Indications for Tonsillectomy in a Six-Year-Old Boy
Tonsillectomy is indicated for this 6-year-old if he has documented obstructive sleep apnea or meets strict Paradise criteria for recurrent tonsillitis (≥7 episodes in the past year, ≥5 episodes per year for 2 years, or ≥3 episodes per year for 3 years with proper documentation), though modifying factors may justify surgery even when these thresholds are not met. 1
Primary Indication: Obstructive Sleep-Disordered Breathing
Tonsillectomy should be recommended if the child has obstructive sleep apnea documented by polysomnography. 1
For children with clinical signs of obstructive sleep-disordered breathing (snoring, gasping during sleep, witnessed apneas, daytime sleepiness) and tonsillar hypertrophy, surgery can be performed without mandatory polysomnography if there are no high-risk comorbidities. 2
Polysomnography is required before tonsillectomy if the child is <2 years old or has any of the following comorbidities: obesity, Down syndrome, craniofacial abnormalities, neuromuscular disorders, sickle cell disease, or mucopolysaccharidoses. 1
Polysomnography should also be obtained when the need for surgery is uncertain or when there is discordance between physical examination findings and reported symptom severity. 1
Ask caregivers about comorbid conditions that may improve after tonsillectomy, including growth retardation, poor school performance, enuresis, asthma, and behavioral problems. 1
Secondary Indication: Recurrent Tonsillitis (Paradise Criteria)
Tonsillectomy may be recommended for recurrent throat infection meeting the following frequency thresholds with proper documentation: 1, 3
- ≥7 documented episodes in the past year, OR
- ≥5 episodes per year for each of the past 2 years, OR
- ≥3 episodes per year for each of the past 3 years
Required Documentation for Each Episode
Each episode must be documented in the medical record 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
Additional Requirements
- Antibiotics must have been administered in conventional dosage for proven or suspected streptococcal episodes. 3
- Documentation should include days of school absence and quality of life impacts. 1
Watchful Waiting Recommendation
Strongly recommend watchful waiting if the child has <7 episodes in the past year, <5 episodes per year in the past 2 years, or <3 episodes per year in the past 3 years. 1
- Many cases of recurrent tonsillitis improve spontaneously, with untreated children experiencing an average of only 1.17 episodes in the first year after observation, 1.03 in the second year, and 0.45 in the third year. 3
Modifying Factors That May Favor Tonsillectomy
Assess for modifying factors that may justify tonsillectomy even when Paradise criteria are not met: 1, 2
- Multiple antibiotic allergies or intolerance 1, 3
- PFAPA syndrome (periodic fever, aphthous stomatitis, pharyngitis, and adenitis) 1, 4, 5
- History of >1 peritonsillar abscess 1, 6
- Concurrent obstructive sleep-disordered breathing with tonsillar hypertrophy 2
- Significant impact on growth and development 3
Special Considerations for Age
- In children under 6 years, tonsillectomy should only be performed for recurrent acute bacterial tonsillitis meeting strict criteria or for obstructive sleep apnea. 4, 5
- For tonsillar hyperplasia without recurrent infections in this age group, partial tonsillectomy (tonsillotomy) should be considered as first-line therapy due to lower postoperative pain and hemorrhage risk. 4, 5
Critical Perioperative Management
Mandatory Interventions
- Administer a single intraoperative dose of intravenous dexamethasone. 1
- Do NOT administer or prescribe perioperative antibiotics unless there is a specific indication. 1, 6
Postoperative Monitoring
- Arrange overnight inpatient monitoring if the child is <3 years old or has severe obstructive sleep apnea (apnea-hypopnea index ≥10 events/hour, oxygen saturation nadir <80%, or both). 1
Pain Management
- Recommend ibuprofen, acetaminophen, or both for postoperative pain control. 1
- Counsel families about the importance of anticipating, reassessing, and adequately treating pain after surgery. 1
Essential Preoperative Counseling
Inform families that obstructive sleep-disordered breathing may persist or recur after tonsillectomy (approximately 79% success rate for resolving OSA) and may require further management such as weight management, medications, or CPAP. 2
Counsel about postoperative bleeding risk, which can occur until complete wound healing (typically 3 weeks), and provide written instructions with emergency contact information. 5, 7
Use a standardized 17-point questionnaire to screen for hereditary coagulopathy rather than routine coagulation blood tests, as this is more sensitive for detecting conditions like von Willebrand disease. 5