Typical appearance of the back of the throat three days post tonsillectomy.
Tonsillectomy is a 3,000-year-old surgical procedure in which, traditionally, each tonsil is removed from a recess in the side of the pharynx called the tonsillar fossa. The procedure is performed in response to repeated occurrence of acute tonsillitis, sleep surgery for obstructive sleep apnea, nasal airway obstruction, diphtheria carrier state, snoring, or peritonsillar abscess. For children, the adenoids are usually removed at the same time, a procedure called adenoidectomy, or tonsilloadenoidectomy, when combined. Adenoidectomy is uncommon in adults in whom the adenoids are usually vestigial. Although tonsillectomy is performed less frequently than in the 1950s, it remains one of the most common surgical procedures in children in the United States.
Tonsillectomy may be indicated when the patient experiences recurrent infections of acute tonsillitis. The number prompting tonsillectomy varies with the severity of the episodes. One case, even severe, is generally not enough for most surgeons to decide tonsillectomy is necessary. Paradise in 1983 defined recurrent tonsillitis warranting surgery by the attack frequency standard as
"Seven or more in a year, five or more per year for two years, or three or more per year for three years. These are the absolute indications for tonsillectomy."
According to the 2012 guidelines of the American Academy of Otolaryngology & Head and Neck Surgery (AAO-HNS), tonsillectomy is indicated as follows:
"Clinicians may recommend tonsillectomy for recurrent throat infection with a frequency of at least 7 episodes in the past year or at least 5 episodes per year for 2 years or at least 3 episodes per year for 3 years with documentation in the medical record for each episode of sore throat and one or more of the following: temperature >38.3oC, cervical adenopathy, tonsillar exudates, or positive test for Group A Beta- hemolytic strep."
Most recently, American Academy of Otolaryngology-Head and Neck Surgery Foundation has published clinical practice guidelines. The panel made a strong recommendation for:
- Watchful waiting for recurrent throat infection if there have been fewer than 7 episodes in the past year or fewer than 5 episodes per year in the past 2 years or fewer than 3 episodes per year in the past 3 years;
- Assessing the child with recurrent throat infection who does not meet criteria in statement 2 for modifying factors that may nonetheless favor tonsillectomy, which may include but are not limited to multiple antibiotic allergy/intolerance, periodic fever, aphthous stomatitis, pharyngitis and adenitis, or history of peritonsillar abscess;
- Asking caregivers of children with sleep-disordered breathing and tonsil hypertrophy about comorbid conditions that might improve after tonsillectomy, including growth retardation, poor school performance, enuresis, and behavioral problems;
- Counseling caregivers about tonsillectomy as a means to improve health in children with abnormal polysomnography who also have tonsil hypertrophy and sleep-disordered breathing;
- Counseling caregivers that sleep-disordered breathing may persist or recur after tonsillectomy and may require further management;
- Advocating for pain management after tonsillectomy and educating caregivers about the importance of managing and reassessing pain; and
- Clinicians who perform tonsillectomy should determine their rate of primary and secondary posttonsillectomy hemorrhage at least annually.
The effectiveness of the tonsillectomy for sore throat has been questioned in a 2009 systematic review of 7765 papers, published in Otolaryngology—Head and Neck Surgery. The review found that the procedure was most likely not effective all the time, but rather was modestly effective, and that not a single paper reported that tonsillectomy is invariably effective in eliminating sore throats. Another systematic review of cases involving children found that there was only a short-term benefit:"'A child who meets these strict criteria will probably suffer from 6 throat infections in the next two years. A child who has surgery now will probably suffer from 3 throat infections. In two years there will probably be no difference."
More than 530,000 procedures are performed annually in children younger than 15 years in the United States. The current tonsillectomy "rate" is 0.53 per thousand children and 1.46 per thousand children for combined tonsillectomy and adenoidectomy.
Morbidity and mortality
A sore throat will persist approximately two weeks following surgery while pain following the procedure is significant and may necessitate a hospital stay. Recovery can take from 7 to 10 days and proper hydration is very important during this time, since dehydration can increase throat pain, leading to a vicious circle of poor fluid intake.
At some point, most commonly 7–11 days after the surgery (but occasionally as long as two weeks (14 days) after), bleeding can occur when scabs begin sloughing off from the surgical sites. The overall risk of bleeding is approximately 1%–2%. It is higher in adults, especially males over age 70 and three quarters of bleeding incidents occur on the same day as the surgery. Approximately 3% of adult patients develop significant bleeding at this time which may sometimes require surgical intervention.
Post-operative pain relief is subject to change. Traditionally, pain relief has been provided by relatively mild narcotic analgesics such as Acetaminophen with codeine, for milder pain, and stronger narcotic analgesics for more severe pain. Recently (January 2011), the FDA reduced the recommended total 24 hour dose because of concern about liver toxicity from the Acetominophen component. An alternative is the use of non-steroidal anti-inflammatory agents, themselves giving rise to concerns that their effect on platelets might increase the risk of post-operative bleeding. In turn, this has renewed interest in techniques other than traditional 'extra-capsular excision' in the hope that post-operative pain might be reduced.
