Tonsil removal, or tonsillectomy, is typically recommended when you’re getting seven or more throat infections in a single year, five per year for two consecutive years, or three per year for three consecutive years. These thresholds, known as the Paradise criteria, form the backbone of clinical guidelines in both the US and UK. But frequent infections aren’t the only reason. Sleep-disordered breathing is now the most common reason children have their tonsils taken out, and adults may qualify for surgery based on chronic infection, airway obstruction, or concerns about abnormal tissue.
The Infection Frequency Threshold
The clearest guideline for tonsillectomy is a specific pattern of recurrent sore throats. If you or your child has experienced seven or more documented episodes in one year, five or more per year for two straight years, or three or more per year for three straight years, surgery becomes a reasonable option. These episodes should be confirmed by a clinician, not just self-reported, and ideally involve positive strep tests, fevers above 100.9°F, swollen lymph nodes, or tonsillar exudates (the white patches on inflamed tonsils).
The American Academy of Otolaryngology updated its clinical practice guidelines for children in 2019, reinforcing these frequency benchmarks. What matters here is consistency of documentation. If you’ve been treating sore throats at home without medical visits, the count may not formally qualify, even if the actual number of infections is high. Keeping a record of each episode and getting seen during active symptoms helps build the case for surgery if it becomes necessary.
Sleep-Disordered Breathing in Children
For children, the most common reason tonsils come out today isn’t infection at all. It’s obstructive sleep-disordered breathing, a spectrum that ranges from habitual snoring to full obstructive sleep apnea. When tonsils and adenoids are large enough to partially or fully block the airway during sleep, children may snore loudly, pause their breathing, sleep restlessly, wet the bed, or struggle with daytime behavior and attention problems.
A sleep study can measure the severity using a score called the apnea-hypopnea index (AHI), which counts how many times per hour breathing is disrupted. Children with mild to moderate scores (roughly 1 to 10 events per hour) tend to see the most obvious improvement after surgery. In more severe cases, surgery still helps but may need to be part of a broader treatment plan. If your child snores most nights and you notice pauses in breathing, mouth breathing, or unusual sleep positions (like sleeping with the neck hyperextended), those are signs worth discussing with a pediatrician or ENT specialist.
Chronic Tonsillitis in Adults
Adults follow the same Paradise criteria for recurrent infections, but the picture often looks a bit different. Chronic infection remains the leading indication for adult tonsillectomy, accounting for about 57% of cases in one large study. Another 27% involve airway obstruction from enlarged tonsils, and roughly 16% are performed to rule out cancer when tissue looks suspicious.
Beyond strict infection counts, adults sometimes pursue surgery for chronic problems that erode quality of life: persistent bad breath caused by tonsil stones (small, calcified debris trapped in tonsillar crypts), ongoing low-grade throat soreness, or recurring strep infections that don’t fully clear between episodes. These situations don’t always meet the formal frequency criteria, but an ENT can weigh the overall burden of disease when making a recommendation.
Peritonsillar Abscess
A peritonsillar abscess is a pocket of pus that forms next to the tonsil, causing severe one-sided throat pain, difficulty swallowing, and sometimes a muffled voice. A single abscess in someone with no prior history of tonsillitis doesn’t automatically mean the tonsils should come out. However, if you had recurrent tonsillitis before the abscess developed, tonsillectomy is generally recommended because the underlying pattern of infection makes recurrence more likely.
When One Tonsil Looks Different
Asymmetric tonsils, where one side is noticeably larger than the other, can be alarming. A large meta-analysis of over 5,000 patients found that tonsillar asymmetry on its own carries less than a 1% probability of malignancy when no other concerning features are present. But when combined with red flags like unexplained neck lumps, persistent ear pain on one side, difficulty swallowing, or unexplained weight loss, the probability of cancer jumps to nearly 39%. In those cases, removing the tonsil for biopsy is standard. An isolated size difference without other symptoms is far less worrisome, though it still warrants evaluation.
Periodic Fever Syndrome (PFAPA)
Some children develop a condition called PFAPA syndrome, which causes clockwork-like episodes of high fever every few weeks, along with mouth sores, sore throat, and swollen neck glands. There’s no single test to confirm it, and no medication that cures it. Tonsillectomy has emerged as an option for children whose episodes are frequent and disruptive enough to significantly affect daily life, school attendance, and family routine. The decision is individualized. If episodes are becoming milder, shorter, or more spaced out, that may signal the condition is resolving on its own, making surgery less urgent.
What Recovery Looks Like
Throat pain after tonsillectomy is significant and typically lasts 10 to 14 days, sometimes longer in adults. The first week generally requires rest and a soft diet. You can eat soft solid foods whenever you feel ready, but crunchy, dry, or sharp-edged foods like chips, toast, and pretzels should be avoided for at least two weeks. Most children miss about a week of school, while adults often need 10 to 14 days off work.
The main surgical risk is post-operative bleeding, which can happen in the first 24 hours or, more commonly, between days 5 and 10 as the scab over the surgical site breaks down. A national study of over 96,000 children found that about 2% returned to the emergency department for bleeding within 30 days of surgery. Most surgical centers advise staying within reasonable distance of a hospital for at least two weeks after the procedure, and avoiding strenuous physical activity until cleared at a follow-up visit.
Long-Term Effects on Immune Function
Tonsils are part of the immune system, so it’s reasonable to wonder whether removing them leaves you more vulnerable to illness. Research shows that children who’ve had tonsillectomies do have measurably lower levels of certain antibodies (IgA, IgM, and IgG) compared to children who kept their tonsils. However, the immune cells responsible for fighting viruses and other pathogens, including key white blood cell types, remain at normal levels after surgery. Importantly, studies have found that the rate of upper respiratory infections does not increase in children after tonsillectomy compared to healthy controls. The body has plenty of other lymphoid tissue throughout the throat and airway that compensates for the loss.