Tonsillectomy

Tonsillectomy
Typical appearance of the back of the throat three days post tonsillectomy.
Other names	Adenotonsillectomy, T&A
ICD-9-CM	28.2-28.3
MeSH	D014068
MedlinePlus	003013
[edit on Wikidata]

Tonsillectomy is a

While generally safe, complications may include bleeding, vomiting, dehydration, trouble eating, and trouble talking.^[1] Throat pain typically lasts about one to two weeks after surgery.^[1][4] Bleeding occurs in about 1% within the first day and another 2% after that.^[1] Between 1 in 2,360 and 1 in 56,000 procedures cause death.^[1] Tonsillectomy does not appear to affect long term immune function.^[1][5]

Following the surgery,

Surgery is not recommended for those with fewer than seven documented throat infections in the last year, fewer than five each year for the last two years, or fewer than three each year for three years.[1] Severely affected children who undergo surgery on average have one fewer sore throat per year in the subsequent one or two years, compared to those who do not.^[1][2][19] Specifically one review of five randomized controlled trials, found a decrease from 3.6 to 3.0 episodes in the year following surgery.^[2] In less severely affected children, surgery results in an increase, rather than a decrease of sore throats when the sore throat directly following surgery is included.^[2] Surgery results in a reduction in school absence in the following year, but the strength of evidence is low.^[19] Surgery does not result in an improvement in the quality of life.^[19] Benefits of surgery do not persist over time.^[1][19] Those with frequent throat infections often spontaneously improve over a year without surgery.^[1][2] Therefore, a certain number of people who undergo surgery will do so unnecessarily as they would not have had further episodes of tonsillitis had they not had surgery.^[2] Evidence in adults is unclear.^[2]

In 2019, the

Significant post-operative primary bleeding occurs in 0.2–2.2% of people, and secondary bleeding in 0.1–3.3%.[1] In several reported case series, the rate of post tonsillectomy bleeding ranged from 2.0% to 7.0%.^[23][24][25] Also in veterinary surgery, bleeding was a common complication.^[26] A meta-analysis reported that frequency of bleeding after tonsillectomy across different techniques did not differ.^[25]

It is estimated 1.3% of people will have a delayed discharge (of 4 to 24 hours) due to a complication, and up to 3.9% will require repeat admission to hospital. The main reasons for either keeping a person in hospital, or readmitting them after tonsillectomy are uncontrolled pain, vomiting, fever, or bleeding. Death occurs as a result in between 1 in 2,360 and 56,000 procedures.^[1] Bleeding accounts for one-third of deaths.^[1] As the procedure is done under general anesthesia, there are anesthesia risks.^[1]

Immune system

There is no evidence tonsillectomy affects long term

For the past 50 years at least, tonsillectomy has been performed by dissecting the tonsil from its surrounding

It is not known whether the benefits of subtotal tonsillectomy in obstructive sleep apnea are enduring. But this is also the case for tonsillectomy for sleep apnea. There have been no randomised controlled trials of long term effectiveness of tonsillectomy for sleep apnea.[3]

Methods

The

• Dissection and snare method: Removal of the tonsils by use of a forceps and scissors with a wire loop called a snare was formerly the most common method practiced by
  general anesthesia; the tonsils are completely removed and the remaining tissue surface is cauterized. The patient will leave with minimal post-operative bleeding
  .
• Electrocautery: Electrocautery uses electrical energy to separate the tonsillar tissue and assists in reducing blood loss through cauterization. Research has shown that the heat of electrocautery (400 °C) may result in thermal injury to surrounding tissue
  . This may result in more discomfort during the postoperative period.
• Radiofrequency ablation: Monopolar
  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 tonsillitis
  .
• Coblation tonsillectomy: This surgical procedure is performed using plasma to remove the tonsils. Coblation technology combines radiofrequency energy and saline to create a plasma field. The plasma field is able to dissociate molecular bonds of target tissue while remaining relatively cool (40–70 °C),[38] which results in minimal or no damage to surrounding healthy tissue. A Coblation tonsillectomy is carried out in an operating room setting, with the patient under general anesthesia. Tonsillectomies are generally performed for two main reasons: tonsillar hypertrophy (enlarged tonsils) and recurrent tonsillitis. It has been claimed that this technique results in less pain, faster healing, and less post operative care.^[39] However, review of 21 studies gives conflicting results about levels of pain, and its comparative safety has yet to be confirmed.^[40] 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 vessels but several papers offer conflicting (some positive, some negative) results. More recent studies of coblation tonsillectomy indicate reduced pain and ostalgia;^[41] less intraoperative or postoperative complications;^[42] lesser incidence of delayed hemorrhage, more significantly in pediatric populations,^[43][44][45] less postoperative pain and early return to daily activities, fewer secondary infections of the tonsil bed and significantly lower rates of secondary hemorrhage.^[46] Unlike the electrosurgery procedure, Coblation Tonsillectomy generates significantly lower temperatures on contacted tissue.^[47] Long-term studies seem to show that surgeons experienced with the technique have very few complications.
• kHz. Invisible to the naked eye, the vibration transfers energy to the tissue, providing simultaneous cutting and coagulation
  . The temperature of the surrounding tissue reaches 80 °C. Proponents of this procedure assert that the result is precise cutting with minimal thermal damage.
• 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: When a laser is used to perform tonsillectomy, it can be under local anaesthetic with anaesthetic spray only, called tonsillotomy (or tonsil resurfacing or partial tonsillectomy), or it can be performed under general anaesthetic when it is called intra-capsular tonsillectomy, using an operating microscope for magnification. The carbon dioxide laser in scanning mode is an excellent vapouriser of tissue, and in conjunction with a computerised pattern generator and operating microscope with micromanipulator, it can result in near total removal of tonsil tissue whilst preserving the capsule of the tonsil. This leads to a significantly reduced bleeding and pain rate.
  outpatient procedure. A carbon dioxide laser is commonly used, and is swept over each tonsil 8–10 times. The smoke is aspirated out of the mouth to prevent smoke inhalation. Often, more than one procedure is required, each lasting about 20 minutes. Due to the frequent requirement for multiple sessions, this treatment may work out more expensive than a single session tonsillectomy. A degree of patient compliance is required, making it unsuitable for young children and anxious persons, who risk harm if they move during the procedure.^[49]
• Microdebrider: The microdebrider is a powered rotary shaving device with continuous suction often used during
  sinus 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 muscles, 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.^{[citation needed}
  ]

