Guideline sources The following summarized guidelines for the evaluation and management of tonsillectomy are prepared by our editorial team based on guidelines from the British Thoracic Society (BTS 2023), the Kidney Disease: Improving Global Outcomes Foundation (KDIGO 2021), the American Academy of Otolaryngology-Head and Neck Surgery Foundation (AAO-HNSF 2019; 2011), the Danish Health Authority (DHA 2016), the Japanese Society of Nephrology (JSN 2016), and the Infectious Diseases Society of America (IDSA 2012). 1 2 3 4 5 6 7 Guidelines 1. Diagnostic investigations Sleep questionnaires: consider using sleep questionnaires combined with clinical examination to identify moderate or severe sleep-disordered breathing in pediatric patients to help decide on pursuing tonsillectomy to improve the airway. E Assessment of comorbidities: assess for comorbid conditions that may improve after tonsillectomy, including growth retardation, poor school performance, enuresis, asthma and behavioral problems in pediatric patients with sleep-disordered breathing and tonsillar hypertrophy. B Preoperative polysomnography: https://web.pathway.md/diseases/recUJKWDF5lJgoNvu 1/5 6/24/23, 4:06 PM Tonsillectomy Pathway As per BTS 2023 guidelines, do not obtain routine preoperative sleep monitoring for surgical decision-making in > 2 years old pediatric patients without comorbidities and if severe obstructive sleep apnea is not suspected. D Show 2 more As per AAO-HNSF 2019 guidelines, obtain polysomnography before tonsillectomy in pediatric patients with obstructive sleep-disordered breathing in case of any of the following, or without any of the following if the need for tonsillectomy is uncertain or if there is a discordance between physical examination and the reported severity of obstructive sleep-disordered breathing: < 2 years of age obesity down syndrome craniofacial abnormalities neuromuscular disorders sickle cell disease mucopolysaccharidoses. B As per AAO-HNSF 2011 guidelines: Inform the anesthesiologist about polysomnography results before induction of anesthesia for tonsillectomy in pediatric patients with sleep-disordered breathing. B Obtain laboratory-based polysomnography, if available, before tonsillectomy if polysomnography is indicated to assess sleep-disordered breathing. B Preoperative overnight pulse oximetry: consider obtaining a preoperative pulse oximetry sleep study before tonsillectomy (with or without adenoidectomy) in pediatric patients without comorbidities and with suspected severe obstructive sleep apnea. E 2. Perioperative care Perioperative antibiotics: do not administer perioperative antibiotics in pediatric patients undergoing tonsillectomy. D Intraoperative corticosteroids: administer a single intraoperative dose of intrevousely dexamethasone in pediatric patients undergoing tonsillectomy. B Postoperative inpatient monitoring: obtain overnight, inpatient monitoring in pediatric patients after tonsillectomy if they are < 3 years of age or have severe obstructive sleep apnea (apnea- hypopnea index 10 obstructive events/hour, oxygen saturation nadir < 80% or both). B Postoperative pain management: As per AAO-HNSF 2019 guidelines: Offer ibuprofen, acetaminophen, or both, for pain control after tonsillectomy. B Do not administer codeine or any medication containing codeine after tonsillectomy in < 12 years old pediatric patients. D https://web.pathway.md/diseases/recUJKWDF5lJgoNvu 2/5 6/24/23, 4:06 PM Tonsillectomy Pathway As per DHA 2016 guidelines, consider offering acetaminophen or NSAIDs, supplemented with opioids if needed, for postoperative pain management in adult and adolescent (> 12 years) patients. E 3. Surgical interventions Setting of care: consider performing tonsillectomy as outpatient surgery in adult and older pediatric (> 4 years or > 20 kg) patients. E Indications for tonsillectomy, recurrent throat infections: As per AAO-HNSF 2019 guidelines, offer watchful waiting for recurrent throat infection if there have been: < 7 episodes in the past year < 5 episodes/year in the past 2 years < 3 episodes/year in the past 3 years. B Show 2 more As per DHA 2016 guidelines, consider performing tonsillectomy in adult and adolescent ( 15 years) patients with recurrent acute tonsillitis meeting the established criteria. C Show 2 more As per IDSA 2012 