What is Tonsillectomy?

Tonsillectomy is defined as the surgical excision of the palatine tonsils. Indications for this procedure remain controversial.

Effects of Tonsillectomy

Paradise and colleagues monitored patients who had recurrent throat infections. Those who had tonsillectomy had fewer throat infections in the first 2 years after treatment than those who did not have tonsillectomy.

Compared with watchful waiting, tonsillectomy or adenotonsillectomy provided an additional, but small, reduction in the episodes of sore throat, days of school absence associated with sore throat, and upper respiratory infections (van Staaij, 2005). Results of other studies have suggested an overall patient satisfaction and improved quality of life.

Levels of alpha-streptococci (inhibitory protective bacteria) have been shown to increase after tonsillectomy. This further explaining why tonsillectomy decreases the rate of streptococcal infection (including pharyngitis).

Candidates for Tonsillectomy

This is another very common procedure and the usual indications are recurrent and acute tonsillitis but also children with obstructive sleep apnoea who because the tonsils tissue is so large that they cannot breath properly at night.

Unfortunately, there may be a time when medical therapy (antibiotics) fails to resolve the chronic tonsillar infections that affect your child. In other cases, your child may have enlarged tonsils, causing loud snoring, upper airway obstruction, and other sleep disorders. The best recourse for both these conditions may be removal or reduction of the tonsils and adenoids. The American Academy of Otolaryngology—Head and Neck Surgery recommends that children who have three or more tonsillar infections a year undergo a tonsillectomy; the young patient with a sleep disorder should be a candidate for removal or reduction of the enlarged tonsils.

Otolaryngology textbooks list a variety of indications for tonsillectomy. The American Academy of Otolaryngology–Head and Neck Surgery (AAO-HNS) publishes clinical indicators for surgical procedures. Paraphrased, these clinical indicators are as follows:

Absolute indications

  • Enlarged tonsils that cause upper airway obstruction, severe dysphagia, sleep disorders, or cardiopulmonary complications
  • Peritonsillar abscess that is unresponsive to medical management and drainage documented by surgeon, unless surgery is performed during acute stage
  • Tonsillitis resulting in febrile convulsions
  • Tonsils requiring biopsy to define tissue pathology

Relative indications

  • Three or more tonsil infections per year despite adequate medical therapy
  • Chronic or recurrent tonsillitis in a streptococcal carrier not responding to beta-lactamase-resistant antibiotics
  • Unilateral tonsil hypertrophy that is presumed to be neoplastic

Your Consultation

Careful history taking is needed to evaluate for the following:

  • Bleeding disorders
  • Anesthesia intolerances
  • Obstructive sleep apnea

The Tonsillectomy Procedure

Cold knife (steel) dissection:Removal of the tonsils by use of a scalpel is the most common method practiced by otolaryngologists today. The procedure requires the young patient to undergo general anesthesia; the tonsils are completely removed with minimal post-operative bleeding.

Harmonic scalpel:This medical device uses ultrasonic energy to vibrate its blade at 55,000 cycles per second. Invisible to the naked eye, the vibration transfers energy to the tissue, providing simultaneous cutting and coagulation. The temperature of the surrounding tissue reaches 80 degrees Celsius. Proponents of this procedure assert that the end result is precise cutting with minimal thermal damage.

Radiofrequency ablation: Monopolar radiofrequency thermal ablation transfers radiofrequency energy to the tonsil tissue through probes inserted in the tonsil.The procedurecan beperformed in an office settingunder light sedation or local anesthesia. After the treatment is performed, scarring occurs within the tonsil causing it to decrease in size over a period of several weeks. The treatment can be performed several times. The advantages of this technique are minimal discomfort, ease of operations, and immediate return to work or school. Tonsillar tissue remains after the procedure but is less prominent. This procedure is recommended for treating enlarged tonsils and not chronic or recurrent tonsillitis.

Carbon dioxide laser:Laser tonsil ablation (LTA) finds the otolaryngologist employing a hand-held CO2 or KTP laser to vaporize and remove tonsil tissue. This technique reduces tonsil volume and eliminates recesses in the tonsils that collect chronic and recurrent infections. This procedure is recommended for chronic recurrent tonsillitis, chronic sore throats, severe halitosis, or airway obstruction caused by enlarged tonsils.

The LTA is performed in 15 to 20 minutes in an office setting under local anesthesia. The patient leaves the office with minimal discomfort and returns to school or work the next day. Post-tonsillectomy bleeding may occur in two to five percent of patients. Previous research studies state that laser technology provides significantly less pain during the post-operative recovery of children, resulting in less sleep disturbance, decreased morbidity, and less need for medications. On the other hand, some believe that children are adverse to outpatient procedures without sedation.

Microdebrider:What is a “microdebrider?” The microdebrider is a powered rotary shaving device with continuous suction often used during sinus surgery. It is made up of a cannula or tube, connected to a hand piece, which in turn is connected to a motor with foot control and a suction device.

The endoscopic microdebrider is used in performing a partial tonsillectomy, by partially shaving the tonsils. This procedure entails eliminating the obstructive portion of the tonsil while preserving the tonsillar capsule. A natural biologic dressing is left in place over the pharyngeal muscles, preventing injury, inflammation, and infection. The procedure results in less post-operative pain, a more rapid recovery, and perhaps fewer delayed complications. However, the partial tonsillectomy is suggested for enlarged tonsils – not those that incur repeated infections.

