Tonsillectomy

Tonsillectomy is defined as the surgical excision of the palatine tonsils. 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.

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. More than 530,000 tonsillectomies are performed in children and adolescents in the United States every year because of recurrent throat infections or sleep-disordered breathing. 

In the UK, few children with evidence-based indications undergo tonsillectomy and seven in eight of those who do (32,500 of 37,000 annually) are unlikely to benefit.[1]

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.

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

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 for tonsillectomy include the following:

• Bleeding diathesis

• Poor anesthetic risk or uncontrolled medical illness

• Anemia

• Acute infection

Coagulation parameters should be assessed if the patient's history reveals a potential bleeding problem.

The American Academy of Otolaryngology-Head and Neck Surgery Foundation (AAO-HNS) suggests that all patients receive a basic coagulation workup.

In one study, coagulation tests produced abnormal results in 4% of 1706 children.[2] The disturbing factor in this study was that the patient's preoperative history did not help in identifying children with abnormal coagulation. This is a point of ongoing debate.

With a negative family history for bleeding, routine preoperative coagulation studies are not recommended. With a positive family history, a bleeding time or a consultation with a hematologist is prudent.

Imaging studies include plain radiography, CT scanning, and MRI in an appropriate patient with a tonsillar mass suggestive of malignancy.

In addition, a patient with a pulsatile area adjacent to the tonsil should undergo magnetic resonance arteriography (MRA) before routine tonsillectomy to evaluate for an aberrant internal carotid artery.

Antibodies for streptolysin-O (ASLO) have been studied as possible indicators for tonsillectomy.[3]

• These antibodies are correlated with previous infection with group A beta-hemolytic streptococcus (GABHS).

• To the authors’ knowledge, no recent work has been published concerning this issue.

• When the diagnosis of recurrent GABHS is questioned, high ASLO titers can shed light on the patient's history.

Historically, GABHS cultured on blood agar and use of a Bacitracin disc has been used to identify the most important agent that causes tonsillitis.

• More recently, several rapid tests for detecting group A streptococcal antigen have been used.

• The rapid tests are specific but not uniformly sensitive; therefore negative results need to be confirmed with a routine culture.

Several studies have shown a higher-than-expected incidence of allergy in children with adenotonsillar disease. Therefore, evaluation for allergy may be helpful, but only in children with the signs and symptoms of allergic disease.

Histologic examination of the tonsils is unnecessary unless cancer is suspected. If tonsils are asymmetric, they should be submitted separately and examined histologically to rule out cancer.

Adjunctive intraoperative medical therapy may include the following:

• Rectal acetaminophen in children

• Intravenous antiemetics

• Intravenous narcotics (except if a history of airway obstruction is present)

• Intravenous steroids (controversial, probably a small benefit)[4]

• Local anesthetic

• Sucralfate (debatable effect)[5]

Careful history taking is needed to evaluate for the following:

• Bleeding disorders or wish to avoid transfusion

• Anesthesia intolerance

• Obstructive sleep apnea

In patients with Down syndrome, order cervical spine images to evaluate for C1-C2 subluxation. Also, be aware of possible underlying cardiac disease.

Sleep studies are recommended if the severity of the patient's symptoms is uncertain.

Regarding admission planning, insurance plans are increasingly disallowing inpatient admission for tonsillectomy or adenoidectomy. Children who should be admitted are those with obstructive sleep apnea, those with significant comorbid disease such as hypotonia or neuromotor delays, and those younger than 3 years.

Place the patient in the Rose position with a shoulder roll.

Carefully, insert a mouth prop, and open and suspend it.

Apply an Alyss clamp to the tonsil to allow for traction during dissection.

Variations in dissection methods include the following:[6, 7, 8, 9]

• Use of cold steel (eg, scissors, curettes)

• Monopolar cautery

• Bipolar cautery with or without a microscope

• Radiofrequency ablation, or coblation (can be used to shrink tonsils)

• Harmonic scalpel with vibrating titanium blades

• Powered instruments (eg, microdebrider) for an intracapsular technique

Variations in hemostasis methods include the following:

• Pressure with sponge for several minutes

• Use of bismuth subgallate

• Use of ties

• Suction cautery

• Bipolar cautery

Tonsillectomy with cautery and suction are shown in the videos below.

Leave the lingual tonsil in situ.

Be cautious when suctioning the patient's airway.

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.)

Sutters et al conducted a study comparing scheduled postoperative opioid analgesia (acetaminophen and hydrocodone 167 mg/2.5 mg per 5 mL PO q4h for 3 d) with as needed (PRN) opioid analgesia in children aged 6-15 years undergoing outpatient tonsillectomy. Children in the scheduled-dose group received more analgesia compared with the PRN group (p < 0.0001). Children in the PRN group had higher pain intensity scores (p=0.017). Pain intensity scores were higher in the morning compared with the evening (p < 0.0001).[10]

Maintain good hydration.

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.

Administer antibiotics. Oral antibiotic use for the week after tonsillectomy is associated with improved outcomes in children.[11, 12]

Instruct the patient to avoid smoking.

