Tonsillectomy in Children

Guideline developed by the American Academy of Otolaryngology-Head and Neck Surgery and endorsed by the American Academy of Family Physicians.

Recommendations

• Watchful waiting for recurrent throat infection is strongly recommended if there have been < 7 episodes in past year, < 5 episodes per year in past two years, or < 3 episodes per year in past three years.

• Tonsillectomy may be considered for recurrent throat infection with a frequency of:
  • 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 with documentation in the medical record for each episode of sore throat and 1 or more of the following:
    • temperature >38.3°C,
    • cervical adenopathy,
    • tonsillar exudate, or
    • positive test for group A beta-hemolytic streptococcus

• The child with recurrent throat infection who does not meet the criteria above should be assessed for modifying factors that may nonetheless favor tonsillectomy, such as multiple antibiotic allergy/intolerance, PFAPA (periodic fever, aphthous stomatitis, pharyngitis and adenitis), or history of > 1 peritonsillar abscess.

• Caregivers of children with obstructive sleep-disordered breathing and tonsil hypertrophy should be asked about comorbid conditions that might improve after tonsillectomy, including growth retardation, poor school performance, enuresis, asthma, and behavioral problems.

• Caregivers should be counseled about tonsillectomy as a means to improve health in children with abnormal polysomnography who also have tonsil hypertrophy and obstructive sleep-disordered breathing.

• Caregivers should be counseled that sleep-disordered breathing may persist or recur after tonsillectomy and may require further management.

• Perioperative antibiotics should not be administered or prescribed for children undergoing tonsillectomy.

• Caregivers should be educated about the importance of managing and reassessing pain after tonsillectomy.

• Postoperative pain should be managed with ibuprofen and/or acetaminophen.  Codeine should not be administered or prescribed for children under the age of 12.

References

Tonsillectomy: Clinical Practice Guideline. AAFP. Available at https://www.aafp.org/family-physician/patient-care/clinical-recommendations/all-clinical-recommendations/tonsil.html.

Mitchell, Ron B et al. “Clinical Practice Guideline: Tonsillectomy in Children (Update).”  Otolaryngology–Head and Neck Surgery 2019, Vol. 160(1S) S1–S42. DOI:10.1177/0194599818801757. http://otojournal.org.