Tonsillectomy

The problem being fixed

Tonsillectomy is performed for two main indications, which carry different evidence and different post-operative risks.

• Recurrent throat infection. Benefit depends on how often infections occur. The American Academy of Otolaryngology–Head and Neck Surgery Foundation guideline recommends watchful waiting unless episodes meet the Paradise criteria: at least seven documented episodes in the past year, five a year for two years, or three a year for three years, each with features such as temperature above 38.3 °C, tender cervical lymph nodes, tonsillar exudate or a positive group A streptococcus test.^1,2
• Obstructive sleep-disordered breathing. In children, enlarged tonsils and adenoids are the commonest cause of obstructive sleep apnoea (OSA), and adenotonsillectomy is first-line treatment for a child with OSA and enlarged tonsils.^1,3 It is now the more common indication in children.

Less common indications include recurrent peritonsillar abscess (quinsy), an asymmetric tonsil where malignancy must be excluded, and, in adults, large tonsils contributing to OSA.

What the operation involves

The tonsils are removed through the mouth under general anaesthetic, usually as day surgery or with one night in hospital. In children with sleep apnoea the adenoids are usually removed at the same time — see Adenoidectomy.

• Extracapsular (total) tonsillectomy removes the tonsil with its capsule, by cold-steel dissection or with heat-based instruments such as diathermy or coblation.
• Intracapsular tonsillectomy (tonsillotomy) removes most of the tonsil but leaves a thin layer of tissue over the capsule. In children with sleep-disordered breathing it causes less pain and allows a faster return to normal diet and activity than total tonsillectomy; the evidence on bleeding is of low certainty, and a small proportion of tonsils regrow.⁴

The guideline recommends a single intra-operative dose of intravenous dexamethasone and advises against routine peri-operative antibiotics. Pain relief is paracetamol and ibuprofen, taken regularly. Codeine must not be given to children under 12, because ultra-rapid metabolisers can develop fatal respiratory depression.¹

Who benefits — and what the evidence shows

Recurrent tonsillitis

In severely affected children who met the Paradise criteria, tonsillectomy reduced throat infections over the first two years, although many children in the control group also improved.² The Cochrane review found that children had about one fewer episode of sore throat in the first year after surgery, including the painful sore throat of the operation itself, with smaller benefit in children who were less severely affected.⁵ In adults, the NATTINA trial randomised 453 people with recurrent acute tonsillitis to immediate tonsillectomy or conservative management; over 24 months the surgical group had fewer sore-throat days (median 9 against 30).⁶

Sleep-disordered breathing

The Childhood Adenotonsillectomy Trial (CHAT) randomised 464 children aged 5 to 9 with OSA, excluding severe disease, to early adenotonsillectomy or watchful waiting for seven months. Attention and executive function did not differ, but surgery improved behaviour, symptoms, quality of life and sleep-study results; the sleep study normalised in 79% of children after surgery and in 46% with watchful waiting.⁷ The Pediatric Adenotonsillectomy Trial for Snoring (PATS) randomised 459 children aged 3 to 12 with snoring and mild OSA; at 12 months executive function again did not differ, while behaviour, sleepiness, symptoms and quality of life improved after surgery.⁸ The Cochrane review reaches the same conclusion: benefit for symptoms, quality of life and sleep studies, and uncertain benefit for cognition.⁹

Two lessons follow. Many children with mild disease improve without surgery, so watchful waiting is a reasonable choice for some families. And surgery does not resolve sleep apnoea in every child: in a large multicentre series only 27% of children had a fully normal sleep study after adenotonsillectomy, and obesity, age over 7, asthma and severe disease at baseline predicted residual OSA.¹⁰

The two serious risks

Physiotherapy around tonsillectomy

The operation itself is not a physiotherapy procedure, but many of the people who have it are physiotherapy clients: children with OSA referred for sleep assessment, children with neuromuscular disease or cerebral palsy whose airway clearance is already fragile, and adults living with obesity and sleep apnoea.

Before surgery

• Flag the high-risk child. Obesity, neuromuscular weakness, Down syndrome, craniofacial differences or severe OSA change the post-operative plan, and the physiotherapist who knows the child is often well placed to raise them.
• Record a baseline for children with neuromuscular disease: cough strength, the usual airway clearance routine and any home ventilation, so the ward team know what normal looks like.
• Set expectations with the family about pain, eating and drinking, and the return to school and sport.

