Tonsillectomy is one of the most common surgical procedures performed in children in the United States. Indications and recommendations for perioperative management are multiple and may vary among clinicians. Although tonsillectomy is a safe procedure, it can be associated with morbidity. Several techniques have been developed to reduce perioperative complications, but evidence of this reduction is lacking. This article provides clinicians with evidence-based guidance on perioperative clinical decision making and surgical technique for tonsillectomy.
The following points are expanded at the conclusion of this article and additional critical points are presented.
- •
Gaps in knowledge about perioperative management for tonsillectomy in children remain.
- •
Outcome measures in sleep-disordered breathing and recurrent throat infections should focus on not only recurrence of disease but also quality of life and school performance as indicators of well-being.
- •
No consensus exists on indications for a preoperative polysomnogram in children without comorbidities. Currently, physicians are recommended to advocate for polysomnogram in patients with sleep-disordered breathing without comorbidities if the need for surgery is uncertain or in the presence of discordance between symptoms and physical examination.
- •
Reported success rates of tonsillectomy for sleep-disordered breathing in obese children are 10% to 20%; in normal-weight children they are 70% to 80%.
- •
Current guidelines do not recommend specific tonsillectomy techniques.
- •
The development of intracapsular tonsillectomy represents a different surgical strategy rather than a different instrumental technique that, with further study, could lead to new recommendations.
Overview
Tonsillectomy is one of the most common surgical procedures performed in children in the United States, with more than 530, 000 procedures performed annually. Tonsillectomy is defined as a surgical procedure that removes the tonsil. Removal of the tonsil may be specified as complete, through dissecting the peritonsillar space between the tonsil capsule and the muscular wall, or partial, through removing a varying amount of tonsillar tissue intracapsularly or subcapsularly. Although tonsillectomy is a common procedure, it is associated with morbidity, including anesthesia risks, throat pain, and postoperative bleeding, which may result in admission for observation or further surgery to control bleeding. These and rarer complications have been well described and should be taken into account when considering surgery in children.
This article provides an evidence-based perspective on perioperative clinical decision making and surgical technique for tonsillectomy.
Evidence-based clinical assessment
Indications for Tonsillectomy
Indications for tonsillectomy are multiple, the most common and generally accepted of which are sleep-disordered breathing (SDB) and recurrent throat infections, with a gradual incidence shift toward SDB over the past 2 decades.
SDB is now the single most common indication for tonsillectomy with or without adenoidectomy; SDB constitutes a range of disorders increasing in severity from snoring and restless sleep to obstructive sleep apnea (OSA). SDB has a multifactorial etiology, and hypertrophic tonsils are usually a contributing factor. A recent meta-analysis has shown that tonsillectomy is effective for treating SDB in children with tonsillar hypertrophy, and a recent clinical practice guideline recommends tonsillectomy in children with tonsil hypertrophy who have a polysomnography indicative of SDB. Success rates are significantly lower for tonsillectomy in obese children with SDB.
Throat infections are defined as episodes of sore throat caused by viral or bacterial infection of the pharynx, palatine tonsils, or both, and include a variety of terms, such as tonsillitis, pharyngitis, and strep throat. Throat infections may be documented for each episode of sore throat with one or more of the following: temperature higher than 38.3°C, cervical adenopathy, tonsillar exudates, or positive test for group A β-hemolytic streptococci.
The actual benefit of tonsillectomy compared with observation in children with throat infections remains a subject of controversy. In 1984, a randomized controlled trial by Paradise and colleagues showed a reduction in frequency and severity of infections in severely affected children with recurrent throat infections in the 2 years after tonsillectomy. In moderately affected children, the same group found only a modest benefit of tonsillectomy, which the authors believed was not sufficient to outweigh the risks, morbidity, and costs of surgery. A recent clinical practice guideline recommended tonsillectomy in children with recurrent throat infections with a frequency of at least seven episodes in the prior year, at least five episodes per year in the prior 2 years, or at least three episodes per year in the prior 3 years. Although the guideline recommended watchful waiting for recurrent throat infections with a lesser frequency, tonsillectomy is recommend in children with fewer throat infections if they exhibit modifying factors, such as multiple antibiotic allergy or intolerance, a combination of periodic fever, aphthous stomatitis, pharyngitis, and adenitis (PFAPA), or a history of peritonsillar abscess.
