Key Points
- Tonsillectomy is one of the most common surgical procedures in the United States, with 289,000 ambulatory procedures performed annually in children <15 years of age based on the most recent published data.
- Indications for surgery include recurrent throat infections and obstructive sleep-disordered breathing (oSDB), both of which can substantially impact child health status and quality of life (QoL).
- Although there are benefits of tonsillectomy, complications of surgery may include throat pain, postoperative nausea and vomiting, dehydration, delayed feeding, speech disorders such as velopharyngeal incompetence (VPI), bleeding, and rarely death.
Table 1. Definitions of Words Used in the Guideline
| Tonsillectomy | A surgical procedure performed with or without adenoidectomy that completely removes the tonsil, including its capsule, by dissecting the peritonsillar space between the tonsil capsule and the muscular wall. |
| Throat infection | Sore throat caused by viral or bacterial infection of the pharynx, palatine tonsils, or both, which may or may not be culture positive for group A streptococcus. This includes the terms strep throat, acute tonsillitis, pharyngitis, adenotonsillitis or tonsillopharyngitis. |
| Obstructive sleep-disordered breathing (oSDB) | Clinical diagnosis characterized by obstructive abnormalities of the respiratory pattern or the adequacy of oxygenation/ventilation during sleep, which include snoring, mouth breathing, and pauses in breathing. oSDB encompasses a spectrum of obstructive disorders that increases in severity from primary snoring to obstructive sleep apnea (OSA). Daytime symptoms associated with oSDB may include inattention, poor concentration, hyperactivity or excessive sleepiness. The term oSDB is used to distinguish oSDB from SDB that includes central apnea and/or abnormalities of ventilation (e.g. hypopnea associated hypoventilation). |
| Obstructive sleep apnea (OSA) | Diagnosed when oSDB is accompanied by an abnormal polysomnography (PSG) with an obstructive apnea-hyponea index (AHI) ≥1. It is a disorder of breathing during sleep characterized by prolonged partial upper airway obstruction and/or intermittent complete obstruction (obstructive apnea) that disrupts normal ventilation during sleep and normal sleep patterns. |
| Caregiver | Used throughout the document to refer to parents, guardians or other adults providing care to children under consideration for or undergoing tonsillectomy. |
Table 2. Summary of Key Action Statements (KAS)
| Statement | Action | Grade |
|---|---|---|
| Diagnosis | ||
| 1. Watchful waiting for recurrent throat infection | Clinicians should recommend watchful waiting for recurrent throat infection if:
| R-A-H |
| 2. Recurrent throat infection with documentation | Clinicians may recommend tonsillectomy for recurrent throat infection with a frequency of at least seven episodes in the past year, or at least five episodes per year for two years, or at least three episodes per year for three years with documentation in the medical record for each episode of sore throat and one or more of the following: temperature greater than 38.3°C (101.0°F), cervical adenopathy, tonsillar exudate, or positive test for group A beta-hemolytic streptococcus. | O-B-M |
| 3. Tonsillectomy for recurrent infection with modifying factors | Clinicians should assess the child with recurrent throat infection who does not meet criteria in KAS2 for modifying factors that may nonetheless favor tonsillectomy, which may include but are not limited to multiple antibiotic allergies/intolerance, PFAPA (periodic fever, aphthous stomatitis, pharyngitis and adenitis), or history of more than one peritonsillar abscess. | R-A-M |
| 4. Tonsillectomy for oSDB | Clinicians should ask caregivers of children with oSDB and tonsillar hypertrophy about co-morbid conditions that may improve after tonsillectomy, including growth retardation, poor school performance, enuresis, asthma, and behavioral problems. | R-B-M |
| 5. Indications for polysomnography (PSG) | Before performing tonsillectomy, the clinician should refer children with oSDB for PSG if they are under two years of age, or if they exhibit any of the following: obesity, Down syndrome, craniofacial abnormalities, neuromuscular disorders, sickle cell disease, or mucopolysaccharidoses. | R-B-H |
| 6. Additional recommendations for PSG | The clinician should advocate for PSG prior to tonsillectomy for oSDB in children without any of the comorbidities listed in KAS5 for whom the need for tonsillectomy is uncertain or when there is discordance between the physical examination and the reported severity of oSDB. | R-B-M |