After surgery

• Position and monitor high-risk children. Side-lying or head-up positioning while drowsy, with continuous oximetry overnight for children in the high-risk group.
• Airway clearance only when it is indicated. Routine chest physiotherapy is not needed. A child with a weak cough, neuromuscular disease or existing lung disease may need the usual regimen restarted early; avoid suctioning into the tonsil beds.
• Encourage drinking and normal food. Pain, dehydration and bleeding are the main reasons for readmission, and regular fluids help with the first two.
• Grade the return to activity. Walking and quiet play from the first day. Most children return to school or childcare after 10 to 14 days and avoid vigorous sport, contact games and swimming for about two weeks, or as the surgeon advises. Adults usually need about two weeks off work.

When sleep apnoea persists

• Reassess. A child whose snoring, witnessed pauses or daytime symptoms continue once healing is complete needs review, and polysomnography after surgery is advised for children at high risk.³
• Treat the contributors. Supervised exercise and family-based lifestyle change for children and adults living with obesity, and treatment of allergic rhinitis — see Rhinitis.
• Support CPAP where residual OSA is treated with it, with mask fitting and adherence support — see NIV (CPAP & BiPAP).
• Consider myofunctional therapy as an adjunct. Oropharyngeal exercises roughly halved the apnoea–hypopnoea index in adults in a meta-analysis; evidence in children is limited to small studies.¹²

Role of the physiotherapist

Know which child is at high risk before the anaesthetic, and say so. After surgery, protect the airway of a child with a weak cough without disturbing the tonsil beds, encourage fluids and movement, and give families the bleeding advice in plain words. Then follow the sleep: a child who still snores once healed has not finished treatment. See also Obstructive Sleep Apnoea.

References & evidence base

1. Mitchell RB, Archer SM, Ishman SL, et al. Clinical practice guideline: tonsillectomy in children (update). Otolaryngol Head Neck Surg 2019;160(1 Suppl):S1–S42.
2. 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;310(11):674–683.
3. Marcus CL, Brooks LJ, Draper KA, et al; American Academy of Pediatrics. Diagnosis and management of childhood obstructive sleep apnea syndrome. Pediatrics 2012;130(3):576–584.
4. Blackshaw H, Springford LR, Zhang LY, et al. Tonsillectomy versus tonsillotomy for obstructive sleep-disordered breathing in children. Cochrane Database Syst Rev 2020;(4):CD011365.
5. Burton MJ, Glasziou PP, Chong LY, Venekamp RP. Tonsillectomy or adenotonsillectomy versus non-surgical treatment for chronic/recurrent acute tonsillitis. Cochrane Database Syst Rev 2014;(11):CD001802.
6. Wilson JA, O’Hara J, Fouweather T, et al. Conservative management versus tonsillectomy in adults with recurrent acute tonsillitis in the UK (NATTINA): a multicentre, open-label, randomised controlled trial. Lancet 2023;401(10393):2051–2059.
7. Marcus CL, Moore RH, Rosen CL, et al; Childhood Adenotonsillectomy Trial (CHAT). A randomized trial of adenotonsillectomy for childhood sleep apnea. N Engl J Med 2013;368(25):2366–2376.
8. Redline S, Cook K, Chervin RD, et al; Pediatric Adenotonsillectomy Trial for Snoring (PATS) Investigators. Adenotonsillectomy for snoring and mild sleep apnea in children: a randomized clinical trial. JAMA 2023;330(21):2084–2095.
9. Venekamp RP, Hearne BJ, Chandrasekharan D, et al. Tonsillectomy or adenotonsillectomy versus non-surgical management for obstructive sleep-disordered breathing in children. Cochrane Database Syst Rev 2015;(10):CD011165.
10. Bhattacharjee R, Kheirandish-Gozal L, Spruyt K, et al. Adenotonsillectomy outcomes in treatment of obstructive sleep apnea in children: a multicenter retrospective study. Am J Respir Crit Care Med 2010;182(5):676–683.
11. Royal College of Surgeons of England. National Prospective Tonsillectomy Audit: final report of an audit carried out in England and Northern Ireland between July 2003 and September 2004. London: RCS; 2005.
12. Camacho M, Certal V, Abdullatif J, et al. Myofunctional therapy to treat obstructive sleep apnea: a systematic review and meta-analysis. Sleep 2015;38(5):669–675.

References are numbered in citation order (Vancouver/BMJ style) and were current at the time of writing. Guidelines are living documents — verify against the latest version before clinical use.