Tonsillectomy
Encyclopedia
A tonsillectomy is a 3,000-year-old surgical procedure in which the tonsil
s are removed from either side of the throat. The procedure is performed in response to cases of repeated occurrence of acute tonsillitis
or adenoiditis
, obstructive sleep apnea
, nasal airway obstruction
, snoring
, or peritonsillar abscess
. For children, the adenoid
s are removed at the same time, a procedure called adenoidectomy
. This is not common for adults. Although tonsillectomy is being performed less frequently than in the 1950s, it remains one of the most common surgical procedures in children in the United States.
(AAO-HNS) stated that "In many cases, tonsillectomy may be a more effective treatment, and less costly, than prolonged or repeated treatments for an infected throat...For the past several years, the Academy has been developing clinical guidelines based on evidence and outcomes research, including ‘Quality of Life after Tonsillectomy,’ a January 2008 supplement to the journal Otolaryngology
—Head and Neck Surgery."
is 1 in 15,000, due to bleeding, airway obstruction, or anesthesia
.
of 7765 papers, published in the journal Otolaryngology—Head and Neck Surgery. The review found that it was most likely not effective all the time, but rather was modestly effective, and that "not a single paper reported that tonsillectomy is invariably effective in eliminating sore throats." Another systematic review of cases involving children found that there was only a short-term benefit: "A child who meets these strict criteria will probably suffer from 6 throat infections in the next two years. A child who has surgery now will probably suffer from 3 throat infections. In two years there will probably be no difference."
Pudding
s, Slushie
s, Sorbet and popsicle
s, on the other hand, are recommended. Large quantities of ice should be prepared in advance.
Pain following the procedure is significant and may include a hospital stay. Recovery can take from 10 up to 20 days, during which narcotic
analgesic
s are typically prescribed. Patients are encouraged to maintain diet of liquid and very soft foods for several days following surgery. Rough textured, acidic or spicy foods may be irritating and should be avoided. Proper hydration is very important during this time, since dehydration
can increase throat pain, leading to a vicious circle
of poor fluid intake.
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% higher in adults. Approximately 3% of adult patients develop significant bleeding at this time. The bleeding might naturally stop quickly or else mild intervention (e.g., gargling cold water) could be needed (but ask the doctor before gargling because it might bruise the area of the skin that has been cauterized). Otherwise, a surgeon must repair the bleeding immediately by cauterization
, which presents all the risks associated with emergency surgery (primarily the administration of anesthesia
particularly on a patient whose stomach may not be empty).
Generally speaking, tonsils will be removed if a patient needs antibiotics to be prescribed six times a year for tonsilitis, and the general practitioner's recommendation is based on how the quality of life will be improved after the operation. Tonsillectomies can be performed while the patient is actually suffering from tonsillitis, however this increases the risk of bleeding.
In adults, often to avoid complications due to bleeding and to help recovery, some experts recommend (in two previous weeks to surgery and during the next one) intramuscular injections of phytomenadione (vitamin K) 10mg/ml, Cyanocobalamin (Vitamin B12) 2 mg, calcium folinate 0.9 mg . It is often prescribed as anti-inflammatory paracetamol 1000 mg. Other painkillers are not recommended because instead they extend the clotting time and they slow down wound healing. In the postoperative course swallowing becomes painful for several days and to avoid physical decay are available in pharmacies liquid dietary foods for special medical purposes indicated for the dietary management of patients at risk of malnutrition (200 ml, 1.5 kcal / ml). Please note that the antibiotic is also available in oral suspension (often prescribed Amoxicillin trihydrate equivalent to amoxicillin 875 mg, potassium clavulanate equivalent to clavulanic acid 125 mg).
There are high chances of Aphthous ulcer
, therefore it's good to be prepared to treat it.
("strep throat
"), particularly Streptococcus pyogenes
; some may be due to other bacteria
, such as Streptococcus viridans
, Staphylococcus aureus
, and Haemophilus influenzae
. However, the etiology
of the condition is largely irrelevant in determining whether tonsillectomy is required.
Most tonsillectomies are performed on children, although many are also performed on teenagers and adults; in the United States, it is the most common major surgical procedure performed on children. The number of tonsillectomies in the United States has dropped significantly from over a million cases per year in the 1950s to approximately 600,000 in the late 1990s. This has been due in part to more stringent guidelines for tonsillectomy and adenoidectomy (see tonsillitis
and adenoid
). Still, debate about the usefulness of tonsillectomies continues. Enlarged tonsils are removed more often among adults and children for sleep apnea (airway obstruction while sleeping), snoring, and upper airway obstruction. Children who have sleep apnea can do poorly in school, are tired during the day, may be bedwetters
beyond what is normal, and have some links to ADHD.
Tonsillectomy in adults is more painful than in children, although each patient will have a different experience. Various procedures are available to remove tonsils, each with different advantages and disadvantages. Children and teenagers sometimes exhibit a noticeable change in voice after the operation.
of tissue that surrounds the tonsils. Removal is typically achieved using a scalpel and blunt dissection or with electrocautery, although harmonic scalpel
s or lasers have also been used. Bleeding is stopped with electrocautery, ligation of sutures, and the topical use of thrombin
, a protein that induces blood clotting.
