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This paper reviews current indications for otolaryngology consultation for tonsillectomy and adenoid -C/·J
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ectomy (T&A). Despite often being performed concurrently, these procedures should be considered CD
separate surgeries done for different indications. The American Academy of Otolaryngology - Head and a.
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Neck Surgery published tonsillectomy guidelines for children in 2019. These recommendations are of
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ten extrapolated to adults in clinical practice despite less robust literature support for this age group. •

T&A should be recommended for pediatric obstructive sleep apnea. Specific frequencies of tonsillitis w
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health factors warrant consideration of surgery with fewer infections. The guidelines include considera
tion of tonsillectomy for poorly validated indications such as halitosis, febrile seizure, dental malocclu
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sion, dysphagia, dysphonia, and psoriasis. (J Am Board Fam Med 2020;33:1025-1030.) 0
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Keywords: Adenoidectomy, Adenoids, Hypertrophy, Obstructive Sleep Apnea, Otolaryngology, Streptococcal •
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Infections, Tonsillectomy, Tonsils 0
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Introduction Recurrent Tons illitis z

Tonsillectomy and adenoidectomy remain common Recurrent tonsillitis in children and adults remains n<0

surgeries, yet their efficacy had not been well stud 0 CD

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a common indication for otolaryngology consultation. --0
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ied until 1984. The pediatric population has more Several studies have demonstrated modest benefit for ::T' N
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robust literature than the adult population. Current tonsillectomy in children having recurrent tonsilli N
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pediatric guidelines support surgery for patients with tis.2'10 Concurrent adenoidectomy conferred no addi •

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obstructive sleep-disordered breathing (OSDB) and tional benefit. One article demonstrated fewer throat
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recurrent tonsillitis. These indications have, in clini infections for 2 years after surgery. A Cochrane 0
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cal practice, been extrapolated to adults but this Review pooled this and other pediatric data and found aCD .

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requires further research. The 2019 AAOHNS 1 year of benefit. Study heterogeneity and patient -,
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guidelines for pediatric tonsillectomy find that sur numbers have limited the strength of these studies.9 3
gery may be appropriate with modifying factors such Parental satisfaction with tonsillectomy, however, is as ,-+
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as multiple antibiotic allergy, certain syndromes, 2 12 -0
high as 92%. ' Current American Academy of
recurrent peritonsillar abscess, enuresis, or poorly O tolaryngology- H ead and N eek Surgery guidelines
validated indications such as halitosis, febrile seizure,
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(AAOHNS guidelines) advise that children with 7 -tu
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malocclusion, dysphagia, or dysphonia. It should be

stressed that tonsillectomy and adenoidectomy con
bouts of tonsillitis in 1year, 5 annual bouts for 2 years,
or 3 annual bouts for 3 years may benefit from 2tonsil
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stitute different procedures with different indications. lectomy while those having fewer bouts will not, 13, 14
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This article discusses indications for otolaryngology 34145 (E-mail: davidarandalhnd@gmail.co1n). T
referral from primary care physicians. on
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This article was externally peer reviewed.
Submitted 26 January 2020; revised 21 April 2020; m
accepted 26 April 2020. y
Fztnding: N o n e.
Conflict of interest: N on e. is
Corresponding aztth or: David A. Randall, MD, Retired als
otolaryngologist, 851 Collier Court #7, Marco Island, FL
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doi: 10.31 22/ Cu.rrent Indications for T onsille ctomy and 102
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doi: 10.31 22/ Cu.rrent Indications for T onsille ctomy and 102
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Table 1. Practice Recommendations with SORT Strengths1

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Referral for tonsillectomy is appropriate for c.hildren having 7 bouts of SORT: A tu
tonsillitis in 12 months, 5 annual bouts for 2 years, or 3 annual bouts for 3 3
years. Watchful waiting is indicated for lesser frequency. s
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Tonsillectomy may reasonably be offered to children having fewer SORT: B1 • •

