Tonsillectomy and/or adenoidectomy in children: Overview of indications and contraindications

INTRODUCTION — 

Tonsillectomy and adenoidectomy are among the most common surgical procedures performed in children. Adenotonsillectomy is often thought of, and most often carried out, as a single, combined operation; however, in assessing indications for surgery, the two components require consideration individually. The two major categories of indications for tonsillectomy and/or adenoidectomy include airway obstruction and recurrent infection.

The indications and contraindications for tonsillectomy and adenoidectomy are reviewed here. Preoperative and postoperative care, complications of adenotonsillectomy, and the conditions for which these procedures may be indicated are discussed in greater detail separately:

●(See "Tonsillectomy and/or adenoidectomy in children: Preoperative evaluation and care".)

●(See "Tonsillectomy (with or without adenoidectomy) in children: Postoperative care and complications".)

●(See "Adenoidectomy in children: Postoperative care and complications".)

●(See "Adenotonsillectomy for obstructive sleep apnea in children".)

●(See "Treatment and prevention of streptococcal pharyngitis in adults and children".)

EPIDEMIOLOGY — 

Tonsillectomy (with or without adenoidectomy) is among the most commonly performed operations in childhood, though its frequency has declined somewhat since the 1970s [1-3]. There is some variability in rates of tonsillectomy and adenotonsillectomy from country to country and region to region [4-6]. Differences in practice regarding management of recurrent tonsillitis, obstructive sleep apnea, and other upper airway conditions among general practitioners, pediatricians, and otolaryngologists may account for some of the variability. Cultural differences and patient/family factors and preferences may also play a role [7].

In the United States, it is estimated that approximately 400,000 to 600,000 tonsillectomies/adenotonsillectomies are performed annually in children (approximately 5 to 8 tonsillectomies/adenotonsillectomies per 1000 children per year) [1,8-10].

Surgical indications for tonsillectomy have shifted since the 1970s and 1980s, with a decrease in the number of tonsillectomies performed for infectious indications (eg, recurrent tonsillitis) and an increase in the number of adenotonsillectomies performed for upper airway obstruction [3,9,11].

The great majority of tonsil and adenoid operations are performed as ambulatory, same-day procedures [1,8,9].

The relative frequency of tonsillectomy, adenoidectomy, and adenotonsillectomy varies somewhat according to age and sex. Tonsillectomy alone is performed infrequently in children <3 years old, whereas adenoidectomy alone is performed infrequently in individuals >14 years old. Adenoidectomy is performed approximately 1.5 times more frequently in males compared with females, whereas the frequency of tonsillectomy is approximately one-third higher in females compared with males [7,8].

INDIVIDUALIZED SHARED DECISION-MAKING — 

Most tonsil-related problems in children tend to decline naturally as the child grows, although not predictably. Decisions regarding elective tonsillectomy and/or adenoidectomy in children should be individualized. Factors to consider include:

●Potential benefits and risks of surgery in comparison with appropriate alternative strategies (eg, watchful waiting, antibiotic therapy)

●Severity of the primary problem (eg, frequency and severity of recurrent tonsillitis episodes, severity of obstructive symptoms)

●Natural course of the primary condition

●Values and preferences of the family/caregivers and child (eg, anxieties, tolerance of illness, willingness to undergo an invasive procedure)

●Child's school performance in relation to illness-related absence

●Accessibility of health care services

●Availability of high-quality surgical and anesthesia services and facilities

●Out-of-pocket costs

In a child who lacks an unequivocal indications for surgery, modifying factors (eg, multiple antibiotic allergy/intolerance) or comorbid conditions (eg, poor school performance) may tip the balance in favor of tonsillectomy [12].

The criteria for surgical intervention described in the following sections may be relaxed in certain circumstances, particularly with regard to combined surgical procedures. For example, in a child who requires adenoidectomy for an unequivocal indication, it would seem reasonable to add tonsillectomy if the tonsils also have been problematic to some degree, even if they do not meet strict criteria for tonsillectomy. By the same token, in a child scheduled for tonsillectomy for an unequivocal indication, it would seem reasonable to add adenoidectomy if the child has had more than occasional bouts of otitis media but had not undergone tympanostomy tube (TT) insertion.

