10

A Review of Tonsillectomy Techniques and

Technologies
S. K. Aremu
Federal Medical Centre, Azare, Bauchi State,
Nigeria
1. Introduction
1.1 Anatomy
The circular band of lymphoid tissue within the pharynx consisting of the adenoids, the
palatine tonsils (Figure 1), and lingual tonsils is known as Waldeyers ring. The palatine
tonsils are lymphoid tissue with prominent germinal centers and the palatine tonsils, in
contrast to the lingual tonsils and adenoids, have a distinct capsule1which separates the
tonsils from the lateral pharyngeal walls. The tonsil lies within a bed of three muscles that
make up the tonsillar fossa. Forming the anterior pillar is the palatoglossus muscle and the
posterior pillar is the palatopharyngeus muscle, while the superior constrictor muscle makes
up the bed of the fossa. Medially, the tonsil crypts lay exposed to the oropharynx with
specialize stratified squamous epithelium.
The tonsils are well vascularized with the majority of the blood supply arising from the
tonsillar branch of the facial artery.1The nerve supply of the tonsils arise from the ninth
cranial nerve and descending branches from the lesser palatine nerves and the tympanic
branch of CN IX is thought to account for the referred ear pain found in some cases of
tonsillitis. The tonsils have no afferent lymphatic vessels. Their efferent lymph drainage is
through the upper cervical nodes, especially to the jugulodigastric group. Tonsils and
adenoids are immunologically most active between the ages of 4 and 10 years, and tend to
involutes after puberty.2

Fig. 1. Orophaynx with Palatine Tonsils.

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1.2 Indications for tonsillectomy

1.2.1 Absolute3
1.
2.
3.
4.
5.

Obstructive sleep apnea

Cardiopulmonary complications secondary to airway obstruction (e.g., cor pulmonale,
alveolar hypoventilation)
Suspected malignancy (asymmetric Tonsillar Hypertrophy) 4
Hemorrhagic tonsillitis
Tonsillitis causing febrile seizures
3

1.2.2 Relative
1.

2.
3.

Recurrent acute tonsillitis meeting one or more of the following criteria:

Seven episodes in 1 year

Five episodes/year for 2 consecutive years

Three episodes/year for 3 consecutive years

Two weeks of missed school or work in 1 year

Chronic tonsillitis refractory to antimicrobial therapy
Tonsillolithiasis with associated halitosis and pain, unresponsive to conservative
measures

Peritonsillar abscess

Dysphagia due to tonsillar hypertrophy.

The indications for tonsillectomy have dramatically changed and are today more clearly
defined. Geographical variations in the incidence of tonsillectomy are recognized and,
although most of this variation may only reflect varying attitudes between physicians, there
is little doubt that geographical variations in pathology are partly responsible5.In adults, the
most common indication is recurrent acute tonsillitis5. However the most common
indication in children is obstructive sleep apnea. Patients with a prior history of recurrent
tonsillitis and prior peritonsillar abscess may be more likely to develop another peritonsillar
abscess and are candidates for tonsillectomy.

2. History
Tonsillectomy has been performed by otolaryngologists, general surgeons, family
practitioners and general practitioners. However, in the past 30 years the recognition for the
need of standardization of surgical technique resulted in a shift in practice patterns so that it
is almost exclusively performed by the otolaryngologists.
The first known removal of tonsils dates back to the first century AD, when Cornelius
Celsius in Rome used his own finger to perform it6.The earliest description of the procedure
was by Paul of Aegina in 625. The early instruments that were used for tonsillectomy were
actually first developed for removal of the uvula. Phillip Syng invented what would become
the forerunner for the modern tonsillotome.Not until the mid 18th century did Caque of
Rheims performs tonsillectomies on a regular basis. Since then several different techniques
have been used for tonsillectomy.

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However, the difficulties encountered by surgeons, especially in controlling the perioperative bleeding, were a major drawback .It was only 1909,when Cohen adopted suture
ligation of bleeding vessels to control the hemorrhage, that tonsillectomy became a common
practice in hospitals 7.
Sixty years later Haase and Noguera8, introduced the use of diathermy and the concept of
electro-dissection was first described by Goycolea6 in 1982 using monopolar diathermy.10
years later Pang9 reported the first electro-dissection tonsillectomy using the bipolar forceps
technique.

