Tonsils and adenoids in children: obstruction, sleep apnoea and when to operate

Topic

Large tonsils and adenoids can cause snoring and pauses in breathing at night; surgery helps some children, chosen by clear criteria.

Updated Nov 5, 2026

Key points

Recurrent throat infection: tonsillectomy is an option with at least 7 episodes in the past year, 5 per year for 2 years or 3 per year for 3 years (Paradise criteria).
Each episode must be documented with at least one of: temperature over 38.3 °C, cervical adenopathy, tonsillar exudate or a positive group A streptococcus test.
Below those numbers the guideline recommends watchful waiting, unless modifying factors: multiple antibiotic allergies, PFAPA syndrome or more than one peritonsillar abscess.
Tonsillectomy is recommended for children with obstructive sleep apnoea documented by polysomnography; enlarged tonsils and adenoids are the main cause in children.
Polysomnography before surgery if the child is under 2 or has obesity, Down syndrome, craniofacial or neuromuscular disease, sickle cell disease or mucopolysaccharidosis.

What it is

Tonsils and adenoids are lymphoid tissue that grows during childhood. Enlarged, they can block the nose and throat and cause sleep-disordered breathing, from snoring to obstructive sleep apnoea, which affects behaviour, learning and growth. Repeated tonsil infections are the other main reason for surgery. This page follows the American Academy of Otolaryngology–Head and Neck Surgery tonsillectomy guideline (2019 update) for indications.

Key facts

Sleep apnoea in children is most common between 2 and 8 years.
Night symptoms: snoring, mouth breathing, pauses in breathing, frequent waking, bedwetting.
Day symptoms: hyperactivity or aggression, poor attention and school performance, morning headache, sleepiness.
Conditions that may improve after tonsillectomy: poor growth, poor school performance, enuresis, asthma and behaviour problems.
Main complication: bleeding, primary (first 24 hours) or secondary (after 24 hours); sleep apnoea may persist or recur after surgery.

Indications and cautions for tonsillectomy (AAO-HNS 2019)

Situation	What the guideline says
Recurrent throat infection below Paradise numbers	Watchful waiting
Recurrent throat infection meeting Paradise numbers, documented	Tonsillectomy may be offered
Obstructive sleep apnoea on polysomnography	Tonsillectomy recommended
Sleep-disordered breathing with doubtful severity	Polysomnography first
Child under 3 years or severe sleep apnoea	Overnight inpatient monitoring after surgery
After surgery	Ibuprofen and/or acetaminophen for pain; no codeine under 12 years; no routine antibiotics

In clinical practice

A child with large tonsils who does not snore and sleeps well does not need surgery: size alone is not an indication.
Obesity, Down syndrome and craniofacial anomalies raise the risk of residual apnoea after surgery.
Bleeding after tonsillectomy, even a small amount, needs urgent assessment because it can herald a larger bleed.

Next step / Initial management

Document each sore throat episode (temperature, exudate, nodes, streptococcal test) to know whether the criteria are met.
Ask about snoring, pauses, mouth breathing, bedwetting, behaviour and growth; examine tonsil size and nasal breathing.
Treat streptococcal pharyngitis with amoxicillin or penicillin; manage overweight and avoid tobacco smoke at home.
Refer on a routine basis to paediatric otolaryngology a child with documented recurrent tonsillitis meeting the criteria or with symptoms of sleep apnoea; request polysomnography when indicated.
Refer urgently a child with apnoea plus poor growth or heart or lung complications, and send to the emergency service any bleeding after tonsillectomy.

Test yourself

Think of the answer, then tap the question to see it.

Which episode counts justify considering tonsillectomy for recurrent throat infection?

At least 7 documented episodes in the past year, at least 5 per year for 2 years, or at least 3 per year for 3 years.

A 5-year-old snores loudly, has pauses in breathing and large tonsils; polysomnography confirms obstructive sleep apnoea. What is recommended?

Tonsillectomy (usually with adenoidectomy), the treatment recommended for documented obstructive sleep apnoea with tonsillar hypertrophy.

Which analgesic must not be given after tonsillectomy to children under 12?

Codeine or any medicine containing it; ibuprofen and/or acetaminophen are recommended.

Which children need polysomnography before tonsillectomy for sleep-disordered breathing?

Children under 2 and those with obesity, Down syndrome, craniofacial or neuromuscular disorders, sickle cell disease or mucopolysaccharidoses.

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Educational content; it does not replace a medical assessment and is not a clinical instruction. For a real case, follow current guidelines and specialist advice.

Sources: Clinical Practice Guideline: Tonsillectomy in Children (Update), Executive Summary (Otolaryngol Head Neck Surg) (PubMed, US National Library of Medicine, 2019); Tonsillectomy (StatPearls (NCBI Bookshelf), 2026); Pediatric Obstructive Sleep Apnea (StatPearls (NCBI Bookshelf), 2025); Sleep Apnea in Children (National Heart, Lung, and Blood Institute (NIH), 2025); Adenoid Hypertrophy (StatPearls (NCBI Bookshelf), 2023).

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