Bipolar Radiofrequency Ablation (Coblation):This procedure produces an ionized saline layer that disrupts molecular bonds without using heat. As the energy is transferred to the tissue, ionic dissociation occurs. This mechanism can be used to remove all or only part of the tonsil. It is done under general anesthesia in the operating room and can be used for enlarged tonsils and chronic or recurrent infections. This causes removal of tissue with a thermal effect of 45-85 C°. The advantages of this techniqueare less pain, faster healing, and less post operative care.

Recovery

Postoperative details:

    • Use liquid acetaminophen (Tylenol) with or without codeine for pain control. (The unwillingness of parents to give analgesics is associated with children’s refusal to eat, which results in dehydration, weight loss, and local infection.)
    • Maintain good hydration.
    • The patient should eat an adequate diet. No evidence suggests that a special diet is required; however, soft foods are more easily swallowed than hard foods.
    • Administer antibiotics. Oral antibiotic use for the week after tonsillectomy is associated with improved outcomes in both adults and children.
    • Instruct the patient to avoid smoking.
    • Instruct the patient to avoid heavy lifting and exertion for 10 days.
    • Warn patients that pain will abate during the first 3-5 days then increase for 1-2 days before completely disappearing.
    • Most often, tonsillectomy is safely performed on an outpatient basis. Individuals who should not receive tonsillectomy as outpatients are those younger than 3 years, those with obstructive sleep apnea, those who live far away from the outpatient facility, or those who have difficulty in complying with instructions.

Follow-up care:

      Ideal times for follow-up care are (1) when the pain has its second peak (at 5-8 days) to reassure patients and (2) at 4-6 weeks after surgery to monitor for the resolution of symptoms. A phone call by a registered nurse may be adequate for postoperative follow-up, though the decision about the method of follow-up is up to the patient and surgeon.

Risks

There are many surgical techniques for removing the tonsil and at present there is no clear advantage of one over the other, although this is at present a subject of a Royal College of Surgeons of England Audit and so it may be possible in the near future to make more specific recommendations. The major complications of tonsillectomy are 1) pain, this is inevitable to some degree and some patients experience minimal pain, others particularly adults may suffer badly. Interestingly children may well complain of earache more than a sore throat, we call this referred pain and is due to the unusual nerve supply of the ear. If this should occur it does not mean that anything has gone wrong with the operation at all. Pain is often worse between the 5th and 10th day after the operation and may require quite strong painkillers. 2) Haemorrhage, this is the most serious and dreaded complication. Haemorrhage may occur within 24 hours of the operation, which we call reactionary haemorrhage. If this does happen then of these cases approximately 80% occur within the first six hours of the operation and the person is usually taken straight back to the operating room to have the bleeding point stopped. After 6-8 hours the chances of bleeding over the next day or two are extremely small, although spitting the odd bit of blood is not unusual. For this reason surgery as a day case is becoming increasingly popular. The second period, during which haemorrhage can occur is between day 5 and day 10 after the operation, this is called secondary haemorrhage. It may or may not be associated with an infection of the area. It is usually treated by admission to hospital with bed rest and antibiotics. The approximate incidence of these complications are that secondary or reactionary haemorrhage occurs in about 3% of cases, approximately half of those patients admitted with secondary haemorrhage can be treated by bed rest and antibiotics alone and approximately half will require a second operation to stop the bleeding.

Hemorrhage is the most common complication. An estimated 2-3% of patients have hemorrhage, and 1 of 40,000 patients die from bleeding.

Pressure can be applied to a bleeding tonsil fossa by using a sponge and a long clamp. Dipping the sponge in epinephrine or thrombin powder may be helpful. If this fails, the patient should be taken to the operating room. Options to stop the bleeding are electrocautery of the tonsil bed, use of further topical hemostatics, or ligation of the ipsilateral carotid artery as the last resort. Diathermy is thought to be superior to ligation because of the risk of perforating large vessels with the needle. In severe situations, a sponge may be fixed in place by using sutures. Another last resort is ligation of other large vessels, such as the external carotid artery.

Bleeding may be classified as intraoperative, primary (occurring within the first 24 hours), or secondary (occurring between 24 hours and 10 days).

Other complications include the following:

  • Pain (eg, sore throat, otalgia)
  • Dehydration (common in children who do not eat because of pain)
  • Weight loss (common in children who do not eat because of pain)
  • Fever (not common, usually related to local infection)
  • Postoperative airway obstruction (because of uvular edema, hematoma, aspirated material)
  • Pulmonary edema (occurs in people with true airway obstruction caused by tonsils)
  • Local trauma to oral tissues
  • Tonsillar remnants
  • Vocal changes (If the tonsils are large, the patient’s voice may be muffled.)
  • Psychological trauma, night terrors, or depression
  • Death (uncommon, usually related to bleeding or anesthetic complications)

Late complications are nasopharyngeal stenosis and velopharyngeal incompetence. These complications are most likely to occur if adenoidectomy or uvulopalatopharyngoplasty is undertaken at the same time as tonsillectomy.