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.

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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.

Problem

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

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:

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

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.

Contraindications

Contraindications for tonsillectomy include the following:

Bleeding diathesis
Poor anesthetic risk or uncontrolled medical illness
Anemia
Acute infection

Workup

Gabriel P, Mazoit X, Ecoffey C. Relationship between clinical history, coagulation tests, and perioperative bleeding during tonsillectomies in pediatrics. J Clin Anesth. 2000 Jun. 12(4):288-91. [Medline].
Fujikawa S, Hanawa Y, Ito H, Ohkuni M, Todome Y, Ohkuni H. Streptococcal antibody: as an indicator of tonsillectomy. Acta Otolaryngol Suppl. 1988. 454:286-91. [Medline].
Carr MM, Williams JG, Carmichael L, Nasser JG. Effect of steroids on posttonsillectomy pain in adults. Arch Otolaryngol Head Neck Surg. 1999 Dec. 125(12):1361-4. [Medline].
Ozcan M, Altuntas A, Unal A, Nalca Y, Aslan A. Sucralfate for posttonsillectomy analgesia. Otolaryngol Head Neck Surg. 1998 Dec. 119(6):700-4. [Medline].
Carr MM, Muecke CJ, Sohmer B, Nasser JG, Finley GA. Comparison of postoperative pain: tonsillectomy by blunt dissection or electrocautery dissection. J Otolaryngol. 2001 Feb. 30(1):10-4. [Medline].
Pizzuto MP, Brodsky L, Duffy L, Gendler J, Nauenberg E. A comparison of microbipolar cautery dissection to hot knife and cold knife cautery tonsillectomy. Int J Pediatr Otorhinolaryngol. 2000 May 30. 52(3):239-46. [Medline].
Lee KC, Bent JP 3rd, Dolitsky JN, Hinchcliffe AM, Mansfield EL, White AK. Surgical advances in tonsillectomy: report of a roundtable discussion. Ear Nose Throat J. 2004 Aug. 83(8 Suppl 3):4-13; quiz 14-5. [Medline].
Nelson LM. Radiofrequency treatment for obstructive tonsillar hypertrophy. Arch Otolaryngol Head Neck Surg. 2000 Jun. 126(6):736-40. [Medline].
Sutters KA, Miaskowski C, Holdridge-Zeuner D, Waite S, Paul SM, Savedra MC, et al. A randomized clinical trial of the efficacy of scheduled dosing of acetaminophen and hydrocodone for the management of postoperative pain in children after tonsillectomy. Clin J Pain. 2010 Feb. 26(2):95-103. [Medline].
Telian SA, Handler SD, Fleisher GR, Baranak CC, Wetmore RF, Potsic WP. The effect of antibiotic therapy on recovery after tonsillectomy in children. A controlled study. Arch Otolaryngol Head Neck Surg. 1986 Jun. 112(6):610-5. [Medline].
Colreavy MP, Nanan D, Benamer M, et al. Antibiotic prophylaxis post-tonsillectomy: is it of benefit?. Int J Pediatr Otorhinolaryngol. 1999 Oct 15. 50(1):15-22. [Medline].
Rakover Y, Almog R, Rosen G. The risk of postoperative haemorrhage in tonsillectomy as an outpatient procedure in children. Int J Pediatr Otorhinolaryngol. 1997 Jul 18. 41(1):29-36. [Medline].
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De Luca Canto G, Pacheco-Pereira C, Aydinoz S, et al. Adenotonsillectomy Complications: A Meta-analysis. Pediatrics. 2015 Oct. 136 (4):702-18. [Medline].
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Steward DL, Grisel J, Meinzen-Derr J. Steroids for improving recovery following tonsillectomy in children. Cochrane Database Syst Rev. 2011 Aug 10. CD003997. [Medline].
van Staaij BK, van den Akker EH, van der Heijden GJ, Schilder AG, Hoes AW. Adenotonsillectomy for upper respiratory infections: evidence based?. Arch Dis Child. 2005 Jan. 90(1):19-25. [Medline].
Paradise JL, Bluestone CD, Bachman RZ, et al. Efficacy of tonsillectomy for recurrent throat infection in severely affected children. Results of parallel randomized and nonrandomized clinical trials. N Engl J Med. 1984 Mar 15. 310(11):674-83. [Medline].
Richtsmeier WJ, Shikhani AH. The physiology and immunology of the pharyngeal lymphoid tissue. Otolaryngol Clin North Am. 1987 May. 20(2):219-28. [Medline].
Tauman R, Gulliver TE, Krishna J, et al. Persistence of obstructive sleep apnea syndrome in children after adenotonsillectomy. J Pediatr. 2006 Dec. 149(6):803-8. [Medline].
Lam YY, Chan EY, Ng DK, et al. The correlation among obesity, apnea-hypopnea index, and tonsil size in children. Chest. 2006 Dec. 130(6):1751-6. [Medline].
Galland BC, Dawes PJ, Tripp EG, Taylor BJ. Changes in behavior and attentional capacity after adenotonsillectomy. Pediatr Res. 2006 May. 59(5):711-6. [Medline].
Maclean JE, Waters K, Fitzsimons D, Hayward P, Fitzgerald DA. Screening for obstructive sleep apnea in preschool children with cleft palate. Cleft Palate Craniofac J. 2009 Mar. 46(2):117-23. [Medline].
Simonsen AR, Duncavage JA, Becker SS. A review of malpractice cases after tonsillectomy and adenoidectomy. Int J Pediatr Otorhinolaryngol. 2010 Sep. 74(9):977-9. [Medline].
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Fowler RH. The rise of the tonsil operation. Tonsil Surgery: Based on a Study of the Anatomy. Philadelphia: FA Davis Co; 1931. 54-60.
US Food and Drug Administration. FDA Drug Safety Communication: Codeine use in certain children after tonsillectomy and/or adenoidectomy may lead to rare, but life threatening adverse events or death. Available at http://www.fda.gov/Drugs/DrugSafety/ucm313631.htm. Accessed: March 27, 2013.

Media Gallery

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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Author

Amelia F Drake, MD ND Fischer Distinguished Professor of Otolaryngology, Executive Associate Dean of Academic Programs, Director, Craniofacial Center, 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, American Society of Pediatric Otolaryngology, North Carolina Medical Society

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;Cliexa, eMedevents, Neosoma, MI10<br/>Received income in an amount equal to or greater than $250 from: , Cliexa;;Neosoma<br/> Received stock from RxRevu; Received ownership interest from Cerescan for consulting; for: Neosoma, eMedevents, MI10.

Additional Contributors

Michele M Carr, MD, DDS, PhD, MEd Professor, Department of Otolaryngology-Head and Neck Surgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo

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

Disclosure: Nothing to disclose.

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.