Tonsillectomy (Tonsillotomy)

Tonsillotomy is a surgical therapeutic procedure in otolaryngology to reduce the size of the palatine tonsils (partial removal of the palatine tonsils). This is used primarily in children, for example, to alleviate or eliminate the symptoms present in childhood sleep apnea (nocturnal breathing problems that can lead to various symptoms such as daytime sleepiness or headaches). It is critical to accurately differentiate tonsillotomy from tonsillectomy. Unlike tonsillectomy, tonsillotomy does not involve the removal of the entire palatine tonsil, leaving a residual function of the tonsillar tissue. This makes it possible, in the case of a significant enlargement of the tonsils (palatine tonsil), to reduce the tissue structure in order to prevent obstructions in breathing and swallowing. When using this surgical procedure, it is important to remember that the tonsils have an important function in immune defense, so a recommendation for surgical intervention requires a defined indication (indication for the use of the therapy). However, the immune function of the tonsils decreases with age. The use of this surgical procedure is usually performed in children between the ages of three and six. Infantile sleep apnea

Approximately one in one hundred children suffers from obstructive sleep apnea syndrome (obstruction of exhalation), which in children is usually due to an enlargement of the tonsils. However, additional factors such as the presence of obesity can complicate the symptomatology. Symptoms of childhood sleep apnea:

  • Sleep apnea (nocturnal snoring with pauses in breathing) – as the main symptom and at the same time the cause of many other symptoms, snoring with pauses in breathing is often the first way to identify infantile sleep apnea.
  • Mouth breathing – normally the majority of breathing occurs through the nose both during the day and at night. However, if there is an enlargement of the tonsils, nasal breathing becomes much more difficult, so affected children breathe through the mouth.
  • Increased night sweats
  • Abnormal posture during sleep with reclination of the head (putting the head in the neck).
  • Enuresis or bedwetting (enuresis) – via a mechanism that is not yet clearly understood, there is also an increased risk of so-called bedwetting in the presence of tonsillar hyperplasia (tonsil enlargement).
  • Restless sleep – due to breathing pauses, sleep is generally less restful. The increased amount of carbon dioxide in the arterial blood leads to increased respiratory drive, so there is a stress response in the body.
  • Cephalgia (headache)
  • Daytime sleepiness
  • Pulmonary hypertension – if adequate treatment of infantile sleep apnea does not occur over a long period of time, this can subsequently lead to the occurrence of an increase in blood pressure in the pulmonary circulation. If this increase in blood pressure in the pulmonary circulation is also not recognized, this can lead to cor pulmonale. Cor pulmonale is a functional impairment of the heart. Due to the pulmonary hypertension, there is a heavy load on the right heart. This functional restriction can be accompanied in the further course with an insufficiency (massive loss of power) of the heart.
  • School problems due to the lack of sleep at night.

Indications (areas of application)

  • Hyperplasia of tonsillar tissue (enlarged palatine tonsils) – regardless of whether the present hyperplasia (increased growth of tissue) leads to infantile sleep apnea or increased mouth breathing, the indication for surgical intervention is nevertheless given clinical symptoms.
  • Chronic tonsillitis (tonsillitis).
  • Recurrent acute tonsillitis
  • Peritonsillar abscess (PTA) – spread of inflammation to the connective tissue between the tonsil (tonsils) and the constrictor pharyngis muscle with subsequent abscessation (accumulation of pus).
  • Multiple antibiotic allergies present, making inflammation therapy impossible.
  • PFAPA syndrome (PFAPA stands for: periodic fever, aphthous stomatitis, pharyngitis, cervical adenitis) – rare disease with typical, fairly uniform course of symptoms: febrile episodes.usually manifest 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.

Contraindications

  • Chronic tonsillitis (tonsillitis) – if chronic tonsillitis is present, laser tonsillotomy is not indicated because only parts of the overall diseased organ can be removed. This has the consequence that the focus of the disease would not be fought and thus left.

