PFAPA syndrome (Periodic Fever, Aphthous stomatitis, Pharyngitis, Adenitis) 1, 2
- History of >1 peritonsillar abscess 1, 2
When to Strongly Recommend Watchful Waiting
Watchful waiting is strongly recommended when patients have: 1, 2
- <7 episodes in the past year 1, 2
- <5 episodes per year in the past 2 years 1, 2
- <3 episodes per year in the past 3 years 1, 2
The rationale is that recurrent tonsillitis is largely self-limited, with untreated children experiencing only 1.17 episodes in the first year after observation, 1.03 in the second year, and 0.45 in the third year 2. The risks of surgery outweigh benefits below these thresholds 1.
Critical Implementation Steps
Primary care providers must collate comprehensive documentation including: 2
- All visits related to throat infections 2
- Specific symptoms and physical findings 2
- Laboratory test results 2
- Days of school/work absence 2
- Quality of life impacts using validated instruments (Tonsillectomy Outcome Inventory 14 or Tonsil and Adenoid Health Status Instrument) 4
Common Pitfalls to Avoid
- Do NOT delay surgery for "watchful waiting" when obstructive symptoms are present - watchful waiting only applies when Paradise criteria are not met AND there are no obstructive symptoms 3
- Do NOT require polysomnography before proceeding unless high-risk comorbidities are present (age <2 years, obesity, Down syndrome, craniofacial abnormalities, neuromuscular disorders, sickle cell disease, mucopolysaccharidoses) 3
- Do NOT perform tonsillectomy for peritonsillar abscess alone unless the abscess cannot be drained otherwise 5
- Do NOT perform tonsillectomy for mononucleosis 5
Evidence Quality and Strength
The 2019 American Academy of Otolaryngology-Head and Neck Surgery guideline upgraded watchful waiting to a strong recommendation with high-quality evidence, reflecting high confidence that surgery should be avoided below the Paradise thresholds 1. The Paradise criteria themselves are based on grade I-II evidence from randomized controlled trials demonstrating efficacy 5, 4.