3. Preoperative evaluation
Adequate history and physical examination are essential in the preoperative diagnosis and
evaluation of the patient being worked up for tonsillectomy. History alone is the most
common method for diagnosing obstructive sleep apnea.10 When the diagnosis is at all in
question, the child is younger than 2 years, or there is concern about the severity of the sleep
apnea, a polysomnogram should be recommended.11Preoperative electrocardiogram and
chest x-ray are not necessary unless there is a history of heart disease.12 Other preoperative
evaluation needs to be decided based on the medical conditions of each individual patient.
For example, a child with von Willebrand disease should have the input of a hematologist
regarding the use of desmopressin to minimize the risk of bleeding during the intraoperative and post-operative periods.

4. General technique
4.1 Exposure
For a successful surgery, adequate exposure, of the oro-pharyn must be achieved. Also
knowledge of the relevant anatomy and tissue tension is important. With the aid of a mouth
gag, e.g, Boyle -Davis (Figure 2), the oropharynx is exposed. Dentition may be protected by
a plastic or rubber athletic mouth guard and careful mouth gag placement. Care is taken not
to allow the lateral anges of the tongue blade of the gag to scratch dental enamel.
Protection of the mucosa from electrical and thermal conductivity is achieved by interposing
a gloved nger between the instrument metal and the patient.13

Fig. 2. Open-sided mouth gag (Davis Mouth Gag).

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Otolaryngology

4.2 Surgical procedure

The method anesthesia induction and patients positioning is similar for most patients
undergoing tonsillectomy, regardless of which technique is used to remove the tonsils. The
patient is placed in the supine position and orally intubated.The endotracheal tube is taped
to the patients chin in the midline. Alternatively, some practitioners prefer to use a
laryngeal mask airway.14,15The bed is turned 90-180 so that the surgeon can sit or stand at
the head of the bed. The patient is positioned at the edge of the bed, and a small shoulder
roll is placed. Either a Crowe-Davis, McIvor, or Dingman mouth gag is inserted and
expanded to keep the mouth open for the duration of the procedure.Tissue tension during
complete tonsillectomy is achieved by strong medial traction of Allis clamps and torsion of
the tonsils medially (Figure 3).
The tonsils are then removed using 1 of the techniques described later.

Fig. 3. Medial Traction on the Tonsil.

5. Patients and methods

50 patients (30 males, 20 females) were studied. 28(56%) had adenotonsillectomy, while
22(44%) had only tonsillectomy alone. The data was obtained by the author from three
centres:University of Ilorin teaching hospital, Kwara state, IBB specialized hospital Minna,
Niger state and Federal medical centre, Azare, Bauchi state.
35(70%) of the surgeries were performed using cold surgical dissection technique, while
15(30%) were done using bipolar electrocautry. All the surgeries were performed by one of
two experienced surgeons. All the children were kept overnight; some were discharged the
following day after they can tolerate liquid diet. Routine antibiotics and analgesics were
given to all the patients.
For the 28 patients who had adenotonsillectomy, the mean operating time for the 8 bipolar
electrocautries was 42.0 minutes and 47.2 minutes for the 20 cold dissection patients.
For the 22 patients who had tonsillectomy alone, the mean operating time was 31.4 minutes
for the 7 bipolar electrocautries, while 34.2 minutes for the 15 cold dissections.
Complication of hemorrhage were seen in 3(6.0%) of all the patients, 2(66.7) were in cold
dissection group and 1(33.3%) in bipolar electrocautry group.

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6. Techniques and technologies

The techniques of Tonsillectomy can be broadly divided into 2 major categories:
extracapsular (total tonsillectomy, subcapsular) and intracapsular (partial tonsillectomy).
Intracapsular is also known as subtotal, and this procedure is referred to as tonsillotomy
in some literatures. Extracapsular tonsillectomy involves dissecting lateral to the tonsil in
the plane between the tonsillar capsule and the pharyngeal musculature, and the tonsil is
generally removed as a single unit. Partial tonsillectomy, or tonsillotomy, involves removal
of most of the tonsil, while preserving a rim of lymphoid tissue and tonsillar capsule in the
most recent iteration of this older technique.16 Preservation of this margin of tissue, this
biologic dressing, may promote an easier recovery, with lower hemorrhage rates and
better recovery of diet and activity reported in comparison with traditional monopolar
tonsillectomy techniques.17,18The most common extracapsular techniques use a cold knife
(sharp dissection), monopolar electrocautery, bipolar cautery (or bipolar scissors),or
harmonic scalpel. Intracapsular techniques may use the microdebrider, bipolar
radiofrequency ablation (which can also be used to remove the entire tonsil), and carbon
dioxide laser. Either extracapsular or intracapsular tonsillectomy can be performed for the
pediatric patient with obstructive sleep apnea, but only extracapsular techniques should be
used for patients undergoing tonsillectomy as a result of tonsillitis or peritonsillar abscess.
In addition, tonsils can be ablated using a laser or monopolar radiofrequency (somnoplasty)
in a cooperative adult in a clinic setting.

