Clinical UM Guideline

This document addresses tonsillectomy in adults with or without adenoidectomy. This surgery has been widely accepted as a treatment for recurrent or chronic throat infections, tonsil hypertrophy, and obstructive sleep apnea (OSA).

Note: For information regarding related procedures, please see:

• CG-SURG-30 Tonsillectomy for Children with or without Adenoidectomy
• CG-SURG-36 Adenoidectomy
• SURG.00129 Oral, Pharyngeal and Maxillofacial Surgical Treatment for Obstructive Sleep Apnea or Snoring

Note: For a high-level overview of this document, please see “Summary for Members and Families” below. 

Medically Necessary:

Tonsillectomy is considered medically necessary for individuals 18 years of age and older who meet one or more of the criteria below:

1. A history of recurrent acute throat infection with a frequency of at least:
   1. Three or more episodes in the previous 6 months; or
   2. Four or more episodes in the previous 12 months;
      and
   3. Documentation in the medical record for each episode of sore throat which includes at least one of the following:
      1. Temperature greater than 38.3 °C (100.9 °F); or
      2. Cervical adenopathy; or
      3. Tonsillar exudate or erythema; or
      4. Positive test for Group A ß-hemolytic streptococcus (GABHS);
         or
2. A history of recurrent acute throat infections not meeting criteria above, but individual has additional factors that favor tonsillectomy, including but not limited to:
   1. Multiple antibiotic allergy/intolerance; or
   2. One or more peritonsillar abscess; or
   3. One or more parapharyngeal abscesses;
      or
3. A history of chronic throat infections, as indicated by 1 or more of the following:
   1. Chronic tonsillitis with all of the following:
      1. Inflammation or infection (symptoms may include pain and discomfort, airway obstruction, and dysphagia); and
      2. Persists for 3 or more months; and
      3. Resistant to medical treatment;
         or
   2. Infectious mononucleosis with all of the following:
      1. Failure to respond to corticosteroid; and
      2. Tonsillar hypertrophy causing airway obstruction or dysphagia;
         or
4. A diagnosis of obstructive sleep apnea (OSA) with documentation of all of the following:
   1. Tonsillar hypertrophy; and
   2. Polysomnographic evidence of OSA with either:
      1. AHI or RDI greater than or equal to 15 events per hour;
         or
      2. AHI or RDI greater than or equal to 5 events per hour, and less than 15 events per hour with documentation demonstrating any of the following symptoms:
         1. Excessive daytime sleepiness, as documented by either a score of greater than 10 on the Epworth Sleepiness scale or inappropriate daytime napping, (for example, during driving, conversation or eating) or sleepiness that interferes with daily activities; or
         2. Impaired cognition or mood disorders; or
         3. Hypertension; or
         4. Ischemic heart disease or history of stroke; or
         5. Cardiac arrhythmias; or
         6. Pulmonary hypertension;
             or
5. IgA nephropathy;
   or
6. Known or suspected tonsillar malignancy.

Not Medically Necessary:

Tonsillectomy is considered not medically necessary for individuals 18 years of age and older when the criteria above have not been met, and in all other circumstances.

This document describes clinical studies and expert recommendations, and explains when tonsillectomy with or without adenoidectomy for adults is clinically appropriate. The following summary does not replace the medical necessity criteria or other information in this document. The summary may not contain all of the relevant criteria or information. This summary is not medical advice. Please check with your healthcare provider for any advice about your health.

Key Information

Tonsillectomy is a surgery to remove the tonsils, which are organs located at the back of the throat and part of the immune system. It may be done alone or with the additional removal of the adenoids (adenoidectomy), which are organs located behind the tonsils. In adults, tonsillectomy with or without adenoidectomy may help treat people who have repeated throat infections, long-lasting tonsil infections that do not improve with treatment, enlarged tonsils that block the airway, obstructive sleep apnea (OSA), a kidney disease called immunoglobulin A nephropathy (IgAN), or suspected cancer of the tonsils. Surgery can improve symptoms and quality of life for some people. However, it also has risks, including pain, bleeding, infection, and problems related to anesthesia. The benefits and risks should be carefully considered for each person.

What the Studies Show

Studies in adults with some types of repeating throat infections found that people who had tonsillectomy had fewer sore throat days and fewer visits for throat infection than people who did not have surgery. Some studies were small or followed people for only a short time, so the results may not apply to all adults. A larger study found that adults who had tonsillectomy had fewer sore throat days over 2 years and reported better quality of life. Studies also found that tonsillectomy can have harms, such as pain, bleeding, infection, problems from anesthesia, and the need for more care after surgery.