Medications

A single dose of the corticosteroid drug dexamethasone may be given during surgery to prevent post-operative vomiting.^[50] A dose of dexamethasone during surgery prevents vomiting in one out of every five children. A dose of dexamethasone may help children return to a normal diet more quickly and have less post-operative pain.^[50] Many people are prescribed antibiotics following a tonsillectomy, however, the benefits and potential harms have not been well studied.^[51] Antibiotics are not suggested to be used routinely following tonsillectomy.^[51]

Post-surgery care

A sore throat will persist approximately two weeks following surgery while pain following the procedure is significant and may necessitate a hospital stay.^[52] Recovery can take from 7 to 10 days and proper hydration is very important during this time, since dehydration can increase throat pain, leading to a circle of poor fluid intake.^[53][54] Tonsillectomy appears to be more painful in adults than children.^[55] Controlling the pain following tonsillectomy is important to ensure that people can start eating again normally following the procedure.^[56]

At some point, most commonly 7 to 11 days after the surgery (but occasionally as long as two weeks after), bleeding can occur when scabs begin sloughing off from the surgical sites. The overall risk of bleeding is approximately 1–2%. It is higher in adults, especially males over age 70 and three-quarters of bleeding incidents occur on the same day as the surgery.^[57] Approximately 3% of adults develop bleeding at this time which may sometimes require surgical intervention.

Recommendations for pain management include ibuprofen and paracetamol (acetaminophen).^[1] The opioid codeine is not recommended for those less than 12 years old.^[1] There is a theoretical concern that NonSteroidal Anti-Inflammatory Drugs (NSAIDs) may increase the risk of bleeding but evidence does not support such a risk.^[58] Further research is required to determine if mouth rinses, mouthwashes and sprays help improve recovery following surgery.^[59]

Rates

There are variations in tonsillectomy rates, both between and within countries.^[12][13] In 2015, tonsillectomy rates in the Netherlands, Belgium, Finland and Norway were at least twice those in the UK but rates in Spain, Italy and Poland were at least a quarter lower.^[12] Tonsillectomy rates even vary considerably between neighbouring countries. For example, rates in Croatia are three times those in Slovenia.^[12] Variations between countries may be explained by a lack of or differences between guidelines.^[9] However differences in guidelines cannot explain the seven-fold variation between local authority areas within England.^[13]

In Germany tonsillectomy rates between regions differ by up to a factor of 8.^[9] A 2010 study in England found the annual tonsillectomy rate per 100,000 between 2000 and 2005 was 754 in the highest region, the national average was 304 and the lowest region was 102.^[13] This means there is a seven-fold difference between the region with the highest tonsillectomy rate and the region with the lowest one.^[13] In 2006, English Chief Medical Officer Liam Donaldson revealed that unnecessary tonsillectomies and unnecessary hysterectomies combined cost the British National Health Service 21 million pounds a year.^[60]

The rise in adenotonsillectomies for sleep apnea in the USA has been greater than the decline in tonsillectomies for sore throat.^[61]

