Management of Unilateral Tonsillar Hypertrophy

Diagnostic Evaluation

The American Academy of Otolaryngology-Head and Neck Surgery recommends assessing tonsillar size using the Brodsky scale to objectively document the degree of asymmetry 1
Consider polysomnography (PSG) when there is discordance between tonsillar size and reported severity of sleep-disordered breathing symptoms, as recommended by the American Academy of Otolaryngology-Head and Neck Surgery 2, 1

The American Academy of Pediatrics recommends adenotonsillectomy as first-line treatment for unilateral tonsillar hypertrophy with obstructive sleep apnea (OSA) 3, 4, 2
Complete tonsillectomy is preferred over tonsillotomy, as residual lymphoid tissue may contribute to persistent obstruction, according to the American Academy of Pediatrics 3, 4
Adenoidectomy should be performed concurrently in most cases, as combined adenotonsillectomy provides better outcomes than tonsillectomy alone, as recommended by the American Academy of Pediatrics and the European Respiratory Society 3, 4, 5

Potential complications of adenotonsillectomy include pain, bleeding, infection, postoperative respiratory difficulties, velopharyngeal incompetence, and rarely death, as reported by the American Academy of Pediatrics 3, 4, 6
Complete resolution of OSA after adenotonsillectomy occurs in 60-70% of normal-weight children but only 10-25% of obese children, according to Praxis Medical Insights 1
Consider postoperative polysomnography in patients with persistent symptoms, severe preoperative OSA, or risk factors for persistent sleep-disordered breathing, as recommended by Praxis Medical Insights 1

For patients who are poor surgical candidates or refuse surgery, radiofrequency tonsil reduction may be considered, though it is less effective than traditional tonsillectomy, as reported by the European Respiratory Society 5, 7
Radiofrequency tonsil reduction appears to have fewer side effects such as bleeding and postoperative pain but provides unpredictable amounts of tonsil reduction, according to the European Respiratory Society 5, 7

The American Academy of Otolaryngology-Head and Neck Surgery recommends intraoperative administration of a single dose of intravenous dexamethasone (0.5 mg/kg, maximum 8-25 mg) to reduce postoperative pain, nausea, and vomiting 8, 9, 10

Complete resolution of obstructive symptoms occurs in 60-70% of normal-weight children but only 10-25% of obese children, according to the American Academy of Otolaryngology-Head and Neck Surgery 11