Tonsillectomy is one of the most commonly performed surgical procedures and is characteristic for pediatric patients. Although the procedure was once performed by general surgeons and even family practitioners, in the past 30 years standardization of surgical methods resulted in a change in practice pattern, thus today it is strictly performed by otorhinolaryngology specialists.
The term tonsil is usually used to refer the palatine tonsil, whereas pharyngeal tonsils situated in the nasopharynx are also known as adenoids. Tonsillectomy can be defined as a surgical approach that is performed with or without adenoidectomy by entirely removing the tonsil (including its capsule) via dissection of the peritonsillar space between the tonsillar capsule and muscular wall.
Despite the fact that this procedure is commonly pursued, the indications for it remain controversial. In the past, tonsillectomy was a common procedure following an episode of tonsillitis, but today it is not recommended unless all other measures to prevent habitual infections prove ineffective.
Indications for tonsillectomy
The indications for tonsillectomy can be divided into absolute and relative indications. Absolute indications are obstructive sleep apnea, cardiopulmonary complications that arise as a result of airway obstruction, suspected malignancies, tonsillitis causing febrile seizures and hemorrhagic tonsillitis.
Obstruction of the oropharyngeal airway by hypertrophied tonsils leading to apnea (i.e. temporary suspension of breathing) during sleep is the most common indication in children, also referred to as obstructive sleep apnea syndrome. Despite only mild tonsillar enlargement on physical examination, these patients have upper airway obstruction while awake and apnea during sleep.
Relative indications for tonsillectomy are recurrent acute tonsillitis (e.g. seven episodes in one year), chronic tonsillitis that is refractory to antimicrobial therapy, dysphagia due to tonsillar hypertrophy, peritonsillar abscess, as well as tonsillolithiasis (tonsil stones) with concomitant halitosis and pain.
Methods of performing tonsillectomy can be divided into two main categories: extracapsular (also known as total tonsillectomy) and intracapsular (partial tonsillectomy or tonsillotomy). Both of aforementioned approaches can be used in children with obstructive sleep apnea, but only extracapsular approaches are warranted for patients with tonsillitis or peritonsillar abscesses.
A commonly employed technique for extracapsular tonsillectomy is the “cold” knife method where both the tonsil and the capsule are removed from the surrounding tissue by using knife, scissors or dissector, while the inferior pole is severed with a tonsil snare. After dissection, hemostasis is achieved with ligatures or diathermy; the latter represents the use of an electric current for the coagulation of blood vessels or for cutting the tissue.
The guillotine for tonsillectomy is rarely used today, whereas newer techniques such as Coblation tonsillectomy or the use of harmonic scalpel have their advocates. Regardless of the technique, surgeons should be adequately trained in the use of all methods that they use and audit their results.
After the surgery patients may complain of increased pain, fetor and difficulty swallowing, usually due to secondary infection. Although adequate diet may help in ameliorating symptoms, antibiotics are sometimes required. Postoperative nausea and earache are also commonly observed.
Hemorrhage after tonsillectomy is a common complication that occurs in up to 3% of the patients. This may be reactionary, occurring within the first 24 hours of surgery, or secondary, occurring 5-10 day after surgery. Any bleeding should be treated seriously, especially in children in whom hypovolemic shock can be very dangerous.
Other rarer complications include temporomandibular joint dislocation, dental trauma, pneumonia, respiratory distress, dehydration, torticollis and velopharyngeal insufficiency. Mortality from tonsillectomy is extremely rare, with most deaths being attributed to bleeding and anesthetic complications.