What are the standard indications for adenotonsillectomy in pediatric patients?

Standard Indications for Adenotonsillectomy in Pediatric Patients

Adenotonsillectomy in children is indicated for two primary conditions: obstructive sleep-disordered breathing with tonsillar hypertrophy, and recurrent throat infections meeting specific frequency criteria with documented clinical features. 1, 2

Primary Indication: Obstructive Sleep-Disordered Breathing (oSDB)

Adenotonsillectomy is recommended for children with obstructive sleep apnea (OSA) documented by polysomnography and tonsillar hypertrophy. 1, 2

Clinical Assessment Requirements

• Clinicians should assess for symptoms including snoring, mouth breathing, witnessed apneas, gasping during sleep, and daytime manifestations such as excessive sleepiness, inattention, poor concentration, or hyperactivity 1
• Evaluate for comorbid conditions that may improve after surgery: growth retardation, poor school performance, enuresis, asthma, and behavioral problems 1, 2
• The presence of adenotonsillar hypertrophy on physical examination supports the indication 1, 3

Polysomnography Requirements

Polysomnography is mandatory before tonsillectomy in specific high-risk populations: 1, 2

• Children younger than 2 years of age
• Obesity
• Down syndrome
• Craniofacial abnormalities
• Neuromuscular disorders
• Sickle cell disease
• Mucopolysaccharidoses

Polysomnography should also be advocated when: 1

• The need for surgery is uncertain despite clinical findings
• Discordance exists between physical examination and reported severity of oSDB

Evidence Base and Outcomes

The CHAT trial (largest and highest quality study) demonstrated that in children aged 5-9 years with mild to moderate OSA, adenotonsillectomy resulted in significant improvements at 7 months compared to watchful waiting: OSA-18 scores improved by 17.7 points, and 79% achieved normalization of polysomnography parameters versus 46% with observation alone 4. However, nearly half of children managed non-surgically showed spontaneous resolution, indicating careful consideration is warranted 4.

Important caveat: Obstructive sleep-disordered breathing may persist or recur after adenotonsillectomy in a clinically relevant proportion of children, with complete resolution reported as low as 25% in some studies with severe OSA 1. Families must be counseled about potential need for further management and follow-up sleep testing if symptoms persist 1, 3.

Secondary Indication: Recurrent Throat Infections

Strict Frequency Criteria (Paradise Criteria)

Adenotonsillectomy may be recommended when recurrent throat infections meet ALL of the following: 1, 2

• Frequency threshold: At least 7 episodes in the past year, OR at least 5 episodes per year for 2 years, OR at least 3 episodes per year for 3 years
• Documentation requirement: Each episode must be documented in the medical record with sore throat PLUS at least one of:
  • Temperature ≥38.3°C (101°F)
  • Cervical adenopathy
  • Tonsillar exudate
  • Positive test for group A beta-hemolytic streptococcus

Watchful Waiting

Watchful waiting is strongly recommended when frequency criteria are NOT met (fewer than 7 episodes in past year, fewer than 5 per year for 2 years, or fewer than 3 per year for 3 years) 1, 2. This reflects the favorable natural history of recurrent throat infections in most children 1.

Modifying Factors

Adenotonsillectomy should be considered even without meeting strict frequency criteria when modifying factors are present: 1, 2

• Multiple antibiotic allergies or intolerance
• PFAPA syndrome (periodic fever, aphthous stomatitis, pharyngitis, and adenitis)
• History of more than one peritonsillar abscess
• Concurrent obstructive sleep-disordered breathing with tonsillar hypertrophy 3

Populations Excluded from Standard Guidelines

The guideline recommendations do not apply to children with: 1

• Neuromuscular disease
• Diabetes mellitus
• Chronic cardiopulmonary disease
• Congenital anomalies of the head and neck
• Coagulopathies
• Immunodeficiency

Additional Considerations

Adenotonsillectomy is strongly indicated but outside standard guideline scope for: 1

• Posttransplant lymphoproliferative disorders
• Suspected malignancy

Limited evidence exists for adenotonsillectomy in: 1

• Orthodontic concerns
• Dysphagia or dysphonia
• Secondary enuresis
• Tonsilloliths or halitosis
• Chronic tonsillitis without meeting recurrent infection criteria

These indications require shared decision-making between clinician and family 1.

Critical Perioperative Management

A single intraoperative dose of intravenous dexamethasone should be administered to all children undergoing tonsillectomy 1, 2

Perioperative antibiotics should NOT be routinely administered or prescribed 1, 2

Overnight inpatient monitoring is recommended for: 2

• Children younger than 3 years of age
• Severe OSA on polysomnography