INDICATIONS — 

The two major categories of indications for tonsillectomy and/or adenoidectomy are obstruction and infection [12]:

●Airway obstruction – Obstruction may involve the nasopharyngeal airway, oropharyngeal airway, and the oropharyngeal deglutitory (swallowing) pathway. (See 'Obstructive sleep apnea' below and 'Nasal obstruction' below and "Adenotonsillectomy for obstructive sleep apnea in children".)

●Infection – Recurrent or chronic infection may involve the tonsils, adenoids, peritonsillar tissues, pharynx, mastoid air cells, paranasal sinuses, middle ear, or cervical lymph nodes. (See 'Recurrent tonsillitis/pharyngitis' below and 'Peritonsillar abscess' below and 'Refractory chronic sinusitis' below and 'Recurrent or chronic otitis media' below and 'PFAPA syndrome' below.)

Obstructive sleep apnea (OSA) and recurrent tonsillitis/pharyngitis are by far the most common indications for adenotonsillectomy in children.

Tonsillectomy (with or without adenoidectomy)

Obstructive sleep apnea — OSA is a common pediatric problem. If untreated, OSA can lead to a wide range of cardiovascular, cognitive, behavioral, and emotional complications. (See "Cardiovascular consequences of obstructive sleep apnea in children" and "Cognitive and behavioral consequences of sleep disorders in children".)

Adenotonsillectomy is a first-line treatment for OSA, as discussed separately. (See "Management of obstructive sleep apnea in children", section on 'Choice of therapy' and "Adenotonsillectomy for obstructive sleep apnea in children".)

Recurrent tonsillitis/pharyngitis — The benefits of tonsillectomy (with or without adenoidectomy) in patients with recurrent tonsillitis or tonsillopharyngitis depend on the frequency and severity of previous episodes [13-16]. (See 'Severely affected children' below and 'Mildly or moderately affected children' below.)

Severely affected children

●Definition of "severely affected" (the Paradise criteria) – We consider children to be severely affected if they have ≥7 episodes of tonsillopharyngitis in one year, ≥5 episodes in each of two consecutive years, or ≥3 episodes in each of three consecutive years. These criteria are commonly referred to as the "Paradise criteria" (in reference to the clinician researcher who conducted the landmark trials in the 1980s) [13]. In determining whether the child meets the Paradise criteria, we consider only episodes that are documented in the child's medical record. A history of recurrent throat infections not requiring medical attention should not serve as the basis for performing tonsillectomy [17].

●Choosing between surgery or nonsurgical management – For children who meet the Paradise criteria, we suggest offering tonsillectomy (with or without adenoidectomy).

However, given the natural decline in tonsil-related problems with increasing age, another reasonable option is watchful waiting and the provision of symptomatic care and antibiotic treatment (if indicated) for recurrent episodes. The decision should be individualized after weighing the risks and benefits as well as the values and preferences of the family/caregivers and child (see 'Individualized shared decision-making' above). Symptomatic care and antibiotic therapy for tonsillopharyngitis are discussed separately. (See "Treatment and prevention of streptococcal pharyngitis in adults and children".)

Both options were incorporated in guidelines from the AAO-HNS and the Scottish Intercollegiate Guidelines Network [12,18]. (See 'Society guideline links' below.)

