Tonsillectomy in adults: Indications

INTRODUCTION — The number of tonsillectomies performed in the United States peaked around 1959 with 1.4 million operations, the majority being performed in children. The rate decreased to 500,000 in 1979 and to 380,000 in 1996 [1,2]. Approximately 130,000 of the tonsillectomies performed in 1996 were for individuals over 15 years of age [3].

The literature regarding indications for tonsillectomy is largely focused on children. The extent to which pediatric data can be reliably extrapolated to adult patients is unclear.

This topic will review indications for performing tonsillectomy in adults. Tonsillectomy procedural techniques and complications in adults, evaluation of the adult with pharyngitis, treatment and prevention of streptococcal tonsillopharyngitis, and tonsillectomy in children are discussed separately. (See "Tonsillectomy in adults: Techniques and perioperative issues" and "Evaluation of acute pharyngitis in adults" and "Treatment and prevention of streptococcal pharyngitis in adults and children" and "Tonsillectomy and/or adenoidectomy in children: Indications and contraindications".)

PHARYNGEAL ANATOMY — Tonsils are lymphoid tissue. The lymphoid contents are covered by respiratory epithelium that can invaginate and cause crypts. The common term "tonsils" refers specifically to the palatine tonsils. Waldeyer's ring, a ring of lymphoid tissue in the pharynx, is formed by the palatine tonsils as well as the pharyngeal tonsils (adenoids), tubal tonsils, and lingual tonsils (figure 1 and figure 2).

Tonsillar crypts can harbor bacteria. Solidified "plugs" may form within the crypts and are termed tonsilloliths ("tonsil stones"). These often have a foul smell and can contribute to halitosis (bad breath). (See "Bad breath", section on 'Oral'.)

Tonsil size is based on a grading scale between 0 and 4:

●Grade 0 – Tonsils absent or atrophied

●Grade 1+ – Tonsils fill 0 to 25 percent of the oropharyngeal diameter

●Grade 2+ – Tonsils fill 25 to 50 percent

●Grade 3+ – Tonsils fill 50 to 75 percent

●Grade 4+ – Tonsils fill 75 to 100 percent

"Kissing tonsils" fill 100 percent of the oropharyngeal diameter and touch each other.

RECURRENT AND CHRONIC PHARYNGOTONSILLITIS — Recurrent acute pharyngitis and chronic tonsillitis are the most common reasons for tonsillectomy in adults [4]. In a retrospective study of 361 tonsillectomy procedures performed in adults in one United States institution between 2001 and 2007, chronic or recurrent infection accounted for 57 percent of tonsillectomies [5].

If the tonsils are affected primarily, then the infection is tonsillitis. If the oropharynx is affected primarily, then it is called pharyngitis. If both are affected, then pharyngotonsillitis is the correct term. In practice, the terms tonsillitis and pharyngitis are often used interchangeably because of the difficulty in distinguishing clinically between them.

Most episodes of acute pharyngitis are caused by viral infection and are benign and self-limited [6,7]. There are also bacterial, as well as non-infectious, causes of pharyngitis. Group A streptococcal (GAS) infection in adults accounts for approximately 10 percent of cases of pharyngitis. The evaluation of acute pharyngitis, possible causes of recurrent acute pharyngitis, and its treatment are discussed separately. Recurrent cultures positive for GAS infection can represent repeated infection, a carrier state, inadequate treatment, or treatment failure. (See "Evaluation of acute pharyngitis in adults" and "Treatment and prevention of streptococcal pharyngitis in adults and children", section on 'Persistent or recurrent symptoms'.)

Chronic tonsillitis refers to the presence of infection and/or inflammation of the oropharynx or tonsils for at least three months. Patients with chronic tonsillitis or pharyngitis often have sore throats that get better during antibiotic treatment, but symptoms recur as soon as the antibiotic is discontinued. The cause of chronic tonsillitis is likely multifactorial. Causes of chronic tonsillar inflammation and/or infection include various viruses (eg, Epstein-Barr virus), bacteria, gastroesophageal reflux disease, and possibly allergies [8] and asthma [9]. Respiratory viruses (eg, adenovirus) are highly prevalent in the adenoid and palatine tonsils of patients with chronic tonsillar diseases [10]. Persistence of these viruses in tonsils may stimulate chronic inflammation. (See "Infectious mononucleosis", section on 'Clinical variants' and "Pathogenesis, epidemiology, and clinical manifestations of adenovirus infection", section on 'Pharyngitis and coryza'.)

In addition to the throat pain and days lost from work, recurrent acute infections from GAS place patients at risk for both suppurative and nonsuppurative (eg, acute rheumatic fever) GAS complications. (See "Complications of streptococcal tonsillopharyngitis".)

Efficacy — Randomized controlled trials in children with recurrent throat infections who are severely affected have shown that tonsillectomy is effective in reducing the overall number and severity of subsequent episodes of throat infection, for up to two, possibly three, years. Major complications occur in approximately 3 percent of cases. These results, however, might not be generalizable to adults. (See "Tonsillectomy and/or adenoidectomy in children: Indications and contraindications", section on 'Severely affected children'.)

