What is tonsillectomy?
Tonsillectomy is a quite common surgical procedure to remove the tonsils with or without adenoid glands. Every year, more than five hundred thousand patients enter the operation to remove their tonsils (tonsillectomy) or remove tonsils and adenoid glands (adenotonsillectomy). Although it is an extremely popular surgical procedure in pediatrics and young adults, but there are a continuous debates and discussion about the procedure specific indications to perform tonsillectomy surgery.
The tonsils are oval shaped lymphoepithelial tissue located at the back of throat. The tonsils consist of two palatine tonsils, adenoid gland, two tubal tonsils, and lingual tonsils. The term tonsillectomy here means removal of palatine tonsils.
Tonsils are part of the lymphatic system, with its specific location, it acts as the first line of defense mechanism against different pathogen that may enter the body. all tonsils and adenoid glands are part of Waldeyer’s ring, which play a key role in the body immune systems.
Indications of tonsillectomy
There are multiple indications for tonsillectomy, but the most common indications are:
-
- Recurrent inflammation of the tonsils
- Sleep breathing problems due to enlarged tonsils
According to the American academy of otolaryngology-head and neck surgery issue a clinical indicator for tonsillectomy as follows
1. Absolute indication
There are specific conditions that mandate surgical removal of tonsils such as an augmented tonsils which may results in
-
- Marked airway obstruction
- Difficulty of swallowing
- The augmented tonsils can compromise breathing while sleeping
- Cardio-pulmonary complications from repeated tonsilitis
In enlarged tonsils, tonsil’s size is not correlated with the severity of symptoms and signs of sleep disorders. The recurrence of airway obstruction during sleep may causes ventilation abnormalities and disturbance in sleep cycles. These abnormalities cause
-
- affecting the child’s quality of life
- delaying child’s growth
- diminish in his learning ability.
Children with sleep disorders due to breathing difficulties have higher rates of using antibiotics, and more hospital visits than normal children. In a study by Bough et al. to provide an evidence-based guidance for clinicians to identify children candidate for tonsillectomy. They founded that certain associated conditions with sleep disorders breathing and enlarged tonsils such as delayed growth, behavioral changes, and learning difficulties would be improved after tonsillectomy.
One of the absolute indications of tonsillectomy is peritonsillar abscess, which is not responding to medical treatment and drainage. The drainage of peritonsillar abscess should be documented. Due to the recurrent nature of peritonsillar abscess; removal of the tonsils (tonsillectomy) is the optimum treatment of this condition.
Recurrent tonsilitis is an indication of tonsilitis especially if the repeated attacks accompanied with fever, also if the repeated attacks are associated with a febrile convulsion.
Another absolute indication of tonsillectomy is unilateral tonsil enlargement with the suspicion of malignancy. The enlarged tonsil require biopsy to identify the causative pathology.
2. Relative indications of tonsillectomy
There are some specific indications for tonsillectomy, but the indications here is not absolute, which may differ from case to case. The decision here is left to the surgeon’s decision for every specific case after explaining to the patients all pros and cons of his decision. Relative indications include:
– Recurrent tonsils infections many times in a specific year, with frequent antibiotic treatment for every infection time. Recurrent tonsilitis is common in children. Guidelines recommends close monitoring for children with a fewer tonsilitis attacks than seven times in the previous year, or less than five attacks of tonsilitis in the previous two years, or less than three attacks of tonsilitis every year for the previous three years. Tonsillectomy is recommended if the patient’s attacks of tonsillitis surpass the guidelines numbers.
– Chronic tonsilitis infections is more common in teenagers and adults. The repeated tonsils infections may respond at first to the antibiotic treatments, but later the tonsil infections do not resolve completely. Chronic tonsilitis symptoms include chronic throat pain, enlarged tonsils, and bad breath which may results in accumulation of food in the tonsils.
– Chronic tonsilitis due to repeated infection by group B streptococcal infections, with no response to the regular antibiotic treatment, or to the beta-lactamase resistant antibiotics.
– Hypertrophy of one or the two tonsils with malignancy is suspected.