infections g·iven certain modifying factors. --, ·

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Tonsillectomy has shown benefit for adults with recurrent tonsillitis. SORT: B2 •3 CD
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Tonsillectomy/adenotonsillectomy may be indicated in adults with sleep SORT: C4 tu
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Adenoidectomy may be considered for chronic middle ear effusion and SORT: B-5
recurrent otitis media in children. •
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chronic tonsillitis, febrile seizures, muffled speech, halitosis, malocclusion, tu
tonsillar hypertrophy, cryptic tonsils, and chronic pharyngeal carriage of
group A /3 hemolytic Streptococcus (GABHS).
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A f3 hemolytic strep (GABHS) carriage, febrile seizure, with recurrent tonsillitis have 1 or more PT As. , 0
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clusion. There is a subst.antial role in shared decision practice listing recurrent PT A as an indication of N
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making for this last group of problems. These situa tonsillectomy.2 It is also common practice in adults z
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tions warrant consideration of referral to an otolaryng and has literature support.15 Patients may undergo n<
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making between the caregivers and the surgeon. ''hot'' or ''Quinsy'' tonsillectomy. In patients meeting (C
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Two studies reported short-term benefit from ton for children or uncooperative patients. •

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decreased :
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absenteeism from work or school. A Cochrane ease and growth impairment. Memory problems, ,-+
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Review combined these data and found that surgery poor school performance, as well as behavioral issues ph
conferred 3.6 fewer cases of tonsillitis and 10.6 less such as aggression, attention deficit, hyperactivity, y
sore throat days for 6 months postoperatively. and aggression have been associated with this condi in
However, they judged this information to be of tion.2'18 Hypertrophy of the adenoid, and particu chi
lower quality due to the short period studied and larly, the tonsils are the most frequent cause.2 The ldr
statistical heterogeneity.10 It is presently a common combined volume of these lymphatic structures tends en
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and quite reasonable clinical practice to offer oto to correlate with severity. Other potential etiologies
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laryngology evaluation for tonsillectomy in adults include obesity, Down syndrome, craniofacial abnor
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meeting the pediatric criteria. malities, and neuromuscular disease.2
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Diagnosis of obstructive sleep-disordered breath e
ing (ODSB) in children is often based on history of
Recurrent Peritonsillar Abscess and examination but may also include video and 2
Peritonsillar abscess (PTA) develops between the audio taping, overnight pulse oximetry, sleep study, ye
tonsil and pharyngeal constrictors, and commonly 2 17
or validated sleep questionnaires.
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occurs in adolescents and young adul ts.15 Ten to Current or
15 % of patients.-typically under 40 years of age or AAOHNS guidelines recommend polysomnogra if
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102 JABFM November- December Vol. 33 No. http://
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have obesity, Down syndrome, craniofacial abnormal

associated with tobacco and alcohol use, and is now ►3
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mucopolysaccharidoses. Certain patients are at higher -t,u
younger patients. Recent tonsil enlargement, a suspi a.
risk for persistent OSDB after tonsillectomy or adeno "'Tl
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tonsillectomy-those with asthma, age over 7years,
obesity, or more severe sleep apn ea- but surgery
may suggest tonsillar malignancy. Rather surprisingly, s
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remains a viable option. 21
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adenotonsillectomy for pediatric OSDB alth ou gh 22 C
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benefit with regard to sleep disturbance, physical The tonsil ipsilateral to the adenopathy is removed at 0

suffering, emotional distress, daytime problems, the time of direct laryngoscopy evaluation with its
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to altered dentofacial development. ·24 Habitual

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a prevalence of nocturnal enuresis of 31%. This was tion) and may also recommend orthodontia and palatal n<
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Otolaryngology consultation for this more commonly -0

Adult Obstructive Sleep Apnea 5 originates from dental colleagues. tu
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Alteration in Speech and Swallowing 3
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sidered as well, although these can aggravate tem "O

trophy may cause dysphagia-typically for solids.

poromandibular joint conditions. Referral for surgical
Adenotonsillar size and obstruction may also cause
management as initial therapy may be considered with a hyponasal voice or interfere with speech. Dysphagia --
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obvious obstructive anatomy (such as tonsil plasm, typically Hodgkin's lymphoma in children and an -
hyperpla sia). Positive airway pressure remains the young adults and squamous cell carcinoma in the older d
mainstay of therapy. Tonsillectomy/adenoidectomy population. Squamous cell carcinoma has long been fai
are often re served supplement ODSB that lur
incompletely responds to Papanicolaou or for patients e
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doi: Cu.rren t Indications for Tonsillectomy and 102
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d with this has been con sidered an indication for
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Involvement of a speech therapist in evaluation