guidelines, do not perform tonsillectomy solely to reduce the frequency of group A streptococcus pharyngitis. D Indications for tonsillectomy, IgA nephropathy: As per KDIGO 2021 guidelines: Do not perform tonsillectomy for the treatment of IgA nephropathy in Caucasian patients. Consider performing tonsillectomy in Japanese patients. D Consider performing tonsillectomy for the treatment of recurrent tonsillitis in patients with IgA nephropathy. C As per JSN 2016 guidelines, consider performing tonsillectomy, with or without corticosteroid pulse therapy, to improve urinary findings and slow the progression of renal dysfunction in patients with IgA nephropathy. Consider performing tonsillectomy also as a treatment option. C Indications for tonsillectomy, sleep-disordered breathing: As per AAO-HNSF 2019 guidelines, perform tonsillectomy in pediatric patients with obstructive sleep apnea documented by overnight polysomnography. B As per DHA 2016 guidelines, consider performing tonsillectomy in < 12 years old pediatric patients with sleep-disordered breathing and tonsillar hypertrophy. C Indications for tonsillectomy (obstructive symptoms): Avoid performing tonsillectomy/tonsillotomy routinely in < 12 years old pediatric patients with tonsillar hypertrophy and solely difficulty swallowing and/or speaking. D Consider performing tonsillotomy over tonsillectomy in < 12 years old pediatric patients with obstructive symptoms and tonsillar hypertrophy. C https://web.pathway.md/diseases/recUJKWDF5lJgoNvu 3/5 6/24/23, 4:06 PM Tonsillectomy Pathway 4. Patient education Patient education: Counsel pediatric patients and caregivers and explain that obstructive sleep-disordered breathing may persist or recur after tonsillectomy and may require further management. B Counsel pediatric patients and caregivers regarding the importance of managing post- tonsillectomy pain as part of the perioperative education process and reinforce the counseling at the time of surgery with reminders about the need to anticipate, reassess, and adequately treat pain after surgery. B 5. Follow-up and surveillance Postoperative assessment of bleeding: Follow-up pediatric patients and caregivers after tonsillectomy and document the presence or absence of bleeding within 24 hours of surgery (primary bleeding) and bleeding occurring > 24 hours after surgery (secondary bleeding) in the medical record. B Determine the rate of primary and secondary post-tonsillectomy bleeding at least annually. B Postoperative polysomnography: consider obtaining sleep monitoring following tonsillectomy (with or without adenoidectomy) in pediatric patients with severe obstructive sleep apnea, with or without comorbidities, if there is a clinical indication (such as < 2 years of age, Down syndrome, obesity, cerebral palsy, neuromuscular disease). E References 1. Danish Health Authority. National clinical guideline for the removal of tonsils (tonsillectomy). Sundhedsstyrelsen. 2016 Jun. Open 2. Hazel J Evans, Neil A Gibson, Joanna Bennett et al. British Thoracic Society guideline for diagnosing and monitoring paediatric sleep-disordered breathing. Thorax. 2023 Jun;78 Suppl 2):s1-s27. Open 3. Mitchell RB, Archer SM, Ishman SL et al. Clinical Practice Guideline: Tonsillectomy in Children Update). Otolaryngol Head Neck Surg. 2019 Feb;160 1_suppl):S1 S42. Open 4. Shulman ST, Bisno AL, Clegg HW et al. Clinical practice guideline for the diagnosis and management of group A streptococcal pharyngitis: 2012 update by the Infectious Diseases Society of America. Clin Infect Dis. 2012 Nov 15;55 10 1279 82. Open 5. Kidney Disease: Improving Global Outcomes KDIGO Glomerular Diseases Work Group. KDIGO 2021 Clinical Practice Guideline for the Management of Glomerular Diseases. Kidney Int. 2021 Oct;100 4S S1 S276. Open 6. Peter S Roland, Richard M Rosenfeld, Lee J Brooks et al. Clinical practice guideline: Polysomnography for sleep-disordered breathing prior to tonsillectomy in children. Otolaryngol Head Neck Surg. 2011 Jul;145 1 Suppl):S1 15. Open https://web.pathway.md/diseases/recUJKWDF5lJgoNvu 4/5 6/24/23, 4:06 PM Tonsillectomy Pathway 7. Yuzawa Y, Yamamoto R, Takahashi K et al. Evidence-based clinical practice guidelines for IgA nephropathy 2014. Clin Exp Nephrol. 2016 Aug;20 4 511 535. Open https://web.pathway.md/diseases/recUJKWDF5lJgoNvu 5/5