Wednesday-August 20, 2014 
    
      Home | Procedures | Pre-Surgery Form | Registration | Search | About Us  
 
FORBES magazine names YourSurgery.Com as one of it's "Best of the Web"
 
Tonsillectomy
Removal of the tonsils

Tonsillectomy with or without adenoidectomy is the second-most common surgery of childhood, but is less commonly performed in adults. Tonsillectomy accounts for 25% of all operations performed by otolaryngologists (ear, nose and throat surgeons).

Anatomy and Physiology

  • They are generally ovoid or bilobed tissue collections with a very irregular surface
  • They are found between the front and back tonsillar arches, located along the sides of the pharynx (back of the throat) (Figure 1). The tonsillar fossa is the depression between the arches in which the tonsil lies
  • The tonsils are highly vascular (contains many blood vessels), which helps them to perform their function of protecting against infection, as foreign material enters the body through the mouth. The blood supply comes from several branches of the external carotid artery (Figure 2)
  • The nerve supply is mainly from the ninth cranial nerve, which provides sensation to much of the throat. This nerve also supplies sensation to a small part of the ear, which explains why ear pain is frequently associated with throat infections or experienced after tonsillectomy
  • The adenoids are lymphoid tissue at the back of the throat and above the palate
Figure 1 - Open mouth view of the tonsils. The tonsils are rounded masses of lymphoid tissue on each side of the pharynx. The palate is the roof of the mouth. In the center of the back of the palate hangs a soft finger of tissue, the uvula. The lowest portion of enlarged adenoids is seen behind and just below the palate ©Rob GordonFigure 2 - The tonsil is very vascular and gets blood from several branches of the external carotid artery

Pathology

  • The tonsils and adenoids are collections of lymphoid tissue that produce lymphocytes and are part of the infection-fighting immune system by producing antibodies to bacteria in the nose and throat
  • This lymphoid tissue may become chronically infected or enlarged such that the tissue obstructs normal breathing and sinus drainage and interfere with sleep
  • The tonsils are graded by size from normal to very large as 1+, 2+, 3+ or 4+
  • They may be described as cryptic (pitted), inflamed or covered with exudates (thin layer of pus)
  • The appearance of the tonsils is usually not important when recommending tonsillectomy

History and Examination

  • Recurrent fever
  • Loss of sleep
  • Impaired hearing because of blockage of the Eustachian tube (the channel between the throat and middle ear that equalizes middle ear pressure) and middle ear infection
  • Sore throat with pain on swallowing and speaking
  • Enlarged tonsils and adenoids with patches of yellow-white pus

Tests

  • Blood tests
    1. blood count- to determine if there is generalized infection
    2. platelet count- if low the patient may bleed excessively
    3. measures of blood clotting ability (coagulation times)- if abnormal there may be excessive bleeding
    4. More specialized tests may be obtained in cases where there is a personal or family history of frequent bleeding or bruising Occasionally, an x-ray of the throat will be done to evaluate the adenoid tissue (enlarged lymphoid tissue at the back of the pharynx)
  • Occasionally, an x-ray of the throat will be done to evaluate the adenoid tissue

Indications for Tonsillectomy/Adenoidectomy

  • The tonsils are removed for various reasons, and generally only after medical therapy has failed
  • The most common indications are tonsillar hypertrophy (enlargement) leading to obstruction which may cause sleep apnea or other sleep disturbance
  • Recurrent ear infections
  • Chronic or recurrent tonsillitis (infection of the tonsils)
  • Five or more episodes of tonsillitis in one year
  • Three or more episodes of tonsillitis per year over at least two years
  • Tonsillitis not responding to antibiotics
  • Less commonly the following may be due to obstructing tonsils and the tonsils may be removed if these conditions are not attributable to other causes. Sometimes the blockage may not be obvious from looking at the tonsils, because the tonsils may be long and the narrowed area is actually lower down the throat
    1. Speech or swallowing abnormalities
    2. Failure to thrive
    3. cor pulmonale- right-sided heart enlargement due to disease in the air passages
  • Rarely, relatively normal sized tonsils are removed because they cause obstruction in a narrow upper airway, due to congenital, orofacial or dental abnormalities
  • Peritonsillar abscess (abscess surrounding the tonsils)
  • Suspicion of tonsillar malignancy

Surgical Procedure

  • Tonsillectomy with or without adenoidectomy is often an out-patient procedure. Small children or patients with special needs or risks may be hospitalized briefly
  • Tonsillectomy is performed under general anesthesia, with the patient completely asleep
  • The patient is positioned on his back, with head forward and mouth wide open
  • The tonsils and adenoids may be removed from their bed by various methods. The method is a matter of surgeon preference and does not alter the length or outcome of the procedure. (Figure 3A and 3B) The methods that may be used are:
    1. Electrocautery- hot electric knife that tends to seal bleeding vessels
    2. Blunt dissecting instruments
    3. Scissors
    4. Metal snare
    5. Laser
  • Any bleeding is controlled, and the patient is awakened
Figure 3&4 - Enlarged tonsil being removed using a scissor. Once removed, bleeding in the tonsillar fossa is stopped

Complications

  • Bleeding after tonsillectomy can be severe and even life-threatening, and is taken very seriously by the otolaryngologist. Any patient who experiences bleeding should be seen immediately by their surgeon or in the emergency room
  • Infection can occur because of the open tissues where the tonsils were removed. This is managed with antibiotics
  • An occasional patient may develop a voice change usually described as nasal speech, which can be permanent
  • Complications of anesthesia. The most serious complications are those of the general anesthesia, since this can cause:
    1. Heart attack
    2. Stroke
    3. Sore throat, tongue soreness or swelling
    4. Damage to the teeth
    5. Deep vein thrombosis (clotting in the veins of the legs or pelvis)
    6. Pulmonary embolus (clot from the leg veins going to the lung)
    7. Anaphylaxis (allergic reaction)
    8. Death
    9. These risks are extremely small in young, healthy patients, but bear mentioning because of their severity

Postoperative Care

  • The most important thing to watch for is bleeding, this necessitates examination by a physician
  • The most common reason patients return to the hospital or clinic is due to dehydration. Because of the pain associated with tonsillectomy, many patients do not eat or drink sufficiently to heal and feel good. Adequate analgesia (usually with narcotics) is important in allowing patients to eat adequately.
  • Antibiotics are often given in the post-operative period as well, to help prevent infection and to reduce pain
  • Significant pain is to be expected for at least a week in children and two weeks in adults, and may be longer
  • Patients are usually most comfortable with cold non-acidic liquids and soft foods for the first several days, and these are encouraged because they are less likely than hard or chewy foods to initiate bleeding