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

Before surgery

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

The surgical procedures

  • Radiofrequency-induced thermotherapy (RFITT) – this surgical procedure for performing tonsillotomy, which has been used since 2000, is a surgical method in which a generated alternating current with high frequency is transmitted through special probes to the tissue to be removed. Depending on the mode selected, the surgeon can perform tissue incision or coagulation of the tissue. The advantage of coagulation over the conventional scalpel incision technique is the simultaneous stopping of bleeding by occluding small blood vessels. With the help of this procedure, it is possible to heat the tissue to approximately 70 °C and make a coagulation incision as needed. The consequence of this coagulation is the shrinkage of the tissue. Depending on the chosen method of application, the volume of the tonsils can be reduced by up to about 75% by intratonsillar application in terms of shrinkage. If the direct incision mode is selected for implementation instead of coagulation, the result of tonsillotomy is comparable.
  • Coblation – this method of performing tonsillotomy is based on the use of special disposable probes through which bipolar radiofrequency energy can be applied to the tissue. The energy is used for partial removal of the tonsils, and in parallel with the removal, the surgical area is flushed with saline solution. However, the targeted administration of saline into the surgical area does not serve to improve the surgeon’s vision, but rather provides the basis for the generation of a plasma field in which the saline serves as a conductive medium. The plasma field can break cell contacts, resulting in molecular disruption of the target tissue. In contrast to radiofrequency-induced thermotherapy, the temperature of the tissue is only raised to approximately 50 °C. The temperature of the tissue is also increased by the plasma field. Because of this, coblation is also a gentler procedure for tonsillotomy. Furthermore, the use of this surgical method enables the performance of tonsillectomy and tonsillotomy. The choice is based on the characteristic of this surgical method, as the surgeon can choose to perform a complete tonsillectomy extracapsularly or only intracapsularly tonsillotomy.
  • Argon plasma coagulation – in addition to the methods presented so far, there is the additional option of using argon plasma coagulation. The reason for using this method is based on the improved blood coagulation properties of argon plasma coagulation. When using this coagulation method, a monopolar high-frequency current is transmitted into the tonsil tissue with the help of the tip of a special applicator. The advantage of this method is that the energy is conducted via ionized argon gas, so that the high-frequency current can be transferred to the tonsillar tissue without contact. Compared with other surgical methods, the temperature reached in the tonsil tissue is very high, at around 100 °C. This means that the high-frequency current can be transmitted to the tonsil tissue without contact. However, the penetration depth during the surgical procedure can be classified as low, at about two millimeters. In addition, this variant of tonsillotomy has the advantage that, as a result of the comparatively simple handling, a significant reduction in operating time can be achieved and, in addition to this, intraoperative blood loss is minimized. Compared to the implementation of a tonsillectomy, no significant difference can be seen in terms of postoperative pain.
  • Laser surgery – in the field of tonsillotomy, the use of various lasers is possible, with a division into contact and non-contact methods. The most commonly used laser in tonsillotomy is the carbon dioxide laser(CO2 laser). Using the carbon dioxide laser, hyperplastic tonsillar tissue can be removed without major bleeding with approximately 15 to 20 watts of power. It has been shown in clinical studies that no significant complications would occur in several thousand surgeries. When using this laser, patients are fed completely orally from the day of surgery. To reduce the risk of infection, antibiotics with penicillin G are administered during surgery. The average inpatient stay after successful surgery was less than three days.

After surgery

Once the procedure 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 – especially on the day of surgery and on the 6th/7th day after surgery, when the eschar is shed; this complication is very common, occurring at about five percent, so careful monitoring is necessary for children who have undergone surgery.
  • Pain, especially radiating into the ear – a concomitant of tonsillectomy is definitely pain, which relatively often requires analgesic treatment administration of painkillers). 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 it may be accompanied by postoperative weight loss.
  • Infections

Other notes

  • The report of the Institute for Quality and Efficiency in Health Care (IQWiG) attests to short-term benefits of tonsillotomy postoperatively compared with tonsillectomy: “Within two weeks after the procedure, there was evidence for or evidence of less harm from tonsillotomy with regard to pain and swallowing and sleep disturbances.”
  • After tonsillotomy, recurrent tonsillitis (recurrence of tonsillitis) and ENT infections are still possible.
  • In 2018, the Federal Joint Committee (G-BA) determined the following:
    • The surgical procedure may only be performed in patients over the age of one.
    • The hyperplasia (enlargement of an organ or tissue) must cause symptomatic, clinically relevant impairment, and conservative therapy may not be sufficient.
    • Sufficient patient monitoring must be ensured following the procedure.
    • The operation may be performed only by ENT physicians who have a KV license.
    • The procedure can also be performed on an outpatient basis.