A
tonsillectomy is a 2,000 year-old
surgical procedure in which the
tonsilPalatine 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
tonsillitisTonsillitis is an infection of the tonsils and will often, but not necessarily, cause a sore throat and fever.-Types:There are 3 main types of tonsillitis: acute, subacute and chronic. Acute tonsillitis can either be bacterial or viral in origin. Subacute tonsillitis is caused by the bacterium...
or
adenoiditisAdenoiditis is the inflammation of the adenoid tissue. Adenoiditis can be treated using medicines, but in recurring cases, may require an adenoidectomy, or removal of the adenoids.-External links:*...
,
obstructive sleep apneaObstructive sleep apnea is a common sleep apnea caused by obstruction of the airway. It is characterized by pauses in breathing during sleep. These episodes, called apneas , each last long enough that one or more breaths are missed, and occur repeatedly throughout sleep...
, nasal
airway obstructionAirway 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...
,
snoringSnoring 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 rather loud and quite unpleasant. Generally speaking, the structures involved are the uvula...
, or
peritonsillar abscessPeritonsillar abscess, also called PTA or quinsy, is a recognised complication of tonsillitis and consists of a collection of pus beside the tonsil .-Causes:...
. Sometimes the
adenoidAdenoids are a mass of lymphoid tissue situated at the very back of the nose, in the roof of the nasopharynx, where the nose blends into the mouth....
s are removed at the same time, a procedure called
adenoidectomyAdenoidectomy 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 common. It is most often done on an outpatient basis under general anesthesia...
. 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 tonsillitis
Tonsillitis is an infection of the tonsils and will often, but not necessarily, cause a sore throat and fever.-Types:There are 3 main types of tonsillitis: acute, subacute and chronic. Acute tonsillitis can either be bacterial or viral in origin. Subacute tonsillitis is caused by the bacterium...
. 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. Lee (2008) suggests the following guideline: "3 per year for 3 years, 5 per year for 2 years, 7 or more in 1 year, or greater than 2 weeks of school or work missed in 1 year".
- Has chronic
In medicine, a chronic disease is a disease that is long-lasting or recurrent. The term chronic describes the course of the disease, or its rate of onset and development. A chronic course is distinguished from a recurrent course; recurrent diseases relapse repeatedly, with periods of remission in...
tonsillitisTonsillitis is an infection of the tonsils and will often, but not necessarily, cause a sore throat and fever.-Types:There are 3 main types of tonsillitis: acute, subacute and chronic. Acute tonsillitis can either be bacterial or viral in origin. Subacute tonsillitis is caused by the bacterium...
, consisting of persistent, moderate-to-severe throat painPharyngitis is an inflammation of the throat or pharynx. In most cases it is painful and the initial infection can extent for a lengthy time period, and is often referred to as a sore throat....
.
- Has multiple bouts of peritonsillar abscess
Peritonsillar abscess, also called PTA or quinsy, is a recognised complication of tonsillitis and consists of a collection of pus beside the tonsil .-Causes:...
.
- Has sleep apnea
Sleep apnea is a sleep disorder characterized by pauses in breathing during sleep. Each episode, called an apnea , lasts long enough so that one or more breaths are missed, and such episodes occur repeatedly throughout sleep...
(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 tonsillolith
A tonsillolith is a piece of calcareous matter which forms in the rear of the mouth, in the crevasses of the palatine tonsils ....
s (tonsil stones) in the back of their mouth.
- Has abnormally large tonsils with crypts (Craters or impacts in the tonsils)
The
American 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...
- Head and Neck Surgery (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." This
press releaseA news release, media release, press release or press statement is a written or recorded communication directed at members of the news media for the purpose of announcing something claimed as having news value. Typically, they are mailed, faxed, or e-mailed to assignment editors at newspapers,...
came out after the President of the United States,
Barack ObamaBarack Hussein Obama II is the 44th and current President of the United States. He is the first African American to hold the office, as well as the first president born in Hawaii...
, stated that "Right now, doctors a lot of times are forced to make decisions based on the fee
payment scheduleThe payment schedule of financial instruments defines the dates at which payments are made by one party to another on for example a bond or derivative...
that's out there. … the doctor may look at the reimbursement system and say to himself, 'You know what? I make a lot more money if I take this kid's tonsils out …".
The Wall Street JournalThe Wall Street Journal is an English-language international daily newspaper published by Dow Jones & Company, a division of News Corporation, in New York City, with Asian and European editions. As of 2007, it has a worldwide daily circulation of more than 2 million, with approximately 931,000...
believes that pediatricians are not making money from doing tonsillectomies. In the United States, otolaryngologists, not pediatricians, do tonsillectomies.
