A 7-year-old child with six episodes of tonsillitis in the past year, snoring, mouth breathing during sleep, and grade III tonsillar hypertrophy—what is the most appropriate management?

Tonsillectomy is the Most Appropriate Management

This 7-year-old child should undergo tonsillectomy based on the presence of obstructive sleep-disordered breathing (oSDB) with grade 3 tonsillar hypertrophy, which serves as the primary surgical indication, with recurrent tonsillitis as a supporting modifying factor. 1, 2

Primary Indication: Obstructive Sleep-Disordered Breathing

The combination of snoring, mouth breathing during sleep, and grade 3 tonsils constitutes sufficient clinical evidence for surgical intervention without requiring polysomnography in this otherwise healthy 7-year-old child. 1, 2

The American Academy of Otolaryngology-Head and Neck Surgery recommends that clinicians ask caregivers about comorbid conditions that may improve after tonsillectomy, including growth retardation, poor school performance, enuresis, asthma, and behavioral problems. 1

When Polysomnography is NOT Required

For this patient, PSG is not mandatory before proceeding to surgery because the child does not have high-risk comorbidities. 1, 2

PSG should only be obtained if the patient has any of the following: 1

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

The clinical presentation of snoring, mouth breathing, and grade 3 tonsillar hypertrophy provides sufficient evidence for surgical decision-making. 2, 3

Secondary Supporting Indication: Recurrent Tonsillitis with Modifying Factors

While this child has 6 episodes of tonsillitis in the past year (one episode short of the Paradise criteria threshold of 7 episodes), the American Academy of Otolaryngology-Head and Neck Surgery recommends assessing children who do not meet strict Paradise criteria for modifying factors that may nonetheless favor tonsillectomy. 1

The presence of concurrent obstructive sleep-disordered breathing with tonsillar hypertrophy serves as a compelling modifying factor that supports surgical intervention. 2, 3

Critical Distinction: Watchful Waiting Does NOT Apply Here

Watchful waiting is strongly recommended ONLY when Paradise criteria are not met AND there are no obstructive symptoms. 1 This child has clear obstructive symptoms (snoring, mouth breathing, grade 3 tonsils), which eliminates watchful waiting as an appropriate option. 2

The strong recommendation for watchful waiting applies to recurrent throat infection with <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—but only in the absence of obstructive sleep-disordered breathing. 1

Why Other Options Are Incorrect

• Family Counseling (Option A): While preoperative counseling is essential, it is not the primary management—surgery is indicated. 1
• Stop Medication (Option B): There is no indication that medications are causing the problem; this is a structural issue requiring surgical intervention. 1
• Sleep Study (Option D): PSG is not required for this otherwise healthy child with clear clinical evidence of oSDB and tonsillar hypertrophy. 1, 2

Essential Preoperative Counseling Requirements

Before proceeding with surgery, families must understand: 1, 2

• Obstructive sleep-disordered breathing may persist or recur after tonsillectomy with an overall success rate for resolving OSA of approximately 79%. 2
• Younger, normal-weight children may have resolution rates of 80%, while obese children have complete resolution <50% of the time. 2
• Additional interventions may be needed including weight loss, medications, or CPAP if symptoms persist. 2
• Repeated sleep testing is recommended if symptoms persist postoperatively. 2

Perioperative Management

The American Academy of Otolaryngology-Head and Neck Surgery strongly recommends: 1

• Administer a single intraoperative dose of intravenous dexamethasone
• Do NOT administer or prescribe perioperative antibiotics
• Recommend ibuprofen, acetaminophen, or both for pain control after tonsillectomy

Common Pitfalls to Avoid

Do not delay surgery for "watchful waiting"—this approach is inappropriate when obstructive symptoms are present, regardless of whether Paradise criteria are fully met. 1, 2

Do not require PSG before proceeding—the clinical presentation provides sufficient evidence for surgical decision-making in this otherwise healthy child. 1, 2

Do not dismiss the recurrent tonsillitis as insignificant—while it falls one episode short of Paradise criteria, it serves as an important modifying factor when combined with oSDB. 2, 3