Other rarer indications for surgery include orthodontic concerns, tonsiliths, halitosis, and chronic tonsillitis, all for which substantial evidence is currently not available or of lesser quality.
Clinical Assessment of Tonsils
Careful history taking is vital and should include symptoms of
- •
Throat infections
- •
Snoring
- •
Apneas
- •
Restless sleep
- •
Nocturnal enuresis
- •
Somnolence
- •
Growth retardation
- •
Poor school performance
- •
Behavioral problems
- •
Attention deficit hyperactivity disorder
Physical examination should focus on the anatomy, which includes the size of the tonsils in relation to the position and size of the palate, tongue, and chin. Tonsil size is currently identified using a tonsil grading scale, with tonsillar hypertrophy defined as 3+ or 4+. An important limitation of this grading system is that it does not provide a three-dimensional assessment of tonsil size, which would be more accurate in quantifying tonsillar hypertrophy. A previous study has shown that tonsillar size alone does not correlate with the severity of SDB, but the combined volume of the tonsils and the adenoids do correlate more closely with SDB severity.
Polysomnography
Unfortunately, neither history nor physical examination alone can reliably predict the presence or severity of SDB. Currently, polysomnography is the gold standard for diagnosing and quantifying SDB in children, and can be a useful diagnostic tool before tonsillectomy. Polysomnography is the electrical recording of physiologic variables during sleep, including gas exchange, respiratory effort, airflow, snoring, sleep stage, body position, limb movement, and heart rhythm. Not only does polysomnography identify the presence of SDB, it also helps define its severity and may serve as an aid in perioperative planning and assessing the risk of postoperative complications.
Since 2002, the American Academy of Pediatrics has recommended overnight polysomnography in all children with suspected SDB to confirm diagnosis. A recent clinical practice guideline on polysomnography in children recommended referral for polysomnography in children with SDB before tonsillectomy if they exhibited one of the following comorbid conditions :
- •
Obesity
- •
Down syndrome
- •
Craniofacial abnormalities
- •
Neuromuscular disorders
- •
Sickle cell disease
- •
Mucopolysaccharidosis
In these children, polysomnography helps determine the need for postoperative pulse oximetry and admission. The same guideline recommends polysomnography before tonsillectomy in children without any of the aforementioned comorbidities, but only if the need for surgery is uncertain or in the presence of discordance between the clinical history and/or tonsillar size on physical examination and the reported severity of SDB.
Polysomnography may be performed in a sleep laboratory or in an ambulatory setting, the latter being referred to as portable monitoring (PM). Because of the cost and inconvenience of laboratory-based polysomnography, several forms of PM have developed, but few devices have been tested in children, and substantial evidence for this method is lacking. Laboratory-based polysomnography is currently the gold standard for evaluation of SDB in children and is recommended in children for whom polysomnography is indicated to assess SDB before tonsillectomy.
Evidence-based clinical assessment
Indications for Tonsillectomy
Indications for tonsillectomy are multiple, the most common and generally accepted of which are sleep-disordered breathing (SDB) and recurrent throat infections, with a gradual incidence shift toward SDB over the past 2 decades.
SDB is now the single most common indication for tonsillectomy with or without adenoidectomy; SDB constitutes a range of disorders increasing in severity from snoring and restless sleep to obstructive sleep apnea (OSA). SDB has a multifactorial etiology, and hypertrophic tonsils are usually a contributing factor. A recent meta-analysis has shown that tonsillectomy is effective for treating SDB in children with tonsillar hypertrophy, and a recent clinical practice guideline recommends tonsillectomy in children with tonsil hypertrophy who have a polysomnography indicative of SDB. Success rates are significantly lower for tonsillectomy in obese children with SDB.
