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    Paradise Criteria for Tonsillectomy in Children

    Predicts which patients with recurring sore throat will benefit from tonsillectomy.
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    INSTRUCTIONS

    Use only in patients aged 1-18 years in whom tonsillectomy is being considered. Do not use in children with diabetes mellitus, cardiopulmonary disease, craniofacial disorders, congenital anomalies of the head/neck, sickle cell disease or other coagulopathies, or immunodeficiency disorders.

    When to Use
    Pearls/Pitfalls
    Why Use

    • Children with recurrent tonsillitis aged 1-18 years in whom tonsillectomy is being considered.

    • Do not use in children with diabetes mellitus, cardiopulmonary disease, craniofacial disorders, congenital anomalies of the head/neck, sickle cell disease or other coagulopathies, or immunodeficiency disorders.

    • Does not apply to tonsillotomy, intracapsular surgery, or other partial tonsil removal techniques (lack of evidence and long-term follow-up).

    • Should not be used if symptoms occurred over the course of <12 months , as efficacy of tonsillectomy in this situation has not been studied and some children may have spontaneous resolution.

    • Documentation of tonsillitis is extremely important. Before the Paradise Criteria were developed, a study showed that over the course of 1 year, only 17% of patients with recurrent pharyngitis (≥7 episodes in one year, 5 in each of two consecutive years, or 3 in each of three consecutive years) had adequate documentation and confirmation of their clinical course (Paradise 1978).

    • In children with repeated Group A beta-hemolytic strep infections, it may be helpful to test for a carrier state to confirm that episodes are due to strep throat and not concurrent viral infection.

    • From MDCalc exclusive interview with Dr. Paradise: "The criteria apply only to children whose indications for tonsillectomy would be based solely on recurrent episodes of throat infection. Children who have obstructive sleep-disordered breathing because of excessively large tonsils constitute a separate group for whom tonsillectomy is clearly indicated."

    Tonsillectomy may provide benefits, but the risk of complications is not insignificant. This criteria helps clinicians identify which patients will most benefit from tonsillectomy.

    Clinical features of an episode

    Sore throat plus ≥1 feature qualifies as an episode:

    Number of episodes
    Treatment
    Documentation

    Diagnostic Result:

    Please fill out required fields.

    Next Steps
    Evidence
    Creator Insights

    Advice

    • If a patient meets the appropriate criteria, then tonsillectomy is recommended due to a modest reduction in the frequency and severity of recurrent throat infection for up to 2 years following surgery.

    • If a patient does not meet the criteria, watchful waiting is recommended. The goal is to avoid surgery and the risk of complications in children who will likely derive no benefit from the procedure.

    Critical Actions

    • In certain situations, children mildly or moderately affected by sore throat may benefit from tonsillectomy. This includes patients with multiple antibiotic allergies, peritonsillar abscess, and history or family history of rheumatic fever.

    • Children who do not meet the criteria but who are affected by tonsillar hypertrophy and/or sleep-disordered breathing may also benefit from tonsillectomy. This is especially true if they suffer from comorbid conditions, including behavioral problems, poor school performance, nocturnal enuresis, and/or growth retardation.

    Formula

    Selection of the appropriate options (all 4 variables must be fulfilled by at least one option). If "None of the above" or "None" is selected for any variable, patient does not meet Paradise Criteria.

    Variable

    Options

    Sore throat episodes

    ≥7 episodes in the preceding year

    ≥5 episodes in each of the preceding 2 years

    ≥3 episodes in each of the preceding 3 years

    None of the above

    Clinical features (sore throat plus ≥1 feature qualifies as an episode)

    Temperature >38.3°C (100.9°F)

    Cervical lymphadenopathy (tender or enlarged (>2 cm) lymph nodes)

    Tonsillar or pharyngeal exudate

    Positive culture for group A β-hemolytic streptococcus

    Treatment

    Antibiotics had been administered in conventional dosage for proven or suspected streptococcal episodes

    None

    Documentation

    Each episode and qualifying features documented

    If not fully documented, subsequent observance by the clinician of 2 episodes of throat infection with patterns of frequency and clinical features consistent with initial history

    None of the above


    Facts & Figures

    Interpretation:

    Paradise Criteria

    Recommendation

    Meets criteria

    Consider tonsillectomy

    Does not meet criteria

    Watchful waiting recommended


    Evidence Appraisal

    The Paradise Criteria were originally derived for a 1984 trial by Paradise et al studying efficacy of tonsillectomy. Patients that met the criteria for “severely affected” had the following outcomes:

    • 1.9 fewer episodes of sore throat of any severity in the first year of follow-up compared to the control group, on average.

    • 1.1 fewer episodes of moderate to severe sore throat in the first year of follow-up compared to the control group, on average.

    • Decreased rate reductions during the second year of follow-up and insignificant reductions in the third year.

    In a follow-up study (Paradise 2002), the entry criteria were relaxed, allowing children who were “moderately affected” to qualify for tonsillectomy. The results of this study showed that the inherent risks, morbidity, and cost of surgery did not justify tonsillectomy in these children.