For adults with OSA and enlarged tonsils, studies found that tonsillectomy may lower the number of breathing pauses during sleep. Some studies also found improved sleepiness scores after surgery. Many of these studies were small, and some did not compare surgery with other treatments. One review article found that adults with infectious mononucleosis and severe airway blockage sometimes benefited from tonsillectomy during their hospital stay. Studies support tonsillectomy when cancer of the tonsils is known or suspected based on concerning clinical findings. A review of published research recommended removing both tonsils in adults with cancer in one tonsil or when the location of the original cancer cannot be identified. For IgAN, some studies found that tonsillectomy with steroid treatment may improve urine test results or kidney outcomes but other studies did not find clear long-term benefit. Better studies are needed to know if tonsillectomy improves health for psoriasis.

When is Tonsillectomy for Adults Clinically Appropriate?

Tonsillectomy (with or without adenoidectomy) may be appropriate in these situations:

• Both of the following are met:
  • Repeated throat infections with one of the following:
    • Three or more episodes in the past 6 months, or
    • Four or more episodes in the past 12 months;
  • Each episode is documented in the medical record with at least one of the following:
    • Fever greater than 38.3°C (100.9°F)
    • Swollen lymph nodes in the neck
    • Pus on the tonsils or redness of the tonsils
    • A positive test for Group A beta-hemolytic streptococcus (strep throat)
• Repeated throat infections that do not meet the frequency above, and there are factors that support surgery, such as:
  • Allergy or intolerance to several antibiotics; or
  • One or more abscesses around the tonsil; or
  • One or more abscesses beside the throat
• Long-lasting throat infection with all of the following:
  • Ongoing inflammation or infection causing symptoms such as pain, trouble swallowing, or blockage of the airway.
  • Symptoms lasting 3 months or longer.
  • The condition has not improved with medical treatment.
• Infectious mononucleosis with:
  • No improvement after corticosteroid treatment; and
  • Enlarged tonsils causing airway blockage or trouble swallowing.
• Obstructive sleep apnea with:
  • Enlarged tonsils; and
  • A sleep study showing obstructive sleep apnea that meets the document's criteria.
• Immunoglobulin A nephropathy.
• Known or suspected cancer of the tonsils.

When is this not Clinically Appropriate?

Tonsillectomy is not clinically appropriate in scenarios other than those listed above. The available studies support surgery only for selected adults who meet specific criteria. Better studies are needed to know if tonsillectomy improves health in other situations, such as psoriasis. Unnecessary surgery can expose people to risks, including pain, bleeding, infection, and complications from anesthesia, without proven benefit.

(Return to Description)

The following codes for treatments and procedures applicable to this guideline are included below for informational purposes. Inclusion or exclusion of a procedure, diagnosis or device code(s) does not constitute or imply member coverage or provider reimbursement policy. Please refer to the member's contract benefits in effect at the time of service to determine coverage or non-coverage of these services as it applies to an individual member.

When services are Medically Necessary:

When services may be Medically Necessary when criteria are met:
For the procedure codes listed above for the following diagnoses

When services are Not Medically Necessary:
For the procedure and diagnosis codes listed above when criteria are not met or for all other diagnoses not listed.

Summary

Tonsillectomy completely removes the tonsil, including its capsule, by dissecting the peritonsillar space between the tonsil capsule and the muscular wall. It may be performed with or without adenoidectomy. The most common indication for tonsillectomy in adults is recurrent acute pharyngitis and chronic tonsillitis. Other indications include infections, sleep-disordered breathing (SDB), suspected malignancy, and immunoglobulin A nephropathy (IgAN).

Indications for tonsillectomy, especially for chronic or recurrent tonsillitis, obstructive sleep apnea (OSA), and IgAN, are less clearly defined due to limited high-quality adult-specific studies. Several randomized controlled trials demonstrate that tonsillectomy reduces episodes of pharyngitis and improves quality of life in adults compared to conservative management. However, generalizability remains a concern due to small sample sizes and single-center designs in some studies. Adult tonsillectomy, especially in overweight individuals with enlarged tonsils, was found to significantly reduce apnea-hypopnea index (AHI). For IgAN, trials indicate that combining tonsillectomy with steroid pulse therapy (SP) may yield better remission rates and renal outcomes than steroids alone. Tonsillectomy in cases of suspected malignancy is advised when clinical features such as mucosal abnormalities or lymphadenopathy are present. However, evidence for other uses, such as psoriasis, remains insufficient, warranting more robust and longer-term studies. Overall, while there is growing support for adult tonsillectomy in select indications, more high-quality, large-scale evidence is needed to refine criteria and ensure appropriate use.

