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Topic Outline
SUMMARY AND RECOMMENDATIONS
INTRODUCTION
EPIDEMIOLOGY
INDICATIONS
General considerations
Tonsillectomy (with or without adenoidectomy)
• Obstructive sleep apnea
• Recurrent throat infection
◦ Severely affected children
◦ Mildly or moderately affected children
• PFAPA syndrome
• Peritonsillar abscess
• Other conditions
Adenoidectomy
• Nasal obstruction
◦ Severe obstructive symptoms
◦ Moderate obstructive symptoms
◦ Adenoid facies
• Chronic sinusitis
• Otitis media
CONTRAINDICATIONS
Velopharyngeal
Hematologic
Infectious
SOCIETY GUIDELINE LINKS
INFORMATION FOR PATIENTS
SUMMARY AND RECOMMENDATIONS
REFERENCES
GRAPHICS
Figures
• Child with allergies
• Nasality relationships
• Palpation for submucous cleft palate
Movies
• Hypernasal speech
• Hyponasal speech
RELATED TOPICS
Acute otitis media in children: Prevention of
recurrence
Acute pharyngitis in children and adolescents:
Symptomatic treatment
Acute rheumatic fever: Treatment and prevention
Adenoidectomy in children: Postoperative care and
complications
Adenotonsillectomy for obstructive sleep apnea in
children
An overview of rhinitis
Approach to the child with recurrent infections
Bad breath
Chronic rhinosinusitis: Management
Cystic fibrosis: Clinical manifestations and
diagnosis
Etiologies of nasal symptoms: An overview
Etiology of speech and language disorders in
children
Oral habits and orofacial development in children
Otitis media with effusion (serous otitis media) in
children: Management
Overview of tympanostomy tube placement,
postoperative care, and complications in children
Patient education: Tonsillectomy and
adenoidectomy in children (The Basics)
Periodic fever with aphthous stomatitis,
pharyngitis, and adenitis (PFAPA syndrome)
Peritonsillar cellulitis and abscess
Primary ciliary dyskinesia (immotile-cilia syndrome)
Society guideline links: Sleep-related breathing
disorders including obstructive sleep apnea in
children
Society guideline links: Streptococcal
tonsillopharyngitis
Society guideline links: Tonsillectomy and
adenoidectomy in children
Taste and olfactory disorders in adults: Anatomy
and etiology
Tonsillectomy (with or without adenoidectomy) in
children: Postoperative care and complications
Tonsillectomy and/or adenoidectomy in children:
Preoperative evaluation and care
Treatment and prevention of streptococcal
pharyngitis in adults and children
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indications of adenotonsillectomy
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Tonsillectomy and/or
adenoidectomy in children:
Indications and
contraindications
Authors: Jack L Paradise, MD, Ellen R Wald, MD
Section Editors: Morven S Edwards, MD, Glenn C Isaacson,
MD, FAAP
Deputy Editor: Carrie Armsby, MD, MPH
Contributor Disclosures
All topics are updated as new evidence becomes available and
our peer review process is complete.
Literature review current through: Jun 2021. | This topic last
updated: Mar 18, 2021.
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 obstruction and recurrent
infection [1].
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".)
view all ● (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 is among the most commonly
performed operations in children. The frequency
with which tonsillectomy is performed varies from
country to country and region to region [2-4]. The
variation appears to be related to differences in
the medical practice of general practitioners,
pediatricians, and otolaryngologists in the
management of recurrent tonsillitis and other
conditions affecting the upper airway [5].
Patient/family factors and preferences may also
influence the decision [6].
In the United States, the number of
tonsillectomies has declined progressively since
the 1970s [7-9]. The estimated number of
tonsillectomies (with or without adenoidectomy)
performed in children <15 years old in the United
States declined from approximately 970,000 in
1965 to approximately 289,000 in 2010 [8-10]. The
estimated number of adenoidectomies (without
tonsillectomy) performed in children declined from
132,000 in 2006 to 69,000 in 2010 [8,9]. A similar
decline was noted in a study from England, where
the total number of tonsillectomies fell from
28,309 in 1990 to 6327 in 2014 [11]. Reports from
both countries indicate that the decline has mainly
involved tonsillectomies performed for infectious
indications, while the number performed for
obstructive indications has increased [11-13].
The great majority of tonsil and adenoid
operations are performed as ambulatory, same-
day procedures [8,9].