Contraindications of tonsillectomy
There is no definite contraindication of tonsillectomy, but there are some conditions that may delay or even prevent the surgery of tonsillectomy such as:
-
- Any patient with risk of post-operative bleeding as in patients with bleeding disorders as leukemia, purpura, hemophilia, and aplastic anemia
- History of malignant hyperthermia
- Anemia that may be worsen from postoperative bleeding
- Acute infection in the upper respiratory tract which may aggravate postoperative bleeding and pulmonary complications
- Uncontrolled systemic diseases as in hypertension, diabetes mellitus, cardiac diseases, and asthma
- Some studies suggested that tonsillectomy is contraindicated in children younger than three-year-old. On the other hand, a study conducted by Berkowitz et al. to study the tonsillectomy in children younger than three years, the authors founded that age should not be a deterministic factor to undergo a tonsillectomy or not.
- Other contraindication include poliomyelitis as tonsillectomy may raise the chance of bulbar poliomyelitis, and active tuberculous infections.
Preparations of tonsillectomy surgery
Before the surgery, a good preparation for the patient can help in lessen postoperative risks, and to ensure a speedy recovery.
History
The clinician should have a full detailed history from the patient about
-
- Full medical history especially diseases that may causes bleeding disorders
- Medications including blood thinning like aspirin
- Family history of the patient especially if there were an allergic reaction to anesthesia
- All history of patient allergy
In the adults, the patient would be advised to stop smoking prior to the surgery, and all his medications doses would be revised with his doctor.
In pediatrics, the child should understand what he will be going through and should be supported and reassured by his parents or caregivers. It is preferable for the child to stay with his parents before and after the surgery if possible. A brief description to the child that he may feel some sore throat postoperatively for a brief time would be beneficial.
Laboratory investigation before tonsillectomy
Coagulation profile is essential before the surgery; according to the American academy of otolaryngology-Head and neck surgery foundation recommends doing a full coagulation profile for all the patient before tonsillectomy.
In a study by Gabriel et al. to assess the relationship between patients’ history and coagulation test results in pediatric age group undergoing tonsillectomy. The study showed that in 4% of the children with abnormal coagulation test results, the history taken from those children before the surgery was not correlated with their test results. The authors recommended taking a full detailed history before the surgery and performing a complete coagulation profile to all patients before the surgery.
Other tests include:
-
- Complete blood picture (CBC)
- Urine analysis
- Liver function tests
- Kidney function tests
Images before tonsillectomy surgery
Most patients do not require specific imaging before tonsillectomy except patients with suspected malignancy; may need to undergo a CT scan or MRI imaging. In patients with down syndrome, cervical spine imaging is important to evaluate for C1-C2 subluxation. There is other routine imaging that may be needed before the surgery.
Chest X-Ray
Chest X-Ray helps in diagnosing infections, to spot any abnormality in patient’s lung or heart that may necessitate a further investigation.
Electrocardiogram
It monitors the electric activity of the heart to exclude any cardiac abnormality that may compromise the anesthesia and the surgery.
Histology of the tonsils tissue
Examining the tonsils tissues after tonsillectomy is not recommended except in the following cases:
-
- Malignancy is suspected
- If there were non-symmetrical enlargements of the tonsils
Tonsillectomy operations techniques
There are multiple techniques in performing tonsillectomy. In the operation room, the patient is placed in the rose position with a shoulder roll. A mouth prop is inserted to open the mouth and keep it open. Then Allison clamp is used to clasp the tonsils. The next step is dissection of the tonsil capsule, which have variable methods such as:
-
- Using of cold steel and known as cold tonsillectomy
- Monopolar cautery
- Bipolar cautery
- Radiofrequency ablation
- Harmonic scalpel with vibrating titanium blades
- Microdebrider for an intracapsular dissection
There are a lot of debate about the optimum surgical technique to use. The choice of one technique over the others depends on the technique cost, postoperative risks, intraoperative bleeding, and time.
Tonsillectomy using cold tonsillectomy technique is suggested to cause less postoperative pain, on the other hand, hot tonsillectomy may be associated with less intraoperative time and complications as intraoperative bleeding.
A study conducted by Chan et al. to determine how cold tonsillectomy technique can affect postoperative recovery time. The authors founded that, the complications that are usually associated with the traditional methods were decreased significantly after using cold tonsillectomy technique, and the residual tonsillar tissue that is usually associated with this technique have no major consequences.
The final decision of the technique of tonsillectomy return to the surgeon experience, and what is useful for every case.
A study by Leinbach et al. to study hot versus cold tonsillectomy. They founded that bleeding postoperatively is similar in both techniques, with no significant difference between hot and cold tonsillectomy.
