The decision whether to refer a child for tonsillectomy is one of the more common dilemmas in paediatric primary care. Parents are usually certain after a year of repeated tonsillitis episodes that surgery is the right thing, but NICE criteria require a specific threshold — and the evidence is clear that most children who have frequent tonsillitis reduce in frequency naturally over time, regardless of surgery.
The surgery is not risk-free. Post-tonsillectomy haemorrhage (bleeding after the operation) occurs in around 2 to 5 per cent of cases, is occasionally severe, and requires emergency re-operation in a small proportion. This is not a reason to avoid surgery when it is indicated, but it is a reason for the criteria to be applied thoughtfully rather than reflexively.
Healthbooq (healthbooq.com) covers common surgical procedures and ENT health in children.
The Tonsils and Adenoids
The tonsils are two pads of lymphoid tissue on either side of the back of the throat, visible when the mouth is open. The adenoids are a similar mass of lymphoid tissue at the back of the nose, above the soft palate — not visible without a scope. Both are part of Waldeyer's ring of lymphoid tissue, which guards the entrance to the upper airways and digestive tract.
This lymphoid tissue is most active in early childhood and naturally involutes (shrinks) from around age seven or eight onwards. Many children who have significant tonsil or adenoid problems in early childhood find the situation improves naturally by the time they approach adolescence.
Recurrent Tonsillitis
Tonsillitis — infection and inflammation of the tonsils — is common in children. The throat is red, the tonsils enlarged and often coated with exudate, and the child has fever, difficulty swallowing, and cervical lymphadenopathy. Most tonsillitis is viral; Group A Streptococcus accounts for around 30 per cent of bacterial cases.
NICE guidance (NG34) recommends considering a specialist referral for tonsillectomy when the Paradise criteria are met:
Seven or more episodes of sore throat in the preceding 12 months, or five or more per year for two years, or three or more per year for three years. The episodes must be disabling enough to prevent normal functioning.
These criteria are minimum thresholds for referral, not automatic indications for surgery. An ENT specialist will take a full history, assess severity, and balance the benefits of surgery against the natural history of the condition and the risks of the procedure.
Peritonsillar Abscess
A peritonsillar abscess (quinsy) — a collection of pus between the tonsil and the surrounding muscle — is an indication for tonsillectomy after a second episode. A single quinsy does not automatically result in a surgical recommendation, though practice varies.
Obstructive Symptoms
Enlarged tonsils and adenoids are the most common cause of sleep-disordered breathing and obstructive sleep apnoea in children (see the related article on snoring and sleep apnoea). For children with OSA confirmed by overnight oximetry, adenotonsillectomy is the first-line treatment. In this context, the operation is indicated not by recurrent infection but by airway obstruction.
Adenoidectomy alone may be recommended for chronic nasal obstruction, chronic rhinorrhoea, or adenoid facies (mouth breathing, nasal voice, and facial changes from persistent nasal obstruction). Adenoidectomy also reduces the need for repeat grommets in children with recurrent otitis media with effusion.
The Operation
Tonsillectomy in children is almost always performed under general anaesthetic as a day case, though some children stay overnight for monitoring. The tonsils are removed by dissection, with bipolar diathermy (heat sealing) being the most common technique. Cold steel dissection and coblation (radiofrequency ablation) are alternatives with slightly different bleed risk profiles.
Adenoidectomy is a brief additional procedure using a curette or suction diathermy to remove the adenoid tissue from the posterior nasopharynx.
Recovery
Recovery takes approximately seven to ten days. The throat is very sore and eating is painful — soft foods, regular analgesia (paracetamol and ibuprofen), and adequate fluid intake are the priorities. A white/grey coating forms in the throat where the tonsils were; this is normal healing tissue and should not be mistaken for infection.
The most important complication to be aware of is post-tonsillectomy haemorrhage. Primary haemorrhage occurs within 24 hours of surgery and is usually managed in hospital. Secondary haemorrhage occurs five to ten days after the operation when the scabs begin to separate. Any bleeding from the mouth or throat after tonsillectomy — including blood-stained saliva — should prompt immediate assessment at an emergency department. Significant secondary haemorrhage is a medical emergency.
Children should avoid school and busy places for two weeks to reduce infection risk. Vigorous physical activity should be avoided for the same period.
Key Takeaways
Tonsillectomy is one of the most commonly performed operations in children in the UK. NICE guidance (NG34, 2019) recommends considering tonsillectomy for recurrent sore throats when a child has had seven or more episodes in the preceding year, or five or more per year for two years, or three or more per year for three years (the Paradise criteria). Adenoidectomy is performed concurrently with tonsillectomy in most paediatric cases, or alone for adenoid-related problems such as chronic nasal obstruction or recurrent otitis media. Recovery takes one to two weeks and carries a small risk of secondary haemorrhage, which requires prompt hospital attendance.