| 7. Tonsillectomy for obstructive sleep apnea (OSA) | Clinicians should recommend tonsillectomy for children with OSA documented by overnight polysomnography. | R-B-M |
| 8. Education regarding persistent or recurrent oSDB | Clinicians should counsel patients and caregivers and explain that oSDB may persist or recur after tonsillectomy and may require further management. | R-B-H |
| 9. Perioperative pain counseling | The clinician should counsel patients and caregivers regarding the importance of managing post-tonsillectomy pain as part of the perioperative education process and should reinforce this counseling at the time of surgery with reminders about the need to anticipate, reassess, and adequately treat pain after surgery. | R-B-M |
| Treatment | ||
| 10. Perioperative antibiotics | Clinicians should NOT administer or prescribe perioperative antibiotics to children undergoing tonsillectomy. | S-A-H |
| 11. Intraoperative steroids | Clinicians should administer a single, intraoperative dose of intravenous dexamethasone to children undergoing tonsillectomy. | S-A-H |
| 12. Inpatient monitoring for children after tonsillectomy | Clinicians should arrange for overnight, inpatient monitoring of children after tonsillectomy if they are under age three years or have severe OSA (apnea-hypopnea index of ≥10 obstructive events/hour, oxygen saturation nadir <80%, or both). | R-B-M |
| 13. Postoperative ibuprofen and acetaminophen | Clinicians should recommend ibuprofen, acetaminophen, or both for pain control after tonsillectomy. | S-A-H |
| 14. Postoperative codeine | Clinicians must NOT administer or prescribe codeine, or any medication containing codeine, after tonsillectomy in children younger than 12 years. | S (against)-B-H |
| 15a. Outcome assessment for bleeding | Clinicians should follow-up with patients and/or caregivers after tonsillectomy and document in the medical record the presence or absence of bleeding within 24 hours of surgery (primary bleeding) and bleeding occurring later than 24 hours after surgery (secondary bleeding). | R-Ca |
| 15b. Post-tonsillectomy bleeding (PTB) rate | Clinicians should determine their rate of primary and secondary PTB at least annually. | R-Ca |
Treatment
Table 3. Paradise Criteria for Tonsillectomy
| Criterion | Definition |
|---|---|
| Minimum frequency of sore throat episodes |
|
| Clinical features (Sore throat plus the presence of one or more qualifies as a counting episode.) | Temperature greater than 38.3°C (>101°F), OR
|
| Treatment |
|
| Documentation |
|
Table 4. Role of PSG in assessing high-risk populations before tonsillectomy for oSDB
| Role of PSG | Rationale |
|---|---|
| Avoid unnecessary or ineffective surgery in children with primarily nonobstructive events |
|
| Confirm the presence of obstructive events that would benefit from surgery |
|
| Define the severity of oSDB to assist in preoperative planning |
|
| Provide a baseline PSG for comparison after surgery |
|
| Document the baseline severity of oSDB |
|
Table 5. Tonsillectomy and oSDB Caregiver Counseling Summary
| 1. Enlarged tonsils is the most common reason that children develop oSDB. |
| 2. oSDB is not solely due to enlarged tonsils; muscle tone also plays a role. |
| 3. Obesity plays a major role in oSDB. |
| 4. PSG is considered the best test to confirm that a child has OSA which would benefit from surgery. It also provides baseline information in case there are persistent symptoms after surgery. |
| 5. A PSG is not necessary in all cases and access may be limited by availability of sleep laboratories and willingness of insurers and third-party payers to cover the cost of testing. For an otherwise healthy child with a strong history of struggling to breathe with daytime symptoms and enlarged tonsils, a PSG is typically not performed unless the parents want to confirm the diagnosis. |
| 6. The success of tonsillectomy is variable. The age, weight, ethnicity, OSA severity, and associated medical conditions all affect the success. Younger, normal weight, non-African-American children may have a resolution of oSDB of 80%. |
| 7. For obese children, tonsillectomy produces complete resolution of oSDB <50% of the time. |
| 8. Caregivers need to be aware that their child may require additional interventions to cure his/her oSDB which can vary from weight loss, medications, or wearing a special mask while sleeping that will keep the airway open. Some children may be candidates for more advanced sleep surgery procedures. |
Figure 1. Subjective Tonsil Grading Scale
Figure 2. Tonsillectomy in Children CPG algorithm