The procedure is carried out with the patient lying flat on their backs, with the shoulders elevated on a small pillow so that the neck is hyperextended – the so-called 'Rose' position. A mouth gag is used to prop the mouth open; if an adenoidectomy
is also being performed, the adenoids are first removed with a curette
; the nasopharynx
is then packed with sterile gauze
. A tonsil is removed by holding it by the upper part, pulling it slightly medially, and making a cut over the anterior faucial pillar. After the tonsil is removed from its position, a snare can be used to make a small cut on the lower portion prior to removal of the tonsil. The use of electrocautery minimizes the blood loss.
is the preferred surgical instrument of many ear, nose, and throat specialists
. However, there are other procedures available – the choice may be dictated by the extent of the procedure (complete tonsil removal versus partial tonsillectomy) and other considerations such as pain
and post-operative bleeding
. A quick review of each procedure follows:
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 prior to being cut out. 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". 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.
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, however, 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. At the time, the function of the tonsils was thought to be to absorb 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.
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. 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.
is performed, and up to 136% in cases of where tonsillectomy with adenoidectomy was performed.
Image:Tonsillitis.jpg|Throat with tonsillitis
.
Image:Tonsillectomy tonsils.JPEG|Two removed tonsil
s.
Image:Tonsilectomia.JPG|Throat 1 day after a tonsillectomy.
Image:Uvula without tonsils.jpg|Throat some days after a tonsillectomy.
Tonsil
Palatine tonsils, occasionally called the faucial tonsils, are the tonsils that can be seen on the left and right sides at the back of the throat....
s are removed from either side of the throat. The procedure is performed in response to cases of repeated occurrence of acute tonsillitis
Tonsillitis
Tonsillitis is an inflammation of the tonsils most commonly caused by viral or bacterial infection. Symptoms of tonsillitis include sore throat and fever. While no treatment has been found to shorten the duration of viral tonsillitis, bacterial causes are treatable with antibiotics...
or adenoiditis
Adenoiditis
Adenoiditis is the inflammation of the adenoid tissue, usually caused by an infection. Adenoiditis is treated using medication or surgical intervention....
, obstructive sleep apnea
Obstructive sleep apnea
Obstructive sleep apnea or obstructive sleep apnea syndrome is the most common type of sleep apnea and is caused by obstruction of the upper airway. It is characterized by repetitive pauses in breathing during sleep, despite the effort to breathe, and is usually associated with a reduction in...
, nasal airway obstruction
Airway obstruction
Airway obstruction is a respiratory problem caused by increased resistance in the bronchioles that reduces the amount of air inhaled in each breath and the oxygen that reaches the pulmonary arteries...
, snoring
Snoring
Snoring is the vibration of respiratory structures and the resulting sound, due to obstructed air movement during breathing while sleeping. In some cases the sound may be soft, but in other cases, it can be loud and unpleasant...
, or peritonsillar abscess
Peritonsillar abscess
Peritonsillar abscess , also called a quinsy or abbreviated as PTA is a recognised complication of tonsillitis and consists of a collection of pus beside the tonsil .-Symptoms and signs:...
. For children, the adenoid
Adenoid
Adenoids are a mass of lymphoid tissue situated posterior to the nasal cavity, in the roof of the nasopharynx, where the nose blends into the throat....
s are removed at the same time, a procedure called adenoidectomy
Adenoidectomy
Adenoidectomy is the surgical removal of the adenoids. They may be removed for several reasons, including impaired breathing through the nose and chronic infections or earaches. The surgery is less common for adults. It is most often done on an outpatient basis under general anesthesia....
. This is not common for adults. Although tonsillectomy is being performed less frequently than in the 1950s, it remains one of the most common surgical procedures in children in the United States.
Indications
Tonsillectomy may be indicated when the patient:- Experiences recurrent infections of acute tonsillitisTonsillitisTonsillitis is an inflammation of the tonsils most commonly caused by viral or bacterial infection. Symptoms of tonsillitis include sore throat and fever. While no treatment has been found to shorten the duration of viral tonsillitis, bacterial causes are treatable with antibiotics...
. The number requiring tonsillectomy varies with the severity of the episodes. One case, even severe, is generally not enough for most surgeons to decide tonsillectomy is necessary. ParadiseJack ParadiseJack L. Paradise is a professor emeritus of pediatrics at University of Pittsburgh School of Medicine and a leading researcher of the placement of tympanostomy tubes in children with persistent otitis media.-Research:...
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." However according to the current guidelines (2000) of the American Academy of Otolaryngology & Head and Neck SurgeryAmerican Academy of OtolaryngologyThe American Academy of Otolaryngology - Head and Neck Surgery, originally started in the 1924, is the world's largest organization of over 13,000 specialist related to the area of ears, nose, and throat.- History :Reference...
(AAO-HNS), tonsillectomy is indicated if a patient contracts "Three or more attacks of sore throat per year despite adequate medical therapy." - Has chronicChronic (medicine)A chronic disease is a disease or other human health condition that is persistent or long-lasting in nature. The term chronic is usually applied when the course of the disease lasts for more than three months. Common chronic diseases include asthma, cancer, diabetes and HIV/AIDS.In medicine, the...
tonsillitisTonsillitisTonsillitis is an inflammation of the tonsils most commonly caused by viral or bacterial infection. Symptoms of tonsillitis include sore throat and fever. While no treatment has been found to shorten the duration of viral tonsillitis, bacterial causes are treatable with antibiotics...
, consisting of persistent, moderate-to-severe throat painPharyngitisPharyngitis is an inflammation of the throat or pharynx. In most cases it is quite painful, and is the most common cause of a sore throat.Like many types of inflammation, pharyngitis can be acute – characterized by a rapid onset and typically a relatively short course – or chronic....
