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Tonsillectomy and/or adenoidectomy in children: Indications and contraindications.Literature review current through: Oct 2019

SUMMARY AND RECOMMENDATIONS

●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. (See 'Introduction' above.)


●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 and child. (See 'General considerations' above.)


●Adenotonsillectomy is considered the first-line treatment for obstructive sleep apnea in otherwise healthy children over two years of age with adenotonsillar hypertrophy. (See "Adenotonsillectomy for obstructive sleep apnea in children".)


●The benefits of tonsillectomy (with or without adenoidectomy) in patients with recurrent throat infections depend on the frequency and severity of previous episodes. 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), we suggest tonsillectomy (with or without adenoidectomy) as an option (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. For children with recurrent throat infection who are only mildly or moderately affected, we suggest not performing tonsillectomy (Grade 2B). (See 'Recurrent throat infection' above and "Treatment and prevention of streptococcal pharyngitis" and "Acute pharyngitis in children and adolescents: Symptomatic treatment".)


●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. (See "Periodic fever with aphthous stomatitis, pharyngitis, and adenitis (PFAPA syndrome)".)


●Tonsillectomy may be warranted in patients with peritonsillar abscess (PTA) who have significant upper airway obstruction or previous episodes of recurrent pharyngitis or PTA. (See "Peritonsillar cellulitis and abscess".)


●Other conditions in which tonsillectomy (with or without adenoidectomy) may be performed include the following (see 'Other conditions' above):


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


•Malignant tumor of the tonsil.


•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.


●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.)


●We suggest adenoidectomy for children with chronic sinusitis that has not responded adequately to medical treatment (Grade 2C). The efficacy of adenoidectomy in such children is variable. (See 'Chronic sinusitis' above.)


●For children with recurrent AOM or chronic 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 unless they have an additional distinct indication for the adenoidectomy (eg nasal obstruction, chronic adenoiditis, chronic sinusitis) (Grade 2B). (See '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'.)


●There are three general categories of contraindications to tonsillectomy and/or adenoidectomy: velopharyngeal, hematologic, and infectious. Patients should be assessed for these conditions prior to proceeding with surgery

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