Tonsillectomy & Adenoidectomy - Tonsil and
adenoid
surgery is the most common major surgery performed in children. This
section contains several graphic videos of tonsillectomy and
adenoidectomy which should only be viewed by adults. To the left,
the top button links to a multimedia presentation (requires Media
Player 9)
on tonsillectomy and adenoidectomy.
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Generally, there are two reasons why a child may need tonsils or adenoids
removed. Most patients believe the most common reason to remove tonsils is
to treat sore throats. However, the most frequent reason for tonsillectomy
and adenoidectomy is airway obstruction. Seventy-five percent of patients
have a tonsillectomy and adenoidectomy for this reason. See American Academy of
Otolaryngology Indications for Tonsillectomy and AdenoidectomyGo To Top
A
tonsillectomy is performed to treat recurrent infections, especially if it is
associated with a "
Strep
Throat," which keeps coming back several times a year
after antibiotic treatment. If medicine cannot treat or prevent the
infections and the infections come back often, a tonsillectomy may be
indicated. Several studies have shown that a tonsillectomy is an effective
treatment for children with frequently recurring tonsillitis (chronic
tonsillitis).
View Abstract.
Click on colored text for word
definitions !!
The most common reason for tonsillectomy and adenoidectomy is is to remove
enlarged tonsils and adenoids which block a child's breathing passages.
The nose may be so blocked by the adenoid (which is located behind the nose and
above the back of the throat--see the below pictures) that a child can't smell,
has a congested nose, and talks like he has a cold all the time. If the
tonsils are to large, a child may not eat well, taking only small, soft foods.
The child may also have some choking and mouth breathing. Often, a child snores
very loudly, may not breathe well while asleep, and may actually stop breathing
for several seconds. If severe and not treated, this can put strain on the
heart and lungs. It has been shown that removal of the tonsils and
adenoids is effective in treating obstructive
sleep apnea
in children.
View Abstract
View Abstract.
The
picture on the far right shows an enlarged adenoid blocking the nasal passage.
The picture on the near right shows 4+ kissing tonsils blocking the oral airway.
Both children needed to have these tissues removed to establish an adequate
airway.
Tonsillar asymmetry
without other indications (i.e.,abnormal appearance, symptoms or history) is
often a benign finding and usually does not require treatment..
View Abstract
However,
not all airway obstruction in children is caused by
hypertrophic
adenoids or tonsils. Here is a case of an 8 year old child with
sleep apnea
who had very small tonsils and adenoids but nasal airway obstruction due to a
nasal
septal
spur and swollen
nasal
membranes.
The
picture to the right shows an enlarged adenoid seen at the time of
surgery. Mouse-over the picture to label the adenoid, click on
picture to enlarge.
Graphic Videos - These Videos May Not Be Suited For All Viewers !!ewers !!
Peritonsillar
Abscess (Quinsy Tonsillectomy): A tonsillectomy may also be performed to acutely
treat a peritonsillar abscess. The picture to the right shows the
physical findings of a peritonsillar abscess in a 5 year old child.
Note the distention of the right peritonsillar pillar (blue arrows) and
the deviation of the uvula to the left (red arrow). The child also
had a "hot potato" voice and mild difficulty swallowing.
A peritonsillar abscess is often confused with severe exudative
tonsillitis. In exudative tonsillitis, it is the tonsils
which are enlarged and not the anterior tonsillar pillar. Often,
needle aspiration is needed to make the diagnosis.
Most peritonsillar abscesses can be treated by incisional or needle
drainage. However, in the young child this is usually not possible
and a trip to the OR is necessary. Often there will also be a
history of chronic tonsillitis. In this case, removing the tonsils
is the preferred treatment.
Adenotonsillectomy is major surgery. Children used to stay overnight
but in the USA this surgery is commonly performed on an outpatient basis.
Surgery usually lasts from 30 minutes to an hour, but sometimes takes longer.
During this time, you can wait in the preoperative waiting room or other part of
the hospital.
There are many different surgical techniques for removing the tonsils.