. - Has multiple bouts of peritonsillar abscessPeritonsillar abscessPeritonsillar abscess , also called a quinsy or abbreviated as PTA is a recognised complication of tonsillitis and consists of a collection of pus beside the tonsil .-Symptoms and signs:...
. - Has sleep apneaSleep apneaSleep apnea is a sleep disorder characterized by abnormal pauses in breathing or instances of abnormally low breathing, during sleep. Each pause in breathing, called an apnea, can last from a few seconds to minutes, and may occur 5 to 30 times or more an hour. Similarly, each abnormally low...
(stopping or obstructing breathing at night due to enlarged tonsils or adenoids) - Has difficulty eating or swallowing due to enlarged tonsils (very unusual reason for tonsillectomy)
- Produces tonsillolithTonsillolithTonsilloliths, also known as a tonsil stones, are clusters of calcified material that form in the crevices of the tonsils. While they occur most commonly in the palatine tonsils, they may also occur in the lingual tonsils. Tonsilloliths have been recorded weighing from 300 mg to 42 g...
s (tonsil stones) in the back of their mouth. - Has abnormally large tonsils with crypts (Craters or impacts in the tonsils)
Controversy over indications
The American Academy of Otolaryngology & Head and Neck SurgeryAmerican Academy of Otolaryngology
The American Academy of Otolaryngology - Head and Neck Surgery, originally started in the 1924, is the world's largest organization of over 13,000 specialist related to the area of ears, nose, and throat.- History :Reference...
(AAO-HNS) stated that "In many cases, tonsillectomy may be a more effective treatment, and less costly, than prolonged or repeated treatments for an infected throat...For the past several years, the Academy has been developing clinical guidelines based on evidence and outcomes research, including ‘Quality of Life after Tonsillectomy,’ a January 2008 supplement to the journal Otolaryngology
Otolaryngology
Otolaryngology or ENT is the branch of medicine and surgery that specializes in the diagnosis and treatment of ear, nose, throat, and head and neck disorders....
—Head and Neck Surgery."
Morbidity and mortality
The morbidity rate associated with tonsillectomy is 2 to 4% due to post-operative bleeding; the mortality rateMortality rate
Mortality rate is a measure of the number of deaths in a population, scaled to the size of that population, per unit time...
is 1 in 15,000, due to bleeding, airway obstruction, or anesthesia
Anesthesia
Anesthesia, or anaesthesia , traditionally meant the condition of having sensation blocked or temporarily taken away...
.
Effectiveness
The effectiveness of the tonsillectomy has been questioned in a 2009 systematic reviewSystematic review
A systematic review is a literature review focused on a research question that tries to identify, appraise, select and synthesize all high quality research evidence relevant to that question. Systematic reviews of high-quality randomized controlled trials are crucial to evidence-based medicine...
of 7765 papers, published in the journal Otolaryngology—Head and Neck Surgery. The review found that it was most likely not effective all the time, but rather was modestly effective, and that "not a single paper reported that tonsillectomy is invariably effective in eliminating sore throats." Another systematic review of cases involving children found that there was only a short-term benefit: "A child who meets these strict criteria will probably suffer from 6 throat infections in the next two years. A child who has surgery now will probably suffer from 3 throat infections. In two years there will probably be no difference."
Post-operative care
A sore throat will persist for around two weeks after the operation. Most patients do not feel like swallowing anything during the first few days after surgery. Patients should try to get as much cold fluid down as possible, as it will help speed recovery. Very cold drinks will help bring down swelling. Ice cream, frozen yogurtFrozen yogurt
Frozen yogurt is a frozen dessert containing yogurt or other dairy products. It is slightly more tart than ice cream, as well as lower in fat...
Pudding
Pudding
Pudding most often refers to a dessert, but it can also be a savory dish.In the United States, pudding characteristically denotes a sweet milk-based dessert similar in consistency to egg-based custards, though it may also refer to other types such as bread and rice pudding.In the United Kingdom and...
s, Slushie
Slush (beverage)
A slush is a flavored frozen drink.There are a number of different kinds of slush drinks:* Frozen carbonated beverages, typified by the Slurpee or ICEE, are made by freezing a carbonated drink. These machines are complicated and expensive, and notably require a carbon dioxide supply...
s, Sorbet and popsicle
Popsicle
Popsicle is the most popular brand of ice pop in the United States and Canada. The first ice pop was created by accident in 1905 when 11-year-old Frank Epperson left a cup of soda on his porch in cold weather overnight. The next morning he went to go get the soda and it was frozen, so he put two...
s, on the other hand, are recommended. Large quantities of ice should be prepared in advance.
Pain following the procedure is significant and may include a hospital stay. Recovery can take from 10 up to 20 days, during which narcotic
Narcotic
The term narcotic originally referred medically to any psychoactive compound with any sleep-inducing properties. In the United States of America it has since become associated with opioids, commonly morphine and heroin and their derivatives, such as hydrocodone. The term is, today, imprecisely...
analgesic
Analgesic
An analgesic is any member of the group of drugs used to relieve pain . The word analgesic derives from Greek an- and algos ....
s are typically prescribed. Patients are encouraged to maintain diet of liquid and very soft foods for several days following surgery. Rough textured, acidic or spicy foods may be irritating and should be avoided. Proper hydration is very important during this time, since dehydration
Dehydration
In physiology and medicine, dehydration is defined as the excessive loss of body fluid. It is literally the removal of water from an object; however, in physiological terms, it entails a deficiency of fluid within an organism...
can increase throat pain, leading to a vicious circle
Positive feedback
Positive feedback is a process in which the effects of a small disturbance on a system include an increase in the magnitude of the perturbation. That is, A produces more of B which in turn produces more of A. In contrast, a system that responds to a perturbation in a way that reduces its effect is...
of poor fluid intake.
