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Tonsillectomy

  • Author: Amelia F Drake, MD; Chief Editor: Arlen D Meyers, MD, MBA  more...
 
Updated: Oct 23, 2015
 

Background

Although a long-practiced procedure, tonsillectomy is still a common operation and considered one of the most common major surgical procedure performed in children. This procedure is still surrounded by controversy, especially regarding indications for surgery and details of surgical technique.

For excellent patient education resources, visit eMedicineHealth's Ear, Nose, and Throat Center. Also, see eMedicineHealth's patient education article Tonsillitis.

Typical appearance on the morning after tonsillectTypical appearance on the morning after tonsillectomy, which was performed by using a blunt dissection method.
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History of the Procedure

First described in India in 1000 BC, the tonsillectomy procedure increased in popularity in the 1800s, when a partial removal of the tonsil was performed. Because part of the tonsil was left behind, it frequently became hypertrophied and caused recurrence of the obstruction. By the early 20th century, the prevalence of tonsil disease was recognized, and the necessity of complete tonsillectomy was appreciated.

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Problem

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

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Epidemiology

Frequency

Although tonsillectomy is performed less often than it once was, it is still among the most common surgical procedures performed in children in the United States. In 1959, 1.4 million tonsillectomies were performed in the United States. This number had dropped to 260,000 by 1987, when it was the 24th most common indication for hospital admission. Indications have evolved from being primarily related to infections to being more commonly caused by obstruction.

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Pathophysiology

The tonsils are 3 masses of tissue: the lingual tonsil, the pharyngeal (adenoid) tonsil, and the palatine or fascial tonsil. The tonsils are lymphoid tissue covered by respiratory epithelium, which is invaginated and which causes crypts.

In addition to producing lymphocytes, the tonsils are active in the synthesis of immunoglobulins. Because they are the first lymphoid aggregates in the aerodigestive tract, the tonsils are thought to play a role in immunity. Although healthy tonsils offer immune protection, diseased tonsils are less effective at serving their immune functions. Diseased tonsils are associated with decreased antigen transport, decreased antibody production above baseline levels, and chronic bacterial infection.

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Presentation

See Preoperative details.

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Indications

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

See the list below:

  • 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

See the list below:

  • Three or more tonsil infections per year despite adequate medical therapy
  • 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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Relevant Anatomy

Tonsils are located laterally in the oropharynx. The tonsils are bordered by the following tissues:

  • Deep - Superior constrictor muscle
  • Anterior - Palatoglossus muscle
  • Posterior - Palatopharyngeus muscle
  • Superior - Soft palate
  • Inferior - Lingual tonsil

Blood supply is through the external carotid artery and its branches, as follows:

  • Superior pole
    • Ascending pharyngeal artery (tonsillar branches)
    • Lesser palatine artery
  • Inferior pole
    • Facial artery branches
    • Dorsal lingual artery
    • Ascending palatine artery

Venous outflow is handled by the plexus around the tonsillar capsule, the lingual vein, and the pharyngeal plexus. Lymphatic drainage involves the superior deep cervical nodes and the jugulodigastric nodes. Sensory supply is provided by the glossopharyngeal nerve and the lesser palatine nerve. Important structures deep to the inferior pole include the glossopharyngeal nerve, the lingual artery, and the internal carotid artery. The tonsil surface is filled with crypts lined with squamous epithelium. Lymphoid cells underlie the epithelium. See Tonsil and Adenoid Anatomy for more information.

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Contraindications

Contraindications for tonsillectomy include the following:

  • Bleeding diathesis
  • Poor anesthetic risk or uncontrolled medical illness
  • Anemia
  • Acute infection
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Contributor Information and Disclosures
Author

Amelia F Drake, MD Newton D Fischer Distinguished Professor of Otolaryngology, Department of Otolaryngology-Head and Neck Surgery, University of North Carolina at Chapel Hill School of Medicine

Amelia F Drake, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Otolaryngology-Head and Neck Surgery, American Cleft Palate-Craniofacial Association, North Carolina Medical Society, American Society of Pediatric Otolaryngology

Disclosure: Nothing to disclose.

Coauthor(s)

Michele M Carr, DDS, MD, MEd, PhD Associate Professor, Department of Otolaryngology, Milton S Hershey Medical Center, Pennsylvania State University College of Medicine

Michele M Carr, DDS, MD, MEd, PhD is a member of the following medical societies: American Academy of Otolaryngology-Head and Neck Surgery

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Chief Editor

Arlen D Meyers, MD, MBA Professor of Otolaryngology, Dentistry, and Engineering, University of Colorado School of Medicine

Arlen D Meyers, MD, MBA is a member of the following medical societies: American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, American Head and Neck Society

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Cerescan;RxRevu;SymbiaAllergySolutions<br/>Received income in an amount equal to or greater than $250 from: Symbia<br/>Received from Allergy Solutions, Inc for board membership; Received honoraria from RxRevu for chief medical editor; Received salary from Medvoy for founder and president; Received consulting fee from Corvectra for senior medical advisor; Received ownership interest from Cerescan for consulting; Received consulting fee from Essiahealth for advisor; Received consulting fee from Carespan for advisor; Received consulting fee from Covidien for consulting.

Acknowledgements

Ari J Goldsmith, MD Chief of Pediatric Otolaryngology, Long Island College Hospital; Associate Professor, Department of Otolaryngology, Division of Pediatric Otolaryngology, State University of New York Downstate Medical Center

Ari J Goldsmith, MD is a member of the following medical societies: American Academy of Otolaryngology-Head and Neck Surgery, American Medical Association, and Medical Society of the State of New York

Disclosure: Nothing to disclose.

Acknowledgments

Medscape Reference thanks Vijay R Ramakrishnan, MD, Assistant Professor, Department of Otolaryngology, University of Colorado School of Medicine, for the videos in this article.

References
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Typical appearance on the morning after tonsillectomy, which was performed by using a blunt dissection method.
Tonsillectomy performed with the cautery technique. A Colorado needle-tip bovie is used to dissect the tonsil from its underlying muscular bed.
A suction bovie is used to achieve hemostasis. Ideally, the least amount of cautery necessary for hemostasis is used. Staying in the proper dissection plane limits the amount of bleeding, and possibly postoperative pain.
 
 
 
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