Another study by Kay W Chang to compare the recovery of patients undergoing coblation assisted intracapsular tonsillectomy in comparison to patients undergoing traditional subcapsular electrocautery tonsillectomy. The authors founded that, patient undergoing coblation assisted intracapsular tonsillectomy have a significantly better postoperative recovery. Those patients had less pain and returned to their normal activity faster than patients with the traditional tonsillectomy.
Postoperative recovery
Postoperative pain control is usually achieved by oral acetaminophen or ibuprofen. Children who refuse to take medications postoperatively are at a significant risk to develop side effects such as dehydration, weight loss, and increase the risk of local infection.
A study by Sutters et al.to evaluate the effect of scheduled acetaminophen postoperative administration to control pain, in comparison to pain medication administration only when needed in children from six-year-old to fifteen-year-old after tonsillectomy. They founded that, patients on a scheduled pain medications had received more analgesia in comparison to other group but have less pain intensity in comparison to pain medication when needed.
A good post operative patient hydration is a key for safe and a speedy recovery. The patient should be kept on balanced nutritious diet with good hydration. Although there is no suggestive data to prefer a specific food for postoperative recovery time but eating soft foods in the first few days is recommended.
Systemic antibiotic in the first few days postoperatively is associated with less incidence of infection and with a good post-operative outcome. A controlled study by Telian et al. to evaluate the effect of antibiotic therapy on post tonsillectomy recovery period in pediatrics. They founded that antibiotic administration was associated with reduction of fever and some postoperative complaints such as pain, decrease appetite, and bad mouth odor.
Another study by Colreavy et al.to evaluate the benefit of post-tonsillectomy antibiotic for prophylaxis. They founded that; a prophylactic antibiotics prescription was associated with decrease in the post-tonsillectomy comorbidities.
Follow up
Before discharging, the patient would be advised to avoid heavy activities and exercises for at least ten days postoperatively.
There is a recommended follow up schedule for post-tonsillectomy clinician visits to reassure the patient, and to make sure his wounds in healing properly, and to look for any sign of complications or morbidity.
First follow up visit usually occurs after five to eight days after tonsillectomy, then another visit after four to six weeks following the surgical procedure.
Complications of tonsillectomy
There are multiple complications following the tonsillectomy
1. Bleeding or hemorrhage
It is a common complications after tonsillectomy surgery. Around 2-3% of patients have bleeding. A study conducted by Rakover et al. to evaluate the risk of postoperative bleeding in pediatrics after tonsillectomy. They founded that; bleeding occurred in children who were classified as high risk for bleeding.
Another review by Randall DA et al. to study the complication of tonsillectomy and adenoidectomy. They founded that; the prevalence of hemorrhage was ranging from 0.1% to 8.1%, and the incidence increases in winter than in summer. They also founded the bleeding incidence increases with age.
On the other hand, a systematic review by De Luca et al. to identify the most frequent risks after adenotonsillectomy. The authors founded that; bleeding is not the most frequent complication with 2.6% prevalence between children.
A retrospective study by Warad et al. to assess the hemorrhagic risk of post adenotonsillectomy in pediatrics and young adults with a bleeding disorder. The study showed that; despite extensive care of hemostasis intraoperatively, and a good executed surgical technique, the risk of bleeding was high especially in patients with bleeding disorders.
Post-tonsillectomy bleeding can be classified into several types
-
- Intraoperative bleeding
- Primary (early) bleedingwhich occurs in the first twenty-four hours after the procedure
- Secondary (late) bleedingwhich occurs after seven to ten days after the procedure
For patients undergoing tonsillectomy, blood transfusion is required in 0.04% of patients, while postoperative mortality due to bleeding is about 0.002%.
Bleeding after tonsillectomy usually responds to cautery or to applied pressure using a pack with local vasoconstrictors. Treatment of bleeding with electrocautery is faster, and more effective than ligation.
2. Postoperative nausea and vomiting
It is also one of the common early post-tonsillectomy complications. usually on the first twenty-four hours after the procedure.
Nausea and vomiting increases in patients who did not receive a prophylactic anti-emetic treatment after the surgery. one dexamethasone dose intra-operative is usually sufficient for treatment of this condition.