●Efficacy – The efficacy of tonsillectomy in severely affected children was demonstrated in two parallel trials (one randomized and one nonrandomized) [13]. Enrolled children met all of the following criteria:

•≥3 episodes of tonsillopharyngitis in each of three years, ≥5 episodes in each of two years, or ≥7 episodes in one year

•Each qualifying episode characterized by at least one of the following:

-Oral temperature ≥101°F (38.3°C)

-Enlarged (>2 cm) or tender anterior cervical lymph nodes

-Tonsillar exudate

-Positive culture for group A Streptococcus (GAS)

•Appropriate antibiotic therapy administered if GAS was identified

Tonsillectomy (with or without adenoidectomy) reduced the overall number and severity of subsequent episodes of throat infection in children who met these criteria. In the first year of follow-up, the mean number of moderate or severe episodes in the tonsillectomy group was 0.08 (3 episodes among 38 children) compared with 1.17 in the control group (41 episodes among 35 children); a similar benefit was seen in the second follow-up year. Third-year differences, although in most cases not statistically significant, also consistently favored the surgical groups.

However, in each follow-up year, many subjects in the nonsurgical groups had <3 episodes of tonsillopharyngitis, and most episodes were mild.

These findings provide support both for surgical and for nonsurgical management of children with recurrent tonsillitis who are severely affected. Treatment decisions for such children should be individualized, taking into account the potential risks of surgery, the values and preferences of the family/caregivers, and other factors described above. (See 'Individualized shared decision-making' above.)

●Potential complications – The potential complications associated with either surgery or medical therapy are discussed separately. (See "Tonsillectomy (with or without adenoidectomy) in children: Postoperative care and complications", section on 'Complications' and "Treatment and prevention of streptococcal pharyngitis in adults and children", section on 'Antibiotic treatment'.)

Mildly or moderately affected children — We suggest not performing tonsillectomy in children who are mildly or moderately affected (ie, recurrent episodes that are less frequent or less severe than the Paradise criteria described above) [14]. For mildly or moderately affected children, the benefits of surgery are modest and outweighed by the potential risks.

However, tonsillectomy is a reasonable option in children with recurrent GAS pharyngitis complicated by one or more of the following:

●Multiple antibiotic allergy/intolerance.

●Peritonsillar abscess (PTA). (See 'Peritonsillar abscess' below.)

●A history of rheumatic heart disease or close contact with a person with a history of rheumatic heart disease. Support for this indication is found in a retrospective cohort study of 290 closely matched children with ≥3 documented episodes of GAS pharyngitis during the preceding year [19]. Compared with children who underwent tonsillectomy, those who did not were 3.1 times more likely to develop subsequent episodes of GAS pharyngitis over a mean follow-up of four years. (See 'Other conditions' below and "Acute rheumatic fever: Treatment and prevention", section on 'Secondary prevention (antibiotic prophylaxis)'.)

For most mildly or moderately affected children, episodes of recurrent infection can be treated with symptomatic care and antibiotic treatment (if indicated). (See "Treatment and prevention of streptococcal pharyngitis in adults and children" and "Acute pharyngitis in children and adolescents: Symptomatic treatment", section on 'General management'.)

In a clinical trial of 328 children with recurrent tonsillopharyngitis of moderate severity who were randomly assigned to surgery (tonsillectomy or adenotonsillectomy) or nonsurgical management, the mean number of recurrent episodes during the first year was modestly lower in the surgical group (0.14 versus 0.35) [14]. However, during three years of follow-up, approximately 70 to 85 percent of patients in the nonsurgical group had no moderate or severe episodes.

Subsequent clinical trials and observational studies in mildly and moderately affected children found that compared with watchful waiting, tonsillectomy modestly reduces the number of throat infections, sore throat days, school absences, and clinic visits in the short term (ie, <12 months); however, there was little to no difference in these outcomes or in quality of life in the longer term (ie, two to three years) [20].

Given the modest benefits seen in these studies and the inherent risks and costs of surgery, tonsillectomy is not warranted in most patients with mild to moderate recurrent tonsillopharyngitis. This conclusion is reflected in the 2019 AAO-HNS guidelines [12]. (See 'Society guideline links' below.)

