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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.

    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

    About the Creator

    Jack L. Paradise, MD, is a pediatrician at the Children’s Hospital of Pittsburgh. He is also a professor in the pediatrics department at the University of Pittsburgh School of Medicine. Dr. Paradise’s primary research is focused on tonsillectomy and adenoidectomy.

    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