Throat infections are defined as episodes of sore throat caused by viral or bacterial infection of the pharynx, palatine tonsils, or both, and include a variety of terms, such as tonsillitis, pharyngitis, and strep throat. Throat infections may be documented for each episode of sore throat with one or more of the following: temperature higher than 38.3°C, cervical adenopathy, tonsillar exudates, or positive test for group A β-hemolytic streptococci.
The actual benefit of tonsillectomy compared with observation in children with throat infections remains a subject of controversy. In 1984, a randomized controlled trial by Paradise and colleagues showed a reduction in frequency and severity of infections in severely affected children with recurrent throat infections in the 2 years after tonsillectomy. In moderately affected children, the same group found only a modest benefit of tonsillectomy, which the authors believed was not sufficient to outweigh the risks, morbidity, and costs of surgery. A recent clinical practice guideline recommended tonsillectomy in children with recurrent throat infections with a frequency of at least seven episodes in the prior year, at least five episodes per year in the prior 2 years, or at least three episodes per year in the prior 3 years. Although the guideline recommended watchful waiting for recurrent throat infections with a lesser frequency, tonsillectomy is recommend in children with fewer throat infections if they exhibit modifying factors, such as multiple antibiotic allergy or intolerance, a combination of periodic fever, aphthous stomatitis, pharyngitis, and adenitis (PFAPA), or a history of peritonsillar abscess.
Other rarer indications for surgery include orthodontic concerns, tonsiliths, halitosis, and chronic tonsillitis, all for which substantial evidence is currently not available or of lesser quality.
Clinical Assessment of Tonsils
Careful history taking is vital and should include symptoms of
- •
Throat infections
- •
Snoring
- •
Apneas
- •
Restless sleep
- •
Nocturnal enuresis
- •
Somnolence
- •
Growth retardation
- •
Poor school performance
- •
Behavioral problems
- •
Attention deficit hyperactivity disorder
Physical examination should focus on the anatomy, which includes the size of the tonsils in relation to the position and size of the palate, tongue, and chin. Tonsil size is currently identified using a tonsil grading scale, with tonsillar hypertrophy defined as 3+ or 4+. An important limitation of this grading system is that it does not provide a three-dimensional assessment of tonsil size, which would be more accurate in quantifying tonsillar hypertrophy. A previous study has shown that tonsillar size alone does not correlate with the severity of SDB, but the combined volume of the tonsils and the adenoids do correlate more closely with SDB severity.
Polysomnography
Unfortunately, neither history nor physical examination alone can reliably predict the presence or severity of SDB. Currently, polysomnography is the gold standard for diagnosing and quantifying SDB in children, and can be a useful diagnostic tool before tonsillectomy. Polysomnography is the electrical recording of physiologic variables during sleep, including gas exchange, respiratory effort, airflow, snoring, sleep stage, body position, limb movement, and heart rhythm. Not only does polysomnography identify the presence of SDB, it also helps define its severity and may serve as an aid in perioperative planning and assessing the risk of postoperative complications.
Since 2002, the American Academy of Pediatrics has recommended overnight polysomnography in all children with suspected SDB to confirm diagnosis. A recent clinical practice guideline on polysomnography in children recommended referral for polysomnography in children with SDB before tonsillectomy if they exhibited one of the following comorbid conditions :
- •
Obesity
- •
Down syndrome
- •
Craniofacial abnormalities
- •
Neuromuscular disorders
- •
Sickle cell disease
- •
Mucopolysaccharidosis
In these children, polysomnography helps determine the need for postoperative pulse oximetry and admission. The same guideline recommends polysomnography before tonsillectomy in children without any of the aforementioned comorbidities, but only if the need for surgery is uncertain or in the presence of discordance between the clinical history and/or tonsillar size on physical examination and the reported severity of SDB.
