The AAO-HNS guideline reduces the use of routine postop antibiotics and points out the FDA black box warning on codeine in children after the surgery.

The American Academy of Otolaryngology–Head and Neck Surgery Foundation just published the Clinical Practice Guideline: Tonsillectomy in Children (Update) in Otolaryngology–Head and Neck Surgery. The update to the 2011 publication, which includes a large amount of new information that applies to a child considered for tonsillectomy, emphasizes education, counseling, and pain management with several tables and handouts that are intended for caregivers.1

“The purpose of this multidisciplinary guideline is to identify quality improvement opportunities in managing children, 18 years of age or less, who are under consideration for tonsillectomy and to create explicit and actionable recommendations. The goal is to educate clinicians and caregivers on the indications and the perioperative management of children undergoing tonsillectomy. There is an emphasis on the need for evaluation and intervention in special populations. We highlight the need for counseling and education of families,” says Ron B. Mitchell, MD, chair of the guideline update group, in a release.

Tonsillectomy is a surgical procedure performed with or without adenoidectomy that completely removes the tonsil, including its capsule, by dissecting the peritonsillar space between the tonsil capsule and the muscular wall. Tonsillectomy is one of the most common ambulatory surgery procedures performed on children in the United States. In the most recent report of the National Health Stat Report, published in 2017, 289,000 ambulatory tonsillectomy procedures were performed in children less than 15 years of age.2 This is a decline in incidence from the National Health Stat Report, published in 2009, which cited more than 530,000 tonsillectomies in children under 15.3 The two most common indications for tonsillectomy are recurrent throat infections and obstructive sleep-disordered breathing.

Changes in practice since the 2011 guideline include a reduction in the use of routine postoperative antibiotics as well as a Food and Drug Administration black box warning on the use of codeine in children posttonsillectomy.

“The frequency of performing tonsillectomy in children, coupled with the significant practice variations in diagnosing and managing children undergoing the surgery, supported the need for an updated evidence-based clinical practice guideline to replace the 2011 version,” says Mitchell.

Changes from the prior guideline include two consumer advocates added to the update group; evidence from one new clinical practice guideline, 26 new systematic reviews, and 13 new randomized controlled trials; enhanced emphasis on patient education and shared decision-making; the addition of an algorithm to clarify action statement relationships; changes to five of the key action statements from the original guideline; incorporation of new evidence profiles to include the role of patient preferences, confidence in the evidence, differences of opinion, quality improvement opportunities, and any exclusion to which the action statement does not apply; and the addition of seven new key action statements.

Of the 15 key action statements, the guideline update group made strong recommendations against the following:

  1. Clinicians should not administer or prescribe perioperative antibiotics to children undergoing tonsillectomy; and
  2. Clinicians must not administer or prescribe codeine, or any medication containing codeine, after tonsillectomy in children younger than 12 years.


1. Mitchell RB, Archer SM, Ishman SL, et al. Clinical practice guideline: Tonsillectomy in children (update). Otolaryngol Head Neck Surg. 2019 Feb;160(1_suppl):S1-S42.

2. Hall MJ, Schwartzman A, Zhang J, Liu X. Ambulatory surgery data from hospitals and ambulatory surgery centers: United States, 2010. Natl Health Stat Report. 2017;(102):1-15.

3. Cullen KA, Hall MJ, Golosinskiy A. Ambulatory surgery in the United States, 2006. Revised. Natl Health Stat Report. 2009 Jan 28;(11):1-25.