Tonsillectomy

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Tonsillectomy
Intervention
Tonsillectomy09.jpg
Typical appearance of the back of the throat three days post tonsillectomy.
ICD-9-CM28.2-28.3
MeSHD014068
MedlinePlus003013
 
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Tonsillectomy
Intervention
Tonsillectomy09.jpg
Typical appearance of the back of the throat three days post tonsillectomy.
ICD-9-CM28.2-28.3
MeSHD014068
MedlinePlus003013

Tonsillectomy is a 3,000-year-old[1] surgical procedure in which, traditionally, each tonsil is removed from a recess in the side of the pharynx called the tonsillar fossa. The procedure is performed in response to repeated occurrence of acute tonsillitis, sleep surgery for obstructive sleep apnea, nasal airway obstruction, diphtheria carrier state, snoring, or peritonsillar abscess. For children, the adenoids (also known as a pharyngeal tonsil or nasopharyngeal tonsil), are usually removed at the same time, a procedure called adenoidectomy, or tonsilloadenoidectomy, when combined. Adenoidectomy is uncommon in adults in whom the adenoids are usually vestigial. Although tonsillectomy is performed less frequently than in the 1950s, it remains one of the most common surgical procedures in children in the United States.

Medical uses[edit]

Appearance of throat prior to tonsillectomy. Note the large tonsils partially blocking the airway.
Throat after tonsillectomy. Note the improvement in the airway space.

Tonsillectomy may be indicated when the patient experiences recurrent infections of acute tonsillitis. As the size of tonsils reaches its maximum at 3 years of age and then regresses gradually, tonsillectomy is usually delayed unless the frequency of infection necessitates it absolutely. The number prompting tonsillectomy varies with the severity of the episodes. One case, even severe, is generally not enough for most surgeons to decide tonsillectomy is necessary. Paradise in 1983 defined recurrent tonsillitis warranting surgery by the attack frequency standard as

"Seven or more in a year, five or more per year for two years, or three or more per year for three years. These are the absolute indications for tonsillectomy."[2]

According to the 2012 guidelines of the American Academy of Otolaryngology & Head and Neck Surgery (AAO-HNS), tonsillectomy is indicated as follows:

"Clinicians may recommend tonsillectomy for recurrent throat infection with a frequency of at least 7 episodes in the past year or at least 5 episodes per year for 2 years or at least 3 episodes per year for 3 years with documentation in the medical record for each episode of sore throat and one or more of the following: temperature >38.3oC, cervical adenopathy, tonsillar exudates, or positive test for Group A Beta- hemolytic strep."[3]

Tonsillectomy is also sometimes performed on those who suffer chronically from tonsilloliths.[4]

Most recently, American Academy of Otolaryngology-Head and Neck Surgery Foundation has published clinical practice guidelines.[5][6] The panel made a strong recommendation for:

  1. Watchful waiting for recurrent throat infection if there have been fewer than 7 episodes in the past year or fewer than 5 episodes per year in the past 2 years or fewer than 3 episodes per year in the past 3 years;
  2. Assessing the child with recurrent throat infection who does not meet criteria in statement 2 for modifying factors that may nonetheless favor tonsillectomy, which may include but are not limited to multiple antibiotic allergy/intolerance, periodic fever, aphthous stomatitis, pharyngitis and adenitis, or history of peritonsillar abscess;
  3. Asking caregivers of children with sleep-disordered breathing and tonsil hypertrophy about comorbid conditions that might improve after tonsillectomy, including growth retardation, poor school performance, enuresis, and behavioral problems;
  4. Counseling caregivers about tonsillectomy as a means to improve health in children with abnormal polysomnography who also have tonsil hypertrophy and sleep-disordered breathing;
  5. Counseling caregivers that sleep-disordered breathing may persist or recur after tonsillectomy and may require further management;
  6. Advocating for pain management after tonsillectomy and educating caregivers about the importance of managing and reassessing pain; and
  7. Clinicians who perform tonsillectomy should determine their rate of primary and secondary posttonsillectomy hemorrhage at least annually.