Observational studies have suggested a benefit of tonsillectomy in adults with recurrent or chronic tonsillitis [11-15].

Early randomized trials demonstrated decreased symptom burden compared to conservative management, but had short follow-up periods. A subsequent 2023 trial with a 24-month follow-up also showed benefit:

●In a trial of 86 adult patients with recurrent pharyngitis (three or more episodes of pharyngitis in the past year), fewer patients in the tonsillectomy group had an episode of pharyngitis compared with the control group after five months of follow-up (39 versus 80 percent, respectively) [16]. The most common adverse outcome of tonsillectomy was postoperative throat pain for a mean of 17±6 days. Of the 46 adults who had tonsillectomy, only one was hospitalized for postoperative pain and two had postoperative hemorrhage.

●In another trial of tonsillectomy for recurrent streptococcal pharyngitis, 70 adults (mean age 26 years) were assigned to immediate surgery or placement on a waiting list for surgery [17]. Entry criteria were three or more episodes of typical acute pharyngitis in six months or four episodes in 12 months, at least one of which was associated with a positive culture or rapid test for GAS infection. During a 90-day follow-up period, pharyngitis recurred in 24 percent of the controls and in 3 percent of the tonsillectomy group. In addition, the time to first pharyngitis episode was significantly shorter and severity of symptoms was higher in the control than in the tonsillectomy group. The most common adverse outcome related to tonsillectomy was postoperative throat pain for a mean of 13±4 days. Minor postoperative bleeding occurred in two of the adults who had tonsillectomy. No serious adverse effects resulted from tonsillectomy.

●In a trial conducted in 27 hospitals in the United Kingdom enrolling 453 adults (median age 23 years) with recurrent acute tonsillitis, those assigned to receive tonsillectomy had fewer days of sore throat during the subsequent 24 months than those in the conservative management group (median 23 days [IQR 11 to 46 days] versus 30 days [IQR 14 to 65 days]) [18]. In adjusted analysis, the incident rate ratio of total sore throat days in the tonsillectomy group compared with the conservative management group was 0.53 (95% CI 0.43-0.65). Adverse events in 39 percent of participants were deemed related to tonsillectomy, the most common was bleeding (19 percent of participants).

Criteria for surgery — Most patients with recurrent pharyngitis secondary to GAS do not require tonsillectomy. For adults who fit the Paradise criteria described below, and whose quality of life is affected significantly by recurrent acute pharyngitis secondary to GAS, we suggest tonsillectomy. We favor a conservative approach by applying the Paradise criteria, although they were not developed for adults, for referring patients for tonsillectomy: three episodes yearly for ≥ three years; five episodes yearly for two years; or seven episodes in one year [19]. Each episode of pharyngitis should be clearly documented with one or more of the following clinical features: temperature >38.3°C, cervical adenopathy, tonsillar exudate, or positive test for group A streptococcal (GAS) infection, before considering tonsillectomy [20].

Our criteria for tonsillectomy consideration are in agreement with the guidelines of the American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS) for indications for tonsillectomy in children [20]. However, 2012 guidelines from the Infectious Disease Society of America (IDSA) recommend that tonsillectomy not be performed for the sole indication of reducing the frequency of GAS infection [21]. They do note that tonsillectomy may be considered in the rare patient with recurrent symptoms of GAS pharyngitis that do not diminish over time and for which there is no alternative explanation.

OTHER POSSIBLE INDICATIONS — Other indications for consideration of tonsillectomy include infectious causes such as recurrent peritonsillar abscess, suspected malignancy, obstructive sleep apnea, or, in rare cases, halitosis caused by cryptic tonsils and tonsilloliths (tonsil stones).

Infections

Peritonsillar abscess — Peritonsillar abscess (PTA) is a bacterial, often polymicrobial, infection in the space between the tonsil and pharyngeal constrictor muscle. It occurs more frequently in young adults than in children. It is typically treated with antibiotic therapy and drainage (incision or aspiration). The recurrence rate for PTA is reported between 10 and 15 percent [22].

We refer patients for consideration of tonsillectomy if they have had a second episode of PTA or a first episode of PTA preceded by three episodes of acute tonsillitis in the previous year. This is based on data that recurrent PTA is more likely if two or three episodes of acute tonsillitis have preceded the occurrence of PTA [4,23]. There are no prospective controlled trials comparing tonsillectomy with close monitoring for preventing recurrent PTA. Tonsillectomy may also be required during acute treatment of PTA if there is significant upper airway obstruction or failure to adequately drain the abscess at the bedside. (See "Peritonsillar cellulitis and abscess", section on 'Tonsillectomy'.)

Streptococcal carrier state — Tonsillectomy is not indicated for the streptococcal carrier state. Streptococcus carriers are unlikely to spread the organism to close contacts and are at very low risk for developing suppurative complications or acute rheumatic fever [24]. (See "Treatment and prevention of streptococcal pharyngitis in adults and children", section on 'Chronic GAS carriers'.)

