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This guideline was published as a supplement in the February 2019 issue of OtolaryngologyHead and Neck Surgery.

This clinical practice guideline (CPG), which is intended for all clinicians in any setting who interact with children aged 1 to 18 years who may be candidates for tonsillectomy, is an update of, and replacement for, the prior CPG that was published in 2011. The purpose of this multidisciplinary CPG is to identify quality improvement opportunities in managing children under consideration for tonsillectomy and to create explicit and actionable recommendations to implement these opportunities in clinical practice. Specifically, the goals are to educate clinicians, patients, and/or caregivers regarding the indications for tonsillectomy and the natural history of recurrent throat infections. 


This plain language summary for patients serves as an overview explaining tonsillectomy in children and to help patients, caregivers, and clinicians in their discussions about the reasons that a tonsillectomy may be needed, management options, and care related to the procedure. This summary applies to patients ages 1 through 18 years and is based on the 2019 “Clinical Practice Guideline: Tonsillectomy in Children (Update).” This evidence-based guideline mainly addresses the need for tonsillectomy based on breathing problems that take place during sleep and repeated sore throats or “tonsillitis.” The guideline was developed to identify quality improvement opportunities in managing children under consideration for tonsillectomy and to create clear recommendations for clinicians to use in medical practice.


This plain language summary is based on the American Academy of Otolaryngology–Head and Neck Surgery Foundation’s (AAO-HNSF’s) “Clinical Practice Guideline: Tonsillectomy in Children (Update),” which updates the 2011 guideline.

1 The purpose of the summary is to share key concepts and recommendations from the guideline in clear, understandable, patient-friendly language. It was developed by consumers, clinicians, and AAO-HNSF staff.

The tonsillectomy guideline was developed using the methods outlined in the AAO-HNSF “Guideline Development Manual, Third Edition.”

2 A literature search from January 2017 through August 2017 was performed by a professional information specialist to identify research studies (systematic reviews, clinical practice guidelines, randomized controlled trials, and observational studies) published in 2010 or later. The guideline update was based on these newer studies as well as those used in the 2011 guideline.

The AAO-HNSF formed a guideline update group representing the fields of advanced practice nursing, anesthesiology, consumers, family medicine, otolaryngology–head and neck surgery, pediatrics, sleep medicine, and infectious diseases. The group also included a staff member from the AAO-HNSF. Prior to publication, the guideline underwent extensive peer review, including open public comment.

What Is a Tonsillectomy?

A tonsillectomy (tahn-suh-LEK-tuh-mee) is an operation done by an ear, nose, and throat (ENT) doctor to remove your tonsils. Sometimes your adenoids (add-eh-noids) will be removed at the same time. Tonsils are the 2 fleshy lumps on each side of the back of your throat. You can see them if you open your mouth wide. Adenoids are high in the throat behind your nose and roof of your mouth. You cannot see adenoids without special medical instruments.3 Tonsils and adenoids are a part of the body’s immune system. They help trap harmful bacteria and viruses that enter your body through your mouth or nose.

Tonsils and adenoids work to protect the body against germs. They can become infected and get sore. If your child gets sore throats a lot or their tonsils cause breathing problems during sleep, your clinician may suggest a tonsillectomy. (Clinician is a term that includes doctors, nurse practitioners, physician assistants, and other qualified health care professionals.) Breathing problems while sleeping is called obstructive sleep-disordered breathing or “oSDB.” Throat infections and oSDB are the 2 most common reasons for tonsillectomies. Removal of the tonsils and adenoids does not increase the risk of infection as other tissue around the throat take their place.4

What Is Obstructive Sleep-Disordered Breathing (oSDB)?

oSDB is a general term for breathing difficulties during sleep.5 It is usually caused by large tonsils and adenoids. oSDB can be worse in children who are overweight, have muscle weakness, or have certain diseases that affect nerves. Children with oSDB may be sleepy during the day, act out, struggle in school, have nighttime bedwetting, and be small for their age. Figure 1 includes patient information on oSDB.

Figure 1. Tonsillectomy and obstructed sleep-disordered breathing (oSDB) for caregivers.

When Should My Child See a Doctor?

You should take your child to a clinician when they have a sore throat and it is hard for your child to eat, drink, or swallow. The clinician will perform a physical examination and review the medical history. No medical action may be taken at this point because your child’s sore throat may go away on its own.

  • A throat infection may include 1 or more of the following:

  • Temperature of 101°F

  • Tender or swollen bumps (lymph nodes) in the neck

  • Large or swollen tonsils with bright white

  • spots or patches

  • A throat culture that shows strep

  • The throat culture should be performed in the clinic and confirmed by a clinician. Antibiotics may be prescribed for strep throat. A tonsillectomy may be recommended if your child has a lot of throat infections in a short time.

How Is oSDB Diagnosed?

