Guidelines Summary

American Academy of Otolaryngology-Head and Neck Surgery Foundation (AAO-HNS)

The 2011 update of guidelines developed by the American Academy of Otolaryngology-Head and Neck Surgery Foundation (AAO-HNS) provides evidence-based recommendations on the pre-, intra-, and postoperative care and management of children 1 to 18 years of age under consideration for tonsillectomy.^[26]

The group's recommendations include, among others:

Clinicians should recommend watchful waiting for recurrent throat infection if there have been < 7 episodes in the past year, < 5 episodes per year in the past 2 years, or < 3 episodes per year in the past 3 years.
Clinicians should administer a single intraoperative dose of intravenous dexamethasone to children undergoing tonsillectomy.
Clinicians should recommend ibuprofen, acetaminophen, or both for pain control after tonsillectomy.
Clinicians should not administer or prescribe perioperative antibiotics to children undergoing tonsillectomy.
Clinicians must not administer or prescribe codeine, or any medication containing codeine, after tonsillectomy in children younger than 12 years.

Medication

Šumilo D, Nichols L, Ryan R, Marshall T. Incidence of indications for tonsillectomy and frequency of evidence-based surgery: a 12-year retrospective cohort study of primary care electronic records. Br J Gen Pract. 2019 Jan. 69 (678):e33-e41. [QxMD MEDLINE Link].
Gabriel P, Mazoit X, Ecoffey C. Relationship between clinical history, coagulation tests, and perioperative bleeding during tonsillectomies in pediatrics. J Clin Anesth. 2000 Jun. 12(4):288-91. [QxMD MEDLINE Link].
Fujikawa S, Hanawa Y, Ito H, Ohkuni M, Todome Y, Ohkuni H. Streptococcal antibody: as an indicator of tonsillectomy. Acta Otolaryngol Suppl. 1988. 454:286-91. [QxMD MEDLINE Link].
Carr MM, Williams JG, Carmichael L, Nasser JG. Effect of steroids on posttonsillectomy pain in adults. Arch Otolaryngol Head Neck Surg. 1999 Dec. 125(12):1361-4. [QxMD MEDLINE Link].
Ozcan M, Altuntas A, Unal A, Nalca Y, Aslan A. Sucralfate for posttonsillectomy analgesia. Otolaryngol Head Neck Surg. 1998 Dec. 119(6):700-4. [QxMD MEDLINE Link].
Carr MM, Muecke CJ, Sohmer B, Nasser JG, Finley GA. Comparison of postoperative pain: tonsillectomy by blunt dissection or electrocautery dissection. J Otolaryngol. 2001 Feb. 30(1):10-4. [QxMD MEDLINE Link].
Pizzuto MP, Brodsky L, Duffy L, Gendler J, Nauenberg E. A comparison of microbipolar cautery dissection to hot knife and cold knife cautery tonsillectomy. Int J Pediatr Otorhinolaryngol. 2000 May 30. 52(3):239-46. [QxMD MEDLINE Link].
Lee KC, Bent JP 3rd, Dolitsky JN, Hinchcliffe AM, Mansfield EL, White AK. Surgical advances in tonsillectomy: report of a roundtable discussion. Ear Nose Throat J. 2004 Aug. 83(8 Suppl 3):4-13; quiz 14-5. [QxMD MEDLINE Link].
Nelson LM. Radiofrequency treatment for obstructive tonsillar hypertrophy. Arch Otolaryngol Head Neck Surg. 2000 Jun. 126(6):736-40. [QxMD MEDLINE Link].
Sutters KA, Miaskowski C, Holdridge-Zeuner D, Waite S, Paul SM, Savedra MC, et al. A randomized clinical trial of the efficacy of scheduled dosing of acetaminophen and hydrocodone for the management of postoperative pain in children after tonsillectomy. Clin J Pain. 2010 Feb. 26(2):95-103. [QxMD MEDLINE Link].
Telian SA, Handler SD, Fleisher GR, Baranak CC, Wetmore RF, Potsic WP. The effect of antibiotic therapy on recovery after tonsillectomy in children. A controlled study. Arch Otolaryngol Head Neck Surg. 1986 Jun. 112(6):610-5. [QxMD MEDLINE Link].
Colreavy MP, Nanan D, Benamer M, et al. Antibiotic prophylaxis post-tonsillectomy: is it of benefit?. Int J Pediatr Otorhinolaryngol. 1999 Oct 15. 50(1):15-22. [QxMD MEDLINE Link].
Rakover Y, Almog R, Rosen G. The risk of postoperative haemorrhage in tonsillectomy as an outpatient procedure in children. Int J Pediatr Otorhinolaryngol. 1997 Jul 18. 41(1):29-36. [QxMD MEDLINE Link].
Randall DA, Hoffer ME. Complications of tonsillectomy and adenoidectomy. Otolaryngol Head Neck Surg. 1998 Jan. 118(1):61-8. [QxMD MEDLINE Link].
De Luca Canto G, Pacheco-Pereira C, Aydinoz S, et al. Adenotonsillectomy Complications: A Meta-analysis. Pediatrics. 2015 Oct. 136 (4):702-18. [QxMD MEDLINE Link].
Henderson D. One fifth of kids have complication after tonsillectomy. Medscape Medical News. Sep 23, 2015. [Full Text].
Steward DL, Grisel J, Meinzen-Derr J. Steroids for improving recovery following tonsillectomy in children. Cochrane Database Syst Rev. 2011 Aug 10. CD003997. [QxMD MEDLINE Link].
van Staaij BK, van den Akker EH, van der Heijden GJ, Schilder AG, Hoes AW. Adenotonsillectomy for upper respiratory infections: evidence based?. Arch Dis Child. 2005 Jan. 90(1):19-25. [QxMD MEDLINE Link].
Paradise JL, Bluestone CD, Bachman RZ, et al. Efficacy of tonsillectomy for recurrent throat infection in severely affected children. Results of parallel randomized and nonrandomized clinical trials. N Engl J Med. 1984 Mar 15. 310(11):674-83. [QxMD MEDLINE Link].
Richtsmeier WJ, Shikhani AH. The physiology and immunology of the pharyngeal lymphoid tissue. Otolaryngol Clin North Am. 1987 May. 20(2):219-28. [QxMD MEDLINE Link].
Tauman R, Gulliver TE, Krishna J, et al. Persistence of obstructive sleep apnea syndrome in children after adenotonsillectomy. J Pediatr. 2006 Dec. 149(6):803-8. [QxMD MEDLINE Link].
Lam YY, Chan EY, Ng DK, et al. The correlation among obesity, apnea-hypopnea index, and tonsil size in children. Chest. 2006 Dec. 130(6):1751-6. [QxMD MEDLINE Link].
Galland BC, Dawes PJ, Tripp EG, Taylor BJ. Changes in behavior and attentional capacity after adenotonsillectomy. Pediatr Res. 2006 May. 59(5):711-6. [QxMD MEDLINE Link].
Maclean JE, Waters K, Fitzsimons D, Hayward P, Fitzgerald DA. Screening for obstructive sleep apnea in preschool children with cleft palate. Cleft Palate Craniofac J. 2009 Mar. 46(2):117-23. [QxMD MEDLINE Link].
Simonsen AR, Duncavage JA, Becker SS. A review of malpractice cases after tonsillectomy and adenoidectomy. Int J Pediatr Otorhinolaryngol. 2010 Sep. 74(9):977-9. [QxMD MEDLINE Link].
Mitchell RB, Archer SM, Ishman SL, Rosenfeld RM, Coles S, Finestone SA, et al. Clinical Practice Guideline: Tonsillectomy in Children (Update)-Executive Summary. Otolaryngol Head Neck Surg. 2019 Feb. 160 (2):187-205. [QxMD MEDLINE Link].
Van Cleve WC. Pediatric Posttonsillectomy Analgesia Before and After the Black Box Warning Against Codeine Use. JAMA Otolaryngol Head Neck Surg. July, 2017. 20:[QxMD MEDLINE Link].
Fowler RH. The rise of the tonsil operation. Tonsil Surgery: Based on a Study of the Anatomy. Philadelphia: FA Davis Co; 1931. 54-60.
US Food and Drug Administration. FDA Drug Safety Communication: Codeine use in certain children after tonsillectomy and/or adenoidectomy may lead to rare, but life threatening adverse events or death. Available at http://www.fda.gov/Drugs/DrugSafety/ucm313631.htm. Accessed: March 27, 2013.

