Tonsillectomy is one of the most popular surgical procedures in the United States. Each year, almost 550,000 cases in children under the age of 15 are conducted. Sleep-disordered breathing and frequent throat infections are two common causes of this operation. Tonsillectomy has been linked to a number of problems, including hemorrhage, velopharyngeal insufficiency, and dehydration. Tonsillectomy is defined as a surgical intervention usually performed with adenoidectomy that entirely removes the tonsil and its capsule, by dissecting the peritonsillar space between the tonsil capsule and the muscular wall, according to the Academy of Otolaryngology-Head and Neck Surgery in America. It may represent tonsillectomy with adenoidectomy, depending on the situation, especially in relation to sleep-disordered breathing.
Tonsillectomy is still a popular operation and one of the most common major surgical procedures performed in children, despite its long history. This treatment is still fraught with controversy, particularly when it comes to surgical reasons and surgical technique.
Adenoidectomy is a surgical treatment that removes the adenoids. The lymphoid tissue in the back of the nose is known as adenoids. They are frequently misunderstood by the general population and non-otolaryngologists because they are rarely seen during standard physical examinations due to their position. Despite the fact that adenoids and tonsils have the same tissue constitution, diseases linked with infected adenoids differ from diseases associated with infected tonsils due to their locations. This adds to the confusion because the adenoids are sometimes lumped in with the tonsils when academic articles publish results. An adenoidectomy is frequently performed in conjunction with other surgeries (e.g., tonsillectomy, placement of tympanostomy tubes).
Because adenotonsillectomy is typically performed in outpatient clinics, data is not carefully regulated or maintained, obtaining recent data is challenging. When the operation was mostly conducted in inpatient settings in the late 1970s and early 1980s, good data was collected. More than 1 million tonsillectomy and adenoidectomy surgeries, tonsillectomy alone, or adenoidectomy alone were performed in the United States in 1971, with 55,000 of these operations involving only adenoidectomy.
In 1987, 260,000 combined or single treatments were conducted, with 15,000 adenoidectomy surgeries alone. However, outpatient tonsillectomy and adenoidectomy, and adenoidectomies began to become increasingly common during this timeframe, which could explain a potential underestimation of the overall number of procedures completed. Unless additional concerns or medical problems necessitate hospital admission or an overnight stay, practically all adenoidectomies are now performed in outpatient settings. Unless the kid is very young, or other concerns or medical problems necessitate hospitalization or an overnight stay, tonsillectomy and adenoidectomy are normally performed in an outpatient environment.
Statistics from all managed health care firms across the United States are probably the best source for determining the actual incidence and frequency of procedures. The most common major surgical treatment in the United States is tonsillectomy and adenoidectomy.
Anatomy and Physiology
Waldeyer's ring of lymphoid tissue includes the palatine tonsils. The adenoid, tubal tonsil, and lingual tonsil are also included. A fibrous capsule that originates from the pharyngobasilar fascia separates the lymphoid tissue from the adjacent musculature. The peritonsillar space is the empty space between the capsule and the muscle. The tonsils are situated between the anterior and posterior pillars, which are formed by the palatoglossus and palatopharyngeal muscles, respectively. The tonsil is lateral to the superior constrictor muscle. The glossopharyngeal nerve is located deep to these muscles and is vulnerable to injury during tonsillectomy. Taste changes and referred otalgia can be caused by temporary swelling around this nerve. The tonsils' vasculature is provided by several blood vessels. The lingual, facial, ascending pharyngeal, and internal maxillary arteries all originate from branches of the external carotid artery. The tonsillar branch is derived from the lingual artery. A tonsillar and ascending palatal branch emerges from the facial artery. Tonsils are supplied by the internal maxillary artery and the descending palatal artery. This architecture may contain a number of abnormalities.
The lingual tonsil, the pharyngeal (adenoid) tonsil, and the palatine tonsil are three tissue masses. The tonsils are lymphoid tissue coated by invaginated respiratory epithelium, which generates crypts.