Surgical procedure[edit]

For the past 50 years at least, tonsillectomy has been performed by dissecting the tonsil from its surrounding fascia, a so-called 'total', or extra-capsular tonsillectomy. Problems include pain and bleeding leading to a recent resurgence in interest in sub-total tonsillectomy or 'tonsillotomy' which was popular 60–100 years ago, in an effort to reduce these complications.[7] The generally accepted procedure for 'total' tonsillectomy uses a scalpel and blunt dissection or electrocautery, although harmonic scalpels or lasers have also been used. Bleeding is stopped with electrocautery, ligation by sutures, and the topical use of thrombin, a protein that induces blood clotting.

It has already been stated that the benefits of tonsillectomy for sore throat are controversial and time limited. Consequently, the main question of importance becomes whether or not the benefits of subtotal tonsillectomy in obstructive sleep apnea are enduring. It appears that this may be the case although most observers agree that further time and study is required.[8]

Methods[edit]

The scalpel is the preferred surgical instrument of many ear, nose, and throat specialists. However, there are other techniques and a brief review of each follows:

Post-operative care[edit]

A sore throat will persist approximately two weeks following surgery while pain following the procedure is significant and may necessitate a hospital stay.[12] Recovery can take from 7 to 10 days and proper hydration is very important during this time, since dehydration can increase throat pain, leading to a vicious circle of poor fluid intake.[13][14]

At some point, most commonly 7–11 days after the surgery (but occasionally as long as two weeks (14 days) after), bleeding can occur when scabs begin sloughing off from the surgical sites. The overall risk of bleeding is approximately 1%–2%. It is higher in adults, especially males over age 70 and three quarters of bleeding incidents occur on the same day as the surgery.[15] Approximately 3% of adult patients develop significant bleeding at this time which may sometimes require surgical intervention.

Post-operative pain relief is subject to change. Traditionally, pain relief has been provided by relatively mild narcotic analgesics such as Acetaminophen with codeine, for milder pain, and stronger narcotic analgesics for more severe pain. Recently (January 2011), the FDA reduced the recommended total 24 hour dose because of concern about liver toxicity from the Acetominophen component. An alternative is the use of non-steroidal anti-inflammatory agents, themselves giving rise to concerns that their effect on platelets might increase the risk of post-operative bleeding.[16] In turn, this has renewed interest in techniques other than traditional 'extra-capsular excision' in the hope that post-operative pain might be reduced.[17]

Tonsillectomy appears to be more painful in adults than children, although there will be individual variations in response.[18]

Effectiveness[edit]

The procedure is often not effective or only modestly effective, and does not get rid of sore throats altogether.[19][20] In children there is only a short-term benefit; without tonsillectomy a child who meets these strict criteria will probably have 6 throat infections in the next two years while one who has surgery will probably have 3 throat infections. After two years there is little difference in the rate of infection.[21]

Complications[edit]

A single dose of the corticosteroid drug dexamethasone may be given during surgery to prevent post-operative vomiting.[22] A systematic review found that a dose of dexamethasone during surgery can prevent vomiting in one out of every five children who receives the drug.[22] The review also found that these children return to a normal diet more quickly and have less post-operative pain.[22]

A recent study states that tonsillectomies in young children (0 to 7 years) are correlated with weight gain in the years following surgery.[23] However, no causal effect has been established.[24]

Adverse effects[edit]

The morbidity rate associated with tonsillectomy is 2% to 4% due to post-operative bleeding; the mortality rate is 1 in 15,000, due to bleeding, airway obstruction, or anesthesia complications.[25]

Frequency[edit]

More than 530,000 procedures are performed annually in children younger than 15 years in the United States.[5] The current tonsillectomy "rate" is 0.53 per thousand children and 1.46 per thousand children for combined tonsillectomy and adenoidectomy.[26]

History[edit]

Tonsillectomy has been practiced for 2,000 years, with varying popularity over the centuries.[1] The procedure is claimed in some books as "Hindu medicine" about 1000 BC (non-evidence based literature). Others refer to it as cleaning of tonsil using the nail of the index finger. Roughly a millennium later the Roman aristocrat Aulus Cornelius Celsus (25 AD – 50 AD) described a procedure whereby using the finger (or a blunt hook if necessary), the tonsil was separated from the neighboring tissue before being cut out.[1] Galen (121 – 200 AD) was the first to advocate the use of the surgical instrument known as the snare, a practice that was to become common until Aetius (490 AD) recommended partial removal of the tonsil, writing "Those who extirpate the entire tonsil remove, at the same time, structures that are perfectly healthy, and, in this way, give rise to serious Hæmorrhage".[1] In the 7th century Paulus Aegineta (625–690) described a detailed procedure for tonsillectomy, including dealing with the inevitable post-operative bleeding. 1,200 years pass before the procedure is described again with such precision and detail.[1]