Polysomnography may be performed in a sleep laboratory or in an ambulatory setting, the latter being referred to as portable monitoring (PM). Because of the cost and inconvenience of laboratory-based polysomnography, several forms of PM have developed, but few devices have been tested in children, and substantial evidence for this method is lacking. Laboratory-based polysomnography is currently the gold standard for evaluation of SDB in children and is recommended in children for whom polysomnography is indicated to assess SDB before tonsillectomy.
Evidence-based surgical technique for tonsillectomy
Procedure
Total tonsillectomy via cold dissection
Traditional techniques for tonsillectomy consist of cold dissection with metal instruments including knife, scissor, or snare. These techniques involve complete removal of the tonsil with its capsule by dissecting the peritonsillar space, with hemostasis obtained through ligation of blood vessels during tonsil removal or cauterization of the wound bed. Complete dissection or total tonsillectomy (TT) with cold steel is still the technique against which effectiveness and safety of other techniques are compared.
Total tonsillectomy via electrosurgery, cautery dissection, coblation, radiofrequency
In recent years, many new surgical approaches for TT have been explored to reduce perioperative morbidity. Electrosurgical or cautery dissection are common techniques used for complete tonsillectomy. Many newer techniques, including radiofrequency, coblation, harmonic scalpel, and PEAK PlasmaBlade, have been introduced to reduce postoperative pain and hemorrhage.
Outcomes of total tonsillectomy techniques
A recent systematic review has studied randomized controlled trials comparing TT performed using vessel sealing systems, harmonic scalpel, or coblation technique with conventional techniques of cold steel and/or cautery dissection. No significant differences in postoperative pain were found in the coblation and/or harmonic scalpel method compared with the cold steel and/or cautery technique. Furthermore, several randomized controlled trials have compared traditional TT with other techniques, including coblation, cautery, and ultrasonic scalpel, without finding a significant difference in postoperative pain.
Intracapsular tonsillectomy
A growing body of evidence suggests lower postoperative morbidity with a partial intracapsular tonsillectomy (IT) technique, in which most tonsillar tissue is removed, leaving a small amount of tonsillar tissue in the tonsillar fossa. The belief is that the rim of tonsillar tissue left in the tonsillar fossa provides a buffer zone that prevents damage to the surrounding pharyngeal muscles, thereby reducing severity and duration of postoperative pain. IT is also thought to reduce the amount of postoperative hemorrhage. Several instruments have been used to perform IT, including the microdebrider, the coblator, and traditional cold steel. A study by Bitar and colleagues compared the effects of microdebrider-assisted IT to electrocautery-assisted TT in children, showing no difference in surgical time or postoperative bleeding, but an earlier return to normal activity and reduced need for analgesics in the IT group. A study by Wilson and colleagues compared microdebrider-assisted IT, coblator-assisted IT, and electrocautery-assisted TT and showed a significantly earlier return to normal diet and preoperative activity level, and reduction of days of pain in both IT groups. No significant differences were seen in occurrence of postoperative complications, such as hemorrhage. Chang showed a significantly shorter postoperative recovery period for coblator-assisted IT compared with electrocautery-assisted TT in children.
A potential concern with IT might be regrowth of tonsillar tissue and need for revision surgery. Derkay and colleagues showed a significantly higher incidence of residual tonsillar tissue in children who underwent microdebrider-assisted IT compared with those who had electrocautery-assisted TT. However, the incidence of recurrence of obstruction or infection in this group was unknown. Chan and colleagues also showed a significantly higher incidence of residual tonsillar tissue, but no difference in recurrence of obstructive disease, pharyngitis, or antibiotic use. Ericsson and colleagues and Bitar and colleagues did not shown tonsillar regrowth at 12 and 20 months after IT, and no recurrence of symptoms after 3 years and 20 months, respectively. Irrespective of tonsillar regrowth, a retrospective chart review by Schmidt and colleagues compared the efficacy of IT versus TT in treating recurrent tonsillitis and showed no difference in postoperative infection rates.