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% higher in adults. Approximately 3% of adult patients develop significant bleeding at this time. The bleeding might naturally stop quickly or else mild intervention (e.g., gargling cold water) could be needed (but ask the doctor before gargling because it might bruise the area of the skin that has been cauterized). Otherwise, a surgeon must repair the bleeding immediately by cauterization
Cauterization
The medical practice or technique of cauterization is the burning of part of a body to remove or close off a part of it in a process called cautery, which destroys some tissue, in an attempt to mitigate damage, remove an undesired growth, or minimize other potential medical harmful possibilities...
, which presents all the risks associated with emergency surgery (primarily the administration of anesthesia
Anesthesia
Anesthesia, or anaesthesia , traditionally meant the condition of having sensation blocked or temporarily taken away...
particularly on a patient whose stomach may not be empty).
Generally speaking, tonsils will be removed if a patient needs antibiotics to be prescribed six times a year for tonsilitis, and the general practitioner's recommendation is based on how the quality of life will be improved after the operation. Tonsillectomies can be performed while the patient is actually suffering from tonsillitis, however this increases the risk of bleeding.
In adults, often to avoid complications due to bleeding and to help recovery, some experts recommend (in two previous weeks to surgery and during the next one) intramuscular injections of phytomenadione (vitamin K) 10mg/ml, Cyanocobalamin (Vitamin B12) 2 mg, calcium folinate 0.9 mg . It is often prescribed as anti-inflammatory paracetamol 1000 mg. Other painkillers are not recommended because instead they extend the clotting time and they slow down wound healing. In the postoperative course swallowing becomes painful for several days and to avoid physical decay are available in pharmacies liquid dietary foods for special medical purposes indicated for the dietary management of patients at risk of malnutrition (200 ml, 1.5 kcal / ml). Please note that the antibiotic is also available in oral suspension (often prescribed Amoxicillin trihydrate equivalent to amoxicillin 875 mg, potassium clavulanate equivalent to clavulanic acid 125 mg).
There are high chances of Aphthous ulcer
Aphthous ulcer
An aphthous ulcer , also known as a canker sore, is a type of mouth ulcer which presents as a painful open sore inside the mouth or upper throat characterized by a break in the mucous membrane. Its cause is unknown, but they are not contagious...
, therefore it's good to be prepared to treat it.
Common causes, demographics
Infections requiring tonsillectomy are often a result of StreptococcusStreptococcus
Streptococcus is a genus of spherical Gram-positive bacteria belonging to the phylum Firmicutes and the lactic acid bacteria group. Cellular division occurs along a single axis in these bacteria, and thus they grow in chains or pairs, hence the name — from Greek στρεπτος streptos, meaning...
("strep throat
Strep throat
Streptococcal pharyngitis, streptococcal tonsillitis, or streptococcal sore throat is a type of pharyngitis caused by a group A streptococcal infection. It affects the pharynx including the tonsils and possibly the larynx. Common symptoms include fever, sore throat, and enlarged lymph nodes...
"), particularly Streptococcus pyogenes
Streptococcus pyogenes
Streptococcus pyogenes is a spherical, Gram-positive bacterium that is the cause of group A streptococcal infections. S. pyogenes displays streptococcal group A antigen on its cell wall. S...
; some may be due to other bacteria
Bacteria
Bacteria are a large domain of prokaryotic microorganisms. Typically a few micrometres in length, bacteria have a wide range of shapes, ranging from spheres to rods and spirals...
, such as Streptococcus viridans
Streptococcus viridans
Viridans Streptococcus is a pseudotaxonomic non-Linnaenan term for a large group of commensal streptococcal bacteria that are either α-hemolytic, producing a green coloration on blood agar plates , or nonhemolytic...
, Staphylococcus aureus
Staphylococcus aureus
Staphylococcus aureus is a facultative anaerobic Gram-positive coccal bacterium. It is frequently found as part of the normal skin flora on the skin and nasal passages. It is estimated that 20% of the human population are long-term carriers of S. aureus. S. aureus is the most common species of...
, and Haemophilus influenzae
Haemophilus influenzae
Haemophilus influenzae, formerly called Pfeiffer's bacillus or Bacillus influenzae, Gram-negative, rod-shaped bacterium first described in 1892 by Richard Pfeiffer during an influenza pandemic. A member of the Pasteurellaceae family, it is generally aerobic, but can grow as a facultative anaerobe. H...
. However, the etiology
Etiology
Etiology is the study of causation, or origination. The word is derived from the Greek , aitiologia, "giving a reason for" ....
of the condition is largely irrelevant in determining whether tonsillectomy is required.