Tonsils have been removed using a
knife, electrocautery, laser, harmonic
scalpel and
coblation tonsillectomy. All of these
techniques have their advantages and disadvantages. Some such as the laser
was very popular in the 1980's but fell out of favor after it was shown to have
delayed healing and increased the time the patient is under general anesthesia.
The microdebrider is slow and does not control bleeding giving it little
advantage using a scalpel.
What is important is the experience of your surgeon. This is one
surgery you do not want to go to the lowest bidder. Find an
experienced surgeon who is skilled with a particular technique and has good
outcomes. Do not worry so much about the exact technique used.
Time Tested:
The oldest and most time tested
techniques are HOT and COLD tonsillectomy. In HOT dissection the
tonsils are removed with an electrocautery. In COLD dissection, a surgical
knifeis used to remove the tonsils. Both techniques have comparable
post-operative bleeding rates but COLD dissection has been shown to produce less
pain.
View Abstract
However, Lee, et.al, found that the
HOT dissection had a significantly higher secondary bleeding rate
View Abstract
and has more post-operative pain than COLD dissection.
Graphic Videos - These Videos May Not
Be Suited For All Viewers !!
Newer
Techniques Which Control Bleeding During the Operation and Reduce Pain.Coblation
tonsillectomy and adenoidectomy was introduced in 2001. In this
technique, a wand is used to coagulate and ablate tissue using a cool
electrical current at the tip of the wand. It produces cooler
tissue temperatures and less adjacent tissue destruction than in a HOT
tonsillectomy. Timms (2002) reported coblation
produces less pain than a HOT tonsillectomy
View Abstract. Bleeding rates have
been reported to be similar to non-coblation tonsillectomy ( Divi and
Benninger 2005 )
View Abstract .
Belloso, et.al.(2003) reported that coblation
tonsillectomy had a lower rate of secondary hemorrhage than non-coblation
tonsillectomy in both children and adults.
View Abstract
.
Lowe D, Van der Meulen J
in the Lancet (2004) reported that the risk of hemorrhage was greater
for HOT (diathermy
) tonsillectomies and
coblation
than for COLD techniques
using knife dissection and suture ligatures to control bleeding.
View Abstract
Search PubMed for Coblation Tonsillectomy
View Coblation Tonsillectomy Presentation
Graphic Video - This Video May Not Be Suited For All Viewers!!
The
harmonic
scalpel is very useful in young
patients, especially those at risk of rapid dehydration due to poor oral
intake secondary to postoperative pain. The
harmonic
scalpel
controls bleeding from small vessels and several
studies have reported that patients experience less postoperative pain. View
Abstract
View Abstract
View Abstract.
The cost of the procedure is increased and in older patients more brisk
bleeding may be encountered which may require the use of electrocautery.
Cauterization will increase postoperative pain and tends to negate the
advantage of using the
harmonic
scalpel.
However, in this case the ability of the
harmonic
scalpel
to reduce the bleeding aids in the performance of the surgery.
Scotch, et.al., has reported that complication rates are comparable to (in
this study actually less than) other techniques.
View Abstract
Search PubMed for Harmonic Scalpel Tonsillectomy
In a recent article by Mehta et. al.
Three techniques for removing tonsils were compared (electrocautery,
harmonic scalpel and coblation). The authors found that pain after
the operation was similar using the harmonic scalpel and electrocautery
but was significantly less using coblation. It also appeared that
patients undergoing coblation tonsillectomy returned more quickly to a
normal diet.
View Abstract
Graphic Video - This Video
May Not Be Suited For All Viewers !!
a
Graphic Video - This Video
May Not Be Suited For All Viewers !!
(Note: You may have noticed that I have quoted one article
that says HOT and COLD techniques have the same post- operative bleeding rates
and another which states that a HOT tonsillectomy has more bleeding than a COLD
tonsillectomy. Such discrepancies are commonly found in the medical
literature and are thought to be due to the differences in skill between
surgeons using the various technique. Thus, if a surgeon has performed
6,000 operations in technique "A" this technique may have better results for him
than technique "B" even though technique "B" may produce better results for the
average surgeon. The most important thing you
need to do is to find an experienced surgeon
who is skilled with a particular technique and has good outcomes. Don't worry so
much about the exact technique used.)