Discussion

The American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS) has a clinical practice guideline addressing the use of tonsillectomy in children (Mitchell, 2019). The AAO-HNS currently does not have a clinical practice guideline for adults. Although many recommendations for adult tonsillectomy indications are derived from these guidelines for children, published studies have not addressed the generalizability of these pediatric guidelines to adults. Burton and associates produced a systematic review and meta-analysis on tonsillectomy or adenotonsillectomy compared to non-surgical treatment for chronic/recurrent acute tonsillitis (Burton 2014). They found only two trials with low or moderate risk of bias addressing this topic for adults. They concluded that there is insufficient information to form firm conclusions on the effectiveness of these procedures for adults.

Alho and others (2007) conducted a randomized controlled single-center trial to determine the efficacy and safety of tonsillectomy for recurrent streptococcal pharyngitis in adults. The participants included 70 adults with documented recurrent episodes of streptococcal group A pharyngitis who were randomly placed in either a waiting list (control) group (n=34) or immediate tonsillectomy group (n=36). Eligible participants had 3 or more pharyngitis episodes in the previous 6 months or 4 in the previous 12 months. Each episode must have been typical for streptococcal infection and severe enough that the participant sought medical care. Results after 90 days showed 8 participants (24%) in the control group experienced an episode of group A streptococcal pharyngitis while this only occurred in 1 in the tonsillectomy group (21% difference, 95% confidence interval (CI) 6%-36%; number needed to treat (NNT) 5, 95% CI 3-16); 14 participants in the control group experienced an episode of pharyngitis with medical consultation and 4 in the tonsillectomy group (30% difference, 95% CI 11%-49%). Although the generalizability of these results to large populations is limited by the small size and single-center design, this study showed that adult participants who underwent tonsillectomy were less likely to have recurrent streptococcal pharyngitis and less likely to seek medical consultation for sore throat.

In 2013, Koskenkorva published a non-blinded, randomized, controlled, parallel group, single-center trial with 86 participants 13 years or older referred for tonsillectomy because of recurrent pharyngitis. Participants were randomly assigned to either a control (watchful waiting) group (n=40) or tonsillectomy group (n=46). The clinical entry criteria for the study were 3 or more episodes of disabling pharyngitis within 12 months. The episodes had to be severe enough for the participants to seek medical attention. The authors reported that 17 participants in the control group (43%) and 2 participants in the tonsillectomy group (4%) consulted a physician for pharyngitis. During a 5-month follow-up, 32 participants in the control group (80%) and 18 participants in the tonsillectomy group (39%) had an episode of pharyngitis. The authors noted that participants in the tonsillectomy group had fewer episodes of pharyngitis and fewer days with sore throat. Lack of blinding may have affected the rates of self-reported symptoms. The small size, short duration of follow-up, and single-center design of this study limit its generalizability to other populations.

A review was completed by Chan in 2001 which included 36 individuals who were admitted with a diagnosis of infectious mononucleosis. Of the 36 individuals, 9 presented with upper airway obstruction and 27 without upper airway obstruction. In the upper airway obstruction group, 8 (89%) underwent tonsillectomy. In the group without upper airway obstruction, 6 (22%) underwent tonsillectomy. The authors noted that tonsillectomy could influence the course of infectious mononucleosis when upper airway obstruction is present, and that tonsillectomy should be considered during the early course of admission.

Amid a rise in severe throat infection-related hospital admissions and a growing emphasis on limiting tonsillectomies, Wilson and colleagues conducted the NAtional Trial of Tonsillectomy IN Adults (NATTINA). It aimed to evaluate if tonsillectomy was indeed an effective and valuable solution for recurrent severe sore throats as compared to non-surgical treatments. The study involved 453 individuals from 27 hospitals who were all 16 years or older and who had experienced 7 or more disabling episodes of sore throat in the previous year, or 5 or more episodes in each of the past 2 years, or 3 or more episodes in the preceding 3 years. Participants were randomly assigned in a 1:1 ratio to either undergo tonsillectomy or receive conservative management (treatment as needed from their general practitioner). Across a 2-year period, weekly text messages were used to track the number of sore throats individuals experienced. Additionally, the impact of sore throats on individuals’ quality of life and their work schedules were assessed. Interviews were also conducted with 47 individuals, general practitioners, and hospital staff to gain their perspectives. Findings revealed that individuals in the tonsillectomy group typically experienced 23 days of sore throat, as compared to 30 days in the conservative management group. Tonsillectomy also led to an improved quality of life. Interviews showed a high degree of satisfaction among participants who had had tonsillectomies. This relatively large study conducted at multiple sites showed that participants treated with tonsillectomy experienced fewer sore throat days over a 24-month period than similar participants who did not undergo tonsillectomy. (Wilson, 2023)