Tonsils are involved in the production of immunoglobulins in addition to lymphocytes. The tonsils are assumed to play a role in immunity because they are the first lymphoid clumps in the aerodigestive tract. Tonsils that are healthy provide immunological defense, but those that are sick are less good at providing their immune duties. Increased antigen transmission, decreased antibody production above baseline, and chronic bacterial infections are all linked to diseased tonsils.
As previously stated, sleep-disordered breathing and recurrent tonsillitis are the two most common reasons for tonsillectomy. Recurrent partial or total upper occlusion during sleep causes sleep-disordered breathing, disrupting normal ventilation and sleep cycles. It can be diagnosed based on the patient's medical history and physical examination. Hyperactivity, daytime fatigue, and irritability are all symptoms of sleep-disordered breathing. Loud snoring, observed apnea, disturbed sleeping, growth retardation, poor academic achievement, and nocturnal enuresis are all symptoms of sleep-disordered breathing. When compared to children without sleep-disordered breathing, children with sleep-disordered breathing have considerably higher rates of antibiotic use, 40 percent more hospital visits, and a 210 percent increase in healthcare use due to increased upper respiratory infections. Sleep-disordered breathing is most commonly caused by tonsillar and adenoid hypertrophies. Tonsillar size does not always correspond with the severity of sleep-disordered breathing, and polysomnography can be used to assess patients with sleep-disordered breathing symptoms but no tonsillar hypertrophy.
In patients with recurrent tonsillitis, careful patience is indicated if they have had less than seven episodes in the previous year, fewer than five episodes yearly in the previous two years, or fewer than three episodes annually in the previous three years. If the number of infections reaches these thresholds, tonsillectomy may be advised as a treatment option. A painful throat and one or more of the following symptoms should be documented for each infection: temperature higher than 38.3 ° C, cervical lymphadenopathy, tonsillar exudates, or a positive GABHS. Antibiotic intolerance, PFAPA (periodic fever, aphthous stomatitis, pharyngitis, and adenitis), or a peritonsillar abscess in recurrent tonsillitis patients may necessitate sooner surgical interventions.
Tonsillar asymmetry and malignancy are two more reasons for tonsillectomy. Squamous cell carcinoma and lymphoma are the most prevalent cancers of the palatine tonsils. Lymphoma is the most common malignant tumor in children.
Total adenoidectomy has some relative contraindications:
- A serious bleeding disease that could be treated with anticoagulants and methods before, during, and after surgery is a relative contraindication to adenoidectomy.
- Kids who are at risk of developing Velopalatal insufficiency due to a short palate, submucous cleft palate, true cleft palate, muscle fatigue, or hypotonia linked with a neurological condition, velocardiofacial syndrome, or Kabuki syndrome. These issues can be resolved with partial adenoidectomy or preoperative planning for post-adenoidectomy muscle speech therapy.
- In 10 percent of children with Down syndrome, there is atlantoaxial joint instability. Surgery in the neutral posture or after neurosurgical immobilization may allow the surgery to be performed without causing injury to the patient.
Contraindications for tonsillectomy include the following:
- Bleeding tendency
- high anesthetic risk or uncontrolled medical diseases
- Acute infection
The tonsillectomy equipment required varies depending on the procedure employed. A mouth gag, Allis clamp, scalpel, curved Metzenbaum scissors, Fisher tonsil knife/dissector, tying snares, adenoidectomy curettes, and a St. Clair-Thompson adenoid forceps are used to accomplish a cold tonsillectomy. Monopolar cautery is used to do hot tonsil dissections. Coblation, which is bipolar radiofrequency ablation, is another possibility. Techniques like Microdebrider are also used (especially when performing intracapsular tonsillectomy).
Regardless of the procedure employed, the anesthetic is administered in the same way. The patient is intubated and placed supine. Oral Ring, Adair, and Elwyn (RAE) endotracheal tubes are preferred by the majority of surgeons. At the midpoint of the tube, the tape is applied. After that, the bed is rotated 45 to 180 degrees to enable the surgeon to sit or stand at the edge of the bed, and a shoulder roller is put. A mouth gag keeps the patient's mouth open.
