Background Although a long-practiced procedure, tonsillectomy is still a common operation and considered one of the most common

major surgical procedure performed in children. This procedure is still surrounded by controversy, especially regarding indications for surgery and details of surgical technique. History of the Procedure First described in India in 1000 BC, the tonsillectomy procedure increased in popularity in the 1800s, when a partial removal of the tonsil was performed. Because part of the tonsil was left behind, it frequently became hypertrophied and caused recurrence of the obstruction. By the early 20th century, the prevalence of tonsil disease was recognized, and the necessity of complete tonsillectomy was appreciated. Epidemiology Although tonsillectomy is performed less often than it once was, it is still among the most common surgical procedures performed in children in the United States. In 1959, 1.4 million tonsillectomies were performed in the United States. This number had dropped to 260,000 by 1987, when it was the 24th most common indication for hospital admission. Indications have evolved from being primarily related to infections to being more commonly caused by obstruction. Pathophysiology The tonsils are 3 masses of tissue: the lingual tonsil, the pharyngeal (adenoid) tonsil, and the palatine or fascial tonsil. The tonsils are lymphoid tissue covered by respiratory epithelium, which is invaginated and which causes crypts. In addition to producing lymphocytes, the tonsils are active in the synthesis of immunoglobulins. Because they are the first lymphoid aggregates in the aerodigestive tract, the tonsils are thought to play a role in immunity. Although healthy tonsils offer immune protection, diseased tonsils are less effective at serving their immune functions. Diseased tonsils are associated with decreased antigen transport, decreased antibody production above baseline levels, and chronic bacterial infection. Indications Otolaryngology textbooks list a variety of indications for tonsillectomy. The American Academy of Otolaryngology–Head and Neck Surgery (AAO-HNS) publishes clinical indicators for surgical procedures. Paraphrased, these clinical indicators are as follows:

Absolute indications 1. Enlarged tonsils that cause upper airway obstruction, severe dysphagia, sleep disorders, or cardiopulmonary complications 2. Peritonsillar abscess that is unresponsive to medical management and drainage documented by surgeon, unless surgery is performed during acute stage 3. Tonsillitis resulting in febrile convulsions 4. Tonsils requiring biopsy to define tissue pathology Relative indications 1. Three or more tonsil infections per year despite adequate medical therapy 2. Persistent foul taste or breath due to chronic tonsillitis that is not responsive to medical therapy

4. 1. Unilateral tonsil hypertrophy that is presumed to be neoplastic Relevant Anatomy Tonsils are located laterally in the oropharynx.[1]The disturbing factor in this study was that the patient's preoperative history did not help in identifying children with abnormal coagulation. Lymphatic drainage involves the superior deep cervical nodes and the jugulodigastric nodes. With a positive family history. 2. the lingual vein. Important structures deep to the inferior pole include the glossopharyngeal nerve. Sensory supply is provided by the glossopharyngeal nerve and the lesser palatine nerve. as follows: 1. 3. Deep . a bleeding time or a consultation with a hematologist is prudent. This is a point of ongoing debate. and the internal carotid artery.Palatoglossus muscle Posterior .Chronic or recurrent tonsillitis in a streptococcal carrier not responding to beta-lactamase-resistant antibiotics 4. routine preoperative coagulation studies are not recommended. With a negative family history for bleeding. See Tonsil and Adenoid Anatomy for more information.Superior constrictor muscle Anterior . 5. Inferior pole  Facial artery branches  Dorsal lingual artery  Ascending palatine artery Venous outflow is handled by the plexus around the tonsillar capsule. In 1 study.Lingual tonsil Blood supply is through the external carotid artery and its branches. Contraindications Contraindications for tonsillectomy include the following:     Bleeding diathesis Poor anesthetic risk or uncontrolled medical illness Anemia Acute infection Laboratory Studies Coagulation parameters should be assessed if the patient's history reveals a potential bleeding problem.Soft palate Inferior . the lingual artery. The tonsils are bordered by the following tissues: 3. coagulation tests produced abnormal results in 4% of 1706 children. Imaging Studies . The AAO-HNS suggests that all patients receive a basic coagulation workup. and the pharyngeal plexus. Superior pole   Ascending pharyngeal artery (tonsillar branches) Lesser palatine artery 2.Palatopharyngeus muscle Superior . Lymphoid cells underlie the epithelium. The tonsil surface is filled with crypts lined with squamous epithelium.