Most tonsillectomies are performed on children, although many are also performed on teenagers and adults; in the United States, it is the most common major surgical procedure performed on children. The number of tonsillectomies in the United States has dropped significantly from over a million cases per year in the 1950s to approximately 600,000 in the late 1990s. This has been due in part to more stringent guidelines for tonsillectomy and adenoidectomy (see tonsillitis
Tonsillitis
Tonsillitis is an inflammation of the tonsils most commonly caused by viral or bacterial infection. Symptoms of tonsillitis include sore throat and fever. While no treatment has been found to shorten the duration of viral tonsillitis, bacterial causes are treatable with antibiotics...
and adenoid
Adenoid
Adenoids are a mass of lymphoid tissue situated posterior to the nasal cavity, in the roof of the nasopharynx, where the nose blends into the throat....
). Still, debate about the usefulness of tonsillectomies continues. Enlarged tonsils are removed more often among adults and children for sleep apnea (airway obstruction while sleeping), snoring, and upper airway obstruction. Children who have sleep apnea can do poorly in school, are tired during the day, may be bedwetters
Bedwetting
Nocturnal enuresis, commonly called bedwetting, is involuntary urination while asleep after the age at which bladder control usually occurs. Nocturnal enuresis is considered primary when a child has not yet had a prolonged period of being dry...
beyond what is normal, and have some links to ADHD.
Tonsillectomy in adults is more painful than in children, although each patient will have a different experience. Various procedures are available to remove tonsils, each with different advantages and disadvantages. Children and teenagers sometimes exhibit a noticeable change in voice after the operation.
Surgical procedure
The generally accepted procedure for tonsillectomy involves separating and removing the tonsils from the subcapsular plane – a fasciaFascia
A fascia is a layer of fibrous tissue that permeates the human body. A fascia is a connective tissue that surrounds muscles, groups of muscles, blood vessels, and nerves, binding those structures together in much the same manner as plastic wrap can be used to hold the contents of sandwiches...
of tissue that surrounds the tonsils. Removal is typically achieved using a scalpel and blunt dissection or with electrocautery, although harmonic scalpel
Harmonic scalpel
The Harmonic scalpel is a cutting instrument used during surgical procedures to simultaneously cut and coagulate tissue.The Harmonic brand is manufactured and distributed by Ethicon Endo-Surgery a subsidiary of Johnson & Johnson....
s or lasers have also been used. Bleeding is stopped with electrocautery, ligation of sutures, and the topical use of thrombin
Thrombin
Thrombin is a "trypsin-like" serine protease protein that in humans is encoded by the F2 gene. Prothrombin is proteolytically cleaved to form thrombin in the first step of the coagulation cascade, which ultimately results in the stemming of blood loss...
, a protein that induces blood clotting.
The procedure is carried out with the patient lying flat on their backs, with the shoulders elevated on a small pillow so that the neck is hyperextended – the so-called 'Rose' position. A mouth gag is used to prop the mouth open; if an adenoidectomy
Adenoidectomy
Adenoidectomy is the surgical removal of the adenoids. They may be removed for several reasons, including impaired breathing through the nose and chronic infections or earaches. The surgery is less common for adults. It is most often done on an outpatient basis under general anesthesia....
is also being performed, the adenoids are first removed with a curette
Curette
A curette is a surgical instrument designed for scraping biological tissue or debris in a biopsy, excision, or cleaning procedure. In form, the curette is a small hand tool, often similar in shape to a stylus; at the tip of the curette is a small scoop, hook, or gouge...
; the nasopharynx
Nasopharynx
The nasopharynx is the uppermost part of the pharynx. It extends from the base of the skull to the upper surface of the soft palate; it differs from the oral and laryngeal parts of the pharynx in that its cavity always remains patent .-Lateral:On its lateral wall is the pharyngeal ostium of the...
is then packed with sterile gauze
Gauze
Gauze is a thin, translucent fabric with a loose open weave.-Uses and types:Gauze was originally made of silk and was used for clothing. It is now used for many different things, including gauze sponges for medical purposes. When used as a medical dressing, gauze is generally made of cotton...
. A tonsil is removed by holding it by the upper part, pulling it slightly medially, and making a cut over the anterior faucial pillar. After the tonsil is removed from its position, a snare can be used to make a small cut on the lower portion prior to removal of the tonsil. The use of electrocautery minimizes the blood loss.
Other methods
The scalpelScalpel
A scalpel, or lancet, is a small and extremely sharp bladed instrument used for surgery, anatomical dissection, and various arts and crafts . Scalpels may be single-use disposable or re-usable. Re-usable scalpels can have attached, resharpenable blades or, more commonly, non-attached, replaceable...
is the preferred surgical instrument of many ear, nose, and throat specialists
Otolaryngology
Otolaryngology or ENT is the branch of medicine and surgery that specializes in the diagnosis and treatment of ear, nose, throat, and head and neck disorders....
. However, there are other procedures available – the choice may be dictated by the extent of the procedure (complete tonsil removal versus partial tonsillectomy) and other considerations such as pain
Pain
Pain is an unpleasant sensation often caused by intense or damaging stimuli such as stubbing a toe, burning a finger, putting iodine on a cut, and bumping the "funny bone."...
and post-operative bleeding
Bleeding
Bleeding, technically known as hemorrhaging or haemorrhaging is the loss of blood or blood escape from the circulatory system...
