What is
Tonsillectomy?
Tonsillectomy is defined as the surgical excision of the
palatine tonsils. Indications for this
procedure remain controversial.
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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).
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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:
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Absolute indications
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Enlarged tonsils that cause upper airway obstruction,
severe dysphagia, sleep disorders,
or cardiopulmonary complications
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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
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Tonsils requiring biopsy to define tissue pathology
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Relative indications
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Three or more tonsil infections per year despite
adequate medical therapy
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Persistent foul taste or breath due to chronic
tonsillitis that is not responsive
to 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
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Your
Consultation
-
Careful history taking is needed to
evaluate for the following:
-
Bleeding disorders
-
Anesthesia intolerances
-
Obstructive sleep apnea
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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.
Electrocautery: Electrocautery burns
the tonsillar tissue and assists in reducing
blood loss through cauterization. Research
has shown that the heat of electrocautery
(400 degrees Celsius) results in thermal
injury to surrounding tissue. This may
result in more discomfort during the
postoperative period.
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
procedure can be performed in an office
setting under 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 technique are less pain,
faster healing, and less post operative
care.
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Recovery
Postoperative details:
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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.)
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Maintain good hydration.
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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.
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Administer antibiotics. Oral antibiotic
use for the week after tonsillectomy is
associated with improved outcomes in
both adults and children.
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Instruct the patient to avoid smoking.
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Instruct the patient to avoid heavy
lifting and exertion for 10 days.
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Warn patients that pain will abate
during the first 3-5 days then increase
for 1-2 days before completely
disappearing.
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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.
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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)
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Weight loss (common in children who do not eat because
of pain)
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Fever (not common, usually related to local infection)
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Postoperative airway obstruction (because of uvular
edema, hematoma, aspirated material)
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Pulmonary edema (occurs in people with true airway
obstruction caused by tonsils)
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Local trauma to oral tissues
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Tonsillar remnants
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Vocal changes (If the tonsils are large, the patient's
voice may be muffled.)
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Psychological trauma, night terrors, or depression
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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.
Hematoma
This is a rare complication, but it deserves
rapid intervention when present.
Blood pools between the cartilage and the
mucoperichondrium and separates the
cartilage from its blood supply. Avascular
cartilage can be viable for up to 3 days.
The cartilage is resorbed when the
chondrocytes die, leading to septal
perforation and potential loss of dorsal
support.
Signs and symptoms include intense pain,
swelling, hematoma of the upper lip and
philtrum area, and complete nasal airway
obstruction.
The risk of hematoma formation is reduced by
the use of splints or a quilting mattress
suture.
Management consists of drainage through a
mucoperichondrial incision. Needle drainage
may be inadequate. After drainage, place
packing and begin administration of oral
antibiotics. Pack both nasal passages to
prevent shifting of the postsurgical septum.
Septal splints are also useful in the
postoperative management of septal hematoma,
whether traumatic or postoperative.
Infection
As a complication of septal hematoma,
infection can lead to rapid resorption of
the septal cartilage. Prompt drainage and
antibiotics minimize the risk of infection.
Infections after Tonsillectomy can be seen
in immunocompromised patients. Resident
nasal florae take advantage of the mucosal
injury to proliferate and invade the
tissues.
TSS is rare today. Symptoms include
postoperative fever, nausea, diarrhea,
erythroderma, and eventual hypotension.
Coating nasal packs with bacitracin ointment
should reduce the growth of
Staphylococcus aureus, the pathogen
responsible for TSS.
Cerebrospinal fluid leak
CSF leak is a rare, but potentially very
serious, complication. It is usually the
result of avulsion or damage to the
cribriform plate.
If a leak is recognized during the
procedure, proper management includes
packing and institution of antibiotics.
A postoperative CSF leak usually is managed
by bed rest, nasal packing, and oral
antibiotics. Spontaneous resolution usually
occurs.
Vigilance for signs and symptoms of
meningitis, which include headache,
photophobia, nuchal rigidity, and fever, is
critical.
Epistaxis
Epistaxis is an uncommon complication.
Pack both sides and begin oral antibiotics.
Nasal obstruction
Persistent obstruction after resolution of
postoperative edema may be due to residual
deviation that was not corrected at the time
of surgery.
Alternatively, synechiae can form between
the septum and turbinates at sites of
mucosal injury. Synechiae are resolved by
lysis and separation of the mucosal surfaces
by placement of silastic splints.
A third possibility for continued nasal
obstruction is a return of the cartilaginous
deviation. Options at this time include
another trial of medical therapy or
reoperation.
Additional causes of persistent nasal
obstruction include a failure to address
hypertrophied turbinates at the time of the
initial surgery and a failure to identify
concomitant allergic or nonallergic
rhinitis, which requires medical treatment
for optimal management. Incompetent nasal
valves are also a frequently overlooked
source of nasal obstruction and become
evident in the patient with persistent
postoperative nasal airway obstruction.
These sources of obstruction underscore the
importance of a thorough preoperative
assessment of the patient.
Septal perforation
Septal perforation is a complication usually
encountered in the long-term postoperative
period.
The patient complains of crusting, epistaxis,
and a whistling sound during normal
respiration.
Diagnosis is made by using anterior
rhinoscopy, and the defect can be repaired
with a variety of mucosal flaps if it is
less than 1.5 cm.
Cosmetic nasal deformity
Cosmetic nasal deformity is a long-term
complication of aggressive SMR and
inadequate residual L-shaped septal strut
support.
Possible deformities include widened alar
rim margins, a drooping nasal tip, a
retracted columnella, and a sunken dorsum
with a supratip saddle formation.
This is best avoided with cartilage
preservation, particularly the dorsal-caudal
L-strut.
Anosmia
This is a very rare complication and is
typically transient. Congestion of both
septal mucosal flaps or accumulation of
bloody serous fluid under the
mucoperichondrial flaps may obstruct airflow
to the olfactory region, producing the
symptom. Careful and thorough
reapproximation of the septal flaps with a
quilting suture decreases the dead space
under the septal flaps, and encouraging head
elevation postoperatively should alleviate
some of the postsurgical congestion.
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Frequently Asked
Questions
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