PFAPA syndrome — Tonsillectomy is a treatment option in children with the syndrome of periodic fever, aphthous stomatitis, pharyngitis, and cervical adenitis (PFAPA) who have not responded to conservative treatment. Controversy exists regarding this practice because PFAPA is a benign and self-limited disease and tonsillectomy has attendant risks. Tonsillectomy for PFAPA syndrome is discussed in greater detail separately. (See "Periodic fever with aphthous stomatitis, pharyngitis, and adenitis (PFAPA syndrome)", section on 'Tonsillectomy'.)

Peritonsillar abscess — Drainage, antimicrobial therapy, and supportive care are the cornerstones of management for PTA. Tonsillectomy may be warranted in patients with PTA who have significant upper airway obstruction or previous episodes of recurrent pharyngitis or PTA. Tonsillectomy for PTA is discussed in greater detail separately. (See "Peritonsillar cellulitis and abscess", section on 'Tonsillectomy'.)

Other conditions — Tonsillectomy (with or without adenoidectomy) is sometimes performed in the following conditions, although the supporting evidence is limited or lacking for many of these indications [12,21]:

●Tonsillar obstruction of the oropharynx that interferes with swallowing or voice quality [22].

●Tonsillar obstruction that alters voice quality.

●Uncontrollable hemorrhage from tonsillar blood vessels.

●Halitosis refractory to other measures. (See "Bad breath".)

●Chronic tonsillitis unresponsive to antimicrobial treatment. This condition is distinct from recurrent episodes of acute tonsillitis discussed above (see 'Recurrent tonsillitis/pharyngitis' above). Chronic tonsillitis is uncommon in adolescents and adults, and it is very rare in young children.

●Chronic pharyngeal carriage of GAS in a child who has had rheumatic heart disease or is in close contact with a person who has had rheumatic heart disease, who has had at least two well-documented episodes of GAS pharyngitis within the preceding year, and in whom treatment with appropriate antibiotics has not been successful in eradicating GAS carriage [23].

We do not endorse performing tonsillectomy to treat pediatric autoimmune neuropsychiatric disorder associated with GAS (PANDAS; also called pediatric acute-onset neuropsychiatric syndrome [PANS] or childhood acute neuropsychiatric symptoms [CANS]). This is consistent with a clinical report from the American Academy of Pediatrics [24]. (See "PANDAS: Pediatric autoimmune neuropsychiatric disorder associated with group A streptococci", section on 'Tonsillectomy'.)

Adenoidectomy — The principal manifestation of adenoidal hypertrophy is nasal obstruction. Other clinical conditions, such as rhinosinusitis, Eustachian tube dysfunction, and otitis media, also may be triggered or complicated by adenoidal disease (hypertrophy and/or infection).

Decisions regarding elective adenoidectomy should be individualized according to the potential benefits and risks as well as the values and preferences of the family and child. (See 'Individualized shared decision-making' above and "Adenoidectomy in children: Postoperative care and complications".)

Nasal obstruction — Nasal obstruction due to adenoidal hypertrophy has a number of clinical effects, including mouth breathing, hyponasal speech, and impaired olfaction [25]. Nasal obstruction caused by large adenoids must be distinguished from obstruction caused by other conditions, such as allergic or infectious rhinitis or structural nasal disorders. (See "Taste and olfactory disorders in adults: Anatomy and etiology", section on 'Olfactory dysfunction' and "Etiologies of nasal obstruction: An overview" and "An overview of rhinitis".)

Severe obstructive symptoms — Severe obstruction due to adenoidal hypertrophy is an absolute indication for surgery. Adenotonsillectomy is preferred over adenoidectomy alone in this setting. (See 'Obstructive sleep apnea' above and "Adenotonsillectomy for obstructive sleep apnea in children".)

Moderate obstructive symptoms — We suggest adenoidectomy for children with moderate nasal obstruction caused by adenoidal hypertrophy, whose obstructive symptoms (mouth breathing, hyponasal speech, impaired olfaction) have been present for ≥1 year and have not responded to conservative measures. Conservative measures include trial courses of antimicrobial treatment for one month [26] and of nasal glucocorticoids for six weeks (continued for up to six months if prompt initial improvement is realized) [27-31]. Occasionally, a favorable response to these measures may obviate the need for surgery. (See "Speech and language impairment in children: Etiology", section on 'Resonance disorders'.)