. A quick review of each procedure follows:
- Dissection and snare method: Removal of the tonsils by use of a forceps and scissors with a wire loop called a 'snare' was formerly the most common method practiced by otolaryngologists, but has been largely replaced in favor of other techniques. The procedure requires the patientPatientA patient is any recipient of healthcare services. The patient is most often ill or injured and in need of treatment by a physician, advanced practice registered nurse, veterinarian, or other health care provider....
to undergo general anesthesia; the tonsils are completely removed and the remaining tissue surface is cauterized. The patientPatientA patient is any recipient of healthcare services. The patient is most often ill or injured and in need of treatment by a physician, advanced practice registered nurse, veterinarian, or other health care provider....
will leave with minimal post-operative bleedingBleedingBleeding, technically known as hemorrhaging or haemorrhaging is the loss of blood or blood escape from the circulatory system...
. - Electrocautery: Electrocautery uses electrical energy to separate the tonsillar tissue and assists in reducing bloodBloodBlood is a specialized bodily fluid in animals that delivers necessary substances such as nutrients and oxygen to the cells and transports metabolic waste products away from those same cells....
loss through cauterizationCauterizationThe medical practice or technique of cauterization is the burning of part of a body to remove or close off a part of it in a process called cautery, which destroys some tissue, in an attempt to mitigate damage, remove an undesired growth, or minimize other potential medical harmful possibilities...
. Research has shown that the heat of electrocautery (400°CCelsiusCelsius is a scale and unit of measurement for temperature. It is named after the Swedish astronomer Anders Celsius , who developed a similar temperature scale two years before his death...
) may result in thermal injury to surrounding tissueCell (biology)The cell is the basic structural and functional unit of all known living organisms. It is the smallest unit of life that is classified as a living thing, and is often called the building block of life. The Alberts text discusses how the "cellular building blocks" move to shape developing embryos....
. This may result in more discomfort during the postoperative period. - Harmonic scalpelHarmonic scalpelThe Harmonic scalpel is a cutting instrument used during surgical procedures to simultaneously cut and coagulate tissue.The Harmonic brand is manufactured and distributed by Ethicon Endo-Surgery a subsidiary of Johnson & Johnson....
: This medical deviceMedical deviceA medical device is a product which is used for medical purposes in patients, in diagnosis, therapy or surgery . Whereas medicinal products achieve their principal action by pharmacological, metabolic or immunological means. Medical devices act by other means like physical, mechanical, thermal,...
uses ultrasonicUltrasoundUltrasound is cyclic sound pressure with a frequency greater than the upper limit of human hearing. Ultrasound is thus not separated from "normal" sound based on differences in physical properties, only the fact that humans cannot hear it. Although this limit varies from person to person, it is...
energy to vibrateVibrationVibration refers to mechanical oscillations about an equilibrium point. The oscillations may be periodic such as the motion of a pendulum or random such as the movement of a tire on a gravel road.Vibration is occasionally "desirable"...
its blade at 55kHz. Invisible to the naked eyeHuman eyeThe human eye is an organ which reacts to light for several purposes. As a conscious sense organ, the eye allows vision. Rod and cone cells in the retina allow conscious light perception and vision including color differentiation and the perception of depth...
, the vibration transfers energy to the tissue, providing simultaneous cutting and coagulationCoagulationCoagulation is a complex process by which blood forms clots. It is an important part of hemostasis, the cessation of blood loss from a damaged vessel, wherein a damaged blood vessel wall is covered by a platelet and fibrin-containing clot to stop bleeding and begin repair of the damaged vessel...
. The temperature of the surrounding tissue reaches 80°C. Proponents of this procedure assert that the end result is precise cutting with minimal thermal damage. - Radiofrequency ablation: Monopolar radiofrequency thermal ablation transfers radiofrequency energy to the tonsil tissue through probes inserted in the tonsil. The procedure can be performed in an office (outpatient) setting under light sedation or local anesthesiaLocal anesthesiaLocal anesthesia is any technique to induce the absence of sensation in part of the body, generally for the aim of inducing local analgesia, that is, local insensitivity to pain, although other local senses may be affected as well. It allows patients to undergo surgical and dental procedures with...
. After the treatment is performed, scarring occurs within the tonsil causing it to decrease in size over a period of several weeks. The treatment can be performed several times. The advantages of this technique are minimal discomfort, ease of operations, and immediate return to work or school. Tonsillar tissue remains after the procedure but is less prominent. This procedure is recommended for treating enlarged tonsils and not chronic or recurrent tonsillitisTonsillitisTonsillitis is an inflammation of the tonsils most commonly caused by viral or bacterial infection. Symptoms of tonsillitis include sore throat and fever. While no treatment has been found to shorten the duration of viral tonsillitis, bacterial causes are treatable with antibiotics...
. - Thermal Welding: A new technology which uses pure thermal energyThermal energyThermal energy is the part of the total internal energy of a thermodynamic system or sample of matter that results in the system's temperature....
to seal and divide the tissue. The absence of thermal spread means that the temperature of surrounding tissue is only 2-3 °C higher than normal body temperature. Clinical papers show patients with minimal post-operative pain (no requirement for narcotic pain-killers), zero edema (swelling) plus almost no incidence of bleeding. Hospitals in the US are advertising this procedure as "Painless Tonsillectomy". Also known as Tissue Welding. - Carbon dioxide laser: LaserLaserA laser is a device that emits light through a process of optical amplification based on the stimulated emission of photons. The term "laser" originated as an acronym for Light Amplification by Stimulated Emission of Radiation...
tonsil ablation (LTA) finds the otolaryngologist employing a hand-held CO2 or KTP laser to vaporize and remove tonsil tissue. This technique reduces tonsil volume and eliminates recesses in the tonsils that collect chronic and recurrent infections. This procedure is recommended for chronic recurrent tonsillitis, chronic sore throats, severe halitosisHalitosisHalitosis is a term used to describe noticeably unpleasant odors exhaled in breathing. Halitosis is estimated to be the third most frequent reason for seeking dental aid, following tooth decay and periodontal disease.- General :...
