The swelling of the tonsils can have a major effect on the health of the patient. Tonsillitis impacts the health of the children considerably. It can either delay the growth of the child or even cause behavioral problems. Hence, doctors continuously monitor the tonsils of the children to check if their sizes have changed due to any cause. Also, they use a grading system to rule out the possibility of any other problem in the throat that is stagnating their growth. 

What is Tonsil Grading?

The tonsil grading is a scale that ENT doctors rely upon to check the change in the tonsil size. It is used to determine the size of the tonsils as well as grade the tonsils and monitor the sizes regularly to document any changes. 

In addition to this, the continuous monitoring of the sizes can help doctors determine if the delaying of the treatment could lead to snoring and ultimately obstructive sleep apnea (OSA). 

There are various types of grading systems that doctors use globally. However, not all of them are as reliable as the Brodsky grading system and Friedman grading system. 

Standardized Grading of Tonsil Size

Brodsky was the first person to introduce a grading system for tonsil size. His main idea behind developing this grading system was that the doctor would be able to check the extent of tonsil enlargement. 


According to the scale he developed, there are four sizes- one to four. The scale is described below.


Size 1 This is the normal size of the tonsils. In this size, the tonsils extend to the pillars. Tonsils occupy less than 25 percent of the oropharynx. The tonsils are not visible properly.
Size 2 This size is also considered as normal size and the tonsils extend to the pillars. Tonsils occupy 26 to 50 percent of the oropharyngeal airway. However, the tongue doesn’t go beyond the tonsillar pillars. 
Size 3The tonsils can get infected leading to its inflammation. Due to this inflammation, these take up 75% of the oropharyngeal airway. Also, tonsils extend beyond pillars but stop beyond the midline. 
Size 4The tonsils reach each other and extend to the midline. This is the most enlarged size of tonsils as these take more than 75% of the airways. 


In addition to the above sizes, there is another size which is size 0. The size 0 is the one in which the tonsils are not present or surgically removed. 

Furthermore, there are certain factors upon which the results of the size depends on include-

  • Minimum distance between medial aspects of two tonsils
  • The distance between the anterior tonsils located midway between the tongue and palate 

How to Use The Scale?

The patient has to make sure that the tongue is well-rested in the mouth for diagnosis. The doctor asks the patient to open their mouth wide open and presses the tongue blades down. 

In addition to this, the patient cannot gag as gagging makes the tonsils move that makes them appear larger than normal. Otherwise, it may result in a false-positive test. Now, the ENT specialist uses a penlight to check at the back of the throat. 

He looks for the following symptoms to understand the underlying condition for enlargement of tonsils-


There is another grading scale that ENT specialists use when tonsillitis causes complications such as obstructive sleep apnea. 

The Friedman grading is a palate grading that is used to inspect the size of the upper airway. When the doctors recommend taking out the tonsils due to the several complications it causes, the doctors use this grading to decide upon the best technique for curing the obstructive sleep apnea. 

According to the Friedman grading system, there are four grades of the palates decided on the basis of the appearance.

    • Grade 1: The uvula and tonsils can be seen separately.
    • Grade 2: The uvula is visible but the tonsils are not.
    • Grade 3: The palate is visible but the uvula is not.
    • Grade 4: The tonsils and the uvula causes crowding leading to a blockage in the airway.

Friedman developed a staging system combining the tonsils size grading, palate grade and BMI. Eventually, this helps the doctors determine the appropriate surgical technique for curing sleep apnea. 

Why the Tonsils Increase in Size?

According to Dr. Siddhartha Vashishta, ENT doctor from Pristyn Care, “The tonsils inflame when there is an infection in the throat. The common causes of a throat infection are influenza viruses and bacteria.” 

Some of the factors that contribute to tonsillitis include-

  • Viruses such as rhinovirus, Epstein-Barr virus, HIV, hepatitis A
  • Bacteria responsible for Strep throat 

When It Is Time To Take the Tonsils Out? 

People suffering from size 3 and size 4 should consult with an ENT specialist without any further delay. The reason being that in both these grades, the tonsils become so enlarged that it covers more than 75% of the oropharyngeal airway. The main reason being that there is an infection that requires immediate medical attention. 

Some of the options to consider include- taking some medicines that mainly include antibiotics and throat sprays or taking out the tonsils completely in a surgery. 

At Pristyn Care, ENT specialists recommend tonsillectomy for patients suffering from recurrent or chronic tonsillitis as they cause chronic throat pain, difficulty in swallowing food or a feeling that something is stuck in the throat. If you are facing any of these symptoms, it indicates that you have a grade 3 or 4 of tonsil size. Book an appointment with our ENT doctor for a proper diagnosis. 

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