Chronic Tonsillar Enlargement in an 8-Year-Old Child
Causes of Chronic Tonsillar Enlargement
Chronic tonsillar enlargement in children results primarily from lymphoid tissue proliferation due to reduced apoptosis rather than infectious causes. 1
Primary Pathophysiologic Mechanisms
Impaired lymphoid cell apoptosis is the fundamental mechanism distinguishing tonsillar hypertrophy from recurrent tonsillitis, with decreased endonuclease activity preventing normal programmed cell death 1
Environmental pollution exposure triggers chronic inflammatory processes without apoptotic cell death, leading to progressive tissue accumulation 1
Increased basophil infiltration in hypertrophic tonsils releases interleukin-4, which inhibits lymphoid apoptosis and promotes cell proliferation 1
Bacterial colonization, particularly with Haemophilus influenzae, correlates directly with tonsillar size through increased aerobic bacterial load and absolute numbers of B and T cells 2
Increased germinal center formation is the primary histopathological feature differentiating hypertrophy from recurrent tonsillitis 3
Anatomic Considerations
Reduced oropharyngeal diameter in children with large tonsils (compared to those with small tonsils) suggests that true tissue enlargement occurs rather than simply reduced anatomic space 4
The nasopharyngeal space dimensions remain normal in children with adenotonsillar hypertrophy, confirming genuine lymphoid tissue expansion 2
Treatment Algorithm
Step 1: Assess for Obstructive Sleep-Disordered Breathing (oSDB)
Ask caregivers specifically about: 5
- Witnessed apneas or gasping during sleep
- Loud snoring
- Daytime somnolence or fatigue
- Morning headaches
- Difficulty concentrating or behavioral changes
Evaluate for comorbid conditions that improve after tonsillectomy: 5
- Growth retardation
- Poor school performance
- Enuresis
- Asthma
- Behavioral problems
Step 2: Determine Need for Polysomnography (PSG)
PSG is mandatory before tonsillectomy if the child has: 5
- Age <2 years
- Obesity
- Down syndrome
- Craniofacial abnormalities
- Neuromuscular disorders
- Sickle cell disease
- Mucopolysaccharidoses
PSG should be strongly advocated when: 5
- The need for tonsillectomy is uncertain
- Discordance exists between physical examination findings and reported severity of oSDB
Step 3: Surgical Decision-Making
Tonsillectomy is recommended for: 5
- Documented obstructive sleep apnea on PSG (this is a firm recommendation, not an option) 5
- Tonsillar hypertrophy with oSDB and comorbid conditions listed above 5
Watchful waiting is appropriate when: 5
- No documented OSA on PSG
- Absence of significant oSDB symptoms
- No comorbid conditions requiring intervention
Step 4: Surgical Technique
Adenotonsillectomy is the preferred procedure: 6
- Complete tonsillectomy is superior to tonsillotomy, as residual lymphoid tissue may cause persistent obstruction 6
- Adenoidectomy should be performed concurrently, as combined surgery provides better outcomes than tonsillectomy alone 6
Step 5: Perioperative Management
Mandatory interventions: 5
- Administer single intraoperative dose of IV dexamethasone (0.5 mg/kg, maximum 8-25 mg) to reduce pain, nausea, and vomiting 5, 6
- Do NOT administer perioperative antibiotics (strong recommendation against) 5
Postoperative monitoring requirements: 5
- Arrange overnight inpatient monitoring if: age <3 years OR severe OSA (AHI ≥10 events/hour OR oxygen saturation nadir <80%) 5
Step 6: Counseling About Outcomes
Set realistic expectations: 5, 6
- Complete OSA resolution occurs in 60-70% of normal-weight children but only 10-25% of obese children 6
- oSDB may persist or recur after tonsillectomy and require further management 5
- Additional interventions may include weight loss, medications, CPAP, or advanced sleep surgery procedures 5
Critical Pitfalls to Avoid
Do not perform tonsillectomy solely for tonsillar size without documented oSDB or recurrent infections meeting Paradise criteria (≥7 episodes in past year, ≥5 episodes/year for 2 years, or ≥3 episodes/year for 3 years with proper documentation) 5
Apparent unilateral tonsillar enlargement is often spurious - in one study, 15% of clinically "larger" tonsils were actually smaller on pathologic examination, and 36% showed no size difference at all 7. Tonsillectomy for biopsy in children with isolated unilateral enlargement (without other suspicious features) results in no malignancies and many unnecessary procedures 7
History and physical examination alone are poor predictors of OSA severity - PSG provides essential baseline information for high-risk patients and guides postoperative management 8