Media Gallery

Typical appearance on the morning after tonsillectomy, which was performed by using a blunt dissection method.
Tonsillectomy performed with the cautery technique. A Colorado needle-tip bovie is used to dissect the tonsil from its underlying muscular bed.
A suction bovie is used to achieve hemostasis. Ideally, the least amount of cautery necessary for hemostasis is used. Staying in the proper dissection plane limits the amount of bleeding, and possibly postoperative pain.

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Author

Amelia F Drake, MD ND Fischer Distinguished Professor of Otolaryngology, Executive Associate Dean of Academic Programs, Director, Craniofacial Center, Department of Otolaryngology-Head and Neck Surgery, University of North Carolina at Chapel Hill School of Medicine

Amelia F Drake, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Otolaryngology-Head and Neck Surgery, American Cleft Palate-Craniofacial Association, American Society of Pediatric Otolaryngology, North Carolina Medical Society

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Chief Editor

Arlen D Meyers, MD, MBA Emeritus Professor of Otolaryngology, Dentistry, and Engineering, University of Colorado School of Medicine

Arlen D Meyers, MD, MBA is a member of the following medical societies: American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, American Head and Neck Society

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Cerescan; Neosoma; MI10;<br/>Received income in an amount equal to or greater than $250 from: Neosoma; Cyberionix (CYBX)<br/>Received ownership interest from Cerescan for consulting for: Neosoma, MI10 advisor.

Additional Contributors

Michele M Carr, DDS, MD, PhD, MEd Professor, Department of Otolaryngology-Head and Neck Surgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo

Michele M Carr, DDS, MD, PhD, MEd is a member of the following medical societies: American Academy of Otolaryngology-Head and Neck Surgery

Disclosure: Nothing to disclose.

Acknowledgements

Ari J Goldsmith, MD Chief of Pediatric Otolaryngology, Long Island College Hospital; Associate Professor, Department of Otolaryngology, Division of Pediatric Otolaryngology, State University of New York Downstate Medical Center

Ari J Goldsmith, MD is a member of the following medical societies: American Academy of Otolaryngology-Head and Neck Surgery, American Medical Association, and Medical Society of the State of New York

Disclosure: Nothing to disclose.

Acknowledgments

Medscape Reference thanks Vijay R Ramakrishnan, MD, Assistant Professor, Department of Otolaryngology, University of Colorado School of Medicine, for the videos in this article.

Tonsillectomy Guidelines

Guidelines Summary

American Academy of Otolaryngology-Head and Neck Surgery Foundation (AAO-HNS)

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