The clinician will discuss your child’s medical history with you and give them a physical exam. You may be asked about other conditions your child has. He or she may request tests or refer you to a sleep specialist. A sleep study or polysomnography (pol-ee-som-nog-ruh-fee) or “PSG” may be needed to see if your child has oSDB. The test is done in a sleep lab. A medical technician will put small discs or pads on your child’s head and body. Your child’s heart rate, body movements, oxygen levels, and breathing through the mouth and nose will be measured.

Will oSDB Go Away after Tonsillectomy?

Tonsillectomy helps almost all normal-weight children with oSDB, and it improves sleep in most children in this group. Tonsillectomy also helps overweight children with oSDB, but sleep is not always improved. Your child’s oSDB may not go away or it may return even after tonsillectomy.

Are There Risks Related to Tonsillectomy?

Tonsillectomy is a surgical procedure that includes some risks. After surgery, your child may have:

  • Throat pain that lasts up to 2 weeks

  • Vomiting or feeling like they have to vomit

  • Thirst or dryness, especially if they are vomiting (dehydration)

  • Bleeding in their mouth (from the tonsils)

  • Temperature greater than 101°F

The clinician will discuss these risks with you before the surgery. It is important that you contact your clinician if your child is having problems after surgery. Your child may need to go back to the hospital for further care if the clinician has concerns.

Will My Child Have Pain after the Surgery?

Pain lasts about 7 to 10 days and can last as long as 2 weeks. A clinician will talk to you about keeping an eye on your child’s pain and discomfort after tonsillectomy. The clinician should have this talk with you before the surgery and again after surgery to remind you. Your child may complain of throat, ear, and neck pain. The pain may be worse in the morning, which is normal. Ask your child every 4 hours if they are having pain, because they may not tell you. It is important that you ask them.

The clinician will give you a medication plan to help you and your child get through the healing process. See Figure 2 for more information on helping your child with pain after tonsillectomy.

Figure 2. Posttonsillectomy pain management education for caregivers.

Some medicines like antibiotics and codeine (koh-DEEN) or any medication containing codeine are not good for children younger than 12 years after tonsillectomy. There are better choices than codeine even for children 12 to 18 years old. Codeine can cause very slow breathing and, if too much is given, death. It can also be habit forming (addictive). Ask your clinician what options there are.

Do I Need to Limit My Child’s Diet after Surgery?

Your child can eat as they normally would as long as it does not bother them. Make sure they drink plenty of fluids like water or juice. This will help them to avoid dehydration. Fluids can help with their pain too. Fruit snacks, popsicles, pudding, yogurt, or ice cream are good foods for your child to eat when recovering.

How Can I Make My Child More Comfortable after Surgery?

Follow the medication plan from the clinician. You can help take your child’s mind off of their pain by playing with them and keeping them entertained. Applying a cold or hot pack to their neck or ears can also help.

When Should I Call the Doctor’s Office?

Call the doctor’s office or seek medical attention right away if your child has any of the following:

  • Bright red bleeding from the mouth

  • Temperature greater than 101°F

  • Uncontrolled pain

  • Signs of dehydration (urination less than 2-3 times a day or crying without tears)6

Where Can I Get More Information?

The updated Clinical Practice Guideline on Tonsillectomy in Children offers recommendations, also called key action statements, to support clinicians in improving the care of children undergoing tonsillectomies. See Table 1 for a summary of these key action statements. Your clinician will provide care that is tailored to your child, but you can still use the guideline recommendations as a source for discussion and shared decision making.

Table 1. Summary of Guideline Key Action Statements.

Table 1. Summary of Guideline Key Action Statements.

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You and your child’s clinician should talk through all treatment options and find the best approach for your child. There are printable patient handouts and clinician resources that can help with decisions about care and surgical options. For more information on tonsillectomy in children, please visit

Author Contributions

Sandra A. Finestone, writer; Terri Giordano, writer; Ron B. Mitchell, writer, chair; Sandra A. Walsh, writer; Sarah S. O’Connor, writer; Lisa M. Satterfield, review and edit.


Competing interests: Sarah S. O’Connor, salaried employee of the AAO-HNSF; Lisa M. Satterfield, salaried employee of the AAO-HNSF.

Sponsorships: American Academy of Otolaryngology–Head and Neck Surgery Foundation.

Funding source: American Academy of Otolaryngology–Head and Neck Surgery Foundation.

Sponsorships or competing interests that may be relevant to content are disclosed at the end of this article.


1.Mitchell, RB, Archer, SA, Ishman, SL. Clinical practice guideline: tonsillectomy in children (update). Otolaryngol Head Neck Surg. 2019;160(suppl 1):S1-S42. Google Scholar2.Rosenfeld, RM, Shiffman, RN, Robertson, P. Clinical practice guideline development manual, 3rd edition: a quality-driven approach for translating evidence into action. Otolaryngol Head Neck Surg. 2013;148(suppl 1):S1-S55. Google Scholar | SAGE Journals | ISI3.American Academy of Otolaryngology–Head and Neck Surgery . Tonsils and adenoids. Accessed November 29, 2018. Google Scholar4.Intermountain Healthcare . Tonsillectomy. Accessed November 29, 2018. Google Scholar5.American Academy of Otolaryngology–Head and Neck Surgery . Pediatric sleep disordered breathing/obstructive sleep apnea. Accessed November 29, 2018. Google Scholar6.American Academy of Otolaryngology–Head and Neck Surgery . Tonsillectomy and adenoids post op. Accessed November 29, 2018. Google Scholar

What is chronic ear infection?