The efficacy of adenoidectomy in children with moderate nasal obstructive symptoms is supported by observational studies and indirect evidence from clinical trials in children with more severe obstruction (ie, OSA) [25,32]. (See "Adenotonsillectomy for obstructive sleep apnea in children", section on 'Success rates'.)

In a retrospective study, the parents of children aged 2 to 17 years (mean 6.5 years) who underwent adenoidectomy for adenoidal obstruction responded to a questionnaire three to five years after the procedure [32]. The improvement rate for individual symptoms ranged from 74 to 87 percent. In a few cases, failure to improve was attributable to regrowth of adenoid tissue, but, in most cases, failure to improve was attributed to nasal mucosal or structural abnormality. (See "Etiologies of nasal obstruction: An overview".)

Adenoid facies — There is a correlation between nasal airway obstruction and "adenoid facies" (eg, long and narrow face, low tongue placement, narrow upper jaw, steep mandible, open anterior bite) (figure 1). Studies are conflicting as to whether adenoidectomy prevents or ameliorates this process [33]. The available data are limited to small observational studies, many of which lacked a control group. (See "Oral habits and orofacial development in children", section on 'Chronic mouth-breathing'.)

Observational studies have described improvement in dentofacial measurements, dental arch morphology, and dental position following adenoidectomy [34-36]. However, these studies failed to include control subjects who did not undergo adenoidectomy.

Nonetheless, adenoidectomy may provide orthodontic benefit to children who have clear evidence of adenoidal obstruction. In the earlier-issued (2000) guidelines from the AAO-HNS, hypertrophy causing dental malocclusion or adversely affecting orofacial growth was included among the indications for tonsil or adenoid surgery [21]. The 2019 guidelines do not provide specific guidance on this issue, as they address indications for tonsillectomy but not for adenoidectomy alone [12]. (See 'Society guideline links' below.)

Refractory chronic sinusitis — Adenoidectomy is a reasonable option for children with chronic sinusitis that is refractory to medical therapy, and in whom endoscopic sinus surgery is being considered [37-39]. Such patients should also be evaluated for underlying contributing conditions (eg, allergy, ciliary dysmotility syndromes, cystic fibrosis, immunodeficiency) before considering surgical intervention of any type [40,41]. (See "Chronic rhinosinusitis: Clinical manifestations, pathophysiology, and diagnosis", section on 'Evaluation' and "Chronic rhinosinusitis without nasal polyposis: Management and prognosis", section on 'Surgical interventions in children'.)

Observational studies suggest that adenoidectomy may improve symptoms and quality of life in patients with refractory chronic sinusitis [37,42-47]. For example, in a prospective study of 60 children (ages 4 to 13 years) who underwent adenoidectomy for refractory chronic sinusitis, 88 percent had improvement in nasal symptom-related quality of life scores following surgery [47].

Clinical trials evaluating adenoidectomy for refractory chronic sinusitis are lacking. Nevertheless, the practice of performing adenoidectomy for this indication is endorsed by a 2014 consensus statement on pediatric chronic rhinosinusitis developed by an expert panel [48]. In addition, in its list of clinical indicators for adenoidectomy, the AAO-HNS endorses adenoidectomy for children <12 years of age with ≥4 episodes of recurrent purulent rhinorrhea within a 12-month period (at least one episode should be documented by intranasal examination or diagnostic imaging) [49]. (See 'Society guideline links' below.)

