Tonsillectomy: Surgical Removal of the Tonsils

Tonsillectomy is the removal of the palatine tonsils (Latin: tonsillae palatinae).

Indications (areas of application)

  • Recurrent (acute) tonsillitis (RAT).
  • Peritonsillar abscess (PTA) – spread of inflammation to the connective tissue between tonsil (tonsils) and M. constrictor pharyngis with subsequent abscessation (accumulation of pus).
  • Severely enlarged palatine tonsils in children.
  • Multiple antibiotic allergies that make inflammation therapy impossible
  • PFAPA syndrome (PFAPA stands for: periodic fever, aphthous stomatitis, pharyngitis, cervical adenitis) – rare disease with typical, quite uniformly proceeding symptoms: febrile episodes. usually manifested before the age of five; these begin very regularly every 3-8 weeks with abruptly rising fever > 39 °C, which spontaneously recedes after 3-6 days.
  • Tonsillar hyperplasia (non-physiological enlargement (hyperplasia) of the palatine or pharyngeal tonsils) with obstructive sleep apnea (breathing pauses during sleep caused by obstruction of the airways).

Tonsillotomy indication for recurrent tonsillitis in children and adolescents:

  • Tonsil size greater than Brodsky grade 1 (narrowing of oropharyngeal diameter by ≥ 25%); and
  • Number of episodes in the previous year (3-5 = possible option, ≥ 6 = therapeutic option).

Notice:

  • Tonsillectomy should not be performed in children under 4-6 years of age, if possible, so as not to affect the development of the immune system.
  • Tonsillotomy (partial removal of the tonsils) should be favored in children younger than 6 years.

Note: There is a second opinion claim for operations on the palatine and/or pharyngeal tonsils (tonsillectomies, tonsillotomies).

Before surgery

Tonsillectomy is considered a standard procedure in otolaryngology, with relatively few complications. No food or liquid intake is allowed before the procedure, as the surgery is performed under general anesthesia.

The surgical procedure

The following surgical procedures are available:

  • Tonsillotomy (TT) – surgical removal of the palatine tonsils.
  • Subtotal (“not complete”)/intracapsular (“inside the capsule”)/partial (“partial”) tonsillectomy (SIPT).

The operation is performed mainly in children. For this purpose, children receive a general anesthesia, in adults, the operation can also be performed under local anesthesia.

After the operation

Once the surgery is completed, the patient should avoid irritating or hard foods, as eating them can be accompanied by severe pain. Foods that should be avoided more include tomatoes, applesauce, pineapple, and canned fruits. However, despite severe pain, regular ingestion of food is absolutely necessary to allow the crusting to scrape off and healing to begin more quickly.

Possible complications

  • Postoperative bleeding (about 5%) – especially on the day of surgery and on the 6th/7th day after surgery, when the eschar is shed; this complication is very common at about five percent, so careful monitoring is necessary for children who have undergone surgery. Note: ENT physicians say, based on their experience, that post-operative bleeding after tonsillectomy occurs preferentially at night.
    • Patients who showed signs and symptoms of infections in the 2 weeks before surgery had disproportionately statistically highly significant postoperative bleeding.CONCLUSION: If preoperative infections are present, postpone surgery; if required, use antibiotics during induction of anesthesia and postoperatively.
    • Caution. Most NSAIDs (nonsteroidal anti-inflammatory drugs; group of anti-inflammatory pain medications) appear to increase postoperative bleeding risk, according to a Cochrane review. Furthermore, perioperative administration of systemic steroids (which reduces nausea and vomiting) in children leads to an increase in the incidence of major bleeding after tonsillectomy.
    • Postoperative administration of ibuprofen is not associated with an increased risk of bleeding in pediatric patients; however, if postoperative bleeding does occur, hemorrhages are more severe (approximately threefold increased rate of major bleeding requiring transfusion).
    • Comparison of acetaminophen with ibuprofen (study of 700 children, mean age 5 years): hemorrhages requiring surgery affected 2.9% of children in the ibuprofen group and 1.2% of children in the acetaminophen group; failure to demonstrate noninferiority of ibuprofen.
  • Pain, especially radiating into the ear – a concomitant of tonsillectomy is definitely pain, which relatively often requires analgesic treatment administration of analgesics). However, it should be noted that under no circumstances should acetylsalicylic acid (ASA) or similar be used to relieve pain in children, as there is a risk of Reye’s syndrome. Reye syndrome is a rare clinical picture, which is associated with the development of a fatty liver and brain damage and occurs mainly before the age of nine.
  • Loss of appetite – especially children do not allow food intake after surgery due to pain, so that it can come as a concomitant dehydration (lack of fluid) and postoperative weight loss.
  • Infections (possibly also fever).

Other notes

  • A US study of complications after tonsillectomy in adults found a 0.03% mortality (death) rate in the first month after surgery, a 1.2% complication rate, and 3.2% of cases required reoperation (a repeat procedure).
  • Obese children gain more weight after adenotonsillectomy (adenotomy + tonsillectomy/ tonsillectomy; T + A). Causes are probably children who have been cured of obstructive sleep apnea (OSA) by surgery, are less hyperactive during the day, ie, move less and, in addition, their nocturnal work of breathing is reduced, which reduces calorie consumption during sleep.
  • Oropharyngeal ambulatory surgical procedures (oral and pharyngeal) combined with septoplasty (nasal septum surgery) did not result in a significant difference in the incidence of unplanned readmissions or rebleeding, except in cases where tonsillectomy had been combined with septoplasty, here there was a small percentage increase in bleeding.
  • The report of the Institute for Quality and Efficiency in Health Care (IQWiG) certifies the tonsillotomy (tonsillectomy) postoperatively short-term advantages compared to tonsillectomy: “Within two weeks after the procedure, there was an indication for or an indication of a lower harm of tonsillotomy with regard to pain and swallowing and sleep disturbances.”
  • Children who had a tonsillotomy (palatine tonsillectomy) or adenotomy (pharyngeal tonsillectomy) before the age of 10 were more likely to develop a range of infections (2-3 times more likely to develop respiratory diseases) and allergic diseases later in life.An observational study of over 1,000. 000 participants from Denmark confirms this finding: by age 30, those who underwent surgery developed a threefold increased risk of upper respiratory disease (RR 2.72); Number Needed to Harm (NNH) was 5, meaning only five tonsillectomies are required for additional disease to develop.