would be prudent in the interest of consid ering all
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(AOM); it may also occur due to Eustachian tube of adenoidectomy is recommended for refractory pe ►3
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dysfunction. OME is most common between the diatric RS. 0
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ages of 6 months and 4years, particularly in chil Adenoid removal for hypertrophy has been per a.
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associated with hearing loss, imbalance, school or be therapy. However, this procedure does involve the
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with hearing loss but may considered sooner in ''at or nasopharyngeal stenosis. The literature seems to 'O
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risk,'' children who have hearing,2 speech, cognitive, support adenoidectomy mostly in conjunction with -·C
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sensory, or behavioral conditions. Although modest treau11ent of other medical conditions such as si ::r
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addition to tympanostomy tube (TT) placement, it
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PFAPA Syndrome
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OME with tubes alone. Current AAOHNS guide N
The syndrome of periodic fever, aphthous ulcers, -N,
lines recommend TI' for children under the age of 4 tu
in the absence of separate indication for adenoidec
tomy such as nasal obstruction or the rare case of
pharyngitis, and cervical adenopathy (PFAPA) is a
rare but recognized entity. It typically affects chil 3
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dren under age 5 years and involves bouts of 5 days 0
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provide rapid resolution but shorten time between •
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episodes. A Cochrane Review found tonsillectomy 0
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Adenoidectomy has long been used as a treatment lessened the average duration from 3.5 to 1.8 days.29 N
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for recurrent AOM.9 Mechanisms of the adenoid The MORNS guidelines consider otolaryngology z0
and referral and tonsillectomy as an option for n<
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causing eustachian tube dysfunction as well as its PFAPA. 1 29 --0 3
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being a bacterial reservoir have been posited to ::::•:! CD
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explain the efficacy of adenoidectomy for this con ;+-o

dition.7 Meta-analysis has shown benefit with ade Psoriasis N

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noidectomy in reducing the need for additional TT Psoriasis affects 1% to 3 % of the population and is 0
30 31 0
2 8 26 felt to be T-cell mediated. · Exacerbations have -
placement and TT otorrhea. ' '9' For recurrent 0
regularly been noted with pharyngitis due to
AOM persistent after TI' placement, it is common 3 32 a.
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and appropriate to offer adenoidectomy with a sec GABHS expressing surface M protein. 0- Its pro
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posed mechanism is a cross-reaction between
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The literature largely comprises uncontrolled case
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series but indicates tonsillectomy to be an effective

Pediatric Rhinosinusitis and Nasal
treau11ent. 30' 31 0 ne rand om. 1zed .
Obstruction
1nve.st1g.at1on of adults demonstrated -
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Chronic pediatric rhinosinusitis (RS) has been vari
ably defined as greater than 90 days of RS symp
benefit for at least 2 years. 3
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This showed a statistically significant reduction in
toms along
findings.
27 with either endoscopic or radiographic
Children may manifest cough, nasal the Psoriasis Area and Severity Index score.
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Improvement also correlated32with a reduction of
circulating effector T cells. The primary care
congestion, rhinorrhea, irritability, or behavioral N
28 physician should consider otolaryngology referral st
problems; headache is less cornmon. Disease se
27 for possible tonsillectomy for patients with psoriasis '<
verity seems unrelated to adenoid size. Adenoidal refractory to medical management. 0N

harboring of bacteria as well as biofilrns and exotox cents2.7 2·8 Otolaryngology referral for
27 28
ins have been implicated etiologies. ' Meta-anal consideration
ysis has shown a 50% to 84% improvement after H
adenoidectomy in younger patients but the benefit ali
of the procedure is with a less clear role in preadoles tos
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102 JABFM November-December Vol. 33 No. http://
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Tonsillectomy has been considered a relative indi cc
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controlled study. ' Halitosis primarily originates
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from an oral source such as tongue coating or den tonsillectomy in adult patients with recurren t ►3
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tal disease. A necrotic upper airway malignancy rep phar yngitis: a randomized controlled 0
33 -t,u
trial. Can Med
Assoc] 2013; l 4:E331- E 336.
resents a possible but rare cause. Bad breath may a.
34 ""Tl
also be caused by tonsillar crypt debris.25' A num 5. Epstein LJ, Kristo D, Strollo PJ, et al. Clinical guide tu
line for the evaluation, management, and long-term 3
ber of case series of tonsillectomy and tonsil crypt s
care of obstructive sleep apnea in adults. J Clin Sleep CD
ablation have reported halitosis improvement or re Med 2009;5:263- 76.
a.
• •

