eMedicine Specialties > Otolaryngology and Facial Plastic Surgery > Pediatric Otolaryngology

Tonsillectomy

Amelia F 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
Michele M Carr, DDS, MD, MEd, Associate Professor, Department of Otolaryngology, Hershey Medical Center

Updated: Aug 6, 2009

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.

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.

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
  • 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

Workup

Laboratory Studies

• Coagulation parameters should be assessed if the patient's history reveals a potential bleeding problem.
• The AAO-HNS suggests that all patients receive a basic coagulation workup.
• In 1 study, coagulation tests produced abnormal results in 4% of 1706 children.¹ 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.
• Coagulation tests should include an activated partial thromboplastin time (aPTT) and a platelet count. These assays are performed to screen for disorders associated with substantial hemorrhage.
• Tests of prothrombin time (PT) and bleeding time help in screening for all inherited or acquired coagulation disorders, such as hemophilia A and B, von Willebrand disease, thrombocytopenia, and other deficiencies.²

Imaging Studies

• 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.

Other Tests

• 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 Findings

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.

Treatment

Medical Therapy

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

Preoperative Details

• 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.

Intraoperative Details

• 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
• Leave the lingual tonsil in situ.
• Be cautious when suctioning the patient's airway.

Postoperative Details

• 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.)
• 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.^10,11
• 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.

Follow-up

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.

Complications

Hemorrhage is the most common complication. An estimated 2-3% of patients have hemorrhage, and 1 of 40,000 patients die from bleeding.^{12 13}

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)

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.

Outcome and Prognosis

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.¹⁴ 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.¹⁵

Levels of alpha-streptococci (inhibitory protective bacteria) have been shown to increase after tonsillectomy.¹⁶ 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.¹⁷ The main determinants for surgical outcome include obesity, which is an increasing occurrence in children, and apnea hypopnea index (AHI) at diagnosis.¹⁸ 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.¹⁹ Lastly, studies are now recognizing the high incidence of obstructive sleep issues in certain populations such as the cleft palate population.²⁰

Future and Controversies

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.¹⁵

Multimedia

Media file 1: Typical appearance on the morning after tonsillectomy, which was performed by using a blunt dissection method.

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. 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].

3. 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].

4. 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].

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

6. 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].

7. 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].

8. 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. Aug 2004;83(8 Suppl 3):4-13; quiz 14-5. [Medline].

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

10. 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. Jun 1986;112(6):610-5. [Medline].

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

12. 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].

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

14. 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. Jan 2005;90(1):19-25. [Medline].

15. 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. Mar 15 1984;310(11):674-83. [Medline].

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

17. Tauman R, Gulliver TE, Krishna J, et al. Persistence of obstructive sleep apnea syndrome in children after adenotonsillectomy. J Pediatr. Dec 2006;149(6):803-8. [Medline].

18. Lam YY, Chan EY, Ng DK, et al. The correlation among obesity, apnea-hypopnea index, and tonsil size in children. Chest. Dec 2006;130(6):1751-6. [Medline].

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

20. 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. Mar 2009;46(2):117-23. [Medline].

21. 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.

Keywords

tonsils, tonsillectomy, tonsillectomy surgery, tonsillectomy procedure, sore throat, swollen tonsils, tonsil infection, tonsillitis, palatine tonsils, tonsillectomy adults

Contributor Information and Disclosures

Author

Amelia F 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 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, and North Carolina Medical Society
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, 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.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

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: Covidien Corp Consulting fee Consulting; US Tobacco Corporation unstricted gift unknown; Axis Three Corporation Ownership interest Consulting; Omni Biosciences Ownership interest Consulting; Sentegra Ownership interest Board membership; Syndicom Ownership interest Consulting; Oxlo  Consulting; Medvoy Ownership interest Management position

Clinical guidelines

Thomas M. Specific management of IgA nephropathy: role of tonsillectomy. Nephrology 2006 Apr;11(S1):S146-8.

Finnish Medical Society Duodecim. Sore throat and tonsillitis. In: EBM Guidelines. Evidence-Based Medicine [Internet]. Helsinki, Finland: Wiley Interscience. John Wiley & Sons; 2007 Feb 2

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