a patient with a pulsatile area adjacent to the tonsil should undergo magnetic resonance arteriography (MRA) before routine tonsillectomy to evaluate for an aberrant internal carotid artery. they should be submitted separately and examined histologically to rule out cancer. Other Tests Antibodies for streptolysin-O (ASLO) have been studied as possible indicators for tonsillectomy. be aware of possible underlying cardiac disease. CT scanning. Also. high ASLO titers can shed light on the patient's history.  When the diagnosis of recurrent GABHS is questioned.Imaging studies include plain radiography. several rapid tests for detecting group A streptococcal antigen have been used. evaluation for allergy may be helpful. but only in children with the signs and symptoms of allergic disease. Medical Therapy Adjunctive intraoperative medical therapy may include the following:       Rectal acetaminophen in children Intravenous antiemetics Intravenous narcotics (except if a history of airway obstruction is present) Intravenous steroids (controversial. Historically.  To the authors’ knowledge.  The rapid tests are specific but not uniformly sensitive. no recent work has been published concerning this issue. therefore negative results need to be confirmed with a routine culture. Several studies have shown a higher-than-expected incidence of allergy in children with adenotonsillar disease.  More recently. In addition. If tonsils are asymmetric. and MRI in an appropriate patient with a tonsillar mass suggestive of malignancy. order cervical spine images to evaluate for C1-C2 subluxation. . Therefore. probably a small benefit)[3] Local anesthetic Sucralfate (debatable effect)[4] Preoperative Details Careful history taking is needed to evaluate for the following:    Bleeding disorders or wish to avoid transfusion Anesthesia intolerance Obstructive sleep apnea In patients with Down syndrome. Histologic Findings Histologic examination of the tonsils is unnecessary unless cancer is suspected.[2]  These antibodies are correlated with previous infection with group A beta-hemolytic streptococcus (GABHS). GABHS cultured on blood agar and use of a Bacitracin disc has been used to identify the most important agent that causes tonsillitis.

or coblation (can be used to shrink tonsils) Harmonic scalpel with vibrating titanium blades Powered instruments (eg.5 mg per 5 mL PO q4h for 3 d) with as needed (PRN) opioid analgesia in children aged 6-15 years undergoing outpatient tonsillectomy. and open and suspend it.0001). Children in the PRN group had higher pain intensity scores (p=0. Pain intensity scores were higher in the morning compared with the evening (p < 0. Variations in dissection methods include the following:[5. Children who should be admitted are those with obstructive sleep apnea.017). the least amount of cautery necessary for hemostasis is used.) Sutters et al conducted a study comparing scheduled postoperative opioid analgesia (acetaminophen and hydrocodone 167 mg/2.      . insurance plans are increasingly disallowing inpatient admission for tonsillectomy or adenoidectomy. A Colorado needle-tip bovie is used to dissect the tonsil from its underlying muscular bed. Regarding admission planning. and local infection. Staying in the proper dissection plane limits the amount of bleeding. Ideally. A suction bovie is used to achieve hemostasis.[9] Maintain good hydration. those with significant comorbid disease such as hypotonia or neuromotor delays.0001). curettes) Monopolar cautery Bipolar cautery with or without a microscope Radiofrequency ablation. weight loss. Intraoperative Details Place the patient in the Rose position with a shoulder roll. and those younger than 3 years. Postoperative Details Use liquid acetaminophen (Tylenol) with or without codeine for pain control. Be cautious when suctioning the patient's airway. and possibly postoperative pain. which results in dehydration. microdebrider) for an intracapsular technique Variations in hemostasis methods include the following: Pressure with sponge for several minutes Use of bismuth subgallate Use of ties Suction cautery Bipolar cautery Tonsillectomy performed with the cautery technique. (The unwillingness of parents to give analgesics is associated with children's refusal to eat. 6] [7. Children in the scheduled-dose group received more analgesia compared with the PRN group (p < 0. Carefully. scissors. insert a mouth prop.Sleep studies are recommended if the severity of the patient's symptoms is uncertain. Leave the lingual tonsil in situ. Apply an Alyss clamp to the tonsil to allow for traction during dissection. 8]       Use of cold steel (eg.