Obstructive Sleep Apnea

OSA is a common disorder affecting at least 2% to 4% of the adult population. According to the American Academy of Sleep Medicine (AASM), the diagnosis of OSA is confirmed if the number of obstructive sleep events on polysomnography is greater than 15 events/hour or greater than 5/hour in individuals who report any of the following: unintentional sleep episodes during wakefulness; daytime sleepiness; unrefreshing sleep; fatigue; insomnia; waking up breath holding, gasping, or choking; or the bed partner describing loud snoring, breathing interruptions, or both during the individual’s sleep.

The frequency of obstructive events is reported as an apnea + hypopnea index (AHI) or respiratory disturbance index (RDI). AASM defines the severity of OSA as following:

• Mild OSA: AHI or RDI of 5-15;
• Moderate OSA: AHI or RDI of 15-30;
• Severe OSA: AHI or RDI of more than 30.

AAO-HNS position statement on the treatment of OSA indicates tonsillectomy alone has shown to be effective in adults with enlarged tonsils.

Senchak and colleagues (2015) conducted a prospective, multi-institutional study to evaluate the effectiveness of tonsillectomy alone as treatment for adult OSA in adults with tonsillar hypertrophy. Between October 2010 and July 2013, 202 consecutive adults scheduled to undergo tonsillectomy for chronic or recurrent tonsillitis or halitosis were enrolled. After exclusions and loss to follow-up, 19 individuals with polysomnography-confirmed OSA completed both preoperative and postoperative assessments. Participants were predominantly young (mean age 27.9 years), overweight (mean body mass index [BMI] 29.6 kg/m²), had large tonsils (median size 3), and were primarily Friedman stage 1. The primary outcome was change in the AHI approximately 2-6 months after surgery. Tonsillectomy resulted in substantial improvements in objective and subjective measures of OSA. Mean AHI decreased from 18.0 to 3.2 events/hour, representing an 82% reduction (p<0.001). The responder rate, defined as at least a 50% reduction in AHI to < 15 events/hour, was 94.7% (18 of 19 individuals). Significant improvements were also observed in the lowest oxygen saturation, Epworth Sleepiness Scale (ESS) scores, and Berlin Questionnaire scores (all statistically significant). BMI did not change significantly following surgery, suggesting that improvements were attributable to tonsillectomy rather than weight loss. The authors concluded that tonsillectomy alone may be particularly effective in young, overweight men with large tonsils, moderate OSA, and low Friedman stage. Limitations include a small sample size substantially limiting statistical power and generalizability. The study lacked a control group or comparison with other OSA treatments such as continuous positive airway pressure (CPAP). Follow-up was relatively short (mean 77 days), preventing assessment of long-term durability of treatment. In addition, only ambulatory sleep monitoring was used rather than in-laboratory polysomnography, and most participants had mild-to-moderate OSA, limiting conclusions regarding severe disease.

Camacho and colleagues (2016) performed a systematic review and meta-analysis evaluating tonsillectomy alone for adults with OSA. The review included 17 studies with 216 adults. Tonsils were generally enlarged, most commonly grade 2-4. Across studies, tonsillectomy was associated with substantial improvement in SDB. Mean AHI decreased from 40.5 to 14.1 events/hour, a 65.2% reduction. Mean lowest oxygen saturation improved from 77.7% to 85.5%, and ESS scores improved from 11.6 to 6.1. Among individuals with available individual data, the overall surgical success rate was 85.2%, and the cure rate was 57.4%. Outcomes were best in those with preoperative AHI < 30 events/hour, where success was 100% and cure was 84%. The evidence base was limited by small, mostly observational studies with no randomized controlled trials. Study quality varied, and there was significant heterogeneity across included studies. Follow-up duration was often short, and many studies included selected adults with enlarged tonsils, limiting generalizability to adults with small tonsils or more complex multilevel airway obstruction. Individual-level data were available for only a subset of participants, and predictors such as tonsil volume, body habitus, and airway anatomy were not consistently reported.

