Tonsillectomy, or removal of the diseased tonsil, is the most common surgical procedure conducted on children. The tonsils are two bulks of lymphoid tissue located on either side of the throat which, when they become enlarged or infected, cause a number of conditions and complication often prompting the need for surgery.
When should a tonsillectomy be performed?
Clinical Indications for a Tonsillectomy
Indications for tonsillectomy may be determined according to those conditions where a tonsillectomy is a necessity (absolute indications) and those complications and conditions which may improve with a tonsillectomy (relative indications).
Absolute indications for tonsillectomy
- Airway obstruction occurs when the tonsils are so enlarged that they cause chronic upper respiratory tract obstruction.
- Sleep apnea is the intermittent closure of the airway at the pharynx causing episodes of apnea or ‘breath holding’ (gagging) during sleep as well as snoring.
- Tonsillar malignancy is a carcinoma of the tonsils, which is not common, but surgical removal is necessary to prevent the spread.
Relative indications for tonsillectomy
- Recurrent acute tonsillitis is the most common relative indication for tonsillectomy in children and adolescents, especially when there is recurrent sore throat due to streptococcal infections (strep throat). This is usually considered when the tonsillitis occurs despite antibiotics.
- Chronic tonsillitis is more common in young adults and may be aggravated by smoking, acid reflux (GERD) and other ENT (ear, nose and throat) conditions like post nasal drip.
- Quinsy or peritonsillar abscess can be managed by incision and drainage, which is the treatment of choice, but in a child there is also likely to be a history of chronic tonsillitis and tonsillectomy is then advisable.
- Tonsillitis causing febrile convulsions.
- Systemic diseases caused by beta-hemolytic streptococcus infection, such as rheumatic fever or nephritis.
What are the techniques used to remove the tonsils?
Surgical techniques for Tonsillectomy
There are various surgical techniques for a tonsillectomy but the success of the tonsil removal procedure is dependent on the skill of the surgeon.
Removal of the tonsils may be conducted using any of the following methods :
- Hot and Cold Tonsillectomy
These techniques are the oldest and most commonly practiced procedures to date.
- Knife or scalpel is when a surgical knife or scalpel is used to perform a tonsillectomy, it is called ‘cold dissection’.
- Electrocautery is a ‘hot dissection’ method where a high frequency electric current is applied to the area, removing the unwanted tissue and ‘sealing’ the surrounding blood vessels.
Post-operative bleeding rates are same in both hot and cold dissection, although hot dissection may have a greater degree of post-operative pain.
- Laser tonsil removal is a technique that was used in the 1980’s but its popularity declined because of the longer period of time that the patient is needed to be under anesthesia and delay in healing.
- Coblation tonsillectomy is a technique came that uses a ‘cool’ electric current at the tip of a wand for coagulation and ablation of the tissue. Since the tissue temperature is cooler, there is less damage to the surrounding tissues resulting in less pain and a lower incidence of post-operative bleeding. Patients are also able to start eating a regular diet sooner with the coblation technique.
- Microdebrider is a slow method and there is no advantage over using the scalpel since it does not control the bleeding.
- The harmonic scalpel is an ultrasonic cutting device used for procedures like tonsil removal surgery. The advantage of this technique is that in young children, the harmonic scalpel controls bleeding from the small blood vessels, and post-operative pain is usually less. This is definitely an advantage in small children, who may refuse oral intake because of post-operative pain and thus are likely to get dehydrated. On the other hand, it is a more costly procedure, and since in older patients there is more chance of bleeding during operation, it may necessitate the use of electrocautery, which in turn increases the chance of post-operative pain. The harmonic scalpel does reduce the amount of bleeding during surgery and allows for a clearer field during the surgery. Complications may also be less than in other methods, as reported by certain studies.
How is a tonsillectomy performed?
Tonsillectomy Surgical Procedure
Tonsillectomy is considered to be a major surgery, which usually takes between 30 minutes to one hour to complete. In the USA it is done on an outpatient basis and the child can go home the same day.
The tonsillectomy is conducted under general anesthesia by any of the surgical techniques for tonsil removal. There are no external incisions, through the skin, and the tonsils are removed through the mouth, with care being taken to ensure that no bleeding points left unattended. No stitches are necessary in the tonsil bed after its removal.
After the operation, the patient is kept under close observation for about one hour in the recovery room to monitor for any signs and symptoms of bleeding. After this period, the patient is transferred to the general ward or private ward. The pulse and blood pressure are monitored closely and no solid food is administered orally for a few hours. This reduces injury to the area but also ensures that should there be an bleeding or need to operate on the area again, the stomach is empty. Surgery cannot be conducted on a patient with food still in the stomach as this can cause the patient to aspirate the gastric contents and cause choking.
After a few hours, if there are no complications, solid food is encouraged and the patient may be discharged on the same day. It is advisable to lie with the head elevated and a cold, light, soft diet is preferable for a few days after the procedure. Antibiotics are routinely prescribed to prevent post-operative infections and an analgesic may be necessary for pain management.
What are the dangers or complications of a tonsillectomy?
Complications of Tonsillectomy
- Bleeding is the most common complication of tonsil operation and it may occur immediately after the operation or any time within the next 10 days (secondary hemorrhage). The late hemorrhage is usually due to infection and both types of bleeding should be dealt with immediately by the doctor as it could be potentially life-threatening.
- Infection, particularly a bacterial infection.
- Prolonged pain after operation.
- Pain in the ears (otalgia).
- Permanent change in voice, especially hyper-nasal speech.
- Electrocautery burns.
- Use of the tonsillar gag during operation may damage the teeth or soft tissues in the mouth and throat.