Paradise Criteria for Tonsillectomy in Children

Paradise Criteria Calculator

Episode Frequency Pattern

Sore Throat with Each Episode

Temperature >38.3°C (101°F)

Cervical Lymphadenopathy

Tonsillar Exudate

Positive Group A Strep Culture

Paradise Criteria: –

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Predicts which patients with recurring sore throat will benefit from tonsillectomy.

Why Use

Tonsillectomy may provide benefits, but the risk of complications is not insignificant. This criteria helps clinicians identify which patients will most benefit from tonsillectomy.

When to 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.

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

Pearls / Pitfalls

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. From MDCalc exclusive interview with Dr. Paradise: "The criteria apply only to children whose indications for tonsillectomy would be based solely on recurrent episodes of throat infection. Children who have obstructive sleep-disordered breathing because of excessively large tonsils constitute a separate group for whom tonsillectomy is clearly indicated."

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.

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.

More Information

Interpretation: Paradise Criteria Recommendation Meets criteria Consider tonsillectomy Does not meet criteria Watchful waiting recommended