Makkonen and colleagues (2025) conducted a prospective pilot randomized controlled trial evaluating tonsillectomy compared to lifestyle counseling for adult OSA. The study included 29 adults with primarily mild-to-moderate OSA, BMI ≤ 35, and Friedman tonsil grade ≥ 1. Participants were randomized to tonsillectomy (n=12) or lifestyle counseling (n=17), with in-laboratory polysomnography performed at baseline and after 1 year. Baseline AHI was not significantly different between groups (21.0 ± 11.4 in controls compared to 15.0 ± 7.2 in the surgery group; p=0.09). Compared to lifestyle modification alone, after 1 year the between-group change in AHI also favored tonsillectomy (−7.6 vs. +2.7 events/hour; p=0.01). After excluding 5 control participants with severe OSA on baseline polysomnography, results remained significant, with 12-month AHI 20.4 in controls compared to 7.4 after surgery (p=0.011). At follow-up, 3 of 12 surgery participants had AHI < 5, 9 of 12 had mild OSA, and none had moderate or severe OSA. ESS scores improved from baseline the surgery group, although the between-group difference was not statistically significant. Weight, BMI, blood pressure, oxygen saturation, and other polysomnography measures did not significantly change. Limitations include the small sample size, single-center design, imbalance between groups, and limited statistical power. The study did not compare tonsillectomy to CPAP or other surgical procedures used to treat OSA. Initial screening used ambulatory cardiorespiratory testing, while outcomes used in-laboratory polysomnography, leading to some reclassification of OSA severity. The study did not separately analyze apnea and hypopnea indices, and did not compare tonsillectomy to CPAP or other surgeries used to treat OSA. Inclusion of some participants with Friedman grade 1 tonsils potentially limits applicability to individuals with marked tonsillar hypertrophy. These findings suggest that tonsillectomy may improve OSA severity in carefully selected adults with mild-to-moderate disease and enlarged tonsils, but confirmation in larger multicenter randomized trials comparing surgery with standard OSA treatments is needed.

IgA Nephropathy

Immunoglobulin A (IgA) is an antibody made by the immune system to protect the body from foreign substances. IgAN is a kidney disease that occurs when deposits of the protein immunoglobulin builds up inside the kidney.

Kawamura and colleagues (2014) conducted a multicenter randomized controlled trial in Japan evaluating tonsillectomy plus steroid pulse therapy (TSP) compared to SP alone for IgAN. A total of 80 participants with biopsy-proven IgAN, proteinuria, and preserved renal function were randomized. There were 33 in the tonsillectomy/steroid group (Group A) and 39 in the steroid-only group (Group B) who were analyzed. Over 12 months, urinary protein excretion decreased more in the tonsillectomy/steroid group than in the steroid-only group (p=0.047). Tonsillectomy was also independently associated with disappearance of proteinuria (odds ratio [OR], 2.98; 95% CI, 1.01-8.83; p=0.049). However, at 12 months, disappearance of proteinuria was not statistically different between groups (Group A, 63%; Group B, 39%; p=0.052), and there were no significant differences in disappearance of hematuria (Group A, 68%; Group B, 64%; p=0.672) or clinical remission, defined as disappearance of both proteinuria and hematuria (p=0.103). Renal function remained stable in both groups, and no tonsillectomy-related or anesthesia-related adverse events were reported. Researchers concluded that tonsillectomy combined with steroid pulses produced similar rates of remission of IgAN compared to treatment with steroid pulses alone. Limitations included the short 12-month follow-up, which was insufficient to assess long-term renal outcomes, relapse, recurrence of proteinuria, or need for additional therapy. The study was relatively small, open-label, and conducted in Japan at centers experienced with tonsillectomy for IgAN, which may limit generalizability. The study also excluded milder IgAN and those with more advanced renal dysfunction.