, or airway obstruction caused by enlarged tonsils. The LTA is performed in 15 to 20 minuteMinuteA minute is a unit of measurement of time or of angle. The minute is a unit of time equal to 1/60th of an hour or 60 seconds. In the UTC time scale, a minute on rare occasions has 59 or 61 seconds; see leap second. The minute is not an SI unit; however, it is accepted for use with SI units...
s in an office setting under local anesthesia. The patient leaves the office with minimal discomfort and returns to schoolSchoolA school is an institution designed for the teaching of students under the direction of teachers. Most countries have systems of formal education, which is commonly compulsory. In these systems, students progress through a series of schools...
or work the next day. Post-tonsillectomy bleeding may occur in 2-5% of patients. Previous research studies state that laser technology provides significantly less pain during the post-operative recovery of childChildBiologically, a child is generally a human between the stages of birth and puberty. Some vernacular definitions of a child include the fetus, as being an unborn child. The legal definition of "child" generally refers to a minor, otherwise known as a person younger than the age of majority...
ren, resulting in less sleepSleepSleep is a naturally recurring state characterized by reduced or absent consciousness, relatively suspended sensory activity, and inactivity of nearly all voluntary muscles. It is distinguished from quiet wakefulness by a decreased ability to react to stimuli, and is more easily reversible than...
disturbance, decreased morbidity, and less need for medicationMedicationA pharmaceutical drug, also referred to as medicine, medication or medicament, can be loosely defined as any chemical substance intended for use in the medical diagnosis, cure, treatment, or prevention of disease.- Classification :...
s. On the other hand, some believe that children are averse to outpatient procedures without sedation.
- Microdebrider: The microdebrider is a powered rotary shaving device with continuous suction often used during sinusParanasal sinusParanasal sinuses are a group of four paired air-filled spaces that surround the nasal cavity , above and between the eyes , and behind the ethmoids...
surgery. It is made up of a cannula or tube, connected to a hand piece, which in turn is connected to a motor with foot control and a suction device. The endoscopic microdebrider is used in performing a partial tonsillectomy, by partially shaving the tonsils. This procedure entails eliminating the obstructive portion of the tonsil while preserving the tonsillar capsule. A natural biologic dressing is left in place over the pharyngeal musclesPharyngeal musclesThe pharyngeal muscles are a group of muscles that act upon the pharynx.They include:* Inferior constrictor muscle* Middle constrictor muscle* Superior constrictor muscle* Stylopharyngeus muscle* Salpingopharyngeus muscle* Palatopharyngeus muscle...
, preventing injury, inflammation, and infection. The procedure results in less post-operative pain, a more rapid recovery, and perhaps fewer delayed complications. However, the partial tonsillectomy is suggested for enlarged tonsils – not those that incur repeated infections.
- Radiofrequency Ablation (see Coblation tonsillectomy): This procedure produces an ionized salineSaline (medicine)In medicine, saline is a general term referring to a sterile solution of sodium chloride in water but is only sterile when it is to be placed intravenously, otherwise, a saline solution is a salt water solution...
layer that disrupts molecular bonds without using heat. As the energy is transferred to the tissue, ionic dissociation occurs. This mechanism can be used to remove all or only part of the tonsil. It is done under general anesthesia in the operating room and can be used for enlarged tonsils and chronic or recurrent infections. This causes removal of tissue with a thermal effect of 45-85 °C. It has been claimed that this technique results in less pain, faster healing, and less post operative care. However, review of 21 studies gives conflicting results about levels of pain, and its comparative safety has yet to be confirmed. This technique has been criticized for a higher than expected rate of bleeding presumably due to the low temperature which may be insufficient to seal the divided blood vesselBlood vesselThe blood vessels are the part of the circulatory system that transports blood throughout the body. There are three major types of blood vessels: the arteries, which carry the blood away from the heart; the capillaries, which enable the actual exchange of water and chemicals between the blood and...
s.
History
The tonsillectomy has been practiced for 3,000 years, with varying popularity over the centuries. The procedure is first mentioned in "Hindu medicine" about 1000 BC; roughly a millennium later the RomanAncient Rome
Ancient Rome was a thriving civilization that grew on the Italian Peninsula as early as the 8th century BC. Located along the Mediterranean Sea and centered on the city of Rome, it expanded to one of the largest empires in the ancient world....
aristocrat Aulus Cornelius Celsus
Aulus Cornelius Celsus
Aulus Cornelius Celsus was a Roman encyclopedist, known for his extant medical work, De Medicina, which is believed to be the only surviving section of a much larger encyclopedia. The De Medicina is a primary source on diet, pharmacy, surgery and related fields, and it is one of the best sources...
(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 prior to being cut out. Galen
Galen
Aelius Galenus or Claudius Galenus , better known as Galen of Pergamon , was a prominent Roman physician, surgeon and philosopher...
(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
Aëtius Amidenus
Aëtius of Amida was a Byzantine physician and medical writer, particularly distinguished by the extent of his erudition. Historians are not agreed about his exact date...
(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". 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.