solution in 75% to 98% of cases.34 The crypt pro --, ·

5. Heidemann CH, Lous J, Berg J, et al. Danish guide lines C/J
,-+

cedures offer potential advantages of reduced on management of otitis media in preschool chil dren. "O
C
convalescent time and pain and avoidance of general Int) Pediatr Otorhinolaryngol 2016;87:154--63. - ·
C
C/J
anesthesia. Unfortunately, these require repeated treat 7. Gisselsson-Solen M. Acute otitis media in children ::r
CD
- Current treatment and prevention. Curr Infec a.
ments; 1 report averaged 7.34 T onsillec to my, despite tu
Dis Rep 2015;17:22- 8. C/J
its postoperative morbidity, offers a I-time therapy
8. Mikals S, Brigger M. Adenoidectomy as adjuvant to 0
and may be the preference of some patients. Despite •
primary tympanostomy tube placement a systematic w
the paucity of data, tonsillectomy or crypt ablation are review and meta-an alysis. JAMA Otola ryngol N

rea -N,
Head
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sonable options for socially bothersome halitosis after Neck Surg 20 14;140:95- 101.
excluding primary oral sources.2 33 34 9. Granath A. Recurrent otitis media: what are the options 3
• , •
N
for treatment and prevention? Curr Otorhinolaryngol 0
N
Rep 2017 ;5:93- 100. 0
Conclusions
•
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10. Bu.r t on M, Glasziou P, Chong L, Venekamp •
rn
N
Tonsillectomy and adenoidectomy have demon R. T onsillect omy or adenotonsillectomy versus non 0
0
strated benefit for a number of conditions described surgical treatment for chronic/recurrent tonsillitis. 0
Cochrane Database System Rev 2014;1:1- 62. w
CD
above. T he AAOHNS guidelines more strongly rec 0
ommend surgery more strongly for some medical 11. Paradise J, Bluestone C, Bachman R, et al. Efficacy of
N
tonsillectomy for recurrent throat infection in severely 0
conditions (eg, pediatric OSDB) than for others. z
affected children. N Engl] Med 1984;310:674--83. 0
Satisfaction for tonsillectomy for tonsillitis remains n<
12. Barraclough J, Anari S. Tonsillectomy for recurrent 0 CD
high.2 •1 2 The role for shared decision making is more --0 3
sore throats in children: indications, outcomes, and '< CY

ef ::::•:! CD
apparent with less well or poorly validated issues (eg, 0, Kristo A, Alho 0. Short-term outcomes of f
halitosis) than others. Further study is warranted i
particularly in adult populations-to better under c
a
stand the benefits and risk of surgical intervention for c
these conditions. Until then, primary care physicians y
may use the AAOHNS guidelines to make prudent .
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decisions regarding evaluation and treaunent options t
to pursue before otolaryngology referral. o
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To see this article online, please go to: htt p:llj abfm .or glcont entl a
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1. Ebell M, Siwek J, Weiss B, et al. Strength of o
l
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15. Johnson R, Stewart M, Wright C. An evidence-based "O

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19. Todd C, Bareiss A, McCoul E, Rodriguez K. . ,-+

"1)
Adenotonsillectomy for obstructive sleep apnea and g. -

quality of life: systematic review and meta-analysis. CD

(")
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Otolaryngol Head Neck Surg 20 17;15 7:767- 73. CD

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20. Jeyakuma.r A, Rahman S, Armbrecht E, Mitchell 27. Neff L, Adil E. What is the role of the adenoid in pe ►3
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R. The association between sleep-disordered diatric chronic rhinosinusitis? Laryngoscope 2015;125: 0
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28. Magit A. Pediatric rhinosinusitis. Otolaryngol Clin tu
21. Van Lierop A, Prescott C, Fagan J, Sinclair-Smith North Am 2014;47:733-46. 3
C. Is diagnostic tonsillectomy indicated in all chil
s
29. Burton M, Pollard A, Ramsden}, Chong L, Venekamp CD
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dren with asymmetrically enlarged tonsils? S Afr R. Tonsillectomy for periodic fever, aphthous stomatitis,
-
• •

MedJ 2007;97:367-70. --,·

pharyngitis and cervical adenitis syndrome (PFAPA). C/J
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22. Randall D, Johnstone P, Foss R, Martin P. Cochrane Database Syst Rev 2014;9:l- 30. "O
C
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