    In 2011, the American Academy of Otolaryngology - Head and Neck Surgery (AAO-HNS) developed a clinical practice guideline (Baugh 2011) entitled “Tonsillectomy in Children”. To develop the guideline, the following sources were used:

    • Published and unpublished consensus and evidence-based guidelines less than 10 years old in English (2 sources).

    • Systematic reviews less than 15 years old in English (36 sources).

    • Randomized controlled trials (RCTs) published in English (705 sources).

    For children with recurrent sore throat that met the original Paradise Criteria for tonsillectomy (recurrent infection with documentation), the evidence quality was grade B (RCTs) and C (observational studies). The evidence profile showed a balance between benefit and harm with an official policy level as “option.”

    For children with recurrent sore throat who did not meet the criteria for tonsillectomy, the evidence quality was grade B (RCTs with minor limitations that failed to show clinically important advantages of surgery over observation alone) and C (observational studies showing improvement with watchful waiting). The evidence profile showed a preponderance of benefit over harm with an official policy level as “recommendation.” It is important to note that those with peritonsillar abscess, personal or family history of rheumatic heart disease, Lemierre syndrome, or severe infections requiring hospitalization were excluded from this recommendation.

    A Cochrane review in 2014 found that, in children fulfilling the Paradise Criteria, those who underwent tonsillectomy had on average 1.1 episodes of sore throat in the first postoperative year (with 1 of these episodes caused by postoperative pain), compared to 1.2 episodes in the control group. Good data on effects following the first year after surgery is lacking (Burton 2014).

    In a review in Pediatrics (Morad 2017), seven studies looking at children with ≥3 throat infections in the previous 1-3 years showed that children who underwent tonsillectomy had greater decreases in sore throat days, clinician contacts, diagnosed group A streptococcal infections, and school absences over the first 12 months.

    American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS) guidelines for tonsillectomy in children are currently under revision.

    Literature

    Dr. Jack L. Paradise

    From the Creator

    Why did you develop the Paradise Criteria? Was there a particular clinical experience or patient encounter that inspired you to create this tool for clinicians?

    When in pediatric practice in a new, union-sponsored health plan in Appalachia, I was often called upon to render judgment as to whether or not tonsillectomy was indicated for individual children for whom a recommendation for tonsillectomy had been made by other physicians. This procedure was instituted because health plan administrators believed that tonsillectomy often was being performed on children without appropriate indications. Accordingly, payment for tonsillectomy by the health plan was made contingent on prior approval by me or by another member of a health-plan-designated group of consultants. In that role, I came to realize that there were then no evidence-based criteria for tonsillectomy. Recommendations by recognized authorities varied widely and were based entirely on clinical experience and/or opinion. When I left practice to head an ambulatory care program in a large teaching hospital, I saw an opportunity to address the question of criteria for tonsillectomy systematically.

    What pearls, pitfalls, and/or tips do you have for users of the Paradise Criteria? Do you know of cases when it has been applied, interpreted, or used inappropriately?

    It is important to recognize that these criteria apply only to children whose indications for tonsillectomy would be based solely on recurrent episodes of throat infection. Children who have obstructive sleep-disordered breathing because of excessively large tonsils constitute a separate group for whom tonsillectomy is clearly indicated.

    What recommendations do you have for doctors once they have applied the Paradise Criteria? Are there any adjustments or updates you would make to the score based on new data or practice changes?

    Rarely is it necessary for decisions about tonsillectomy to be made without delay. In many children, the problem of recurrent throat infection diminishes spontaneously with time. Application of the criteria serves to divide children with histories of recurrent throat infection into two clinical groups: the large majority who should not undergo tonsillectomy, and the minority for whom tonsillectomy is a reasonable option, but not a requirement.

    How do you use the Paradise Criteria in your own clinical practice? Can you give an example of a scenario in which you use it?

    Documentation of the frequency, clinical features, and severity of episodes of throat infection is essential. To that end, watchful waiting is often the most appropriate course to follow, particularly in children not previously known to the clinician. For the child being evaluated for the first time, whose parents are predisposed to ask for tonsillectomy, I have found that it is a mistake to simply declare that tonsillectomy is not indicated. Rather, I would acknowledge that the parent's request is understandable, and that tonsillectomy might prove to be appropriate, but that following the child over time permits a level of certainty about the indications. In my experience, most parents are able to accept that course of action because they appreciate the concern and conscientiousness that underlie it.

    About the Creator

    Jack L. Paradise, MD, now retired, was the medical director of the Ambulatory Care Center at the Children’s Hospital of Pittsburgh. He was also a professor in the pediatrics department at the University of Pittsburgh School of Medicine. Dr. Paradise’s primary research was focused on indications for tonsillectomy and adenoidectomy, and on the diagnosis, management, and clinical significance of otitis media.

    To view Dr. Jack L. Paradise's publications, visit PubMed

    Content Contributors
    • Christian Hietanen, DO
    About the Creator
    Dr. Jack L. Paradise
    Content Contributors
    • Christian Hietanen, DO