Evidence-based indications

In 2018, a study of the medical records of 1.6 million UK children found 15,760 had sufficient sore throats to justify tonsillectomy and 13.6% (2,144) underwent surgery.^[62] The same study found 18,281 children who had undergone tonsillectomy, and of these only 11.7% (2,144) had evidence-based indications (i.e. frequent enough sore throats to justify surgery).^[62] The majority of tonsillectomies were undertaken for indications which did not have an evidence-base: five to six sore throats in one year (12.4%), two to four sore throats in one year (44.6%), sleep disordered breathing (12.3%), or obstructive sleep apnoea (3.9%).^[62] In the UK therefore, most children who undergo tonsillectomy probably do not benefit and most children who might benefit do not undergo tonsillectomy.^[62] The study concluded that 32,500 (close to 90%) out of the 37,000 children who have their tonsils removed annually "are unlikely to benefit" and that surgery therefore may do more harm than good to those children.^[62] Tonsillectomy rates are lower in the UK than in most other western European countries.^[12]

Table: Numbers of children (from 1.6 million children between 2005 and 2016 in the UK) identified with possible indications for tonsillectomy and the numbers who subsequently undergo tonsillectomy.

Condition which might be considered an indication for tonsillectomy	Number of children consulting with this indication	Proportion with this indication undergoing tonsillectomy	Proportion of all tonsillectomies attributable to this indication
Tonsillar tumour	5	0%	0.0%
Aphthous stomatitis, pharyngitis & cervical adenitis syndrome	435	3.4%	0.1%
Paradise criteria	15,320	13.9%	11.6%
Obstructive sleep apnoea	3,185	22.2%	3.9%
Other sleep disordered breathing	15,205	14.8%	12.3%
Peritonsillar abscess	675	14.8%	0.5%
Recurrent sore throats / tonsillitis (episodes per year):
5 to 6	25,420	8.9%	12.4%
3 to 4	170,687	3.2%	30.1%
2 to 4 with guttate / chronic psoriasis	939	3.7%	0.2%
2 to 4 with glomerulonephritis	148	4.7%	0.0%
2	251,247	1%	14.3%
1	446,275	0.4%	9.9%
No indication identified	701,266	0.1%	4.7%
Total	1,630,807	1.1%	100.0%

Source: Šumilo et al. 2018^[62]

Financial incentives

According to a study from 2009, surgery rates on average increase by 78% when surgeons are paid fee-for-service reimbursements instead of a fixed salary.^[63] Regarding tonsillectomy, a 1968 Canadian study pointed out that ENT specialists working on a fee-for-service programme were twice as likely to perform a tonsillectomy than those who were not.^[64][65] In 2009 then US President Obama remarked:

Right now, doctors, a lot of times, are forced to make decisions based on the fee payment schedule that's out there. So if they're looking and – and you come in and you've got a bad sore throat, or your child has a bad sore throat, or has repeated sore throats, 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." Now, that may be the right thing to do. But I'd rather have that doctor making those decisions just based on whether you really need your kid's tonsils out or whether it might make more sense just to change – maybe they have allergies. Maybe they have something else that would make a difference.^[66]

History

Tonsillectomies have been practiced for over 2,000 years, with varying popularity over the centuries.

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.^[67]

The

Dionis (1672) and Lorenz Heister censured the procedure.^{[citation needed}

]

In 1828, physician Philip Syng Physick modified an existing instrument originally designed by Benjamin Bell for removing the uvula; the instrument, known as the tonsil guillotine (and later as a tonsillotome), became the standard instrument for tonsil removal for over 80 years.^[67] 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 eventually fell out of favor in America.^[67]

In the beginning of the 20th century, tonsillectomy became more common in the United Kingdom and the United States and by the 1930s was very common in both countries.

bulbar poliomyelitis.^[68] From the 1940s to 1970s, further studies found an association between tonsillectomy and bulbar poliomyelitis with recommendations not to do the operation during outbreaks.^{[71][72][73][74]} Controversy surrounding tonsillectomy increased further in the United Kingdom in the 1960s because of the financial costs associated with the number of surgeries being performed and because of unexplainable variations in tonsillectomy rates between geographic regions and between social classes.^[68] In the media, tonsillectomy was criticised for being "fashionable" or a "status symbol".^[68] There was also an increasing concern regarding the psychological and physical suffering of young children as a result of surgery.^[70] Furthermore, opponents of surgery argued that the tonsils should be retained whenever possible because of their role in the immune system and that the benefits of surgery were marginal.^[70] In the 1970s, tonsillectomy rates in the United Kingdom started to decline after several studies concluded that tonsillectomy was not as effective for sore throats and many other indications as previously thought.^[68]

Tonsillectomy rates in the United States have declined since 1978, when experts of the National Institutes of Health concluded that there was insufficient evidence that the benefits of tonsillectomy outweighed the risks and therefore recommended more research, which subsequently led to stricter guidelines.^[69]

As doctors took a more conservative approach towards tonsillectomy, parental pressure became one of the most important reasons for surgery.^[70]

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External links

Wikimedia Commons has media related to Tonsillectomy.

• Tonsillectomy Procedures Archived 5 July 2008 at the Wayback Machine
• History of tonsillectomy
• "Clinical UM Guideline CG-SURG-30: Tonsillectomy for Children". Blue Cross Blue Shield Association of Georgia.