Katafuchi and colleagues (2016) performed a multicenter, randomized, controlled trial comparing TSP with SP alone in IgAN. Of the original 72 trial participants, 59 biopsy samples were available for analysis: 26 in the TSP group and 33 in the steroid-only group. All had biopsy-proven IgAN, urinary protein excretion of 1.0-3.5 g/day, and serum creatinine ≤ 1.5 mg/dL. Outcomes were assessed at 12 months. TSP appeared to provide greater benefit in those with more severe pathologic findings. In participants with histologic grade 2-3, TSP was associated with higher odds of proteinuria disappearance compared with steroid therapy alone (OR, 6.75; 95% CI, 1.32-34.6; p=0.022) and higher odds of clinical remission, defined as disappearance of both proteinuria and hematuria (OR, 8.17; 95% CI, 1.30-51.4; p=0.025). Limitations include that this was a post hoc sub-analysis of the original randomized trial, and biopsy samples were not available for all enrolled participants. The sample size was small, and subgroup analyses produced wide confidence intervals. Follow-up was limited to 12 months, so the study could not determine whether short-term improvement in urinary findings translated into long-term kidney survival or reduced progression to kidney failure. There were also no participants with the most severe histologic grade, so findings may not apply to very advanced disease.

A retrospective cohort study was conducted by Hirano and colleagues in 2019. The study included 1065 individuals over 18 years of age and were diagnosed with IgAN by renal biopsy between 2002 and 2004. The participants were divided into 2 groups, those who underwent tonsillectomy (n=252) and those who did not (n = 813). The authors noted significantly better renal survival in individuals in the tonsillectomy group than in the without-tonsillectomy group (hazard ratio [HR], 0.34; 95% CI, 0.13-0.77; p=0.009). The association between tonsillectomy and reduced risk of the outcome was also observed in an inverse treatment probability weighted model, as well as throughout the entire group of participants. This remained the case as the authors used two larger sample sizes from this same group. Tonsillectomy correlated with a decreased need for additional treatments 1 year after renal biopsy, both in the cohort matched 1:1 (HR, 0.36; 95% CI, 0.17-0.71; p=0.003) and throughout the overall study group (adjusted HR, 0.37; 95% CI, 0.20-0.63; p<0.001). The findings of this study need to be confirmed in a prospective randomized trial.

A large retrospective cohort study reported by Komatsu in 2024 explored the effectiveness of tonsillectomy combined with SP for treating IgAN. This study focused on the severity of proteinuria at diagnosis in a nationwide cohort in Japan. The study included 632 individuals categorized by urinary protein levels into mild, moderate, and severe groups, and compared the outcomes of 3 treatment regimens. TSP therapy was compared with corticosteroid therapy alone and with conservative treatment over an average follow-up of 6.2 years. Results showed that TSP therapy significantly improved urinary remission rates and reduced the progression to increased serum creatinine levels, particularly in moderate and severe cases, and was associated with fewer serious adverse events compared to corticosteroid therapy. Clinical remission occurred in 63.8%, 50.5%, and 48.0% of the TSP group in the mild, moderate, and severe proteinuria groups, respectively, compared with 43.0%, 45.1%, and 30.3% with corticosteroid therapy and 41.3%, 27.7%, and 21.6% with conservative therapy. Proteinuria disappearance was also higher with TSP: 76.6%, 57.1%, and 48.0% across the mild, moderate, and severe groups. Hematuria disappearance did not differ meaningfully by treatment. Despite limitations such as outdated protocols and absent histopathological data, the study supports TSP therapy as an effective strategy for moderate-to-severe IgAN.

Hayashi and colleagues (2025) conducted a retrospective cohort study using a Japanese nationwide healthcare records database to evaluate whether TSP was associated with improved renal outcomes compared with SP alone in adults with IgAN. The study included 550 adults diagnosed between 2002 and 2021 who received methylprednisolone pulse therapy within 1 year of diagnosis and had baseline estimated glomerular filtration rate (eGFR) ≥ 30 mL/min/1.73 m². Of these, 221 received TSP and 329 received SP alone. Analysis included use of inverse probability of treatment weighting (IPTW) based on propensity scores to adjust for measured baseline differences. The primary outcome was a composite of 30% decline in eGFR or dialysis initiation. This occurred in 18 individuals in the SP group and 5 individuals in the TSP group. Although fewer renal events occurred in the TSP group, the confidence intervals were wide and  the difference was not statistically significant (HR, 0.58; 95% CI, 0.22-1.54; p=0.28). Only 23 primary outcome events occurred, limiting the precision of the estimates. Secondary outcomes also did not differ significantly, including the composite of end-stage renal failure or dialysis (HR, 0.35; 95% CI, 0.04-3.43; p=0.37). Limitations include the retrospective observational design, potential residual confounding despite propensity score adjustment, lack of renal histology data, and possible exposure misclassification if tonsillectomy, biopsy, or follow-up occurred outside the captured healthcare system. The study also had relatively few renal outcome events, and the authors noted it may have been underpowered. Follow-up may also have been insufficient to assess long-term renal outcomes.