Recurrent or chronic otitis media — For children with recurrent acute otitis media (AOM) or chronic otitis media with effusion (OME) who have previously undergone TT insertion, whose tubes have been extruded, and who subsequently develop recurrent AOM or chronic OME to a degree that they are undergoing repeat TT placement, we suggest adenoidectomy in addition to TT placement rather than TT placement alone. We do not suggest adenoidectomy for children with recurrent AOM or chronic OME who have not undergone TT insertion unless they have an additional distinct indication for adenoidectomy (eg, nasal obstruction, chronic sinusitis). Although adenoidectomy may be helpful in the resolution of middle-ear effusion, the additional surgical and anesthetic risks outweigh the benefits [50-53]. (See "Acute otitis media in children: Prevention of recurrence", section on 'Adenoidectomy or adenotonsillectomy' and "Otitis media with effusion (serous otitis media) in children: Management", section on 'Adenoidectomy'.)

The cumulative evidence from randomized controlled trials evaluating the effectiveness of adenoidectomy or adenotonsillectomy in children with recurrent AOM or chronic OME suggests that adenoidectomy offers a measure of benefit to at least some of these children [52,54-57].

In a randomized controlled trial involving 213 children who underwent TT insertion and subsequently developed recurrent AOM or OME after extrusion of the tubes, children randomized to adenoidectomy had substantially less time with otitis media and substantially fewer episodes of AOM over the succeeding two-year period than did children in the control group [55]. Importantly, most of the children studied were ≥3 years old. For such children, we suggest that the decision for or against adenoidectomy be made on a case-by-case basis, after considering the risks and benefits as well as the values and preferences of the family/caregivers and child. (See 'Individualized shared decision-making' above and "Tonsillectomy (with or without adenoidectomy) in children: Postoperative care and complications".)

In children with recurrent AOM or chronic OME who have not undergone TT insertion, the efficacy of adenoidectomy or adenotonsillectomy is, at best, limited and of short duration [54,57-59]. If surgery is deemed necessary in such children, TT insertion is the most appropriate initial surgical procedure [54,60]. (See "Overview of tympanostomy tube placement, postoperative care, and complications in children".)

CONTRAINDICATIONS — 

There are three general categories of contraindications to tonsillectomy and/or adenoidectomy: velopharyngeal, hematologic, and infectious.

Cleft palate and other conditions predisposing to velopharyngeal insufficiency — Certain anatomic or functional abnormalities of the palate and pharynx can predispose to velopharyngeal insufficiency and therefore are considered contraindications to adenoidectomy. (See "Adenoidectomy in children: Postoperative care and complications", section on 'Velopharyngeal insufficiency'.).

These abnormalities include:

●Overt cleft of the palate

●Submucous (covert) cleft of the palate

●Short palate

●Unusually capacious pharynx

●Bifid uvula

●Neurologic or neuromuscular abnormalities associated with impaired palatal function

These abnormalities usually can be identified by careful inspection of the palate and evaluation for symptoms of hypernasality. Hypernasality results from the inability to seal the soft palate against the posterior pharyngeal wall (figure 2) and is demonstrated by air escape when the child says words or phrases that contain plosive consonants, especially "b" and "p" (eg, "puppy" or "Bobby"), or sibilant fricatives such as "s," "z," or "sh" (eg, "sister Suzie sells shells") (movie 1) [61]. By contrast, hyponasality can be approximated by saying words or phrases containing the nasal consonants "m" and "n" (eg, "my name means money") with the nostrils alternately open and pinched closed (movie 2) [25].

Hypernasal speech may markedly worsen if adenoidectomy is undertaken in children mistakenly thought to have hyponasality since the adenoids help fill the relative velopharyngeal void and facilitate normal speech sound production. (See "Speech and language impairment in children: Etiology", section on 'Resonance disorders'.)

Examination of the oropharynx for submucous cleft should be performed in all children for whom adenoidectomy is being considered, whether or not hypernasality is present. Submucous cleft of the palate should be suspected when a bifid uvula or widening and attenuation of the median raphe of the soft palate is observed. On examination, palpation of a V-shaped midline notch (rather than the normal rounded curve) along the junction of the hard and soft palates strongly suggests the presence of a submucous cleft (figure 3).