Morbidity and mortality
The morbidity rate associated with tonsillectomy is 2% to 4% due to post-operative bleeding; the
mortality rateMortality rate is a measure of the number of deaths in some population, scaled to the size of that population, per unit time. Mortality rate is typically expressed in units of deaths per 1000 individuals per year; thus, a mortality rate of 9.5 in a population of 100,000 would mean 950 deaths per...
is 1 in 25,000, due to bleeding, airway obstruction, or
anesthesiaAnesthesia, or anaesthesia , has traditionally meant the condition of having sensation blocked or temporarily taken away. This allows patients to undergo surgery and other procedures without the distress and pain they would otherwise experience...
.
Effectiveness
The effectiveness of the tonsillectomy has been questioned in a 2009
systematic reviewA systematic review is a literature review focused on a single 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. Most patients do not feel like swallowing anything during the first few days after surgery. Patients should try to get as much fluid down as possible, as it will help speed recovery. Very cold drinks will help bring down swelling. Ice cream,
frozen yogurtFrozen yogurt is a frozen dessert made from, or containing yogurt or other dairy products. It is slightly more tart than ice cream, as well as lower in fat...
and other
dairy productDairy products are generally defined as foodstuffs produced from milk. They are usually high-energy-yielding food products. A production plant for such processing is called a dairy or a dairy factory. Raw milk for processing generally comes from cows, but occasionally from other mammals such as...
s are not recommended because they leave a film in the mouth that is difficult to swallow. Sherbert and
popsiclePopsicle is the most popular brand of ice pop in the U.S. and Canada. Popsicle is a trademark owned by Unilever, although it has entered the general vernacular in North America. It was founded in Michigan.- History :...
s, on the other hand, are recommended. Additionally, Icees/Slurpies are particularly helpful for sore throats and now come in sugar free flavors.
Pain following the procedure is significant and may include a hospital stay. Recovery can take from 10 up to 20 days, during which
narcoticThe term narcotic is believed to have been coined by the Greek physician Galen to refer to agents that benumb or deaden, causing loss of feeling or paralysis. It is based on the Greek word ναρκωσις , the term used by Hippocrates for the process of benumbing or the benumbed state...
analgesicAn analgesic is any member of the diverse 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
dehydrationDehydration is defined as excessive loss of body water. It is literally the removal of water from an object. In physiological terms, it entails a relative deficiency of water molecules in relation to other dissolved solutes...
can increase throat pain, leading to a vicious cycle 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
scabScab can refer to the following:* Scab, a hard coating on the skin formed during the wound healing reconstruction phase* Derogatory term for a strikebreaker, a person who works despite strike action or against the will of other employees...
s 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
cauterizationThe medical practice or technique of cauterization is a medical term describing 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
, which presents all the risks associated with emergency surgery (primarily the administration of anesthesiaAnesthesia, or anaesthesia , has traditionally meant the condition of having sensation blocked or temporarily taken away. This allows patients to undergo surgery and other procedures without the distress and pain they would otherwise experience...
particularly on a patient whose stomach may not be empty).
Generally Tonsils will be removed after a patient needing antibiotics to be prescribed 6 times in a year, GP's recomendation is based on how the quality of life will be improved after the operation. Tonsillectomies can be done while the patient is suffering from tonsillitis, however this increases the risk of bleeding.
Common causes, demographics
Infections requiring tonsillectomy are often a result of StreptococcusStreptococcus 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 throatStreptococcal pharyngitis or streptococcal sore throat is a form of group A streptococcal infection that affects the pharynx and possibly the larynx and tonsils.- Signs and symptoms :...
"), particularly Streptococcus pyogenesStreptococcus pyogenes is a spherical gram-positive bacterium that grows in long chains and 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, such as Streptococcus viridansViridans Streptococcus is a pseudo-taxonomic 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 non-hemolytic...
, Staphylococcus aureusStaphylococcus aureus is the most common cause of staph infections. It is a spherical bacterium, frequently part of the skin flora found in the nose and on skin. About 20% of the population are long-term carriers of S. aureus. S...
, and Hemopholus influenzae. However, the etiologyEtiology 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 tonsillitisTonsillitis is an infection of the tonsils and will often, but not necessarily, cause a sore throat and fever.-Types:There are 3 main types of tonsillitis: acute, subacute and chronic. Acute tonsillitis can either be bacterial or viral in origin. Subacute tonsillitis is caused by the bacterium...
and adenoidAdenoids are a mass of lymphoid tissue situated at the very back of the nose, in the roof of the nasopharynx, where the nose blends into the mouth....