The Middle Ages saw tonsillectomy fall into disfavor; Ambroise Pare (1509) wrote it to be "a bad operation" and suggested a procedure that involved gradual strangulation with a ligature. This method was not popular with the patients due to the immense pain it caused and the infection that usually followed. Scottish physician Peter Lowe in 1600 summarized the three methods in use at the time, including the snare, the ligature, and the excision.[1] At the time, the function of the tonsils was thought to be absorption of secretions from the nose; it was assumed that removal of large amounts of tonsillar tissue would interfere with the ability to remove these secretions, causing them to accumulate in the larynx, resulting in hoarseness. For this reason, physicians like Dionis (1672) and Lorenz Heister censured the procedure.

Tonsil guillotine.

In 1828, physician Philip Syng Physick modified an existing instrument originally designed by Benjamin Bell for removing the uvula; the instrument, known as the tonsil guillotine (and later as a tonsillotome), became the standard instrument for tonsil removal for over 80 years.[1] By 1897, it became more common to perform complete rather than partial removal of the tonsil after American physician Ballenger noted that partial removal failed to completely alleviate symptoms in a majority of cases. His results using a technique involving removal of the tonsil with a scalpel and forceps were much better than partial removal; tonsillectomy using the guillotine eventually fell out of favor in America.[1]

Image gallery[edit]

See also[edit]

Footnotes[edit]

