Practice Guidelines

Tonsillectomy in Children: AAO–HNS Updates Guideline


Am Fam Physician. 2019 Sep 1;100(5):316-317.

Author disclosure: No relevant financial affiliations.

Key Points for Practice

• Watchful waiting is recommended over tonsillectomy for recurrent throat infections in the absence of having seven infections in one year, five annually for two years, or three annually for three years.

• Physicians should ask about growth retardation, enuresis, asthma, poor school performance, or behavioral problems when considering tonsillectomy for obstructive sleep-disordered breathing.

• Polysomnography is recommended in patients with sleep-disordered breathing without comorbidities and in patients younger than two years or with specific disorders such as obesity, Down syndrome, or craniofacial disorders

From the AFP Editors

Tonsillectomy is one of the most common surgical procedures in the United States. It involves complete removal of each tonsil and capsule and is performed with or without adenoidectomy. The American Academy of Otolaryngology–Head and Neck Surgery (AAO–HNS) has updated its 2011 guideline on tonsillectomy indications and perioperative care in children one to 18 years of age.

The purpose of this update is to identify quality improvement opportunities in managing children undergoing tonsillectomy and to create clear and actionable recommendations to implement these opportunities into clinical practice based on more recent evidence. This guideline mainly addresses indications for tonsillectomy based on obstructive and infectious causes.

Tonsillectomy for Recurrent Throat Infections


Based on a systematic review of limited randomized controlled trials (RCTs) and observational studies showing benefit, watchful waiting is strongly recommended for recurrent throat infection if there have been less than seven episodes in the past year, five episodes per year for the past two years, or three episodes per year for the past three years.


Children with recurrent throat infection who meet the watchful waiting criteria but have certain modifying factors may benefit from tonsillectomy. These factors

Author disclosure: No relevant financial affiliations.

Coverage of guidelines from other organizations does not imply endorsement by AFP or the AAFP.

This series is coordinated by Sumi Sexton, MD, Editor-in-Chief.

A collection of Practice Guidelines published in AFP is available at



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