The rates for specific procedures vary depending
upon age and sex. Tonsillectomy alone is
performed infrequently in children <3 years old,
whereas adenoidectomy alone is performed
infrequently in individuals >14 years old. The rate
of adenoidectomy is approximately 1.5 times as
high in boys as in girls, whereas the rate of
tonsillectomy is approximately one-third higher in
girls than in boys [6,8].
INDICATIONS
General considerations — The two major
categories of indications for tonsillectomy and/or
adenoidectomy are obstruction and infection
[1,14]:
● Obstruction – Obstruction may involve the
nasopharyngeal airway, oropharyngeal
airway, and the oropharyngeal deglutitory
(swallowing) pathway
● Infection – Recurrent or chronic infection may
involve the middle ears, mastoid air cells,
nose, nasopharynx, adenoids, paranasal
sinuses, oropharynx, tonsils, peritonsillar
tissues, and cervical lymph nodes
Most tonsil-related problems in children tend to
decline naturally with increasing age, 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, antimicrobial
therapy)
● Natural course of disease
● Clinical factors related to the disease process
(eg, frequency and severity of episodes of
recurrent throat infection)
● Values and preferences of the family and child
(eg, anxieties, tolerance of illness)
● Child's tolerance of antimicrobial drugs and
other conservative therapies
● Child's school performance in relation to
illness-related absence
● Accessibility of health care services
● Out-of-pocket costs
● Nature of available anesthetic and surgical
services and facilities
In children who lack absolute 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 [14].
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 unequivocal
indications, it would seem reasonable to add
tonsillectomy if the tonsils also have been
problematic to some degree, even if he or she
does not meet strict criteria for tonsillectomy. By
the same token, in a child scheduled for
tonsillectomy for unequivocal indications, it would
seem reasonable to add adenoidectomy if the
child had had more than occasional bouts of otitis
media but had not undergone tympanostomy
tube (TT) insertion.
Tonsillectomy (with or without adenoidectomy)
Obstructive sleep apnea — Obstructive sleep
apnea (OSA) is common in the pediatric
population. If untreated, the disease has been
associated with a wide range of cardiovascular and
cognitive morbidities [15-17]. Surgical removal of
the tonsils and adenoids is considered the first-line
treatment for OSA in otherwise healthy children
over two years of age with adenotonsillar
hypertrophy, as recommended in guidelines from
the American Academy of Pediatrics and the
American Academy of Otolaryngology-Head and
Neck Surgery (AAO-HNS) [14,18]. Indications for
adenotonsillectomy in children with OSA are
discussed separately. (See "Adenotonsillectomy for
obstructive sleep apnea in children", section on
'Indications for surgery'.)
Recurrent throat infection — The benefits of
tonsillectomy (with or without adenoidectomy) in
patients with recurrent throat infections (ie,
tonsillitis, pharyngitis, tonsillopharyngitis) depend
on the frequency and severity of previous episodes
[19-22]. (See 'Severely affected children' below and
'Mildly or moderately affected children' below.)
When making decisions regarding surgical
intervention in children with recurrent throat
infection, the clinician must also consider the
extent to which the episodes are documented in
medical records. A history of recurrent throat
infection that is not documented is a poor
predictor of subsequent experience and hence
should not serve as the basis for performing
tonsillectomy [23].
Severely affected children — We suggest
tonsillectomy (with or without adenoidectomy) as
an option for children with recurrent throat
infection 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). 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 antimicrobial treatment (as indicated) for
recurrent episodes. The decision should be made
on a case-by-case basis after weighing the risks
and benefits as well as the values and preferences
of the family and child. These options were
incorporated in guidelines from the AAO-HNS and
the Scottish Intercollegiate Guidelines Network
[14,24]. (See 'General considerations' above and
"Treatment and prevention of streptococcal
pharyngitis in adults and children" and
"Tonsillectomy (with or without adenoidectomy) in
children: Postoperative care and complications"
and "Acute pharyngitis in children and
adolescents: Symptomatic treatment", section on
'General management'.)
The efficacy of tonsillectomy in severely affected
children was demonstrated in two parallel trials
(one randomized and one nonrandomized) [19].
Enrolled children met each of the following
criteria:
● ≥3 episodes 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 beta-
hemolytic streptococci
● Apparently adequate antibiotic therapy
administered for proven or suspected
streptococcal episodes
● Each qualifying episode confirmed by
examination with the clinical features
described in a clinical record at the time of
occurrence or, if not fully documented,
subsequent observance of two episodes of
throat infection with patterns of frequency
and clinical features consistent with the initial
history
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 fewer than three
episodes of throat infection and most episodes
among subjects in the nonsurgical groups were
mild.
