Overview
Tonsillectomy (with or without adenoidectomy) is one of the most common paediatric surgical procedures, performed for two principal indications: recurrent throat infection and sleep-disordered breathing / obstructive sleep apnoea (OSA). This reference summarises when surgery is and is not indicated, anchored to the AAO-HNS 2019 clinical practice guideline. The over-arching message of that guideline is restraint: most children with recurrent sore throat do better with watchful waiting than with surgery.
Recurrent throat infection — the Paradise criteria
The frequency threshold at which tonsillectomy may be considered (the Paradise criteria) is:
- ≥7 episodes in the past year, or
- ≥5 episodes per year over the past 2 years, or
- ≥3 episodes per year over the past 3 years.
Each episode must be documented in the medical record and accompanied by at least one of: temperature >38.3°C, cervical adenopathy, tonsillar exudate, or a positive test for group A beta-haemolytic streptococcus. Children who meet the frequency threshold but lack documentation of these features, or who fall below it, are unlikely to derive clinically meaningful benefit. AAO-HNS makes watchful waiting a strong recommendation for children who do not meet Paradise frequency criteria, and recommends at least 12 months of observation before surgery in children without modifying factors.
Modifying factors that may tip the decision toward earlier surgery despite not strictly meeting criteria include multiple antibiotic allergy/intolerance, PFAPA (periodic fever, aphthous stomatitis, pharyngitis, adenitis), or a history of peritonsillar abscess.
See the full criteria: Tonsillectomy
Obstructive sleep-disordered breathing
OSA is the other major indication and, in young children, the more common one. Clinicians should ask about snoring and obstructive symptoms in any child being considered for tonsillectomy. Where there is a discordance between examination (tonsil size) and reported severity, or in high-risk children (obesity, Down syndrome, craniofacial anomalies, neuromuscular disease, mucopolysaccharidoses, sickle-cell disease), polysomnography is recommended before surgery. Adenotonsillectomy is first-line for paediatric OSA caused by adenotonsillar hypertrophy and improves quality of life, behaviour, and polysomnographic indices.
Red flags
- Suspected OSA in a high-risk child — obtain polysomnography before surgery rather than operating on history alone.
- Asymmetric tonsillar enlargement, rapid unilateral growth, or systemic features — consider malignancy (lymphoma) and refer.
- Bleeding diathesis or family history of bleeding — screen before any tonsillectomy given post-tonsillectomy haemorrhage risk.
- Very young age (<3 years) or significant comorbidity — higher peri-operative respiratory risk; consider inpatient post-operative monitoring.
Management overview
When surgery is indicated, perioperative care emphasises multimodal analgesia avoiding routine codeine (contraindicated post-tonsillectomy in children) and a single intraoperative dose of a corticosteroid-class agent to reduce post-operative nausea and vomiting. Routine perioperative antibiotics are not recommended. Families should be counselled on the main early complication, post-tonsillectomy haemorrhage (primary <24 h, secondary typically days 5–10), and given clear return advice. Drug classes only are named here; dosing is outside the scope of this reference.
References
- Mitchell RB, et al. Otolaryngol Head Neck Surg. 2019;160(1_suppl):S1–S42 (AAO-HNS update).
- Paradise JL, et al. N Engl J Med. 1984;310:674–683 (original Paradise trial).
- Nelson Textbook of Pediatrics, 21st ed.
Decision support for qualified clinicians only — verify against current primary guidelines and your clinical judgement.