Cases in Tonsil Disease: From the Routine to the Serious

Gordon H. Sun, MD, MS


May 23, 2017


During the first half of the 20th century, tonsillectomy was the most common surgery in the United States. After a period of decline, the incidence of tonsillectomy rose over the past 35 years, primarily due to the increase of upper airway obstruction or sleep-disordered breathing (SDB) as the surgical indication.[19] Currently, tonsillectomy is second only to myringotomy and tube insertion in surgical case volume among US children.[20] In contrast, Bhattacharyya and Lin[21] found that the rate of adenotonsillectomy for infectious indications declined from 1996 to 2006 among US children.

The Paradise criteria[2,3] for tonsillectomy encompass frequency of sore throat episodes, clinical characteristics, treatment, and documentation. The patient must have had seven or more episodes in the preceding year, five or more episodes in each of the preceding 2 years, or three or more episodes in each of the preceding 3 years. Each episode of sore throat must be accompanied by at least one of the characteristics mentioned above.

Treatment should include antibiotics administered in routine doses for proven or suspected streptococcal episodes. Finally, all sore throat episodes must be verifiable in the patient's medical record; or, if not fully documented, the provider must have subsequently observed two episodes of throat infection meeting all other aforementioned criteria. The American Academy of Otolaryngology-Head and Neck Surgery Foundation (AAO-HNSF) clinical practice guideline on tonsillectomy in children recommends that clinicians assess patients not meeting the Paradise infection-based criteria for other modifying factors that may favor surgery, including a history of peritonsillar abscess or periodic fever, aphthous stomatitis, pharyngitis, and adenitis; recurrent and severe infections requiring hospitalization; family history of rheumatic heart disease; or multiple repeat infections within a single household.[20]

Two parallel randomized controlled trials[22] published in 2002 found that children with less severe and less thoroughly documented throat infections received only modest benefit from tonsillectomy that did not outweigh surgical morbidity and risks. A Cochrane review[23] in 2014 verified this finding in children (across four separate trials) but did not find enough evidence to draw firm conclusions in adults. Both the Cochrane review and a recent pediatric-only systematic review identified reductions in the number of episodes of sore throat in children in the first year after tonsillectomy, with the greatest benefit in severely affected patients.[1,23] Owing to study attrition, there are no reliable data about the clinical effectiveness of tonsillectomy beyond the first postoperative year in children and adults.


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