7. Cold knife
A frequently used method for total tonsillectomy is thecoldor sharp dissection
technique. In this technique, the tonsil and capsule are dissected from surrounding tissue
using scissors, knife, or t dissector (Figure 4) and the inferior pole is amputated with a
tonsil snare.

Fig. 4. Tonsil Dissector.

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8. Harmonic scalpel
The harmonic scalpel (Figure 5) can be used to perform an extracapsular tonsillectomy
(Ethicon Endo-Surgery Inc, Cincinnati, OH).It uses ultrasonic energy to vibrate its blade at
55,000 cycles per second. The vibration transfers energy to the tissue, providing
simultaneous cutting and coagulation, so, typically, no additional instrument is needed for
haemostasis. The components of the device include a generator, a hand piece, and a
disposable blade. A high-frequency power supply provides energy to the hand piece. The
blade oscillations dissect tissues by creating intra-cellular cavities as pressure waves are
conducted through the tissues. The expansion and contraction of these cavities results in the
lysis of cellular connections, resulting in tissue dissection.

Fig. 5. Harmonic/ultrasonic scalpel.

9. Bipolar radiofrequency ablation

Bipolar radiofrequency ablation can be used to perform an extracapsular or intracapsular
tonsillectomy; however, it is most commonly used to perform a partial tonsillectomy (Figure
6). The equipment includes a radiofrequency generator, foot control, saline irrigation
regulator, and the coblation wand (PlasmaCare Corp, Sunnyvale, CA). During a bipolar
radiofrequency ablation tonsillectomy, conductive saline solution is converted into an
ionized plasma layer, resulting in molecular dissociation with minimal thermal energy
transfer. Haemostasis can usually be performed with the coblation wand alone.

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167

Fig. 6. Bipolar Probe.

10. Microdebrider tonsillectomy

This is another method for intracapsular tonsillectomy. The microdebrider is a powered
rotary shaving device with continuous suction, made up of a tube, and connected to a hand
piece, which, in turn, is connected to a motor with foot control and a suction device. A
partial tonsillectomy is completed with the removal of approximately 90% to 95% of the
tonsil, while preserving the tonsillar capsule.

11. Advantages and disadvantages of the techniques

There is great debate about the relative merits of the various tonsillectomy techniques
published in many studies, with many more ongoing that compare the techniques. The
existing literature consistently reports that the intracapsular (partial) techniques result in
less postoperative pain, however, the degree of lessened pain continues to be much
debated.19,20,21In addition; there is a small risk of tonsil regrowth and the necessity for an
additional procedure with the intracapsular techniques. Of the extracapsular techniques,
cold tonsillectomy results in less postoperative pain compared with an electrocautery or
hot tonsillectomy; however, the latter procedure is typically faster and has less
intraoperative blood loss.22,23,24 Although not extensively researched thus far, a total
tonsillectomy with the coblation unit may have slight advantages over electrocautery
tonsillectomy.25 The studies on outcomes of surgeries completed with the harmonic scalpel
do not show any denitive advantage to the scalpel.26,27 It is not clear which technique, if
there is one, results in the lowest rate of postoperative hemorrhage.28,29
Most of the data available to date suggest that there is no difference in the bleeding rates
between extracapsular and intracapsular tonsillectomy.30The equipment involved with
various techniques varies in price, although the largest cost factor in any tonsillectomy is the
operating time.