Suspected Malignancy

After thyroid and larynx carcinoma, tonsillar carcinoma is the third most common head and neck malignancy. Theodoraki and colleagues (2017) completed a systematic review of the literature and recommends bilateral tonsillectomy for adults with unilateral tonsillar carcinoma or in cases where the primary cancer is unknown.

Sunkaraneni et al. (2006) conducted a retrospective case-note review of all tonsillectomies performed for histological examination at 1 facility over a 5-year period and reviewed the histological findings in those with unilateral tonsillar enlargement alone and those with unilateral tonsillar enlargement with other clinical features. The other clinical features included chronic pain, dysphagia, the presence of tonsillar or peritonsillar mucosal abnormality, and cervical lymphadenopathy. There were 53 individuals who had unilateral tonsillar enlargement, 33 had unilateral tonsillar enlargement alone and 20 had other clinical features. In the unilateral tonsillar enlargement alone group, none of the individuals were found to have malignancy. In the group with other clinical findings, 9 (45%) individuals had a malignancy. The authors concluded that, for individuals with unilateral tonsil enlargement, a ‘watch and wait’ policy is initially appropriate for a period of up to 6 weeks. If signs or symptoms progress or are consistent with malignancy, tonsillectomy should then be advised.

Other Considerations

For tonsillectomy for psoriasis, the evidence is insufficient and additional research is recommended. Thorleifsdottir and colleagues conducted a randomized controlled trial to analyze the effects of tonsillectomy on individuals with streptococcal-associated psoriasis exacerbations. A total of 29 individuals were randomly assigned to tonsillectomy (n=15) or control (n=14) and were followed for 24 months. The Psoriasis Disability Index (PDI) and Psoriasis Life Stress Inventory (PLSI) were used at 12 and 24 months to assess the individual’s health related quality of life (HRQoL). A positive connection was noted between increased HRQoL and clinical improvement (r=0.297, p=0.008). Researchers noted that more robust trials and long-term follow-up of tonsillectomized individuals with plaque psoriasis are needed.

Apnea-Hypopnea index (AHI) or Respiratory Disturbance index (RDI): A measure of apnea severity defined by the total number of episodes of apnea or hypopnea during a full period of sleep divided by the number of hours asleep.

Cervical adenopathy: Enlargement of the cervical lymph nodes, located on both sides of the neck.

Group A β-hemolytic streptococcus (GABHS): A bacteria commonly associated with serious throat infections.

Infectious mononucleosis: An infection usually caused by the Epstein-Barr virus that often occurs in teens and young adults with symptoms including fever, sore throat, and swollen lymph glands.

IgA Nephropathy: A chronic kidney disease that occurs when deposits of the protein immunoglobulin (IgA) build up inside the filters in the kidney.

Obstructive sleep apnea (OSA): A condition that is characterized by cessation of breathing during sleep, caused by temporary collapse of the upper airway.

Pharyngitis: The medical term for a “sore throat.”

Polysomnography: Also known as a “sleep study.” A test used to diagnose sleep disorders.

Tonsils: Organs of the lymphatic system located at the back of the throat. The purpose of the tonsils is to capture germs entering the body through the mouth and nose.

Peer Reviewed Publications:

