Tonsillectomy
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Although a long-practiced procedure, tonsillectomy is still a common operation and considered one of the most common major surgical procedure performed in children. This procedure is still surrounded by controversy, especially regarding indications for surgery and details of surgical technique.
For excellent patient education resources, visit eMedicineHealth’s Ear, Nose, and Throat Center. Also, see eMedicineHealth’s patient education article Tonsillitis.
First described in India in 1000 BC, the tonsillectomy procedure increased in popularity in the 1800s, when a partial removal of the tonsil was performed. Because part of the tonsil was left behind, it frequently became hypertrophied and caused recurrence of the obstruction. By the early 20th century, the prevalence of tonsil disease was recognized, and the necessity of complete tonsillectomy was appreciated.
Tonsillectomy is defined as the surgical excision of the palatine tonsils. Indications for this procedure remain controversial.
Although tonsillectomy is performed less often than it once was, it is still among the most common surgical procedures performed in children in the United States. In 1959, 1.4 million tonsillectomies were performed in the United States. This number had dropped to 260,000 by 1987, when it was the 24th most common indication for hospital admission. Indications have evolved from being primarily related to infections to being more commonly caused by obstruction.
The tonsils are 3 masses of tissue: the lingual tonsil, the pharyngeal (adenoid) tonsil, and the palatine or fascial tonsil. The tonsils are lymphoid tissue covered by respiratory epithelium, which is invaginated and which causes crypts.
In addition to producing lymphocytes, the tonsils are active in the synthesis of immunoglobulins. Because they are the first lymphoid aggregates in the aerodigestive tract, the tonsils are thought to play a role in immunity. Although healthy tonsils offer immune protection, diseased tonsils are less effective at serving their immune functions. Diseased tonsils are associated with decreased antigen transport, decreased antibody production above baseline levels, and chronic bacterial infection.
See Preoperative details.
Otolaryngology textbooks list a variety of indications for tonsillectomy. The American Academy of Otolaryngology–Head and Neck Surgery (AAO-HNS) publishes clinical indicators for surgical procedures. Paraphrased, these clinical indicators are as follows:
See the list below:
Enlarged tonsils that cause upper airway obstruction, severe dysphagia, sleep disorders, or cardiopulmonary complications
Peritonsillar abscess that is unresponsive to medical management and drainage documented by surgeon, unless surgery is performed during acute stage
Tonsillitis resulting in febrile convulsions
Tonsils requiring biopsy to define tissue pathology
See the list below:
Three or more tonsil infections per year despite adequate medical therapy
Persistent foul taste or breath due to chronic tonsillitis that is not responsive to medical therapy
Chronic or recurrent tonsillitis in a streptococcal carrier not responding to beta-lactamase-resistant antibiotics
Unilateral tonsil hypertrophy that is presumed to be neoplastic
Tonsils are located laterally in the oropharynx. The tonsils are bordered by the following tissues:
Deep – Superior constrictor muscle
Anterior – Palatoglossus muscle
Posterior – Palatopharyngeus muscle
Superior – Soft palate
Inferior – Lingual tonsil
Blood supply is through the external carotid artery and its branches, as follows:
Superior pole
Ascending pharyngeal artery (tonsillar branches)
Lesser palatine artery
Inferior pole
Facial artery branches
Dorsal lingual artery
Ascending palatine artery
Venous outflow is handled by the plexus around the tonsillar capsule, the lingual vein, and the pharyngeal plexus. Lymphatic drainage involves the superior deep cervical nodes and the jugulodigastric nodes. Sensory supply is provided by the glossopharyngeal nerve and the lesser palatine nerve. Important structures deep to the inferior pole include the glossopharyngeal nerve, the lingual artery, and the internal carotid artery. The tonsil surface is filled with crypts lined with squamous epithelium. Lymphoid cells underlie the epithelium. See Tonsil and Adenoid Anatomy for more information.
Contraindications for tonsillectomy include the following:
Bleeding diathesis
Poor anesthetic risk or uncontrolled medical illness
Anemia
Acute infection
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US Food and Drug Administration. FDA Drug Safety Communication: Codeine use in certain children after tonsillectomy and/or adenoidectomy may lead to rare, but life threatening adverse events or death. Available at http://www.fda.gov/Drugs/DrugSafety/ucm313631.htm. Accessed: March 27, 2013.
Amelia F Drake, MD ND Fischer Distinguished Professor of Otolaryngology, Executive Associate Dean of Academic Programs, Director, Craniofacial Center, Department of Otolaryngology-Head and Neck Surgery, University of North Carolina at Chapel Hill School of Medicine
Amelia F Drake, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Otolaryngology-Head and Neck Surgery, American Cleft Palate-Craniofacial Association, American Society of Pediatric Otolaryngology, North Carolina Medical Society
Disclosure: Nothing to disclose.
Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference
Disclosure: Received salary from Medscape for employment. for: Medscape.
Arlen D Meyers, MD, MBA Professor of Otolaryngology, Dentistry, and Engineering, University of Colorado School of Medicine
Arlen D Meyers, MD, MBA is a member of the following medical societies: American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, American Head and Neck Society
Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Cerescan;RxRevu;Cliexa;Preacute Population Health Management;The Physicians Edge<br/>Received income in an amount equal to or greater than $250 from: The Physicians Edge, Cliexa<br/> Received stock from RxRevu; Received ownership interest from Cerescan for consulting; for: Rxblockchain;Bridge Health.
Michele M Carr, MD, DDS, PhD, MEd Professor, Department of Otolaryngology-Head and Neck Surgery, West Virginia University School of Medicine
Michele M Carr, MD, DDS, PhD, MEd is a member of the following medical societies: American Academy of Otolaryngology-Head and Neck Surgery
Disclosure: Nothing to disclose.
Ari J Goldsmith, MD Chief of Pediatric Otolaryngology, Long Island College Hospital; Associate Professor, Department of Otolaryngology, Division of Pediatric Otolaryngology, State University of New York Downstate Medical Center
Ari J Goldsmith, MD is a member of the following medical societies: American Academy of Otolaryngology-Head and Neck Surgery, American Medical Association, and Medical Society of the State of New York
Disclosure: Nothing to disclose.
Acknowledgments
Medscape Reference thanks Vijay R Ramakrishnan, MD, Assistant Professor, Department of Otolaryngology, University of Colorado School of Medicine, for the videos in this article.
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