Tonsillectomy

Tonsillectomy is the second-most common surgery of childhood, but is

less commonly performed in adults. Tonsillectomy accounts for 25% of all
operations performed by otolaryngologists

Anatomy and Physiology

The tonsils are collections of lymphoid tissue that produce

lymphocytes and are part of the infection-fighting immune
system.
They are generally ovoid or bilobed tissue collections with a very
irregular surface.
They are found between the front and back tonsillar arches,
located along the sides of the pharynx (back of the throat)
(Figure 1). The tonsillar fossa is the depression between the
arches in which the tonsil lies

Figure 1 - Open mouth view of the tonsils. The tonsils are

rounded masses of lymphoid tissue on each side of the
pharynx. The palate is the roof of the mouth. In the center
of the back of the palate hangs a soft finger of tissue, the
uvula. (Rob Gordon)

The tonsils are highly vascular (contains many blood vessels),

which helps them to perform their function of protecting against
infection, as foreign material enters the body through the mouth.
The blood supply comes from several branches of the external
carotid artery (Figure 2)

Figure 2. The tonsil is very vascular and

gets blood from several branches of the
external carotid artery.

The nerve supply is mainly from the ninth cranial nerve, which
provides sensation to much of the throat. This nerve also
supplies sensation to a small part of the ear, which explains why
ear pain is frequently associated with throat infections or
experienced after tonsillectomy

Examination

The tonsils are graded by size from normal to very large as 1+,
2+, 3+ or 4+
They may be described as cryptic (pitted), inflamed or covered
with exudates (thin layer of pus)
The appearance of the tonsils is usually not important when
recommending tonsillectomy

Tests
Blood tests

blood count- to determine if there is generalized infection

platelet count- if low the patient may bleed excessively
measures of blood clotting ability (coagulation times)- if abnormal
there may be excessive bleeding
More specialized tests may be obtained in cases where there is a
personal or family history of frequent bleeding or bruising
Occasionally, an x-ray of the throat will be done to evaluate the
adenoid tissue (enlarged lymphoid tissue at the back of the
pharynx)

Indications for Tonsillectomy

The tonsils are removed for various reasons, and generally only

after medical therapy has failed

The most common indications are tonsillar hypertrophy
(enlargement) leading to obstruction which may cause sleep
apnea or other sleep disturbance
Recurrent ear infections
Chronic or recurrent tonsillitis (infection of the tonsils)
1. Five or more episodes of tonsillitis in one year
2. Three or more episodes per year over at least two years
3. Tonsillitis not responding to antibiotics
Less commonly the following may be due to obstructing tonsils
and the tonsils may be removed if these conditions are not
attributable to other causes. Sometimes the blockage may not be
obvious from looking at the tonsils, because the tonsils may be
long and the narrowed area is actually lower down the throat
1. speech or swallowing abnormalities
2. failure to thrive
3. cor pulmonale- right-sided heart enlargement due to
disease in the air passages
Rarely, relatively normal sized tonsils are removed because they
cause obstruction in a narrow upper airway, due to congenital,
orofacial or dental abnormalities
Peritonsillar abscess (abscess surrounding the tonsils) 20.
Suspicion of tonsillar malignancy

Procedure

Tonsillectomy is often an out-patient procedure. Small children or

patients with special needs or risks may be hospitalized briefly
Tonsillectomy is performed under general anesthesia, with the
patient completely asleep
The patient is positioned on his back, with head forward and
mouth wide open
The tonsils may be removed from their bed by various methods.
The method is a matter of surgeon preference and does not alter
the length or outcome of the procedure. (Figure 3A and 3B)

Figure 3&4. Enlarged tonsil being removed using a scissor. Once

removed, bleeding in the tonsillar fossa is stopped.

The methods that may be used are

1. electrocautery- hot electric knife that tends to seal

bleeding vessels
2. blunt dissecting instruments
3. scissors
4. metal snare
5. laser
Any bleeding is controlled, and the patient is awakened

Complications

Bleeding after tonsillectomy can be severe, and even lifethreatening, and is taken very seriously by the otolaryngologist
(ear and throat doctor). Any patient who experiences bleeding
should be seen immediately by their surgeon, or in the
emergency room
Infection can occur because of the open tissues where the tonsils
were removed. This is managed with antibiotics
An occasional patient may develop a voice change usually
described as nasal speech, which can be permanent
Complications of anesthesia. The most serious complications are
those of the general anesthesia, since this can cause
1. heart attack
2. stroke
3. sore throat, tongue soreness or swelling
4. damage to the teeth
5. deep vein thrombosis (clotting in the veins of the legs or
pelvis)
6. pulmonary embolus (clot from the leg veins going to the
lung)
7. anaphylaxis (allergic reaction)
8. death
These risks are extremely small in young, healthy patients, but
bear mentioning because of their severity

Postoperative Care

The most important thing to watch for is bleeding, this

necessitates examination by a physician
The most common reason patients return to the hospital or clinic
is due to dehydration. Because of the pain associated with
tonsillectomy, many patients do not eat or drink sufficiently to
heal and feel good. Adequate analgesia (usually with narcotics)
is important in allowing patients to eat adequately
Antibiotics are often given in the post-operative period as well, to
help prevent infection and to reduce pain
Significant pain is to be expected for at least a week in children
and two weeks in adults, and may be longer
Patients are usually most comfortable with cold non-acidic liquids
and soft foods for the first several days, and these are
encouraged because they are less likely than hard or chewy
foods to initiate bleeding

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