). 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 bedwettersBedwetting is involuntary urination while asleep after the age at which bladder control would normally be anticipated. The medical term for this condition is "nocturnal enuresis." Primary nocturnal enuresis is when a child has not yet stayed dry on a regular basis...
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 , pl. fas·ci·ae , adj. fascial is the soft tissue component of the connective tissue system that permeates the human body. It interpenetrates and surrounds muscles, bones, organs, nerves, blood vessels and other structures...
of tissue that surrounds the tonsils. Removal is typically achieved using a scalpel or with electrocautery, although harmonic scalpels or lasers have also been used. Bleeding is stopped with electrocautery, ligation of sutures, and the topical use of thrombinThrombin also commonly called pro-thrombin is a coagulation protein in the blood stream that has many effects in the coagulation cascade...
, 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 adenoidectomyAdenoidectomy 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 common. It is most often done on an outpatient basis under general anesthesia...
is also being performed, the adenoids are first removed with a curetteA 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 nasopharynxThe 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 gauzeGauze is a thin, translucent fabric with a loose open weave.-Etymology:Gauze was traditionally woven in Palestine and the etymology of the English word derives from the place name for Gaza , a center of weaving in the region...
. A tonsil is removed by holding it by the upper part, pulling it slightly medially, and making a cut over the anterior faucial pillarThe fauces , in anatomy, is the posterior part of the mouth, which leads into the pharynx....
. 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 scalpelA scalpel is a small but extremely sharp bladed instrument used for surgery, anatomical dissection, and various arts and crafts. Scalpels may be disposable or re-usable. Re-usable scalpels can have attached, resharpenable blades or, more commonly, non-attached, replaceable blades...
is the preferred surgical instrument of many ear, nose, and throat specialistsOtolaryngology or ENT is the branch of medicine that specializes in the diagnosis and treatment of ear, nose, throat, and head and neck disorders. The full name of the specialty is otolaryngology-head and neck surgery. Practitioners are called otolaryngologists-head and neck surgeons, or sometimes...
. 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 painPhysical Pain is the unpleasant feeling common to a headache and a stubbed toe. It typically consists of negative affect and aversion, and has location, duration, intensity and a distinctive quality...
and post-operative bleedingBleeding, 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' is the most common method practiced by otolaryngologists today. The procedure requires the patient
A patient is any person who receives medical attention, care, or treatment. The person is most often ill or injured and in need of treatment by a physician or other health care professional, although one who is visiting a physician for a routine check-up may also be viewed as a patient.The word...
to undergo general anesthesia; the tonsils are completely removed and the skin is cauterized. The patientA patient is any person who receives medical attention, care, or treatment. The person is most often ill or injured and in need of treatment by a physician or other health care professional, although one who is visiting a physician for a routine check-up may also be viewed as a patient.The word...
will leave with minimal post-operative bleedingBleeding, technically known as hemorrhaging or haemorrhaging is the loss of blood or blood escape from the circulatory system...
.
- Electrocautery: Electrocautery burns
A burn is a type of injury that may be caused by heat, electricity, chemicals, light, radiation, or friction. Burns can be highly variable in terms of the tissue affected, the severity, and resultant complications. Muscle, bone, blood vessel, dermal and epidermal tissue can all be damaged with...
the tonsillar tissue and assists in reducing bloodBlood is a specialized bodily fluid that delivers necessary substances to the body's cells — such as nutrients and oxygen — and transports waste products away from those same cells....
loss through cauterizationThe medical practice or technique of cauterization is a medical term describing 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
. Research has shown that the heat of electrocautery (400°CCelsius is a temperature scale that is named after the Swedish astronomer Anders Celsius , who developed a similar temperature scale two years before his death...
) results in thermal injury to surrounding tissueThe cell is the basic structural and functional unit of all known living organisms. It is the smallest unit of an organism that is classified as living, 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 scalpel: This medical device
A medical device is a product which is used for medical purposes in patients, in diagnosis, therapy or surgery. If applied to the body, the effect of the medical device is primarily physical, in contrast to pharmaceutical drugs, which exert a biochemical effect. Specific regional definitions of...
uses ultrasonic energy to vibrateVibration 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 eyeEyes are organs that detect light, and send electrical impulses along the optic nerve to the visual and other areas of the brain. Complex optical systems with resolving power have come in ten fundamentally different forms, and 96% of animal species possess a complex optical system...
, the vibration transfers energy to the tissue, providing simultaneous cutting and coagulationCoagulation is a complex process by which blood forms clots. It is an important part of hemostasis , 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 anesthesia
Local anesthesia is any technique to render part of the body insensitive to pain without affecting consciousness. It allows patients to undergo surgical and dental procedures with reduced pain and distress. In many situations, such as cesarean section, it is safer and therefore superior to...