Referral to an individual or a team skilled in cleft palate evaluation and management is warranted if submucous cleft of the palate is detected and/or if hypernasality related to velopharyngeal insufficiency is suspected, even if the oropharyngeal examination is normal.

Bleeding disorders and anemia — Bleeding disorders and moderate or severe anemia (ie, hemoglobin concentration <9 or 10 g/dL) are relative contraindications to tonsil and adenoid surgery. For children with acute anemia due to a treatable cause (eg, iron deficiency), the anemia should be treated before undergoing surgery. For children with chronic anemia (eg, sickle cell anemia) and those with known or suspected bleeding disorders (eg, von Willebrand disease, hemophilia), surgical decisions should be made in consultation with a pediatric hematologist. (See "Sickle cell disease: Overview of management during hospital admission", section on 'Surgical considerations' and "Red blood cell transfusion in sickle cell disease: Indications, RBC matching, and modifications", section on 'Prophylactic preoperative transfusion' and "von Willebrand disease (VWD): Treatment of major bleeding and major surgery" and "Acute treatment of bleeding and surgery in hemophilia A and B".)

In otherwise healthy children, it is not routinely necessary to perform a hematologic evaluation prior to performing tonsillectomy and/or adenoidectomy unless there is a personal or family history of significant bleeding problems. This is discussed in detail separately. (See "Tonsillectomy and/or adenoidectomy in children: Preoperative evaluation and care", section on 'Hematologic evaluation'.)

Acute upper respiratory infections — Elective tonsillectomy and/or adenoidectomy should not be undertaken in children with active infections of the upper respiratory tract (ie, tonsillitis, pharyngitis, common cold). Rare exceptions include a child who requires surgery urgently due to severe airway obstruction or a child with chronic tonsillitis persisting despite prolonged appropriate antimicrobial treatment.

In most cases when the child has an acute infection at the time of preoperative screening or on the day of surgery, we suggest postponing surgery until at least two to four weeks after symptoms subside. This interval allows for general recuperation and it may reduce the risk of anesthesia-related complications and/or hemorrhage. These issues are discussed in greater detail separately. (See "Anesthesia for the child with a recent upper respiratory infection", section on 'Timing of elective procedures' and "Tonsillectomy (with or without adenoidectomy) in children: Postoperative care and complications", section on 'Hemorrhage'.)

SOCIETY GUIDELINE LINKS — 

Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Streptococcal tonsillopharyngitis" and "Society guideline links: Sleep-related breathing disorders including obstructive sleep apnea in children" and "Society guideline links: Tonsillectomy and adenoidectomy in children".)

INFORMATION FOR PATIENTS — 

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Here are the patient education articles that are relevant to this topic. We encourage you to print or email these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword[s] of interest.)

●Basics topic (see "Patient education: Tonsillectomy and adenoidectomy in children (The Basics)")

SUMMARY AND RECOMMENDATIONS

●Individualized shared decision-making – Decisions regarding elective tonsillectomy and/or adenoidectomy should be individualized according to the potential benefits and risks, the natural course of the disease, and the values and preferences of the family/caregivers and child. (See 'Individualized shared decision-making' above.)

●Potential indications for tonsillectomy (with or without adenoidectomy)

•Obstructive sleep apnea (OSA) – Adenotonsillectomy is a first-line treatment for OSA in children, as discussed separately. (See "Adenotonsillectomy for obstructive sleep apnea in children".)

•Recurrent pharyngitis – The benefits of tonsillectomy (with or without adenoidectomy) in patients with recurrent pharyngitis or tonsillopharyngitis depend on the frequency and severity of previous episodes (see 'Recurrent tonsillitis/pharyngitis' above):

-Severely affected – For children who are severely affected (ie, ≥7 episodes in one year, ≥5 episodes in each of two years, or ≥3 episodes in each of three years), we suggest tonsillectomy (with or without adenoidectomy) (Grade 2B). However, given the natural decline in tonsil-related problems with increasing age, watchful waiting and provision of symptomatic care and antimicrobial treatment (as indicated) for recurrent episodes is a reasonable alternative to surgery. (See "Treatment and prevention of streptococcal pharyngitis in adults and children" and "Acute pharyngitis in children and adolescents: Symptomatic treatment".)