Infectious mononucleosis — Tonsillectomy is not generally performed for infectious mononucleosis. Management of tonsillitis related to infectious mononucleosis involves symptomatic care with acetaminophen or nonsteroidal antiinflammatory drugs (NSAIDs). Corticosteroids are not routinely used but may be needed if there is risk of airway obstruction [25]. Rarely, tonsillectomy may be indicated if there is upper airway obstruction from tonsillar hypertrophy that does not respond to corticosteroids [26], if the tonsils failed to regress in size after the resolution of the infection, especially asymmetric tonsils, or to rule out malignancy/lymphoproliferative disease. The risk of postoperative hemorrhage is increased in this subset of patients [27]. (See "Infectious mononucleosis" and "Infectious mononucleosis", section on 'Complications including airway obstruction'.)

Suspected malignancy

Asymmetric tonsils — Tonsillectomy is indicated in patients with marked tonsillar asymmetry who also have associated signs or symptoms suggesting possible malignancy, which include chronic pain, dysphagia, ulceration or other mucosal abnormality, persistent cervical adenopathy, new or progressive tonsillar enlargement, and/or systemic symptoms such as weight loss [4,28-30]. Tobacco smoking, alcohol consumption, and human papilloma virus infection are risk factors associated with tonsil cancer [31]. In cases of suspected cancer, tonsillectomy may be required to obtain tissue for pathologic examination and diagnosis. Bilateral tonsillectomy is recommended for such cases.

In the absence of other signs or symptoms, unilateral stable tonsillar enlargement carries a low risk for malignancy [28,29]. In a retrospective review of 53 patients who underwent tonsillectomy for unilateral tonsillar enlargement, malignancy was identified in 9 of 20 patients with symptoms or additional findings, and 0 of 33 patients without such findings [28]. In most cases, asymmetric tonsils are due to benign factors such as anatomical variant, unequal scarring from infections, asymmetric lymphoid hyperplasia, or an illusion created by a difference in the depth of the tonsillar fossae.

For patients with tonsillar asymmetry but without any associated signs or symptoms of malignancy, evaluation by otolaryngology is appropriate, and may reveal lymphoma/lymphoproliferative disease, or other masses in the parapharyngeal space, which create the potential appearance of asymmetric tonsils. In addition to close clinical follow-up, imaging (eg, computed tomography [CT]) may be warranted for further evaluation.

Unknown (occult) primary — Tonsillectomy may be performed in patients with head and neck squamous cell carcinoma of unknown primary. (See "Head and neck squamous cell carcinoma of unknown primary", section on 'Staging surgical endoscopy'.)

Other

Obstructive sleep apnea — Tonsillar hypertrophy can cause and/or contribute to sleep-disordered breathing including obstructive sleep apnea [32]. For most adults, first-line treatment for obstructive sleep apnea is weight loss (if appropriate), sleep hygiene, and continuous positive airway pressure (CPAP). Tonsillectomy may be part of a surgical treatment protocol, usually combined with uvulopalatopharyngoplasty for patients who failed CPAP. (See "Obstructive sleep apnea: Overview of management in adults", section on 'Hypoglossal nerve surgery'.)

Halitosis — Most cases of chronic halitosis (bad breath) can be readily alleviated by simple measures (eg, proper dental care or treatment of acid reflux disease). We consider tonsillectomy for halitosis only in patients with documented malodorous tonsillar crypt stones and persistent symptoms despite conservative therapy with self-manual clearing of the crypts and optimal medical management for other likely etiologies of halitosis. Tonsillar crypt stones (tonsilloliths) are a rare cause of halitosis, occurring in about 3 percent of cases [33]. (See "Bad breath", section on 'Oral'.)

Some have cited chronic halitosis as an indication for tonsillectomy [34,35], but there are limited data to support this practice [4,36].

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: Tonsillectomy in adults" and "Society guideline links: Streptococcal tonsillopharyngitis".)

SUMMARY AND RECOMMENDATIONS

●Anatomy – Tonsils are lymphoid tissue covered by respiratory epithelium. The common term "tonsils" refers specifically to the palatine tonsils. (See 'Pharyngeal anatomy' above.)

●Criteria for surgery – Most adults with recurrent pharyngitis secondary to GAS infection do not require tonsillectomy. For adults who fit the Paradise criteria (three episodes yearly for ≥3 years; five episodes yearly for two years; or seven episodes in one year) and whose quality of life is affected significantly by recurrent acute pharyngitis secondary to GAS infection, we suggest tonsillectomy (Grade 2C). (See 'Criteria for surgery' above.)

●Other possible indications – Tonsillectomy is also indicated in rare cases of airway obstruction due to acute infection or when malignancy is suspected. Other possible indications include other chronic, recurrent infections unresponsive to other treatments, rare cases of obstructive sleep apnea, and refractory halitosis secondary to tonsillar crypt stones. Tonsillectomy is not indicated for the streptococcal carrier state. (See 'Other possible indications' above.)

●Outcomes – Tonsillectomy appears to be effective in the short term in decreasing the frequency of episodes of recurrent pharyngitis and in improving the quality of life of adults who suffer from the symptoms of chronic tonsillitis. Long-term follow-up data in adults are lacking. (See 'Recurrent and chronic pharyngotonsillitis' above.)