  1. ^ a b c d e f g h McNeill RA., RA (1 June 1960). "A History of Tonsillectomy: Two Millenia of Trauma, Hæmorrhage and Controversy". Ulser Medical Journal 29 (1): 59–63. PMC 2384338. PMID 20476427. 
  2. ^ Paradise JL (1983). "Tonsillectomy and Adenoidectomy". Pediatric otolaryngology: 122–6. 
  3. ^ American Academy of Otolaryngology—Head and Neck Surgery. 2012 Clinical Indicators Compendium. Clinical Indicators: Tonsillectomy, Adenoidectomy, Adenotonillectomy.
  4. ^ Svoboda, Elizabeth (August 31, 2009). "In Tonsils, a Problem the Size of a Pea". The New York Times. Retrieved January 8, 2011. 
  5. ^ a b Baugh RF, Archer SM, Mitchell RB, Rosenfeld RM, Amin R, Burns JJ, Darrow DH, Giordano T, Litman RS, Li KK, Mannix ME, Schwartz RH, Setzen G, Wald ER, Wall E, Sandberg G, Patel MM (January 2011). "Clinical practice guideline: tonsillectomy in children". Otolaryngology-Head and Neck Surgery 144 (1 Suppl): S1–30. doi:10.1177/0194599810389949. PMID 21493257. 
  6. ^ Randel, A (2011 Sep 1). "AAO-HNS Guidelines for Tonsillectomy in Children and Adolescents.". American family physician 84 (5): 566–73. PMID 21888309. 
  7. ^ Walton J, Ebner Y, Stewart MG, April MM (2012). "Systematic Review of Randomized Controlled Trials Comparing Intracapsular Tonsillectomy With Total Tonsillectomy in a Pediatric Population". Arch Otolaryngol Head Neck Surg 138 (3): 243–49. doi:10.1001/archoto.2012.16. PMID 22431869. 
  8. ^ Koempel JA, Solares CA, Koltai PJ (December 2006). "The evolution of tonsil surgery and rethinking the surgical approach to obstructive sleep-disordered breathing in children". J Laryngol Otol 120 (12): 993–1000. doi:10.1017/S0022215106002544. PMID 16923328. 
  9. ^ Friedman M, LoSavio P, Ibrahim H, Ramakrishnan V (2003). "Radiofrequency tonsil reduction: safety, morbidity, and efficacy". Laryngoscope 113 (5): 882–7. doi:10.1097/00005537-200305000-00020. PMID 12792327. 
  10. ^ Windfuhr JP. (2007). "[Coblation tonsillectomy: a review of the literature.]". HNO 55 (5): 337–48. doi:10.1007/s00106-006-1523-3. PMID 17431570. 
  11. ^ a b "Interventional procedure overview of laser assisted serial tonsillectomy". National institute of clinical excellence. Retrieved 30 November 2013. 
  12. ^ Graham, John M.; Glenis K. Scadding, Peter D. Bull (2008). Pediatric ENT. Springer. p. 136. ISBN 3-540-69930-9. 
  13. ^ Timby, Barbara Kuhn; Nancy Ellen Smith (2006). Introductory medical-surgical nursing. Lippincott Williams & Wilkins. p. 357. ISBN 0-7817-8032-2. 
  14. ^ Pemberton, Cecilia M. (1988). Mayo Clinic diet manual. B.C. Decker. ISBN 1-55664-032-3. 
  15. ^ Windfuhr JP, Chen YS, Remmert S. (2005). "Hemorrhage following tonsillectomy and adenoidectomy in 15,218 patients". Otolaryngology-Head and Neck Surgery 132 (2): 281–86. doi:10.1016/j.otohns.2004.09.007. PMID 15692542. 
  16. ^ Møiniche S, Rømsing J, Dahl JB, Tramèr MR (January 2003). "Nonsteroidal antiinflammatory drugs and the risk of operative site bleeding after tonsillectomy: a quantitative systematic review". Anesth Analg 96 (1): 68–77. doi:10.1213/00000539-200301000-00015. PMID 12505926. 
  17. ^ Chimona T, Proimos E, Mamoulakis C, Tzanakakis M, Skoulakis CE, Papadakis CE (September 2008). "comparison of cold knife tonsillectomy, radiofrequency excision and thermal welding tonsillectomy in children". Int J Pediatr Otorhinolaryngol 72 (9): 1431–6. doi:10.1016/j.ijporl.2008.06.006. PMID 18620759. 
  18. ^ Graumüller S, Laudien B (November 2003). "Postoperative pain after tonsillectomy—comparison of children and adults". Advances in Pediatric ORL. Proceedings of the 8th International Congress of Pediatric Otorhinolaryngology 1254: 469–72. doi:10.1016/S0531-5131(03)01073-2. 
  19. ^ Blakley, BW, Magit A (2009). "Response to: The role of tonsillectomy in reducing recurrent pharyngitis: A systematic review, from Jeremy Hornibrook". Otolaryngology-Head and Neck Surgery 141 (1): 155–156. doi:10.1016/j.otohns.2009.04.017. 
  20. ^ Blakley, BW; Magit, AE (March 2009). "The role of tonsillectomy in reducing recurrent pharyngitis: a systematic review". Otolaryngology--head and neck surgery : official journal of American Academy of Otolaryngology-Head and Neck Surgery 140 (3): 291–7. doi:10.1016/j.otohns.2008.12.013. PMID 19248931. 
  21. ^ Marshall T (2002). "Effectiveness of tonsillectomy? A reply to Howel et al". Family Practice 19 (6): 707–708. doi:10.1093/fampra/19.6.707-a. PMID 12429681. 
  22. ^ a b c Steward, DL; Grisel, J; Meinzen-Derr, J (Aug 10, 2011). "Steroids for improving recovery following tonsillectomy in children". In Steward, David L. Cochrane database of systematic reviews (Online) (8): CD003997. doi:10.1002/14651858.CD003997.pub2. PMID 21833946. 
  23. ^ Wijga, AH; Scholtens, S; Wieringa, MH; Kerkhof, M; Gerritsen, J; Brunekreef, B; Smit, HA (2009 Apr). "Adenotonsillectomy and the development of overweight.". Pediatrics 123 (4): 1095–101. doi:10.1542/peds.2008-1502. PMID 19336367. 
  24. ^ Wei, JL (2011 Jun). "Weight gain after tonsillectomy: myth or reality? Interpreting research responsibly.". Otolaryngology--head and neck surgery : official journal of American Academy of Otolaryngology-Head and Neck Surgery 144 (6): 855–7. PMID 21515804. 
  25. ^ Lee KL, p. 544.
  26. ^ Bhattacharyya N, Lin HW (November 2010). "Changes and consistencies in the epidemiology of pediatric adenotonsillar surgery". Otolaryngology-Head and Neck Surgery 43 (5): 680–4. doi:10.1016/j.otohns.2010.06.918. PMID 20974339. 

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