Instruct the patient to avoid heavy lifting and exertion for 10 days.

Warn patients that pain will abate during the first 3-5 days then increase for 1-2 days before completely disappearing.

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, those with Down syndrome, or those who have difficulty in complying with instructions.

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.

Hemorrhage is the most common complication. An estimated 2-3% of patients have hemorrhage, and 1 of 40,000 patients die from bleeding.[13, 14]  However, a literature review by De Luca Canto et al indicated that respiratory compromise is the most frequent complication occurring in children (9.4%) following adenotonsillectomy, with secondary hemorrhage being the second most frequent (2.6%). The investigators also found that in children who undergo adenotonsillectomy, the risk of respiratory complications is 4.9 times higher in those who have obstructive sleep apnea than in children who do not, but the risk of postoperative bleeding is lower.[15, 16]

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)

• Weight loss (common in children who do not eat because of pain)

• Fever (not common, usually related to local infection)

• Postoperative airway obstruction (because of uvular edema, hematoma, aspirated material)

• Pulmonary edema (occurs in people with true airway obstruction caused by tonsils)

• Local trauma to oral tissues

• Tonsillar remnants or subsequent regrowth

• Vocal changes (If the tonsils are large, the patient's voice may be muffled, as the resonance has changed)

• Temporomandibular joint dysfunction, pain or clicking, which can be associated with any procedure in which the mouth is opened widely

• Psychological trauma, night terrors, or depression

• Death (uncommon, usually related to bleeding or anesthetic complications)

A single intravenous dose of the corticosteroid drug dexamethasone, administered intraoperatively, reduces likelihood of vomiting and postoperative pain and morbidity in children.[17]

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.

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.[18] Results of other studies have suggested an overall patient satisfaction and improved quality of life.

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.[19]

Levels of alpha-streptococci (inhibitory protective bacteria) have been shown to increase after tonsillectomy.[20] This further explains why tonsillectomy decreases the rate of streptococcal infection (including pharyngitis).

Recent literature that looks at the persistence of obstructive sleep apnea syndrome in children after surgery shows that adenotonsillectomy yields improvements in respiratory abnormalities in children with obstructive sleep apnea, but complete normalization occurs in only 25% of the patients.[21] The main determinants for surgical outcome include obesity, which is an increasing occurrence in children, and apnea hypopnea index (AHI) at diagnosis.[22] Authors noted that, in cases of ADHD, it is helpful to treat not just the disorder of attentional issues, but also underlying sleep problems, which have adverse effects on daytime behavior and attention.[23] Lastly, studies are now recognizing the high incidence of obstructive sleep issues in certain populations such as the cleft palate population.[24]

Research on tonsillectomy is still popular. Whether an optimal method of tonsillectomy exists, whether perioperative steroids are useful, and whether outpatient tonsillectomy is safe are still unclear.

To treat airway obstruction from large tonsils, tonsillotomy with lasers may be less painful than tonsillectomy and just as successful. Radiofrequency reduction of the volume of submucosal tissue may also be used to achieve this end in adults. Well-designed studies are necessary to prove the effectiveness of these methods.

Further research on the efficacy of tonsillectomy to treat recurrent sore throats is still needed. We know of no definitive studies since the original study by Paradise et al, which showed that tonsillectomy is beneficial in patients with recurrent sore throats.[19]

A study of malpractice claims filed after tonsillectomy provided by 16 medical liability insurance companies identified 154 claims between 1985 and 2006. Bleeding complications led to 17.5% of the claims, while miscellaneous claims such as uvular injuries and postoperative scarring led to 45.5% of claims. Burn injuries accounted for 18.2% of claims. These figures suggest that the majority of malpractice claims following tonsillectomy stem from complications other than hemorrhage, which is typically considered the most common complication of the procedure.[25]

American Academy of Otolaryngology-Head and Neck Surgery Foundation (AAO-HNS)

The 2011 update of guidelines developed by the American Academy of Otolaryngology-Head and Neck Surgery Foundation (AAO-HNS) provides evidence-based recommendations on the pre-, intra-, and postoperative care and management of children 1 to 18 years of age under consideration for tonsillectomy.[26]

The group's recommendations include, among others:

1. Clinicians should recommend watchful waiting for recurrent throat infection if there have been < 7 episodes in the past year, < 5 episodes per year in the past 2 years, or < 3 episodes per year in the past 3 years.

2. Clinicians should administer a single intraoperative dose of intravenous dexamethasone to children undergoing tonsillectomy.

3. Clinicians should recommend ibuprofen, acetaminophen, or both for pain control after tonsillectomy.

4. Clinicians should not administer or prescribe perioperative antibiotics to children undergoing tonsillectomy.

5. Clinicians must not administer or prescribe codeine, or any medication containing codeine, after tonsillectomy in children younger than 12 years.

The FDA issued a black box warning about the use of codeine after tonsillectomy due to concerns about respiratory depression and death.[27] Use of other opiods for tonsillectomy is evolving, as an opiod epidemic is ongoing. Surgeons now abide by state regulations to prescribe no more than 7–10 days of narcotics, depending on the individual state's medical board.