1. Alho OP, Koivunen P, Penna T, et al. Tonsillectomy versus watchful waiting in recurrent streptococcal pharyngitis in adults: randomized controlled trial. BMJ. 2007; 334(7600):939.
2. Camacho M, Li D, Kawai M, et al. Tonsillectomy for adult obstructive sleep apnea: a systematic review and meta-analysis. Laryngoscope. 2016; 126(9):2176-2186.
3. Chan SC, Dawes PJ. The management of severe infectious mononucleosis tonsillitis and upper airway obstruction. J Laryngol Otol. 2001; 115(12):973-977.
4. Hayashi A, Mizuno K, Shinkawa K, et al. Association between tonsillectomy plus steroid pulse therapy and renal outcomes in patients with IgA nephropathy: a retrospective cohort study. BMC Nephrol. 2025; 26(1):484.
5. Hirano K, Matsuzaki K, Yasuda T, et al. Association between tonsillectomy and outcomes in patients with immunoglobulin A nephropathy. JAMA Netw Open. 2019; 2(5):e194772.
6. Katafuchi R, Kawamura T, Joh K, et al.; IgA nephropathy Study Group in Japan. Pathological sub-analysis of a multicenter randomized controlled trial of tonsillectomy combined with steroid pulse therapy versus steroid pulse monotherapy in patients with immunoglobulin A nephropathy. Clin Exp Nephrol. 2016; 20(2):244-252.
7. Kawamura T, Yoshimura M, Miyazaki Y, et al.; Special IgA Nephropathy Study Group. A multicenter randomized controlled trial of tonsillectomy combined with steroid pulse therapy in patients with immunoglobulin A nephropathy. Nephrol Dial Transplant. 2014; 29(8):1546-1553.
8. Komatsu H, Fujimoto S, Sato Y, et al. Effect of tonsillectomy combined with steroid pulse therapy upon IgA nephropathy depending on proteinuria status at diagnosis: a nationwide multicenter cohort study in Japan. Clin Exp Nephrol. 2024; 28(12):1272-1281.
9. Koskenkorva T, Koivunen P, Koskela M, et al. Short-term outcomes of tonsillectomy in adult patients with recurrent pharyngitis: a randomized controlled trial. CMAJ. 2013; 185(8):E331-E336.
10. Makkonen J, Blomster H, Raappana A, et al. Adult obstructive sleep apnea treated with tonsillectomy: a randomized controlled clinical trial. Acta Otolaryngol. 2025; 145(10):989-996.
11. Senchak AJ, McKinlay AJ, Acevedo J, et al. The effect of tonsillectomy alone in adult obstructive sleep apnea. Otolaryngol Head Neck Surg. 2015; 152(5):969-973.
12. Sunkaraneni VS, Jones SE, Prasai A, et al. Is unilateral tonsillar enlargement alone an indication for tonsillectomy? J Laryngol Otol. 2006; 120(7):E21.
13. Theodoraki MN, Veit JA, Hoffmann TK, Greve J. Synchronous bilateral tonsil carcinoma: case presentation and review of the literature. Infect Agent Cancer. 2017; 12:38.
14. Thorleifsdottir RH, Sigurdardottir SL, Sigurgeirsson B, et al. Patient-reported outcomes and clinical response in patients with moderate-to-severe plaque psoriasis treated with tonsillectomy: a randomized controlled trial. Acta Derm Venereol. 2017; 97(3):340-345.

Government Agency, Medical Society, and Other Authoritative Publications:

1. American Academy of Otolaryngology - Head and Neck Surgery. Position statement: treatment of obstructive sleep apnea. June 9, 2021. Available at: https://www.entnet.org/resource/position-statement-treatment-of-obstructive-sleep-apnea/. Accessed July 30, 2026.
2. Burton MJ, Glasziou PP, Chong LY, et al. Tonsillectomy or adenotonsillectomy versus non-surgical treatment for chronic/recurrent acute tonsillitis. Cochrane Database Syst Rev. 2014;2014(11):CD001802.
3. Mitchell RB, Archer SM, Ishman SL, et al.; American Academy of Otolaryngology-Head and Neck Surgery Foundation. Clinical practice guideline: tonsillectomy in children. Otolaryngol Head Neck Surg. 2019; 160(1S):S1-S42.
4. NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines^®). © 2026 National Comprehensive Cancer Network ^®. For additional information visit the NCCN website at: http://www.nccn.org/index.asp. Accessed on July 16, 2026.
   • Head and Neck Cancer (V2.2026). Revised May 12, 2026.
5. Wilson JA, Fouweather T, Stocken DD, et al. Tonsillectomy compared with conservative management in patients over 16 years with recurrent sore throat: the NATTINA RCT and economic evaluation. Health Technol Assess. 2023; 27(31):1-195.

1. National Institute of Diabetes and Digestive and Kidney Disease. IgA Nephropathy. Last reviewed September 2022. Available at: https://www.niddk.nih.gov/health-information/kidney-disease/iga-nephropathy. Updated September 2022. Accessed on July 30, 2026.
2. National Library of Medicine. Infectious Mononucleosis. Last updated June 10, 2024. Available at: https://medlineplus.gov/infectiousmononucleosis.html. Accessed on July 30, 2026.
3. National Library of Medicine. Sleep apnea. Last updated September 28, 2025. Available at: https://www.nlm.nih.gov/medlineplus/sleepapnea.html. Accessed on July 30, 2026.

Obstructive sleep apnea
Sleep-disordered breathing
Tonsillectomy

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