What is the next step in management for a 5-year-old child with recurrent adenotonsillitis, snoring, mouth breathing, and grade 3 tonsils, who has had 6 episodes of adenotonsillitis since starting kindergarten?

Refer for Adenotonsillectomy

This child meets criteria for adenotonsillectomy based on obstructive sleep-disordered breathing (oSDB) symptoms, making surgical referral the appropriate next step without requiring polysomnography first. 1, 2

Primary Surgical Indication: Obstructive Sleep-Disordered Breathing

The presence of snoring, mouth breathing, and grade 3 tonsillar hypertrophy constitutes sufficient clinical evidence for surgical intervention in an otherwise healthy 5-year-old child. 2, 3 The American Academy of Otolaryngology-Head and Neck Surgery guidelines explicitly state that children with oSDB and tonsillar hypertrophy are candidates for tonsillectomy, particularly when accompanied by symptoms like those present in this case. 1

Polysomnography is NOT required before proceeding to surgery in this clinical scenario. 2 Sleep studies should only be obtained if the child has high-risk comorbidities including: 1, 2

• Age <2 years
• Obesity
• Down syndrome
• Craniofacial abnormalities
• Neuromuscular disorders
• Sickle cell disease
• Mucopolysaccharidoses

Since this 5-year-old has none of these conditions, the clinical presentation alone justifies surgical referral. 2, 3

Secondary Supporting Factor: Recurrent Adenotonsillitis

While the 6 episodes of adenotonsillitis fall one episode short of the strict Paradise criteria (which requires ≥7 episodes in the past year), this serves as an important modifying factor that further supports the surgical decision. 1, 4 The guidelines specifically recommend assessing children who don't fully meet Paradise criteria for modifying factors that may nonetheless favor tonsillectomy. 1, 2

The combination of oSDB symptoms with near-threshold recurrent infections creates a compelling case where the benefits clearly outweigh the risks. 2, 3

Critical Distinction: Why NOT Watchful Waiting

Watchful waiting is only appropriate when Paradise criteria are not met AND there are no obstructive symptoms. 1, 4 The strong recommendation for watchful waiting applies to children with <7 episodes in the past year who lack signs of airway obstruction. 1 This child has clear obstructive symptoms (snoring, mouth breathing, grade 3 tonsils), which independently justify surgery regardless of infection frequency. 2

Delaying surgery for observation would be inappropriate because: 2

• The oSDB symptoms alone meet surgical criteria
• Grade 3 tonsils with clinical airway obstruction require intervention
• Natural resolution of obstructive symptoms is unlikely with this degree of tonsillar hypertrophy

Expected Outcomes and Counseling Points

Families should understand that: 2, 3

• Overall success rate for resolving OSA is approximately 79%
• Younger, normal-weight children have resolution rates around 80%
• oSDB may persist or recur after surgery in some cases
• Additional interventions (weight management, CPAP) may be needed if symptoms persist
• Repeated sleep testing is recommended if obstructive symptoms continue postoperatively 2

The recurrent infections will likely improve as well, though this is a secondary benefit. 5

Perioperative Management

When surgery proceeds, ensure: 1, 3

• Single intraoperative dose of IV dexamethasone is administered
• Perioperative antibiotics are NOT routinely given
• Postoperative pain control with ibuprofen, acetaminophen, or both 1