Tonsillectomy is effective in improving or resolving recurrent or chronic sore throat and sleep disordered breathing (SDB) in most children, with improved behavioral parameters, school performance, and quality of life in children after surgery. However, tonsillectomy as a surgical procedure has drawbacks, including hospitalization, anesthetic risks, intraoperative and postoperative complications, postoperative trauma pain, and corresponding economic costs. In January 2011, the American Academy of Otolaryngology Head and Neck Surgery published guidelines for tonsillectomy in children in its journal Otolaryngology Head Neck surg. (Note: SDB is the ENT term for what is commonly known in respiratory medicine as OSAHS, OSAS.) The guideline applies to children 1-18 years of age who are likely to need a tonsillectomy; it does not apply to children who have had a tonsillectomy, capsulotomy, or other partial tonsillectomy; and it does not apply to children who have had diabetes mellitus that precludes a tonsillectomy. The primary goal of this guideline is to provide clinicians with evidence-based practice guidelines for determining which children are best suited for surgery, and the secondary goal is to optimize the perioperative management of children undergoing tonsillectomy. The guideline encourages clinicians to evaluate children on an individual basis. Evidence-based recommendations for children with throat infections 1. Watchful waiting for children with frequent throat infections Clinicians should recommend watchful waiting for children who have had <7 throat infections in the past 1 year or an average of <5 throat infections per year in the past 2 and <3 throat infections per year in the past 2 and 3 years, respectively. Studies from randomized controlled trials have confirmed that the benefits of adopting watchful waiting in this situation outweigh the disadvantages. This is to avoid unnecessary interventions in children with recurrent throat infections, so that they have a good natural history and the potential to improve their quality of life without surgery. Watchful waiting means that the child should be closely monitored and the episodes of tonsillitis should be accurately recorded. Primary care physicians and the child's guardians should record and organize the child's history of throat infections and health history. Children with a history of less than 12 months should be observed for at least 12 months, as throat infections tend to resolve on their own after a history of more than 12 months, and until then, tonsillectomy should be used only as an intervention. However, tonsillectomy is not an absolute contraindication, and may be considered in children with recurrent severe infections requiring hospitalization, complications (e.g., peritonsillar abscess, family history of thrombophlebitis of the internal jugular vein, or rheumatic heart valve disease, or a significant number of recurrent infections), even if the history is less than 12 months. Surgery is not always indicated for children older than 12 months, but may not be necessary if the child improves during follow-up and no longer meets the Paradise criteria. Attachment: the Paradise criteria for tonsillectomy (1984). Include the following: 1. (1) Minimum frequency of episodes of pharyngolaryngeal infection equal to or greater than 7 occurrences during the past 1 year, or an average of ≥5 pharyngolaryngeal infections per year during the past 2 years, or an average of ≥3 pharyngolaryngeal infections per year during a 3-year question period; and (2) Clinical features that include a temperature of >38.3°C, enlarged cervical lymph nodes (lymph nodes >2 cm in diameter), or exudate from the tonsils, or A group B hemolytic streptococcus culture positive; (3) confirmed or suspected treatment with antibiotics in regular doses; (4) medical records of streptococcal infection with a medical record of clinical symptoms at the time of each infection; and, if no medical records were available, two subsequently observed episodes of throat infection with a history consistent with the clinical features. 2. Tonsillectomy was recommended for children with a medical record of frequent throat infections ￌ each episode of sore throat was medically documented and had one of the following findings: temperature >38.3°C, cervical lymphadenitis, pus spillage on the surface of the tonsils, or a positive test for group A β-hemolytic streptococcus, if at least 7 throat infections had occurred during the past 1 year or an average of at least 1 infection per year in the past 2 or 3 years, respectively. years, who have had an average of at least 5 or 3 throat infections per year, respectively, may be considered for tonsillectomy to treat recurrent throat infections. The recommendation is based on randomized controlled trials, and the benefits of surgical treatment outweigh the harms. It is important to ensure that the severity of disease in children with recurrent throat infections meets the description of the indication for surgery. It is incumbent on clinicians to accurately characterize the number of throat infections in an individual and to document the frequency of these events to aid in medical decision making for surgical treatment. However, many custodial patients may not visit a medical facility for every throat infection, and therefore the medical record is incomplete. However, even if the medical record is incomplete, the child should still be treated surgically as long as all other criteria for tonsillectomy are met. Tonsillectomy modifying factors for recurrent infectionsRandomized controlled trials have confirmed that children with recurrent throat infections who do not meet the above indications for tonsillectomy can still be treated with tonsillectomy as long as the following modifying factors are met. Modifying factors include: multiple antibiotic allergy and/or intolerance; periodic fever-aphthous stomatitis-pharyngitis-adenitissyndrome (PFAPA); and peritonsillar abscess. In children with multiple antibiotic allergies and/or intolerances, Paradise criteria for frequent throat infections, when met, are effective in reducing the number and extent of infections for at least 2 years after tonsillectomy. PFAPA and recurrent peritonsillar abscesses may be indications for tonsillectomy. The role of tonsillectomy in peritonsillar abscesses remains controversial, but the threshold for surgery for peritonsillar abscesses decreases when a child has recurrent pharyngeal infections or a history of previous pharyngeal infections; also the role of tonsillectomy in the treatment of streptococcal infection-associated autoimmune neuropsychiatric disorders in children is unproven. Impractical surgical indications for tonsillectomy include chronic tonsillitis, febrile convulsions, muffled speech, halitosis, malocclusion, enlarged tonsils, unexplained tonsillitis, or chronic throat infection. Clinicians should thoroughly evaluate the pros and cons of surgery before deciding whether to perform surgical treatment. Evidence-based recommendations for tonsillectomy in children with SDB The physician should ask the child’s guardian if the child has any comorbidities that could be improved by tonsillectomy, such as growth retardation, poor academic performance, enuresis, and behavioral problems. Based on observational studies from pre- and post-surgical clinics, the benefits of surgery outweigh the drawbacks, with the goal of helping clinicians and guardians make informed decisions about whether to perform tonsillectomy in children with SDB and emphasizing the importance of taking a history of comorbidities. SDB results in a range of outwardly abnormal behaviors (e.g., irritability, hyperactivity), inwardly abnormal behaviors (e.g., depression), poor academic performance, decreased quality of life, enuresis, and growth retardation. These concomitant symptoms improve or resolve in children with SDB after tonsillectomy, and biomarkers of height, body mass, and growth increase significantly, so factors such as sDB, secondary tonsillar and/or adenoidal hypertrophy should be taken into account when screening, diagnosing, and treating children with growth retardation. Tonsil and/or adenoidectomy results in significant improvement compared with nonsurgical treatment. ￌ In children with asymmetrically enlarged tonsils, the need for surgery needs to be determined in conjunction with relevant history, physical examination, and laboratory tests. Asymmetrically enlarged tonsils that are neoplasms, especially lymphomas on the tonsils, require surgery, whereas asymmetrically enlarged tonsils alone do not require tonsillectomy.