3. Respiratory problems
In the study of De Luca et al., the most frequent complication was respiratory problems, with incidence rate of 9.4% of all children following tonsillectomy. One of the possible respiratory complications after tonsillectomy is pulmonary edema, which may occur during the surgery, or just after a few hours post-operatively. Treatment of mild cases is usually by using diuretics and morphine. Children with obstructive sleep apnea, and down syndrome are at higher risk of developing post-operative pulmonary edema.
Intra-operative administration of steroids can help to decrease post-operative pharyngeal swelling, which may lead to airway obstruction. In this case, uses of narcotics and respiratory depressants drugs should be used with cautious.
4. Sore throat
Post-tonsillectomy sore throat is quite common, nearly all patients would complaints from various degree of sore throat after the surgery. cold tonsillectomy is the least technique of tonsillectomy that would induce post-operative pain, in comparison to other techniques. Early administration of antibiotic therapy is associated with decrease in post-operative duration of pain.
In a controlled study conducted by Telian et al. to evaluate the effect of antibiotic treatment on post-operative recovery phase after tonsillectomy in pediatrics. They founded that; administration of ampicillin/amoxicillin antibiotic combination therapy is tolerated and safe in children, who are not allergic to these antibiotics. These treatments were effective in decrease the incidence of postoperative comorbidities as fever.
5. Otalgia
Otalgia or ear pain is one of the post operative common complaints, otalgia is usually associated with throat pain. It is usually a referred pain.
In cases of persistent otalgia, patient should be examined to rule out infection.
6. Fever
It can be manifested in the first day after tonsillectomy, the causes range from anesthesia effect, short-term bacteremia, or even post-surgical stress.
Fever increases the risk of dehydration.
7. Dehydration
There are multiple factors that can increase the risk of dehydration such as post-operative nausea, vomiting, and odynophagia that decrease oral intake. Vomiting and dehydration may delay patient discharge from the hospital.
The risk of dehydration increases in small children because they are less co-operative and refuse the oral intake after the surgery. single intra-operative steroid injection can enhance the patient ability to return to their preoperative diet.
8. Nasopharyngeal stenosis
It is a rare complication of tonsillectomy; it occurs due to formation of circumferential contracture of Waldeyer’s ring of the pharynx.
⇒ Other complications
Other complications of tonsillectomy include:
-
-
- Atlanto-axial subluxation
- Mandible fracture
- Local infection
- Trismus
- Weight loss in postoperative early stage in young children
- Voice changes due to local trauma during tonsillectomy
- Psychological trauma in young children and even depression
-
Outcomes and prognosis of tonsillectomy
Tonsillectomy and adenoidectomy results in a reduction in
-
- attacks of tonsilitis
- recurrent days of school absence
- recurrent episodes of upper respiratory infections
Paradise et al. conducted a study to evaluate the efficacy of tonsillectomy for treating recurrent throat infection in severely affected patients in pediatric age group. They founded that; patients who underwent tonsillectomy had a fewer attacks of throat infections in the first two post-operative years, in comparison to patients without tonsillectomy.
There are persistent of obstructive sleep breathing problems in some children post-operatively. Some studies founded that; although adenotonsillectomy surgery may causes improvements in respiratory problems in children with obstructive sleep apnea, but complete recovery and normalization of symptoms occurs only in 25% of patients.
Guidelines pearls
The American academy of otolaryngology head and neck surgery foundation recommends an evidence-based guidelines for every step-in tonsillectomy surgery in the children aging from one- year- old to eighteen -year- old.
The recommendation include:
- The clinician should wait and monitor their patients for recurrent upper airway infections if the attacks was
- less than seven attacks in the previous year
- less than five attacks per year in the previous two years
- less than three attacks per year in the previous three years
- Single dose intravenous dexamethasone is recommended for children during tonsillectomy
- Clinician should prescribe oral pain medication such as ibuprofen, acetaminophen, or both for pain managements after tonsillectomy
- Antibiotic administration has an effective role in decrease post operative co-morbidities
Tonsillectomy in adults
Tonsillectomy in adult population is a safe procedure, but not a common surgery as in pediatrics. The centers for disease control and preventions, in 2006, reported around 300,000 tonsillectomies in patients with fifteen-year-old and older.
The most common indications of adenotonsillectomy in adults are:
-
- Recurrent acute tonsilitis
- Snoring
- Obstructive sleep apnea
- Chronic abscess
- Tonsil’s abscess
- Unilateral tonsil enlargements are an indication for tonsillectomy in adults