those with Down syndrome. otalgia) Dehydration (common in children who do not eat because of pain) Weight loss (common in children who do not eat because of pain) Fever (not common. a sponge may be fixed in place by using sutures. If this fails. Follow-up Ideal times for follow-up care are (1) when the pain has its second peak (at 5-8 days) to reassure patients and (2) at 4-6 weeks after surgery to monitor for the resolution of symptoms. A phone call by a registered nurse may be adequate for postoperative follow-up. sore throat. such as the external carotid artery. Another last resort is ligation of other large vessels. Complications Hemorrhage is the most common complication.[12] [13] Pressure can be applied to a bleeding tonsil fossa by using a sponge and a long clamp. 11] Instruct the patient to avoid smoking. Diathermy is thought to be superior to ligation because of the risk of perforating large vessels with the needle. aspirated material) Pulmonary edema (occurs in people with true airway obstruction caused by tonsils) Local trauma to oral tissues Tonsillar remnants or subsequent regrowth Vocal changes (If the tonsils are large. those who live far away from the outpatient facility. In severe situations. or secondary (occurring between 24 hours and 10 days). and 1 of 40. Instruct the patient to avoid heavy lifting and exertion for 10 days. Administer antibiotics. or ligation of the ipsilateral carotid artery as the last resort. primary (occurring within the first 24 hours). Warn patients that pain will abate during the first 3-5 days then increase for 1-2 days before completely disappearing. those with obstructive sleep apnea. hematoma. soft foods are more easily swallowed than hard foods. An estimated 2-3% of patients have hemorrhage. though the decision about the method of follow-up is up to the patient and surgeon. or those who have difficulty in complying with instructions. Options to stop the bleeding are electrocautery of the tonsil bed. No evidence suggests that a special diet is required. Dipping the sponge in epinephrine or thrombin powder may be helpful. however. Oral antibiotic use for the week after tonsillectomy is associated with improved outcomes in children. Individuals who should not receive tonsillectomy as outpatients are those younger than 3 years.[10. as the resonance has changed) . the patient's voice may be muffled. usually related to local infection) Postoperative airway obstruction (because of uvular edema. Most often. tonsillectomy is safely performed on an outpatient basis.The patient should eat an adequate diet. Other complications include the following:          Pain (eg.000 patients die from bleeding. Bleeding may be classified as intraoperative. use of further topical hemostatics. the patient should be taken to the operating room.

reduction in the episodes of sore throat. which showed that tonsillectomy is beneficial in patients with recurrent sore throats. Those who had tonsillectomy had fewer throat infections in the first 2 years after treatment than those who did not have tonsillectomy. To treat airway obstruction from large tonsils. it is helpful to treat not just the disorder of attentional issues.[16] A study of malpractice claims filed after tonsillectomy provided by 16 medical liability insurance companies identified 154 claims between 1985 and 2006. which have adverse effects on daytime behavior and attention.[15] Results of other studies have suggested an overall patient satisfaction and improved quality of life. Whether an optimal method of tonsillectomy exists. but complete normalization occurs in only 25% of the patients. Further research on the efficacy of tonsillectomy to treat recurrent sore throats is still needed. usually related to bleeding or anesthetic complications) A single intravenous dose of the corticosteroid drug dexamethasone. and whether outpatient tonsillectomy is safe are still unclear. and upper respiratory infections.[14] Late complications are nasopharyngeal stenosis and velopharyngeal incompetence. These complications are most likely to occur if adenoidectomy or uvulopalatopharyngoplasty is undertaken at the same time as tonsillectomy. Temporomandibular joint dysfunction. days of school absence associated with sore throat. which can be associated with any procedure in which the mouth is opened widely  Psychological trauma. but also underlying sleep problems. night terrors.[17] This further explains why tonsillectomy decreases the rate of streptococcal infection (including pharyngitis).[20] Lastly. tonsillotomy with lasers may be less painful than tonsillectomy and just as successful.[21] Future and Controversies Research on tonsillectomy is still popular. whether perioperative steroids are useful. Outcome and Prognosis Compared with watchful waiting. which is an increasing occurrence in children. pain or clicking. Recent literature that looks at the persistence of obstructive sleep apnea syndrome in children after surgery shows that adenotonsillectomy yields improvements in respiratory abnormalities in children with obstructive sleep apnea. We know of no definitive studies since the original study by Paradise et al. studies are now recognizing the high incidence of obstructive sleep issues in certain populations such as the cleft palate population. in cases of ADHD. reduces likelihood of vomiting and postoperative pain and morbidity in children. Well-designed studies are necessary to prove the effectiveness of these methods.[19] Authors noted that. Bleeding complications . Radiofrequency reduction of the volume of submucosal tissue may also be used to achieve this end in adults. but small. administered intraoperatively. or depression  Death (uncommon. and apnea hypopnea index (AHI) at diagnosis. Paradise and colleagues monitored patients who had recurrent throat infections.[16] Levels of alpha-streptococci (inhibitory protective bacteria) have been shown to increase after tonsillectomy.[18] The main determinants for surgical outcome include obesity. tonsillectomy or adenotonsillectomy provided an additional.

which is typically considered the most common complication of the procedure. while miscellaneous claims such as uvular injuries and postoperative scarring led to 45.led to 17.[22] .5% of the claims. Burn injuries accounted for 18.5% of claims. These figures suggest that the majority of malpractice claims following tonsillectomy stem from complications other than hemorrhage.2% of claims.

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