Extracapsular or intracapsular tonsillectomy are both options. In the United States, the "hot" extracapsular method using monopolar cautery is the most prevalent. The tonsil is medialized after the superior tip of the tonsil is gripped with the Allis clamp. Submucosally, the tonsils' lateral margin is recognized. If a standard tip is used, the superior tip is cut with roughly 20W of power. Between the tonsil and the muscles, the avascular plane is discovered. In most cases, the whole palatine tonsil is removed from the superior to inferior tip. Packing, suction, cautery, or sutures are used to maintain hemostasis.
A sharp dissector is used to achieve a cold tonsillectomy. With the Allis clamp, the tonsil is gripped and medialized. A scalpel is used to identify and cut the lateral portion of the tonsil. The avascular plane is then identified using Metzenbaum scissors. Once inside the plane, a Fisher tonsil dissector separates the tonsil from the fossa until just the inferior pole of the tonsil connection remains. The tonsil is then separated from its inferior pole using a snare. Hemostasis is maintained with the use of a tonsil pad, suction, cautery, or sutures.
Coblation, which is comparable to monopolar cautery, can be performed to remove the tonsil. Coblation uses saline irrigation to create an ionized plasma film, which causes tissue to disintegrate molecularly. There is very little heat generated, and this is a frequent method for partial tonsillectomy. A partial tonsillectomy can also be done using a microdebrider.
The benefits of one technique over the other are still a point of contention. Overall, the cost, reduced complication rates (i.e., bleeding risks), time in the operation room, and post-operative pain all influence the advantage of one procedure. "Cold" tonsillectomy is expected to cause less postoperative pain, whereas "hot" tonsillectomy is thought to cause less intraoperative blood loss and surgery time. The procedure chosen is determined by the surgeon's skill and comfort level.
Adenotonsillectomy Side Effects
Following tonsillectomy along with adenoidectomy, hemorrhage is one of the most prevalent and scary consequences. Between 2009 and 2013, research involving over 100,000 children found that about 3 percent of children had unscheduled consultations for hemorrhage after tonsillectomy, 1.7 percent of patients went to the emergency room, and 1 percent required surgery. Variations in circadian rhythm, vibratory effects of snoring on the oropharynx, or dryness of the oropharyngeal mucosa from mouth breathing are suggested to be the causes of increased hemorrhage at night, with 50 percent of hemorrhage happening between 10 pm-1 am. Patients with documented coagulopathy may be at an increased risk of bleeding.
Another common consequence after tonsillectomy is postoperative nausea and vomiting. It affects up to 70 percent of individuals who were not given prophylactic antiemetics. postoperative nausea and vomiting can result in higher admission rates, a greater requirement for intravenous fluids, more pain medication, and lower patient satisfaction. To prevent these complications, a single dose of intraoperative dexamethasone is recommended after tonsillectomy. Because postoperative nausea and vomiting are most prevalent within the first 24 hours after surgery, some practitioners will frequently give a single dose of ondansetron for outpatient procedures.
Pain is the most common cause of morbidity after tonsillectomy, which leads to decreased oral intake, dehydration, difficult swallowing, and weight loss. It is critical that caregivers are capable of recognizing indicators of dehydration and encouraging their kids to keep hydrated. Alternating timed doses of acetaminophen and ibuprofen is one way to reduce oropharyngeal pain.
Tonsillectomy and adenoidectomy can also cause velopharyngeal incompetence. Hyper-nasal speech and food reflux through the nasal passage during eating are two common symptoms.
