eMedicine Specialties > Otolaryngology and Facial Plastic Surgery > Pediatric Otolaryngology

Tonsillectomy

Author: Amelia Drake, MD, Chief, Division of Pediatric Otolaryngology, Newton D. Fischer Distinguished Professor of Surgery, Department of Otolaryngology-Head and Neck Surgery, University of North Carolina School of Medicine
Coauthor(s): Michele M Carr, DDS, MD, MEd, Associate Professor, Department of Otolaryngology, Hershey Medical Center
Contributor Information and Disclosures

Updated: Oct 2, 2007

Introduction

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 eMedicine's Ear, Nose, and Throat Center. Also, see eMedicine's patient education article Tonsillitis.

History of the Procedure

Tonsillectomy was first described in India in 1000 BC. The procedure increased in popularity in the 1800s, when a tonsillectomy or 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 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
    • 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
    • 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.

Contraindications

Contraindications for tonsillectomy include the following:

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

More on Tonsillectomy

Overview: Tonsillectomy
Workup: Tonsillectomy
Treatment: Tonsillectomy
Follow-up: Tonsillectomy
Multimedia: Tonsillectomy
References
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References

  1. Gabriel P, Mazoit X, Ecoffey C. Relationship between clinical history, coagulation tests, and perioperative bleeding during tonsillectomies in pediatrics. J Clin Anesth. Jun 2000;12(4):288-91. [Medline].

  2. 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].

  3. Carr MM, Williams JG, Carmichael L, Nasser JG. Effect of steroids on posttonsillectomy pain in adults. Arch Otolaryngol Head Neck Surg. Dec 1999;125(12):1361-4. [Medline].

  4. Ozcan M, Altuntas A, Unal A, Nalça Y, Aslan A. Sucralfate for posttonsillectomy analgesia. Otolaryngol Head Neck Surg. Dec 1998;119(6):700-4. [Medline].

  5. Carr MM, Muecke CJ, Sohmer B, Nasser JG, Finley GA. Comparison of postoperative pain: tonsillectomy by blunt dissection or electrocautery dissection. J Otolaryngol. Feb 2001;30(1):10-4. [Medline].

  6. 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. May 30 2000;52(3):239-46. [Medline].

  7. van Staaij BK, van den Akker EH, van der Heijden. Adenotonsillectomy for upper respiratory infections: evidence based?. Arch Dis Child. 2005;90(1):19-25.

  8. Tauman R, Gulliver TE, Krishna J, Montgomery-Downs HE, O'Brien LM, Ivanenko A, et al. Persistence of obstructive sleep apnea syndrome in children after adenotonsillectomy. J Pediatr. Dec 2006;149(6):803-8. [Medline].

  9. Lam YY, Chan EY, Ng DK, Chan CH, Cheung JM, Leung SY, et al. The correlation among obesity, apnea-hypopnea index, and tonsil size in children. Chest. Dec 2006;139(5):1751-6. [Medline].

  10. Galland BC, Dawes PJ, Tripp EG, Taylor BJ. Changes in behavior and attentional capacity after adenotonsillectomy. Pedatr Res. May 2006;59(5):711-6. [Medline].

  11. Colreavy MP, Nanan D, Benamer M, Donnelly M, Blaney AW, O'Dwyer TP. Antibiotic prophylaxis post-tonsillectomy: is it of benefit?. Int J Pediatr Otorhinolaryngol. Oct 15 1999;50(1):15-22. [Medline].

  12. Fowler RH. The rise of the tonsil operation. In: Tonsil Surgery: Based on a Study of the Anatomy. Philadelphia: FA Davis Co; 1931:54-60.

  13. Howells RC 2nd, Wax MK, Ramadan HH. Value of preoperative prothrombin time/partial thromboplastin time as a predictor of postoperative hemorrhage in pediatric patients undergoing tonsillectomy. Otolaryngol Head Neck Surg. Dec 1997;117(6):628-32. [Medline].

  14. Lee KC, Bent JP 3rd, Dolitsky JN. Surgical advances in tonsillectomy: report of a roundtable discussion. Ear Nose Throat J. 2004;83(8 Suppl 3):4-13.

  15. Nelson LM. Radiofrequency treatment for obstructive tonsillar hypertrophy. Arch Otolaryngol Head Neck Surg. June 2000;126(6):736-40. [Medline].

  16. Paradise JL, Bluestone CD, Bachman RZ, Colborn DK, Bernard BS, Taylor FH. Efficacy of tonsillectomy for recurrent throat infection in severely affected children. Results of parallel randomized and nonrandomized clinical trials. N Engl J Med. Mar 15 1984;310(11):674-83. [Medline].

  17. Rakover Y, Almog R, Rosen G. The risk of postoperative haemorrhage in tonsillectomy as an outpatient procedure in children. Int J Pediatr Otorhinolaryngol. Jul 18 1997;41(1):29-36. [Medline].

  18. Randall DA, Hoffer ME. Complications of tonsillectomy and adenoidectomy. Otolaryngol Head Neck Surg. Jan 1998;118(1):61-8. [Medline].

  19. Richtsmeier WJ, Shikhani AH. The physiology and immunology of the pharyngeal lymphoid tissue. Otolaryngol Clin North Am. May 1987;20(2):219-28. [Medline].

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Further Reading

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Keywords

tonsillectomy, sore throat, swollen tonsils, tonsil infection, tonsillitis, palatine tonsils

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Contributor Information and Disclosures

Author

Amelia Drake, MD, Chief, Division of Pediatric Otolaryngology, Newton D. Fischer Distinguished Professor of Surgery, Department of Otolaryngology-Head and Neck Surgery, University of North Carolina School of Medicine
Amelia Drake, MD is a member of the following medical societies: American Academy of Otolaryngology-Head and Neck Surgery
Disclosure: Nothing to disclose.

Coauthor(s)

Michele M Carr, DDS, MD, MEd, Associate Professor, Department of Otolaryngology, Hershey Medical Center
Michele M Carr, DDS, MD, MEd is a member of the following medical societies: American Academy of Otolaryngology-Head and Neck Surgery
Disclosure: Nothing to disclose.

Medical Editor

Ari J Goldsmith, MD, Program Director, 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.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Gregory C Allen, MD, Assistant Professor, Department of Otolaryngology-Head and Neck Surgery, University of Colorado School of Medicine
Gregory C Allen, MD is a member of the following medical societies: American Academy of Otolaryngology-Head and Neck Surgery, American Academy of Pediatrics, American Cleft Palate/Craniofacial Association, American College of Surgeons, American Laryngological Rhinological and Otological Society, American Medical Association, Christian Medical & Dental Society, and Colorado Medical Society
Disclosure: Nothing to disclose.

CME Editor

Christopher L Slack, MD, Otolaryngology-Facial Plastic Surgery, Private Practice, Associated Coastal ENT; Medical Director, Treasure Coast Sleep Disorders
Christopher L Slack, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, and American Medical Association
Disclosure: Nothing to disclose.

Chief Editor

Arlen D Meyers, MD, MBA, Professor, Department of Otolaryngology-Head and Neck Surgery, 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, and American Head and Neck Society
Disclosure: UST Grant/research funds Consulting

 
 
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