Paradise Criteria for Tonsillectomy in Children

Why did you develop the Paradise Criteria? Was there a particular clinical experience or patient encounter that inspired you to create this tool for clinicians?

When in pediatric practice in a new, union-sponsored health plan in Appalachia, I was often called upon to render judgment as to whether or not tonsillectomy was indicated for individual children for whom a recommendation for tonsillectomy had been made by other physicians. This procedure was instituted because health plan administrators believed that tonsillectomy often was being performed on children without appropriate indications. Accordingly, payment for tonsillectomy by the health plan was made contingent on prior approval by me or by another member of a health-plan-designated group of consultants. In that role, I came to realize that there were then no evidence-based criteria for tonsillectomy. Recommendations by recognized authorities varied widely and were based entirely on clinical experience and/or opinion. When I left practice to head an ambulatory care program in a large teaching hospital, I saw an opportunity to address the question of criteria for tonsillectomy systematically.

What pearls, pitfalls, and/or tips do you have for users of the Paradise Criteria? Do you know of cases when it has been applied, interpreted, or used inappropriately?

It is important to recognize that these 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.

What recommendations do you have for doctors once they have applied the Paradise Criteria? Are there any adjustments or updates you would make to the score based on new data or practice changes?

Rarely is it necessary for decisions about tonsillectomy to be made without delay. In many children, the problem of recurrent throat infection diminishes spontaneously with time. Application of the criteria serves to divide children with histories of recurrent throat infection into two clinical groups: the large majority who should not undergo tonsillectomy, and the minority for whom tonsillectomy is a reasonable option, but not a requirement.

How do you use the Paradise Criteria in your own clinical practice? Can you give an example of a scenario in which you use it?

Documentation of the frequency, clinical features, and severity of episodes of throat infection is essential. To that end, watchful waiting is often the most appropriate course to follow, particularly in children not previously known to the clinician. For the child being evaluated for the first time, whose parents are predisposed to ask for tonsillectomy, I have found that it is a mistake to simply declare that tonsillectomy is not indicated. Rather, I would acknowledge that the parent's request is understandable, and that tonsillectomy might prove to be appropriate, but that following the child over time permits a level of certainty about the indications. In my experience, most parents are able to accept that course of action because they appreciate the concern and conscientiousness that underlie it.

Jack L. Paradise, MD, now retired, was the medical director of the Ambulatory Care Center at the Children’s Hospital of Pittsburgh. He was also a professor in the pediatrics department at the University of Pittsburgh School of Medicine. Dr. Paradise’s primary research was focused on indications for tonsillectomy and adenoidectomy, and on the diagnosis, management, and clinical significance of otitis media.