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 tonsillectomy, which was performed by using a blunt dissection method.
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.
Problem
Tonsillectomy is defined as the surgical excision of the palatine tonsils. Indications for this procedure remain controversial.
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.
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.
Presentation
See Preoperative details.
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:
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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
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Tonsillitis resulting in febrile convulsions
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Tonsils requiring biopsy to define tissue pathology
Relative indications
See the list below:
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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
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Chronic or recurrent tonsillitis in a streptococcal carrier not responding to beta-lactamase-resistant antibiotics
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Unilateral tonsil hypertrophy that is presumed to be neoplastic
Relevant Anatomy
Tonsils are located laterally in the oropharynx. The tonsils are bordered by the following tissues:
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Deep - Superior constrictor muscle
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Anterior - Palatoglossus muscle
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Posterior - Palatopharyngeus muscle
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Superior - Soft palate
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Inferior - Lingual tonsil
Blood supply is through the external carotid artery and its branches, as follows:
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Superior pole
- Ascending pharyngeal artery (tonsillar branches)
- Lesser palatine artery
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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.
Contraindications
Contraindications for tonsillectomy include the following:
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Bleeding diathesis
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Poor anesthetic risk or uncontrolled medical illness
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Anemia
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Acute infection
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Typical appearance on the morning after tonsillectomy, which was performed by using a blunt dissection method.
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Tonsillectomy performed with the cautery technique. A Colorado needle-tip bovie is used to dissect the tonsil from its underlying muscular bed.
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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.
