Sizing Up Those Tonsils

The Brodsky grading scale is the most commonly used way to grade tonsillar size, and uses a scale from 0 to 4. It has been shown to have acceptable intra- and inter-observer reliability (in comparison with other scales). In children, tonsillar hypertrophy is associated with dysphagia and airflow obstruction, a predisposing factor for sleep-related breathing disorders such as OSA.

Source: UpToDate
  • 0: Tonsils are entirely within the tonsillar pillar or previously removed by surgery;
  • 1: Tonsils occupy <25% of the lateral dimension of the oropharynx, as measured between the anterior tonsillar pillars (solid yellow arrow);
  • 2: Tonsils occupy 26-50% of the lateral dimension of the oropharynx;
  • 3: Tonsils occupy 51-75% of the lateral dimension of the oropharynx;
  • 4: Tonsils occupy >75% of the lateral dimension of the oropharynx.

In contrast, the Mallampati index is a method of evaluating the relationship between the tongue and oral cavity, originally developed as a means to predict the ease of intubation but also may be useful in predicting OSA. It is graded from 1 to 4 (and each grade may be easier to remember using the “PUSH” mnemonic). Last, it’s important to note that tonsillar size does not affect the score.

Source: Myers et al. JAMA. 2013
  • Class 1: Tonsillar pillars, uvula and soft palate are all visible; 
  • Class 2: Partial visibility of the tonsillar pillars, uvula and soft palate;
  • Class 3: Base of the uvula, soft and hard palate visible;
  • Class 4: Only hard palate is visible.
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