The results described above provide support both
for surgical and for nonsurgical management of
children with recurrent tonsillitis who are severely
affected. Treatment decisions for such children are
best made on a case-by-case basis. The decision
should take into account the potential adverse
consequences of surgery, the values and
preferences of the family, and other factors
described elsewhere. (See 'General considerations'
above and "Tonsillectomy (with or without
adenoidectomy) in children: Postoperative care
and complications".)
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 in any respect than
as described above for severely affected children)
[20]. For such children, the benefits of surgery are
modest and outweighed by the potential risks.
However, tonsillectomy is a reasonable option in
such children with recurrent group A streptococcal
(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 [25]. 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 'Prevention'.)
For most mildly or moderately affected children,
episodes of recurrent infection can be treated with
symptomatic care and antimicrobial treatment (as
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'.)
The efficacy of tonsillectomy in moderately
affected children was evaluated in a randomized
trial of 328 children with recurrent throat infection
despite adequate antibiotic therapy [20]. The
history standards were less stringent than those
used in the earlier trials described above for
severely affected children regarding either
frequency, clinical features, or documentation of
previous infections. The study included two
parallel trials. One trial compared
adenotonsillectomy with nonsurgical management
in patients with coexisting indications for
adenoidectomy (eg, recurrent otitis media); the
other was a three-way comparison of
tonsillectomy, adenotonsillectomy, and
nonsurgical management in patients who lacked
indications for adenoidectomy.
The following results were noted [20]:
● In the first year of follow-up, the mean
number of moderate or severe episodes in the
combined surgical groups (tonsillectomy and
adenotonsillectomy) was 0.14 compared with
0.35 in the combined control groups.
● During each of the three years of follow-up,
the incidence of throat infection was
significantly lower in the surgical groups than
in the corresponding control groups. Results
in surgical subjects were similar to those of
the trials for severely affected children,
described above [19]. However, the
proportions of control subjects who developed
no moderate or severe episodes of throat
infection in a given year ranged from 70 to 84
percent (compared with 34 and 41 percent of
control subjects in the first and second years
of follow-up in the trials of severely affected
children).
● The outcomes in children who underwent
adenotonsillectomy were not more favorable
than those in children who underwent
tonsillectomy only.
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, mainly 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) [26].
Thus, the modest benefits seen in these patients
do not justify the inherent risks, morbidity, and
cost of surgery, a conclusion also incorporated in
the 2019 AAO-HNS guideline [14]. (See
"Tonsillectomy (with or without adenoidectomy) in
children: Postoperative care and complications".)
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) may be performed in a
number of other conditions, although evidence
from prospective controlled trials is generally
lacking. These include the following [1,7,14]:
● Tonsillar obstruction of the oropharynx that
interferes with swallowing [27].
● Tonsillar obstruction that alters voice quality.
● Malignant tumor of the tonsil (or suspicion of
malignancy).
● Uncontrollable hemorrhage from tonsillar
blood vessels.
● Halitosis refractory to other measures. (See
"Bad breath".)
● Chronic (as distinct from recurrent acute)
tonsillitis unresponsive to antimicrobial
treatment. This condition is uncommon in
adolescents and adults and is rare in young
children.
● Chronic pharyngeal carriage of group A beta-
hemolytic streptococci 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 streptococcal throat
infection within the preceding year, and in
whom treatment with antimicrobials
(including clindamycin, cephalosporins,
amoxicillin-clavulanate, azithromycin, or a
combination of penicillin and rifampin) has
not been successful in eradicating the
organism [28].
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 'General
considerations' above and "Tonsillectomy (with or
without 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 [29]. 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 symptoms: 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 [30] and of nasal
glucocorticoids for six weeks (continued for up to
six months if prompt initial improvement is
realized) [31-35]. Occasionally, a favorable
response to these measures may obviate the need
for surgery. (See "Etiology of speech and language
disorders in children", 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) [29,36]. (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 [36]. 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 symptoms:
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 [37]. 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 [38-40]. 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 is included
among the indications for tonsil or adenoid
surgery [7]. The 2019 guidelines do not provide
specific guidance on this issue, as they address
indications for tonsillectomy but not for
adenoidectomy alone [14].
Chronic sinusitis — Adenoidectomy is a
reasonable option for children with chronic
sinusitis that has been refractory to medical
therapy, and in whom endoscopic sinus surgery is
being considered [41-43]. Such patients should
also be evaluated for underlying contributing
conditions (eg, allergy, ciliary dysmotility