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Tonsillitis Surgery: When is a Tonsillectomy Necessary?

Tonsillectomy remains one of the most common pediatric surgeries, but indications have narrowed significantly. Current guidelines emphasize evidence-based criteria over historical practice.

Evidence-Based Indications (AAO-HNS / Paradise Criteria)

Recurrent Tonsillitis (Absolute Indications)

Frequency	Duration	Documentation Required
≥7 episodes	1 year	Each: fever >38.3°C, adenopathy, exudate, +GABHS
≥5 episodes/year	2 years	Same documentation
≥3 episodes/year	3 years	Same documentation

Paradise criteria (NEJM 1984, validated): sore throat + ≥1: temp >38.3°C, cervical adenopathy, tonsillar exudate, +GABHS culture

Relative Indications (Individualized)

Chronic/recurrent tonsillitis not meeting Paradise criteria but significant morbidity
Peritonsillar abscess: Quinsy; drainage + interval tonsillectomy (6-12 wks) or acute (controversial)
Obstructive sleep-disordered breathing: Snoring, witnessed apneas, gasping; AHI >1-5 on PSG
Tonsillar hypertrophy causing: Dysphagia, failure to thrive, speech articulation issues, dental malocclusion
Asymmetric tonsils: Neoplasm concern (lymphoma, carcinoma) — adult > pediatric
Halitosis/tonsilloliths: Refractory to conservative management
PFAPA syndrome: Periodic fever, aphthous stomatitis, pharyngitis, adenitis — tonsillectomy curative

Contraindications / Cautions

Bleeding diathesis (uncorrected)
Acute infection (operate 2-4 weeks post-resolution)
Uncontrolled medical disease
Cleft palate / submucous cleft (velopharyngeal insufficiency risk)
Age <3 years (higher complication rate; airway risk)

Surgical Techniques

Postoperative Care Essentials

Hydration: #1 priority — prevents bleeding, dehydration, readmission
Pain control: Scheduled acetaminophen + ibuprofen; opioid PRN breakthrough
Diet: Soft, cool; advance as tolerated; avoid citrus, spicy, sharp
Activity: Rest 7-10 days; no heavy exertion 2 weeks
Bleeding: Primary (<24h) or delayed (5-10 days) — ER immediately if >2 tbsp bright red

Shared Decision-Making

Discuss: natural history without surgery, realistic expectations (not "never sore throat again"), technique options, surgeon experience, family/school logistics. Tonsillectomy improves quality of life for appropriate candidates — not all sore throats warrant surgery.

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Method	Mechanism	Pain	Bleeding	Recovery
Cold steel (dissection)	Scalpel, scissors, snare	Moderate	Low primary	7-10 days
Electrocautery (monopolar/bipolar)	Cut + coagulate	More	Low primary	7-10 days
Coblation	Radiofrequency plasma (40-70°C)	Less	Slightly higher delayed	5-7 days
Microdebrider	Powered shaver	Less	Low	5-7 days
Laser (CO₂, KTP)	Vaporization	Variable	Low	Variable