Tonsillectomy and/or adenoidectomy in children: 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 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".)

●(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). These criteria are commonly referred to as the "Paradise criteria" (in reference to the clinician researcher who conducted the landmark trials in the 1980s) [19].

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 'Secondary prevention (antibiotic prophylaxis)'.)

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 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 [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 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 [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 syndromes, cystic fibrosis, and immunodeficiencies) before considering surgical intervention of any type [44,45]. (See "Primary ciliary dyskinesia (immotile-cilia syndrome)" and "Cystic fibrosis: Clinical manifestations and diagnosis" and "Approach to the child with recurrent infections".)

The efficacy of adenoidectomy for children with chronic sinusitis that has not responded adequately to medical treatment is uncertain but has been endorsed by a 2014 consensus statement on pediatric chronic rhinosinusitis developed by an expert panel [46]. Favorable results are seen in some children in observational studies [41,47-52], but there are no available randomized trial data. (See "Chronic rhinosinusitis without nasal polyposis: Management and prognosis".)

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 adenoiditis, chronic sinusitis). Although adenoidectomy may be helpful in the resolution of middle-ear effusion, the additional surgical and anesthetic risks outweigh the benefits [53-56]. (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 [55,57-60].

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 control children [58]. 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 and child. (See 'General considerations' 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, both in children three years of age or older [57] and in those less than two years of age [57,60-62]. If surgery is deemed necessary in such children, TT insertion is the most appropriate initial surgical procedure [57,63]. (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.

Velopharyngeal — A number of abnormal conditions that result in or predispose to velopharyngeal insufficiency constitute contraindications to adenoidectomy (see "Adenoidectomy in children: Postoperative care and complications", section on 'Velopharyngeal insufficiency'). These include:

●Overt cleft of the palate

●Submucous (covert) cleft of the palate

●Neurologic or neuromuscular abnormalities leading to impaired palatal function

●An unusually capacious pharynx

These disorders are 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) [64]. 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) [29].

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 "Etiology of speech and language disorders in children", 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.

Hematologic — Anemia and disorders of hemostasis are the hematologic contraindications to tonsil and adenoid surgery. Surgery should not be undertaken if the hemoglobin concentration is less than 10 g/dL or if the hematocrit is less than 30 percent. Preoperative evaluation for hematologic disorders is reviewed in detail separately. (See "Tonsillectomy and/or adenoidectomy in children: Preoperative evaluation and care", section on 'Hematologic evaluation'.)

Consultation with the hematology service is critical for preoperative and postoperative management when surgery is deemed appropriate for children with anemia or disorders of hemostasis.

Infectious — Neither tonsillectomy nor adenoidectomy should be undertaken in children with active local infection (ie, pharyngitis, common cold) unless urgent obstructive symptoms are present or prolonged appropriate antimicrobial treatment has been maintained unsuccessfully. An interval of at least three weeks after an episode of acute infection usually is sufficient for general recuperation and to reduce the risk of operative hemorrhage. (See "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".)

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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

●Clinical importance – 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.)

●General considerations – 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.)

●Potential indications for tonsillectomy (with or without adenoidectomy)

•Obstructive sleep apnea (OSA) – Adenotonsillectomy is the first-line treatment for OSA in otherwise healthy children over two years of age with adenotonsillar hypertrophy. This is 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 throat infection' 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 2B).

•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) 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.

●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 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 '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 2B) unless they have an additional distinct indication for the adenoidectomy (eg, nasal obstruction, chronic adenoiditis, chronic sinusitis). (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'.)

●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 'Velopharyngeal' above)

•Hematologic (see 'Hematologic' above)

•Infectious(see 'Infectious' above)

ACKNOWLEDGMENT — We are saddened by the death of Jack Paradise, MD, who passed away in December 2021. UpToDate acknowledges Dr. Paradise's past work as an author for this topic.