Harley listed criteria for when tonsillectomy should be considered in a child with asymmetrical enlargement of the tonsils. The author is from Georgetown University Hospital in Washington, D.C.


Tonsillar asymmetry in a child is usually due to one of the following:

(1) benign lymphoid hyperplasia

(2) variation in the depth of the tonsillar fossa



(1) Are both tonsils enlarged or only one?

(2) If one tonsil is larger than the other, by how much?

(3) Is it necessary to take out both tonsils? (The paper seemed to indicate that a bilateral tonsillectomy was performed.)


Asymmetry was defined as a difference in tonsillar size of >= 1+ on the Brodsky scale (see previous section).


This definition may pose problems:

(1) The Brodsky classification is based on how much of the airway is or is not obstructed rather than the actual size of the tonsils.

(2) The Brodsky scale is based on percentage obstruction of the oropharynx and a minor change in percent can change the grade. For example, a 24% obstruction is considered Grade 1 while a 26% obstruction is Grade 2.

(3) The original method is based on widths between the anterior tonsillar pillars and between medial surfaces of the tonsils. The only way to determine asymmetry is to take the distance from the anterior pillar and medial surface of the tonsil to the midline.

(4) If both tonsils are enlarged then asymmetry could be masked.


percent obstruction on one side =

= ((distance from anterior tonsillar pilar to the midline) - (distance from the medial surface of the tonsil to the midline)) / (distance from anterior tonsillar pilar to the midline) * 100%


difference in obstruction between the 2 sides =

= ABSOLUTE VALUE((percent obstruction on left side) - (percent obstruction on right side))


For the implementation I will use a difference >= 25% as indicative of asymmetry.


A special case may be when one tonsil is still behind its tonsillar pillar while the other protrudes across.


Indications for tonsillectomy when there is asymmetry:

(1) tonsillar enlargement associated with significant dysphagia, recurrent tonsillitis or obstructed breathing

(2) rapid enlargement

(3) presence of prominent cervical lymphadenopathy

(4) presence of hepatosplenomegaly

(5) presence of constitutional symptoms (weight loss, fever, night sweats)

(6) immunosuppression, including transplant patient


A child with mild tonsillar asymmetry that is asymptomatic and not associated with risk factors can be followed clinically.


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