Tonsillectomy Indications
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Direct answer
Tonsillectomy is indicated when the tonsils cause recurrent, documented infections meeting the Paradise criteria (seven or more episodes in one year, five or more per year for two years, or three or more per year for three years), when they obstruct the airway in sleep-disordered breathing, when they harbour a peritonsillar abscess history or suspicion of malignancy, or when they drive complications such as PFAPA, tonsillolithiasis or diphtheria carriage. Absolute indications are few; the decision is a balance of episode frequency and severity, antibiotic courses missed from school or work, and obstruction. The operation itself — dissection tonsillectomy remains the standard technique in India, with coblation, electrocautery and harmonic scalpel as alternatives — carries a small but fixed bleeding risk that every candidate must articulate: primary or reactionary haemorrhage within the first 24 hours, and secondary haemorrhage around the fifth to tenth day when the slough separates, the latter managed as an emergency with readmission, theatre control and transfusion if needed.
What you must remember
- Paradise criteria for recurrent infection: at least 7 episodes in the preceding year, or 5 per year for 2 consecutive years, or 3 per year for 3 consecutive years — each episode documented with fever, cervical adenopathy, tonsillar exudate or a positive streptococcal culture.
- Obstructive indications now dominate paediatric lists: snoring with sleep-disordered breathing and OSA, failure to thrive and cor pulmonale in extreme cases.
- Quinsy (peritonsillar abscess): drained acutely, with interval tonsillectomy commonly offered weeks later, especially after recurrent quinsy; tonsillectomy is not performed in the acute, inflamed stage routinely.
- Oncological and unusual indications: unilateral tonsillar enlargement or gross asymmetry suspected of lymphoma, persistent tonsillolithiasis with halitosis, haemorrhagic tonsillitis, PFAPA syndrome refractory to medical care, and diphtheria carrier state unresponsive to treatment.
- Contraindications and cautions: acute tonsillitis (relative — infection increases bleeding and post-operative discomfort), uncorrected coagulopathy, uncontrolled systemic disease, and palatal insufficiency risk in submucous cleft palate (velopharyngeal insufficiency after removal).
- Techniques: cold steel dissection with ties or packs (traditional standard), electrocautery, coblation, harmonic scalpel, radiofrequency and (historically) the guillotine — each trading speed and pain against haemostasis and cost.
- Haemorrhage classification: primary/reactionary within 24 hours (slipped ligature, incomplete haemostasis) and secondary at 5–10 days (infected slough separating) — secondary bleeds can occur up to two weeks after surgery and are the classic readmission.
- Grisel syndrome — atlanto-axial rotatory subluxation after surgery presenting with torticollis and neck pain — and post-operative velopharyngeal insufficiency are the two non-bleeding complications examiners ask by name.
A typical exam case, decision to discharge
An 8-year-old has had "sore throat every month" for two years, each episode with fever above 38.5°C, tender neck nodes and pus on the tonsils, treated with repeated antibiotic courses; she snores heavily and her school report is falling. First, verify the counts against Paradise: her mother's diary shows six documented episodes in each of the last two years — meeting the "5 per year × 2 years" criterion — and her snoring with restless sleep adds an obstructive indication. Examine for obstruction (mouth breathing, adenoid facies, grade 3–4 tonsils) and check for relative contraindications (recent antibiotic course finished, no acute infection now, no bleeding history, no cleft or submucous cleft on oral examination and voice).
Counsel with the numbers that matter: pain for about a week controlled by paracetamol and ibuprofen, soft diet and fluids, no aspirin, and immediate return for any fresh bleeding — from the mouth or swallowed (vomited blood, swallowing frequency in a "watching the child swallow" child is a red flag). Operate by cold dissection with haemostasis by ties; the tonsil is dissected in the subcapsular plane out of the fossa, avoiding the musculature that causes pain and bleeding when violated.
Post-operative day 6, the child spits fresh blood at home: this is secondary haemorrhage — admit, keep nil by mouth, cross-match, and take to theatre for examination and diathermy or suture of the bleeding point under anaesthesia; a calm summary and antibiotics for the infected slough. Had the bleed occurred within 24 hours, the label would be reactionary haemorrhage with the same destination — theatre — after resuscitation. The discharge advice for both is the same: two weeks of avoidance of hard, hot food and strenuous activity.
How the exam frames it
Expect three formats. Numbers: the 7-5-3 Paradise counts, asked verbatim year after year, and the haemorrhage timing (primary within 24 hours, secondary at 5–10 days). Case-selection: quinsy management — the sequence is drainage plus antibiotics acutely, interval tonsillectomy weeks later; OSA in a child — adenotonsillectomy; unilateral tonsillar enlargement in an adult — think lymphoma, image and biopsy. Complications by name: secondary haemorrhage management, Grisel syndrome (torticollis after tonsillectomy from atlanto-axial rotatory subluxation), velopharyngeal insufficiency in the submucous cleft palate child, and dental or temporomandibular injury from the gag. A viva favourite asks why tonsillectomy is avoided during acute infection — increased bleeding and a hostile, inflamed field.
Frequently asked questions
What are the Paradise criteria for tonsillectomy?
Seven or more documented episodes of tonsillitis in one year, five per year for two successive years, or three per year for three successive years, with each episode supported by fever, cervical adenopathy, exudate or positive culture.
How are primary and secondary post-tonsillectomy haemorrhage defined and managed?
Primary (reactionary) bleeding occurs within 24 hours and secondary at 5–10 days from slough separation; both need readmission, resuscitation and theatre control of the bleeding point, with transfusion as indicated.
How is a peritonsillar abscess (quinsy) managed, and what is the role of tonsillectomy?
Acute drainage — needle aspiration or incision — with antibiotics and analgesia; interval tonsillectomy weeks later, particularly after recurrent quinsy, since operating in the acute inflamed stage is avoided.
Which children are at risk of velopharyngeal insufficiency after tonsillectomy?
Those with overt, submucous or occult cleft palate — screening the palate and voice before surgery prevents this hypernasal speech complication.
What is Grisel syndrome?
Atlanto-axial rotatory subluxation presenting as torticollis and neck pain after tonsillectomy or pharyngeal surgery, treated with analgesia, muscle relaxants and immobilisation.