Tonsillectomy remains one of the most common surgical procedures performed on children. In contrast to several decades ago when infectious indications were common, the reason most children undergo tonsillectomy today is to relieve upper airway obstruction. Traditional “extracapsular” tonsillectomy remains a fairly morbid procedure. Children routinely require several days off from school, and parents are often forced to take time off from work. Despite advances in surgical technology, a significant reduction in postoperative pain after this procedure has eluded surgeons. This is evidenced by the wide array of techniques available to the surgeon. Furthermore, the rate of postoperative hemorrhage has remained fairly stable despite the technique practiced. Partial “intracapsular” tonsillectomy seeks to significantly reduce postoperative pain and hemorrhage risk while effectively treating upper airway obstruction. The “intracapsular” tonsillectomy can be performed with the microdebrider or with Coblation techniques.
Patients suffering from upper airway obstruction secondary to tonsil hypertrophy are candidates for partial tonsillectomy. Caregivers are fully informed of the differences between total and partial tonsillectomy and the rationale for each procedure. The potential for tonsil regrowth and the risk for development of chronic streptococcal tonsillitis need to be addressed (see Postoperative Management and Complications ) during the informed consent process.
Relative contraindications to the performance of intracapsular tonsillectomy include a history of chronic tonsillitis and tonsil regrowth after a previous partial tonsillectomy.
The safety of intracapsular tonsillectomy in the young patient has been studied. Bent et al. found no significant difference in the rate of readmission, pain, oral intake, or analgesic requirements in patients younger than 3 years of age who underwent partial tonsillectomy compared with a control group. Chang found that children who underwent intracapsular tonsillectomy had significantly less pain on postoperative day 5 and 6 compared with matched subcapsular tonsillectomy patients, were more active, and were eating more.
Outline of Procedure
After general anesthesia is achieved, the patient is placed in the Rose position. According to surgeon preference, the airway may be managed with a straight endotracheal tube, an oral Ring–Adair–Elwyn tube, or a laryngeal mask airway. A gentle shoulder roll can be used if there are no contraindications. The jaw is opened using a mouth gag, which can then be suspended. If concurrent adenoidectomy is to be performed, the soft palate is first inspected and palpated for the presence of a submucous cleft and then retracted using catheters that are placed through the nasal cavities and retrieved from the oropharynx. This maneuver also helps stabilize the tonsillar pillars and pulls the uvula out of the surgical field.
Microdebrider-Assisted Intracapsular Tonsillectomy
Microdebrider-assisted intracapsular tonsillectomy is typically done with a microdebrider headpiece that is different from that used for adenoidectomy. The tonsillectomy handpiece is gently curved with a 12-degree angle, whereas the adenoidectomy headpiece has a 40-degree curvature. Both typically come in a set, without need for irrigation. With the microdebrider set at a rate of 1500 rpm on oscillating mode, dissection of the tonsil begins at the inferior pole ( Fig. 71.1 ). This helps prevent blood from obscuring visualization of the anterior and posterior pillars. Dissection proceeds from a lateral to medial direction until the plane of the pillars is reached. At this point it is generally helpful to further stabilize and control the anterior pillar to maximize tissue removal and minimize injury to mucosa. A Hurd elevator is particularly helpful in this circumstance, as it can also help to medialize the remaining tonsil tissue, making dissection easier. Dissection is carried down to—but not through—the capsule of the tonsil. The use of a mirror can facilitate dissection of the superior pole. Care is taken to avoid inadvertent injury to the uvula, which can occur rapidly given the suction associated with the microdebrider. After dissection is completed, hemostasis is achieved using suction cautery with settings generally between 20 and 40 watts according to surgeon preference ( Fig. 71.2 ). The contralateral tonsil is then dissected in an identical fashion.