12. Postoperative care

A majority of children can safely be discharged home on the same day of surgery, regardless
of the surgical technique used.10,30Children younger than 2 years or who live far from a
hospital should be kept overnight for observation. Pain medication should be
recommended, and most physicians prescribe either acetaminophen or acetaminophen with
codeine postoperatively.31 Some physicians recommend a soft diet postoperatively, others
recommend diet as tolerated.10 In our centres we commence the child on firstly on cold ice
cream and subsequently on liquid diet.
Studies have not shown any difference in recovery between children who have a restricted
versus those who have non-restricted diets postoperatively.32,33

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13. Long-term follow-up

Typically, the patient will be seen in the office in 2 weeks, then 1 month of the tonsillectomy
to conrm adequate healing, although it is also acceptable to follow-up with a phone call
only.10,34

14. Conclusions
Appreciation of the indications and the use of new tonsillectomy techniques and
technologies, as well as an awareness of the economic ramications of their adoption, will
ultimately provide the best care for tonsillectomy patients.

15. References
[1] Casselbrant ML: What is wrong in chronic adenoiditis/tonsillitis anatomical
considerations? Int J Pediatr Otorhinolaryngol 49:S133-135,1999.
[2] Richtsmeier WJ, Shikhani AH. The physiology and immunology of the pharyngeal
lymphoid tissue. Otolaryngol Clin North Am 20(2):219-28, May 1987.
[3] Paradise JL: Tonsillectomy and adenoidectomy. In Bluestone CD, Stool SE, Alper
CM,et al (eds): Pediatric Otolaryngology 4th ed. Philadelphia,W.B Saunders:12101222, 2002.
[4] Hoddeson EK, Gourin CG: Adult Tonsillectomy: Current Indications and Outcomes
Otolaryngol Head Neck Surg 140(1):19-22, jan 2009.
[5] B.C.Okafo. Tonsillectomy: An Appraisal of Indications in Developing Countries.
Laryngoscope 96(5 & 6 ):517 -522,July 1983.
[6] J. McAuliffe-Curtain, The history of tonsil and adenoid surgery. Otolaryngol. Clin. North
Am. 20:415419,1987.
[7] H. Feldman, Two hundred year history of tonsillectomy. Images from the history of
otorhinolaryngology, highlighted by instruments from the collection of the German
Medical History Museum in Ingolstadt. Laryngorhinootologie 76:751760, 1997.
[8] F.R. Haase and J.T. Noguera, Hemostasis in tonsillectomy. Arch. Otolaryngol. 75:125,
1962.
[9] Y.T. Pang, H. El-Hakim and M.P. Rothera, Bipolar diathermy tonsillectomy. Clin.
Otolaryngol.19:355357, 1992.
[10] Kay DJ, Mehta V, Goldsmith AJ: Perioperative adeno-tonsillectomy management in
children:Current practices. Laryngoscope 113:592-597,2003.
[11] Messner AH: Evaluation of obstructive sleep apnea by polysomnography prior to
pediatric adenotonsillectomy. Arch Otolaryngol Head Neck Surg 125:353-356, 1999.
[12] James AL, Runciman M, Burton MJ, et al: Investigation of cardiac function in children
with suspected obstructive sleep apnea. J Otolaryngol 32:151-154, 2003.
[13] Shah UK: Letter to editor, A simple suggestion to reduce perioral burns during
adenotonsillectomy,inre:NauraMJ et al.Perioral burns after adenotonsillectomy.
Arch Otolaryngol Head Neck Surg 134:673,2008.
[14] Hatcher IS,Stack CG:Postal survey of the anaesthetic techniques used for paediatric
tonsillectomy surgery. Paediatr Anaesth 9:311-315,1999.

