Published by Dr. Alok Banka
Tonsillectomy is one of the most common surgical procedures performed in children. Tonsillectomy is defined as a surgical procedure that removes the tonsil. The procedure may be a complete tonsil removal – by dissecting the peritonsillar space between the tonsil capsule and the muscular wall; or a partial removal - through removing a varying amount of
tonsillar tissue intracapsularly or subcapsularly.
Indications for Tonsillectomy
Indications for tonsillectomy are multiple, the most common and generally accepted of which are sleep-disordered breathing (SDB) and recurrent throat infections.
SDB is now the single most common indication for tonsillectomy with or without adenoidectomy. SDB constitutes a range of disorders - increasing in severity from snoring and restless sleep to obstructive sleep apnea (OSA). SDB has a multifactorial etiology, and hypertrophic tonsils are usually a contributing factor.
Throat infections are defined as episodes of sore throat caused by viral or bacterial infection of the pharynx, palatine tonsils, or both, and could be known by a variety of names - like tonsillitis, pharyngitis, and strep throat. Throat infections may be documented for each episode of sore throat with one or more of the following: temperature higher than 38.3C, cervical adenopathy, tonsillar exudates, or positive test for group A b-hemolytic streptococci.
A recent clinical practice guideline recommended for
tonsillectomy in children with recurrent throat infections with a frequency of at least three episodes in a year. Although the guideline recommended watchful waiting for recurrent throat infections with a lesser frequency, tonsillectomy is recommend in children with fewer throat infections if they exhibit modifying factors, such as multiple antibiotic allergy or intolerance, a combination of periodic fever, aphthous stomatitis, pharyngitis, and adenitis (PFAPA), or a history of peritonsillar abscess.
Other rarer indications for surgery include orthodontic concerns, tonsiliths, halitosis, and chronic tonsillitis.
Clinical Assessment of Tonsils
It is vital that the doctor takes a careful aacount of the history of the patient and the infections. Symptoms will include:
- Throat infections
- Restless sleep
- Nocturnal enuresis
- Growth retardation
- Poor school performance
- Behavioral problems
- Attention deficit hyperactivity disorder (ADHD)
Physical examination should focus on the anatomy, which includes the size of the tonsils in relation to the position and size of the palate, tongue, and chin.
Polysomnography is done in children with SDB before tonsillectomy if they exhibit one of the following co-morbid conditions:
- Down syndrome
- Craniofacial abnormalities
- Neuromuscular disorders
- Sickle cell disease
Total tonsillectomy via cold dissection:
Traditional techniques for tonsillectomy consist of cold dissection with metal instruments including knife, scissor, or snare. These techniques involve complete removal of the tonsil with its capsule by dissecting the peritonsillar space, with hemostasis obtained
through ligation of blood vessels during tonsil removal or cauterization of the wound bed. Complete dissection or total tonsillectomy (TT) with cold steel is still the technique against which effectiveness and safety of other techniques are compared like total tonsillectomy via electrosurgery, cautery dissection, coblation, radiofrequency. No significant differences in postoperative pain were found in the coblation and/or harmonic scalpel method compared with the cold steel and/or electrocautery.