Postoperative Management of Tonsillectomy: Hospitalization
Several studies have established that pediatric tonsillectomy may be safely performed in an outpatient setting. A previous clinical guideline recommends that children with complicated medical histories, including cardiac complications of OSA, neuromuscular disorders, prematurity, obesity, failure to thrive, craniofacial anomalies, or a recent upper respiratory tract infection, should be admitted overnight because of a higher risk of postoperative respiratory complications. SDB severity has also been identified as a risk factor for postoperative respiratory complications and is therefore considered an indication for postoperative admission by many. Although tonsillectomy resolves or at least significantly improves OSA in most children, they may continue to experience upper airway obstruction and oxygen desaturation in the direct postoperative period. An apnea-hypopnea index of 10 or more obstructive events per hour and/or oxygen saturation nadir less than 80% is currently considered the level of severity required for postoperative hospitalization with monitoring. Admission after total tonsillectomy is also recommended for children younger than 3 years, regardless of indication, because of postoperative pain resulting in poor oral intake. With the advent of techniques such as IT, reduction of postoperative morbidity might lead to new insights on postoperative management. Bent and colleagues compared children younger than 3 years with children aged 3 years or older undergoing IT for postoperative parameters such as pain, oral intake, or analgesic requirements. Because no significant differences were found between the age groups, the investigators concluded that children younger than 3 years may undergo IT on an outpatient basis.
Postoperative Hemorrhage in Tonsillectomy
Postoperative hemorrhage is a well-known complication of tonsillectomy and may be categorized as primary or secondary. Primary hemorrhage is defined as bleeding within the first 24 hours after tonsillectomy, and occurs in 0.2% to 2.2% of patients. Secondary hemorrhage occurs more than 24 hours after surgery, often between 5 and 10 days, because of sloughing of the primary eschar during healing of the tonsil bed. Rates of secondary hemorrhage for tonsillectomy range from 0.1% to 3%. Clinicians who perform tonsillectomy are recommended to always inquire about bleeding after surgery, and determine their rate of primary and secondary posttonsillectomy hemorrhage at least annually.
Surgical technique can have an impact on postoperative bleeding. Several new techniques were recently introduced to reduce postoperative hemorrhage. Many previous studies have focused on comparison of “hot” (electrosurgery or electrocautery techniques) versus cold tonsillectomy with respect to postoperative bleeding, with similar unequivocal outcomes. Several systematic reviews have summarized randomized controlled trials on conventional cold steel tonsillectomy versus diathermy, monopolar cautery, coblation, or harmonic scalpel techniques, but none has shown a significant difference in postoperative hemorrhage rates among techniques.
Other studies have focused on comparison of IT and TT with respect to postoperative complications such as hemorrhage. Three large retrospective case series have shown a significantly lower rate of postoperative bleeding for IT compared with TT. However, most prospective trials fail to demonstrate a significant difference in postoperative hemorrhage between IT and TT, although one trial reports a significantly lower intraoperative blood loss with IT.
SDB and Other Postoperative Concerns in Tonsillectomy
With SDB being the most common indication for tonsillectomy, postoperative monitoring for possible residual SDB is an important consideration. Before surgery, caregivers must be counseled that tonsillectomy is not curative in all cases of SDB in children, especially in children with obesity, and further treatment may be required after surgery. Clinical guidelines do not recommend routine polysomnography after tonsillectomy in children with SDB. When SDB or related comorbid conditions, such as growth retardation, poor school performance, enuresis, or behavioral problems, have been the indication for surgery, SDB is considered cured when the caregiver reports that symptoms are resolved postoperatively. In these cases, postoperative polysomnography is deemed unnecessary, but substantial evidence for this assumption is lacking. Any postoperative report of continuing symptoms of SDB should be taken seriously and indicates the need for further evaluation, including consideration of formal polysomnography. A recent systematic review does recommend postoperative polysomnography for children with perioperative evidence of moderate to severe OSA, obesity, craniofacial anomalies, and neurologic disorders.
Stay updated, free articles. Join our Telegram channel
Full access? Get Clinical Tree
