Tonsillectomy is the Most Appropriate Management
This patient meets clear indications for tonsillectomy based on obstructive sleep-disordered breathing (oSDB) with grade 3 tonsillar hypertrophy, making surgery the definitive treatment regardless of the recurrent tonsillitis history. 1, 2
Primary Surgical Indication: Obstructive Sleep-Disordered Breathing
The presence of snoring, mouth breathing during sleep, and grade 3 tonsils constitutes sufficient clinical evidence for surgical intervention without requiring polysomnography in an otherwise healthy child. 2, 3 The American Academy of Otolaryngology-Head and Neck Surgery guidelines explicitly recommend tonsillectomy for children with oSDB and tonsillar hypertrophy, particularly when accompanied by symptoms of airway obstruction. 1, 2
Grade 3 tonsils with clinical symptoms of airway obstruction provide sufficient justification for surgery without mandatory sleep study. 2, 3 Polysomnography is only required if the patient has high-risk comorbidities including age <2 years, obesity, Down syndrome, craniofacial abnormalities, neuromuscular disorders, sickle cell disease, or mucopolysaccharidoses—none of which are mentioned in this case. 2
Secondary Supporting Factor: Recurrent Tonsillitis
While the patient has 6 episodes of tonsillitis in the past year (one episode short of the strict Paradise criteria of ≥7 episodes/year), this serves as an additional modifying factor that supports the surgical decision. 1, 4 The guidelines recommend assessing children who don't fully meet Paradise criteria for modifying factors that may favor tonsillectomy, and concurrent oSDB with tonsillar hypertrophy qualifies as such a factor. 2, 3
Watchful waiting is NOT appropriate in this case because the patient has clear obstructive symptoms—watchful waiting only applies when Paradise criteria are not met AND there are no obstructive symptoms. 2, 4
Why Other Options Are Incorrect
Family Counseling (Option A): While preoperative counseling is essential, it is not the primary management—surgery is indicated first, with counseling as an adjunct. 2, 3
Stop Medication (Option B): There is no indication that medications are causing the problem; this is a structural issue requiring surgical intervention. 1, 2
Sleep Study (Option D): PSG is not required before proceeding with surgery in this otherwise healthy child with clear clinical evidence of oSDB and tonsillar hypertrophy. 2, 3 Requiring unnecessary testing would delay appropriate treatment.
Essential Preoperative Counseling Points
Families must understand that oSDB may persist or recur after tonsillectomy in approximately 21% of cases, with overall success rates around 79%. 2, 3 Success rates vary based on age, weight, and ethnicity—younger, normal-weight children may have resolution rates of 80%, while obese children have complete resolution <50% of the time. 2 Additional interventions including weight management, medications, or CPAP may be needed if symptoms persist postoperatively. 2, 3
Perioperative Management
Administer a single intraoperative dose of intravenous dexamethasone. 1, 3 Do NOT routinely prescribe perioperative antibiotics unless a specific indication exists. 1, 3