After surgery, your child will be in the recovery room for about an hour.
He or she will then be brought to the room to see you and spend some time slowly
waking up.
(1) Anesthesia - this is a chemical in the body not normally
there, so a chance for problems is always present. But, because of their
experience and skill, the anesthesiologists and nurse anesthetists have very few
problems. Specific questions can be answered by them.
(2) Bleeding- Approximately one in fifty children return to
the operating room for bleeding. The incidence may be higher in
adults and may approach one in twenty patients depending upon the surgical
technique used.
There is usually not to much bleeding during the operation, but there is
always a chance of bleeding after your child comes home after the
operation. Granell, et.al, (
View Abstract
) reported that 2.9% of children had to return to the operating room for
control of bleeding and Windfuhr, et. al., (2005) also reported a 1.5%
postoperative bleeding rate using a "COLD" technique. However in this
study, the bleeding occurred in the first 24 hours in 76% of tonsillectomy
patients.
View Abstract
In my practice, patients rarely bleed within the first 24 hours.
The most common time for a child to bleed after tonsillectomy or adenoidectomy
is between 4 to 8 days after surgery.
A few children will bleed on the first day after surgery, usually within the
first 2 hours. Nicklaus, et. al., reported a post-tonsillectomy
bleeding rate in the first 24 hours of 1.4% and all of these bleeds occurred
within 75 minutes after surgery.
View Abstract
For this reason, your child will be watched for at least 2 hours
after surgery. View
Abstract . However, bleeding
can occur at any time, until everything is healed, which takes about two to
three weeks. Most children do not have significant bleeding afterwards,
but every year a few do. If this occurs, have the child swallow some
ice water. If the bleeding persists, you should bring your child to the
Emergency Room for evaluation. Sometimes, the child may have to return to
the operating room to control the bleeding.
Over the past decade, using the technique shown in the "Tonsillectomy and
Adenoidectomy Video" I have a postoperative bleeding rate of under 2%. The
technique is a combination of a COLD and HOT technique with removal of the
tonsils with a scalpel and snare
and control of bleeding with electrocautery on a low setting.
I have performed coblation
tonsillectomy on over 300 patients. The rate of bleeding for return to the
operating room or requiring cautery was over 4%.
3) Pain - Having adenoids removed requires 2-3 days of recovery with
some pain or discomfort. After tonsils are removed, it hurts! It
usually takes a week to 10 days for full recovery. A shorter period of
time may occur with the use of
coblation. Pain medicine and
diet instructions are given on the day of surgery. Another technique
commonly used to remove tonsils is "Sharp Dissection" with the use of
electrocautery to control bleeding. This technique has been shown in
multiple studies to create less pain than excising the tonsils using an
electrocautery or "bovie", with little difference in the postoperative bleeding
rates.
View Abstract
4) Hypernasal speech may rarely occur after an adenoidectomy. This
type of speech results from the failure of the
soft palate
(back part of the roof of the mouth) to close off the
nasopharynx
(back part of the nose). This may normally occur during the first four
weeks after surgery but prolonged cases may require speech therapy.
If the speech is very poor, corrective surgery may be needed. This
complication usually happens in children who have abnormalities in their
soft palate
and occurs in about 1 in 3000 surgeries. It is extremely rare to occur
from a tonsillectomy alone.
5) Rarely, a small through and through hole may develop in one of the
folds in the back of the throat. This will not cause any problems and does
not require treatment.
6) Other very rare complications include: Nasopharyngeal stenosis
(the back part of the nose scars shut) from an adenoidectomy and tonsillectomy
and damage and dislocation of the cervical spine.
7) Death: This is a very rare but devastating complication.
The factors which can cause death is massive hemorrhage and anesthetic
complications such as reaction to the anesthestic or inhaling stomach contents.
The incidence of death after tonsillectomy is one in every 15,000 patients. An
ENT surgeon will perform 5 to 10 thousand tonsillectomy patients in his carrier
giving him about a 50-50 chance of having one of his patients die from the
surgery.
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