The Middle Ages
Middle Ages
The Middle Ages is a periodization of European history from the 5th century to the 15th century. The Middle Ages follows the fall of the Western Roman Empire in 476 and precedes the Early Modern Era. It is the middle period of a three-period division of Western history: Classic, Medieval and Modern...
saw tonsillectomy fall into disfavor; Ambroise Pare
Ambroise Paré
Ambroise Paré was a French surgeon. He was the great official royal surgeon for kings Henry II, Francis II, Charles IX and Henry III and is considered as one of the fathers of surgery and modern forensic pathology. He was a leader in surgical techniques and battlefield medicine, especially the...
(1509) wrote it to be "a bad operation" and suggested a procedure that involved gradual strangulation with a ligature
Ligature (medicine)
In surgery or medical procedure, a ligature consists of a piece of thread tied around an anatomical structure, usually a blood vessel or another hollow structure to shut it off. With a blood vessel the surgeon will clamp the vessel perpendicular to the axis of the artery or vein with a hemostat,...
. This method was not popular with the patients, however, due to the immense pain it caused, and the infection that usually followed. Scottish physician Peter Lowe
Peter Lowe (surgeon)
Peter Lowe was a surgeon and founder of the institution now known as the Royal College of Physicians and Surgeons of Glasgow.-Biography:Lowe was born in Scotland around 1550 and left in 1565 to study medicine on the Continent...
in 1600 summarized the three methods in use at the time, including the snare, the ligature, and the excision. At the time, the function of the tonsils was thought to be to absorb 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
Larynx
The larynx , commonly called the voice box, is an organ in the neck of amphibians, reptiles and mammals involved in breathing, sound production, and protecting the trachea against food aspiration. It manipulates pitch and volume...
, resulting in hoarseness. For this reason, physicians like Dionis (1672) and Lorenz Heister
Lorenz Heister
Lorenz Heister was a German anatomist, surgeon and botanist born in Frankfurt am Main....
censured the procedure.
In 1828, physician Philip Syng Physick
Philip Syng Physick
Philip Syng Physick was an American physician born in Philadelphia.-Biography:Physick graduated from the University of Pennsylvania in 1785, then began the study of medicine under Dr. Adam Kuhn, and continued it in London under Dr. John Hunter, becoming, on January 1, 1790, house surgeon of St....
modified an existing instrument originally designed by Benjamin Bell
Benjamin Bell
Benjamin Bell of Hunthill FRSE FRCSE is considered by many to be the first Scottish scientific surgeon. He is commonly described as the 'father of the Edinburgh school of surgery', or the first of the Edinburgh scientific surgeons,,...
for removing the uvula
Uvula
The palatine uvula, usually referred to as simply the uvula , is the conic projection from the posterior edge of the middle of the soft palate, composed of connective tissue containing a number of racemose glands, and some muscular fibers .-Function in language:The uvula plays a role in the...
; the instrument, known as the tonsil guillotine (and later as a tonsillotome), became the standard instrument for tonsil removal for over 80 years. 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.
Tonsillectomy and weight gain in children
A recent study states that tonsillectomy increases the risk of being overweight or obese in the years following surgery by as much as 61% in cases where tonsillectomy without adenoidectomyAdenoidectomy
Adenoidectomy is the surgical removal of the adenoids. They may be removed for several reasons, including impaired breathing through the nose and chronic infections or earaches. The surgery is less common for adults. It is most often done on an outpatient basis under general anesthesia....
is performed, and up to 136% in cases of where tonsillectomy with adenoidectomy was performed.
Image gallery
Image:Tonsillitis.jpg|Throat with tonsillitis
Tonsillitis
Tonsillitis is an inflammation of the tonsils most commonly caused by viral or bacterial infection. Symptoms of tonsillitis include sore throat and fever. While no treatment has been found to shorten the duration of viral tonsillitis, bacterial causes are treatable with antibiotics...
.
Image:Tonsillectomy tonsils.JPEG|Two removed tonsil
Tonsil
Palatine tonsils, occasionally called the faucial tonsils, are the tonsils that can be seen on the left and right sides at the back of the throat....
s.
Image:Tonsilectomia.JPG|Throat 1 day after a tonsillectomy.
Image:Uvula without tonsils.jpg|Throat some days after a tonsillectomy.
See also
- TonsilTonsilPalatine tonsils, occasionally called the faucial tonsils, are the tonsils that can be seen on the left and right sides at the back of the throat....
- AdenoidAdenoidAdenoids are a mass of lymphoid tissue situated posterior to the nasal cavity, in the roof of the nasopharynx, where the nose blends into the throat....
- AdenoidectomyAdenoidectomyAdenoidectomy is the surgical removal of the adenoids. They may be removed for several reasons, including impaired breathing through the nose and chronic infections or earaches. The surgery is less common for adults. It is most often done on an outpatient basis under general anesthesia....
- Tonsilitis
- PharyngitisPharyngitisPharyngitis is an inflammation of the throat or pharynx. In most cases it is quite painful, and is the most common cause of a sore throat.Like many types of inflammation, pharyngitis can be acute – characterized by a rapid onset and typically a relatively short course – or chronic....
- Tonsillolith(tonsil stones)TonsillolithTonsilloliths, also known as a tonsil stones, are clusters of calcified material that form in the crevices of the tonsils. While they occur most commonly in the palatine tonsils, they may also occur in the lingual tonsils. Tonsilloliths have been recorded weighing from 300 mg to 42 g...