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[15] Hern JD, Jayaraj SM, Sidhu VS, et al: The laryngeal mask airway in tonsillectomy: The
surgeons perspective. Clin Otolaryngol 24:122-125, 1999.
[16] Koltai PJ, Solares CA, Mascha EJ, et al: Intracapsular partial tonsillectomy for tonsil
hypertrophy in children. Laryngoscope 112:17-19, 2002.
[17] Solares CA, Koempel JA, Hirose K, et al: Safety and efcacy of powered intracapsular
tonsillectomy in children: A multi-center retrospective case series. Int J Pediatr
Otorhinolaryngol 69:21-26, 2005.
[18] Schmidt R, Herzog A, Cook S, et al: Complications of tonsillectomy: A comparison of
techniques. Arch Otolaryngol Head Neck Surg 133:925-928, 2007.
[19] Chan KH, Friedman NR, Allen GC, et al: Randomized, controlled, multisite study of
intracapsular tonsillectomy using low-temperature plasma excision. Arch
Otolaryngol Head Neck Surg 130:1303-1307, 2004.
[20] Chang K: Randomized controlled trial of Coblation versus electrocautery tonsillectomy.
Otolaryngol Head Neck Surg 132:273-280, 2005.
[21] Hall MDJ, Littleeld CPD, Birkmire-Peters DP, et al: Radiofrequency ablation versus
electrocautery in tonsillectomy. Otolaryngol Head Neck Surg 130:300-305, 2004.
[22] Leinbach RF, Markwell SJ, Colliver JA, et al: Hot versus cold tonsillectomy: A
systematic review of the literature. Otolaryngol Head Neck Surg 129:360-364, 2003.
[23] Hanasono MM, LalakeaML, Mikulec AA,etal: Perioperative steroids in tonsillectomy
using electrocautery and sharp dissection techniques. Arch Otolaryngol Head Neck
Surg 130:917-921, 2004.
[24] Perkins J, Dahiya R: Microdissection needle tonsillectomy and postoperative pain: A
pilot study. Arch Otolaryngol Head Neck Surg 129:1285-1288, 2003.
[25] Stoker KE, Don DM, Kang DR, et al: Pediatric total tonsillectomy using coblation
compared to conventional electrosurgery: a prospective,controlled single-blind
study. Otolaryngol Head Neck Surg 130:666-675, 2004.
[26] Shinhar S, Scotch BM, Belenky W, et al: Harmonic scalpel tonsillectomy versus hot
electrocautery and cold dissection: An objective comparison. Ear Nose Throat J
83:712-715, 2004.
[27] Willging JP,Wiatrak B:Harmonic scalpel tonsillectomy in children:A randomized
prospective study. Otolaryngol Head Neck Surg 128: 318-325, 2003.
[28] OLeary S, Vorrath J: Postoperative bleeding after diathermy hage:Cold versus hot
dissection.Otolaryngol Head Neck Surg131:833-836,2004.
[29] Lee MS, Montague ML, Hussain SS: Post-tonsillectomy hemorrhage:Cold versus hot
dissection.Otolaryngol Head Neck Surg131:833-836,2004.
[30] Mills N, Anderson BJ, Barber C, et al: Day stay pediatric tonsillectomyA safe
procedure. Int J Pediatr Otorhinolaryngol 68:1367-1373,2004.
[31] Moir MS, Bair E, Shinnick P, et al: Acetaminophen versus acetaminophen with codeine
after pediatric tonsillectomy. Laryngoscope 110: 1824-1827, 2000.
[32] Brodsky L, Radomski K, Gendler J: The effect of post-operative instruction on recovery
after tonsillectomy and adenoidectomy. In J Pediatr Otorhinolaryngol 25:133140,1993

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[33] Hall MD, Brodsky L: The effect of post-operative diet on recovery in the rst twelve
hours after tonsillectomy and adenoidectomy. Int J Pediatric Otorhinolaryngol
31:215-220, 1995.
[34] RosbeKW,JonesD,JalisiS,etal:Efcacy of postoperative follow-up telephone calls for
patients who underwent adenotonsillectomy. Arch Otolaryngol Head Neck Surg
126:718-721, 2000.

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Otolaryngology

Edited by Prof. Balwant Singh Gendeh

ISBN 978-953-51-0624-1
Hard cover, 198 pages
Publisher InTech

Published online 23, May, 2012

Published in print edition May, 2012

This book emphasizes on different aspects of otolaryngology - the medical sciences of diagnosis and
treatment of ENT disorders. "Otolaryngology" is divided into various clinical sub-specialities, namely otology,
rhinology, laryngology, and head and neck. This book incorporates new developments, as well as future
perspectives in otolaryngology. I would like to dedicate this book to those of you who will pick up the torch and
by continued research, close clinical observation and the highest quality of clinical care, as well as by
publication and selfless teaching, further advance knowledge in otolaryngology from this point forward. It is
intended to be a guide to other books to follow. Otolaryngologists, researches, specialists, trainees, and
general practitioners with interest in otolaryngology will find this book interesting and useful.

How to reference

In order to correctly reference this scholarly work, feel free to copy and paste the following:
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Singh Gendeh (Ed.), ISBN: 978-953-51-0624-1, InTech, Available from:
http://www.intechopen.com/books/otolaryngology/a-review-of-tonsillectomy-techniques-and-technologies

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