When is tonsillectomy recommended for a child or young adult with recurrent streptococcal (strep) pharyngitis?

Tonsillectomy Guidelines for Recurrent Streptococcal Pharyngitis

Direct Recommendation

Recommend watchful waiting if the patient has fewer than 7 episodes in the past year, fewer than 5 episodes per year for 2 years, or fewer than 3 episodes per year for 3 years; tonsillectomy may be offered when these frequency thresholds are met with proper documentation. 1

Frequency Criteria for Tonsillectomy

The American Academy of Otolaryngology-Head and Neck Surgery provides specific thresholds based on documented episodes:

• ≥7 episodes in the past 12 months, OR 1, 2
• ≥5 episodes per year for 2 consecutive years, OR 1, 2
• ≥3 episodes per year for 3 consecutive years 1, 2

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, 2

• Temperature ≥38.3°C (101°F) 1, 2
• Cervical lymphadenopathy 1, 2
• Tonsillar exudate 1, 2
• Positive test for group A beta-hemolytic streptococcus (rapid antigen or culture) 1, 2

Common pitfall: Many patients are referred without adequate documentation. The primary care provider must collate all visits (including emergency department and urgent care) with specific clinical characteristics recorded for each episode. 1 Without this documentation, the clinical benefits achieved in randomized trials cannot be assured. 1

Strong Recommendation for Watchful Waiting

Below the frequency thresholds, watchful waiting is strongly recommended because: 1, 2

• The condition is largely self-limited with favorable natural history 1
• Randomized controlled trials show that benefits of surgery are significantly lessened for children with mild disease burden 1
• The surgical risks (bleeding, pain, dehydration, anesthetic complications) outweigh benefits when frequency criteria are not met 1, 2
• Benefits do not extend beyond the first year postoperatively 1

The number needed to treat with tonsillectomy to prevent one recurrence is 5 (95% CI: 3-16) in adults meeting frequency criteria. 3

Modifying Factors That May Favor Surgery

Even when frequency criteria are not met, assess for modifying factors that may nonetheless favor tonsillectomy: 1, 2

• Multiple antibiotic allergies or intolerance 1, 2
• PFAPA syndrome (periodic fever, aphthous stomatitis, pharyngitis, and adenitis) 1, 2
• History of >1 peritonsillar abscess 1, 2

Note: Patients with a single peritonsillar abscess, personal or family history of rheumatic heart disease, Lemierre's syndrome, or severe infections requiring hospitalization are excluded from the watchful waiting recommendation and should be evaluated individually. 1

Evidence Quality and Clinical Outcomes

The 2019 guideline represents a strong recommendation for watchful waiting below thresholds (Grade A evidence from systematic reviews), reflecting high confidence that surgery should be avoided in these circumstances. 1, 2

When surgery is performed in patients meeting criteria: 3, 4

• Streptococcal pharyngitis recurrence at 90 days: 3% in tonsillectomy group vs. 24% in control group (21% absolute risk reduction) 3
• Any pharyngitis at 5 months: 39% in tonsillectomy group vs. 80% in control group 4
• Physician consultations for pharyngitis: 4% in tonsillectomy group vs. 43% in control group 4
• Significantly fewer days with throat pain and fever 3, 4

Expected morbidity: Postoperative throat pain averages 13 days (SD 4 days). 3

Practical Algorithm

1. Document all episodes with temperature, physical findings, and strep testing results 1
2. Count qualifying episodes over the specified time periods 1
3. If below thresholds: Strongly recommend watchful waiting with close monitoring 1, 2
4. If meeting thresholds: Tonsillectomy may be offered as an option after discussing modest benefits (limited to first year) and surgical risks 1
5. If modifying factors present: Consider surgery even below frequency thresholds 1, 2

Watchful waiting does not mean inaction—patients require regular clinic visits with accurate documentation of each pharyngotonsillitis episode, including symptoms, rapid antigen testing or culture results, and days of school/work absence. 1