Advice After Adenotonsillectomy
It's common for your child to have a sore throat. This will get worse approximately three days following the surgery, but it will improve day by day afterward. You must ensure that you have enough pain medication at least for the next seven days. To ensure that your child is comfortable, the pain medication should be administered on a daily basis, including nighttime, for seven days. To make eating and drinking more enjoyable, pain treatment should be given half an hour before meals. It's typical for their tonsils to leave yellow crusts in their throat. These will be present for approximately ten days. Although your child's throat may be painful when they return home, it's critical that you make sure they eat and drink regularly to help the throat recover. The healing tonsil beds shall be kept clean at all times with toast, biscuits, and crisps. For a few days following the surgery, earaches and unpleasant breath are frequent, and your kid may snore for several weeks until the swelling subsides. It's also usual for them to have a congested or clogged nose. For the first few days, your child should relax as much as possible and avoid contact with others who have coughs or a common cold. This is done to avoid infection. They will be required to take two weeks off from school. For the first three weeks after surgery, avoid flying and international travel.
Tonsillectomy or adenotonsillectomy produced an extra, but minor, decrease in bouts of sore throat, days of school absenteeism due to sore throat, and upper respiratory infections when compared to watchful observation. Other studies have found that patients are happier and have a better quality of life overall.
Patients with frequent throat infections were studied by Paradise and colleagues. Tonsillectomy patients had fewer throat infections in the first two years after therapy than non-tonsillectomy patients.
After tonsillectomy, alpha-streptococci levels have been found to rise. This clarifies why tonsillectomy reduces the risk of streptococcal infection including pharyngitis.
According to recent research on the persistence of obstructive sleep apnea disease in children following surgery, adenotonsillectomy improves respiratory disturbances in children with obstructive sleep apnea, although only 25 percent of patients achieve complete normalization. Obesity, which is becoming more common in children, and the apnea-hypopnea index at diagnosis are the key factors of surgical prognosis. The authors emphasized that treating not only the attentional disease but also underlying sleep disorders, which have negative impacts on daytime behavior and concentration, is beneficial in cases with attention-deficit hyperactivity disorder. Finally, research is slowly realizing the high prevalence of obstructive sleep apnea in some groups, such as those with cleft palates.
Future and Controversies
Tonsillectomy research is still important. It is still uncertain whether there is an optimal method of tonsillectomy, whether perioperative corticosteroids are beneficial, and whether outpatient tonsillectomy is acceptable.
Tonsillotomy with lasers may be less painful and effective than tonsillectomy for treating airway blockage caused by enlarged tonsils. Adults can also accomplish that goal by reducing the volume of submucosal tissue with radiofrequency. To demonstrate the efficiency of these strategies, well-designed studies are required.
There is still a need for more research into the effectiveness of tonsillectomy in treating frequent sore throats. Since the original study by Paradise et al, which indicated that tonsillectomy is advantageous in patients with frequent sore throats, there have been no conclusive studies.
Between 1985 and 2006, 155 malpractice complaints were filed after tonsillectomy, according to a survey conducted by 16 medical liability insurance companies. 18 percent of claims were for bleeding issues, while 46 percent were for miscellaneous claims such as uvular injuries and surgical scars. Burn injuries made up 18 percent of all claims. These findings imply that complications other than bleeding, which is traditionally regarded as the most prevalent consequence after tonsillectomy, account for the majority of malpractice claims.
Because of worries of respiratory depression and death, the FDA issued a black box warning against the use of codeine following tonsillectomy. As the opioid epidemic continues, other opiates are being used for tonsillectomy. Regional regulations currently require surgeons to provide 5 to 10 days of opioids, according to the doctor’s medical board.
Tonsillectomy and adenoidectomy were first used to manage Group A beta-hemolytic streptococcal pharyngotonsillitis and its dreaded consequence, rheumatic heart disease, in the early twentieth century. Many children had tonsillectomy and adenoidectomy procedures that were not necessary, due to a negative history of streptococcal disease, but were considered surgical candidates because another family member had a recurrent streptococcal infection or worse.
In children, sleep-disordered breathing has replaced recurrent illness as the most common reason for a tonsillectomy and adenoidectomy. The rate of problems has decreased as surgical and anesthetic procedures have improved. Effective pain management and a reduction in bleeding and dehydration complication rates are among the therapy aim for the future.