-Mildly affected – For children with recurrent throat infection who are only mildly or moderately affected, we suggest not performing tonsillectomy (Grade 2C).

•Periodic fever, aphthous stomatitis, pharyngitis, and cervical adenitis (PFAPA) – Tonsillectomy is a treatment option in children with the syndrome of PFAPA who have not responded to conservative treatment. This is discussed separately. (See "Periodic fever with aphthous stomatitis, pharyngitis, and adenitis (PFAPA syndrome)", section on 'Tonsillectomy'.)

•Peritonsillar abscess (PTA) – Tonsillectomy may be warranted in patients with PTA who have significant upper airway obstruction or previous episodes of recurrent pharyngitis or PTA. This is discussed separately. (See "Peritonsillar cellulitis and abscess", section on 'Tonsillectomy'.)

•Other conditions – Other conditions in which tonsillectomy (with or without adenoidectomy) is sometimes performed include the following (see 'Other conditions' above):

-Tonsillar obstruction of the oropharynx that interferes with swallowing or that alters voice quality.

-Uncontrollable hemorrhage from tonsillar blood vessels.

-Halitosis refractory to other measures.

-Chronic (as distinct from recurrent acute) tonsillitis unresponsive to antimicrobial treatment.

-Chronic pharyngeal carriage of group A beta-hemolytic streptococci in a child who has had or is in close contact with a person who has had rheumatic heart disease, who had at least two well-documented episodes of streptococcal throat infection within the preceding year, and in whom treatment with antimicrobials has not been successful in eradicating the organism.

●Potential indications for adenoidectomy

•Nasal obstruction – For children with adenoidal hypertrophy and associated moderate nasal obstructive symptoms (mouth breathing, hyponasal speech, impaired olfaction) that have been present for ≥1 year without an adequate response to conservative measures (including antimicrobial treatment for one month and/or nasal glucocorticoids for six weeks to six months), we suggest adenoidectomy rather than ongoing conservative management (Grade 2C). (See 'Nasal obstruction' above.)

•Refractory chronic sinusitis – For most children with chronic sinusitis that has not responded adequately to medical treatment, we suggest adenoidectomy (Grade 2C). The efficacy of adenoidectomy in such children is variable. (See 'Refractory chronic sinusitis' above.)

•Recurrent acute otitis media (AOM) or chronic otitis media with effusion (OME) – For children with recurrent AOM or OME who have previously undergone tympanostomy tube (TT) insertion, whose tubes have been extruded, and who are undergoing repeat TT placement, we suggest adenoidectomy in addition to TT placement rather than TT placement alone (Grade 2B). We suggest not performing adenoidectomy in children with recurrent AOM or chronic OME who have not undergone TT insertion (Grade 2C) unless they have an additional distinct indication for the adenoidectomy (eg, nasal obstruction, chronic adenoiditis, chronic sinusitis). (See 'Recurrent or chronic otitis media' above and "Acute otitis media in children: Prevention of recurrence", section on 'Adenoidectomy or adenotonsillectomy' and "Otitis media with effusion (serous otitis media) in children: Management", section on 'Adenoidectomy'.)

●Contraindications – Patients should be assessed for potential contraindications prior to proceeding with surgery. There are three general categories of contraindications to tonsillectomy and/or adenoidectomy (see 'Contraindications' above):

•Velopharyngeal (see 'Cleft palate and other conditions predisposing to velopharyngeal insufficiency' above)

•Hematologic (see 'Bleeding disorders and anemia' above)

•Infectious (see 'Acute upper respiratory infections' above)

ACKNOWLEDGMENT — 

The UpToDate editorial staff acknowledges Jack Paradise, MD, who contributed to earlier versions of this topic review.