. 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 tonsillitisTonsillitis is an infection of the tonsils and will often, but not necessarily, cause a sore throat and fever.-Types:There are 3 main types of tonsillitis: acute, subacute and chronic. Acute tonsillitis can either be bacterial or viral in origin. Subacute tonsillitis is caused by the bacterium...
.
- Thermal Welding: A new technology which uses pure thermal energy 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: Laser
A laser is a device that emits light through a process called stimulated emission. Laser light is usually spatially coherent, which means that the light either is emitted in a narrow, low-divergence beam, or can be converted into one with the help of optical components such as lenses...
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 halitosisHalitosis, or most commonly bad breath are terms used to describe noticeably unpleasant odors exhaled in breathing – whether the smell is from an oral source due to bacteria....
, or airway obstruction caused by enlarged tonsils. The LTA is performed in 15 to 20 minuteA 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 occasionally has 59 or 61 seconds; see leap second...
s in an office setting under local anesthesia. The patient leaves the office with minimal discomfort and returns to schoolA school , is an institution designed to allow and encourage students to learn, under the supervision 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 childA child is a human being between the stages of birth and puberty. 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 sleepSleep is a naturally recurring state of relatively suspended sensory and motor activity, characterized by total or partial unconsciousness and the inactivity of nearly all voluntary muscles. It is distinguished from quiet wakefulness by a decreased ability to react to stimuli, and it is more easily...
disturbance, decreased morbidity, and less need for medicationA 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 adverse to outpatient procedures without sedation.
- Microdebrider: The microdebrider is a powered rotary shaving device with continuous suction often used during sinus
Paranasal sinuses are air-filled spaces, communicating with the nasal cavity, within the bones of the skull and face.-Types in humans:Humans possess a number of paranasal sinuses, divided into subgroups that are named according to the bones within which the sinuses lie:*the maxillary sinuses, also...
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 musclesThe pharyngeal muscles are a group of muscles that act upon the pharynx.They include:* Inferior pharyngeal constrictor muscle* Middle pharyngeal constrictor muscle* Superior pharyngeal constrictor muscle* Stylopharyngeus muscle* Salpingopharyngeus 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.
- Bipolar Radiofrequency Ablation (see Coblation tonsillectomy
Coblation is a method used by otolaryngologists, also known as ENT specialists, to perform tonsillectomy, adenoidectomy, and other surgical procedures, including turbinate reduction and the treatment of snoring. Unlike traditional electrocautery methods, Coblation methods use radiofrequency to...
): This procedure produces an ionized salineIn medicine, saline is a general term referring to a sterile solution of sodium chloride in water. It is used for intravenous infusion, rinsing contact lenses, and nasal irrigation. Saline solutions are available in various formulations for different purposes...
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 vesselThe blood vessels are the part of the circulatory system that transport 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 2000 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 was a civilization that grew out of a small agricultural community founded on the Italian Peninsula as early as the 10th century BC. Located along the Mediterranean Sea, it became one of the largest empires in the ancient world....
aristocrat Celcus (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. GalenAelius Galenus or Claudius Galenus , better known as Galen of Pergamum , was a prominent Greek physician and philosopher and probably the most accomplished medical researcher of the Roman period. His theories dominated and influenced Western medical science for well over a millennium...
(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 AetiusAëtius Amidenus or 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 Dark AgesThe Dark Ages is a term in historiography referring to a perceived period of cultural decline or societal collapse that took place in Western Europe between the fall of Rome and the eventual recovery of learning. Increased understanding of the accomplishments of the Middle Ages in the 19th century...
saw tonsillectomy fall into disfavor; Ambroise Pase (1509) wrote it to be "a bad operation" and suggested a procedure that involved gradual strangulation with a ligatureIn surgery or medical procedure, a ligature consists of a piece of thread tied around an anatomical structure, usually a blood vessel or an other hollow structure to shut it off...
. 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 larynxThe larynx , colloquially known as the voicebox, is an organ in the neck of mammals involved in protection of the trachea and sound production...
, resulting in hoarseness. For this reasons physicians like Dionis (1672) and Lorenz HeisterLorenz Heister was a German anatomist, surgeon and botanist born in Frankfurt am Main....
censured the procedure.
In 1828, physician Philip Syng PhysickPhilip 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 BellBenjamin Bell was a Scottish surgeon. Bell was born in Dumfries and educated in that town. His family owned Blackett House in Middlebie Parish , which Bell was later to sell to fund the education of himself and his family...
for removing the uvulaThe 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 voice:...
; 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 fell out of favor in America.
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