Chronic ear infection is an ear infection that does not heal. A recurring ear infection can act like a chronic ear infection. This is also known as recurring acute otitis media. The space behind the eardrum (the middle ear) is affected by this infection.

The eustachian tube, a tube that drains fluid from the middle ear, can become plugged and lead to an infection. This buildup of fluid in the middle ear presses on the eardrum, causing pain. If an infection progresses quickly or is left untreated it can cause the eardrum to rupture. Eustachian tubes in children are smaller and more horizontal, so they can become plugged more easily. This is one reason ear infections occur oftener in children.

What are the symptoms of chronic ear infection?

A chronic ear infection can cause milder symptoms than an acute ear infection. Symptoms may affect one or both ears and may be constant or come and go. Symptoms of a chronic ear infection include:

  • feeling of pressure in the ear

  • mild ear pain

  • fluid draining from ear

  • slow fever

  • hearing loss

  • trouble sleeping

An infant with an ear infection may seem fussier than usual, especially when lying down, as this puts pressure on the ear. Your baby’s eating and sleeping habits may also change. Pulling and tugging on the ear can also be a sign of a chronic ear infection in infants. However, this can also be caused by teething or exploration of the body.

When to see your doctor

If you or your child is having symptoms of an acute ear infection, like ear pain, fever, and trouble hearing, you should see your doctor. Getting an acute ear infection treated promptly can help prevent a chronic ear infection. You should also see your doctor if:

  • you have been diagnosed with an acute ear infection but it’s not responding to treatment recommended by your doctor

  • you have been diagnosed with an acute ear infection and experience new symptoms, or if the symptoms get worse

  • if your child shows symptoms of a recurring ear infection

Treatment options

Chronic ear infections require medical treatment. However, home treatments can help relieve your symptoms. Home treatments include:

  • holding a warm or cool wash cloth to the painful area

  • using numbing ear drop

  • staking an over-the-counter pain reliever, such as acetaminophen or nonsteroidal anti-inflammatory drugs (NSAIDs) like ibuprofen


If you have a chronic ear infection, your doctor will prescribe antibiotics. These may be taken orally or (rarely) given intravenously if the infection is severe. Your doctor may suggest ear drops if you have a hole (perforation) in the eardrum. But you shouldn’t use some types of ear drops if your ear drum has a perforation. Your doctor may also recommend antibiotic ear drops or suggest using a diluted vinegar solution.


Sometimes surgery is recommended for chronic ear infections that aren’t responding to treatment or are causing hearing problems. Hearing problems can be especially problematic in children. Hearing problems can cause speech and language problems at an important time in development.

Your doctor may surgically insert a small tube through the eardrum to connect the middle ear and the outer ear. Inserting ear tubes helps the fluid in the middle ear drain, which can reduce the number of infections and the severity of symptoms. Ear tubes are usually placed in both ears. This procedure is called a bilateral tympanostomy.

To do this procedure, a surgeon will make a tiny hole in the eardrum (myringotomy). The fluid will be suctioned out of the ear, and a small tube will be inserted through the hole. Tubes usually fall out on their own, about six to 18 months after they are inserted. You may need to have the tubes surgically removed if they don’t fall out.

Other types of surgery may be required if the infection has spread. There are small bones in the middle ear that may become infected. If this happens, surgery may be required to repair or replace them. A chronic ear infection can also damage the eardrum. If the eardrum isn’t healing properly, you may need surgery to repair damage.

Rarely, the infection can spread to the mastoid bone, which is located behind the ear. Surgery is required to clean out the infection if it spreads to the mastoid bone. This is known as a mastoidectomy.

What are the consequences of untreated symptoms?

A chronic ear infection can cause several problems if left untreated. Possible complications include:

  • hearing loss

  • damage to the bones in the middle ear

  • infection of the mastoid bone

  • damage to the balance function in the ear

  • drainage from a hole in the eardrum

  • tympanosclerosis, a hardening of tissue in the ear

  • cholesteatoma, a cyst in the middle ear

  • facial paralysis

  • inflammation around or in the brain

Prevention tips

There are a number of things you can do to help reduce your and your child’s risk of developing a chronic ear infection. Make sure to talk to your doctor if you have an acute ear infection so it can be treated and doesn’t become chronic.

It’s also important to stay up-to-date with vaccinations for influenza, pneumonia, and meningitis. Pneumococcal bacteria, which can cause both pneumonia and pneumococcal meningitis, also causes about half of middle ear infections, according to the Centers for Disease Control and Prevention (CDC).

Other tips for preventing ear infections include:

  • stopping smoking and avoiding secondhand smoke

  • breastfeeding infants for the first year of life

  • practicing good hygiene, including washing hands regularly