Tonsillectomy appears to be more painful in adults than children, although there will be individual variations in response.
For the past 50 years at least, tonsillectomy has been performed by dissecting the tonsil from its surrounding fascia, a so-called 'total' , or extra-capsular tonsillectomy. Problems include pain and bleeding leading to a recent resurgence in interest in sub-total tonsillectomy or 'tonsillotomy' which was popular 60–100 years ago, in an effort to reduce these complications. The generally accepted procedure for 'total' tonsillectomy uses a scalpel and blunt dissection or electrocautery, although harmonic scalpels or lasers have also been used. Bleeding is stopped with electrocautery, ligation by sutures, and the topical use of thrombin, a protein that induces blood clotting.
It has already been stated that the benefits of tonsillectomy for sore throat are controversial and time limited. Consequently, the main question of importance becomes whether or not the benefits of subtotal tonsillectomy in obstructive sleep apnea are enduring. It appears that this may be the case although most observers agree that further time and study is required.
- Dissection and snare method: Removal of the tonsils by use of a forceps and scissors with a wire loop called a 'snare' was formerly the most common method practiced by otolaryngologists, but has been largely replaced in favor of other techniques. The procedure requires the patient to undergo general anesthesia; the tonsils are completely removed and the remaining tissue surface is cauterized. The patient will leave with minimal post-operative bleeding.
- Electrocautery: Electrocautery uses electrical energy to separate the tonsillar tissue and assists in reducing blood loss through cauterization. Research has shown that the heat of electrocautery (400°C) may result in thermal injury to surrounding tissue. This may result in more discomfort during the postoperative period.
- Radiofrequency Ablation (see Coblation tonsillectomy): 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. It has been claimed that this technique results in less pain, faster healing, and less post operative care. However, review of 21 studies gives conflicting results about levels of pain, and its comparative safety has yet to be confirmed. This technique has been criticized for a higher than expected rate of bleeding presumably due to the low temperature which may be insufficient to seal the divided blood vessels but several papers offer conflicting (some positive, some negative) results. Long term studies seem to show that surgeons experienced with the technique have very few complications.
- Harmonic scalpel: This medical device uses ultrasonic energy to vibrate its blade at 55kHz. 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°C. 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 (outpatient) 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.
- Thermal Welding: A new technology which uses pure thermal energy to seal and divide the tissue. The absence of thermal spread means that the temperature of surrounding tissue is only 2-3 °C higher than normal body temperature. Clinical papers show patients with minimal post-operative pain (no requirement for narcotic pain-killers), zero edema (swelling) plus almost no incidence of bleeding. Hospitals in the US are advertising this procedure as "Painless Tonsillectomy". Also known as Tissue Welding.
- 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 2-5% 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 averse to outpatient procedures without sedation.
- 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.
Tonsillectomy has been practiced for 3,000 years, with varying popularity over the centuries. The procedure is claimed in some books as "Hindu medicine" about 1000 BC (non-evidence based literature). Others refer to it as cleaning of tonsil using the nail of the index finger. Roughly a millennium later the Roman aristocrat Aulus Cornelius Celsus (25 AD – 50 AD) described a procedure whereby using the finger (or a blunt hook if necessary), the tonsil was separated from the neighboring tissue before being cut out. Galen (121 – 200 AD) was the first to advocate the use of the surgical instrument known as the snare, a practice that was to become common until Aetius (490 AD) recommended partial removal of the tonsil, writing "Those who extirpate the entire tonsil remove, at the same time, structures that are perfectly healthy, and, in this way, give rise to serious Hæmorrhage". In the 7th century Paulus Aegineta (625–690) described a detailed procedure for tonsillectomy, including dealing with the inevitable post-operative bleeding. 1,200 years pass before the procedure is described again with such precision and detail.
The Middle Ages saw tonsillectomy fall into disfavor; Ambroise Pare (1509) wrote it to be "a bad operation" and suggested a procedure that involved gradual strangulation with a ligature. This method was not popular with the patients due to the immense pain it caused and the infection that usually followed. Scottish physician Peter Lowe in 1600 summarized the three methods in use at the time, including the snare, the ligature, and the excision. At the time, the function of the tonsils was thought to be to absorb secretions from the nose; it was assumed that removal of large amounts of tonsillar tissue would interfere with the ability to remove these secretions, causing them to accumulate in the larynx, resulting in hoarseness. For this reason, physicians like Dionis (1672) and Lorenz Heister censured the procedure.
In 1828, physician Philip Syng Physick modified an existing instrument originally designed by Benjamin Bell for removing the uvula; the instrument, known as the tonsil guillotine (and later as a tonsillotome), became the standard instrument for tonsil removal for over 80 years. By 1897, it became more common to perform complete rather than partial removal of the tonsil after American physician Ballenger noted that partial removal failed to completely alleviate symptoms in a majority of cases. His results using a technique involving removal of the tonsil with a scalpel and forceps were much better than partial removal; tonsillectomy using the guillotine eventually fell out of favor in America.
Tonsillectomy and weight gain in children
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