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Tonsillectomy
ALTERNATIVE NAMES: Palatine tonsillectomy, lingual tonsillectomy
WHAT IS THE PROCEDURE? Removal of the palatine or lingual tonsils
WHO IS A CANDIDATE FOR THE PROCEDURE? There are several indications for removal of the palatine tonsils. They are easily visible on either side of the throat at the level of the soft palate. Patients who have had three to five bacterial tonsillar infections over three to five years, chronic tonsillitis not responding to medical management, seven or more tonsillitis episodes in one year, or who have a tonsillar infection which is not being cured after numerous courses of antibiotics all have indications for removal of the tonsils. As the adenoid commonly participates in the tonsillar infection, it frequently is also removed. Other noninfectious causes for tonsillectomy would be the presence of obstructive sleep apnea syndrome (particularly in children), difficulty swallowing because of the enlarged tonsils, or the suspicion of tonsillar malignancy.
In the case of lingual tonsillectomy, the most common reason for removal is recurrent or chronic infections, lingular tonsillar enlargement causing obstructive sleep apnea syndrome, or suspicion of malignancy.
HOW IS IT PERFORMED? This procedure is usually performed under general anesthesia. A device holds the mouth open, and a clamp is applied to the tonsil. When the tonsil is pulled toward the center of the throat, it is easy to see where it sits on the palate musculature. An incision is then made in the lining of the palate overlying the tonsil. This incision can be made with scissors, knife, laser, or cautery. Once it is made, it exposes a loose tissue layer between the tonsil and the muscles of the palate. The dissection then proceeds in the plane of the soft tissue layer, in the process shelling the tonsil out. As there are five different arterial supplies to the tonsil, bleeding can be quite brisk. Electric cautery is usually employed to control any bleeding.
In the case of lingual tonsillectomy, the mouth is held open by an instrument called a laryngoscope, which is an illuminated tube through which the lingual tonsils can be visualized and removed. The lingual tonsils rest at the back part of the tongue and are rather firmly attached to the posterior tongue musculature. They are separated from the tongue musculature using either laser or cautery. The advantage of these two tools is minimal bleeding. Once one lingual tonsil is removed, then a similar procedure is done on the other side.
WHAT HAPPENS AFTER THE PROCEDURE? The care of a patient after either palatine or lingual tonsillectomy is identical. Regardless of what instrument is used to remove the tonsils, there is usually significant throat pain. In general, the older the patient, the greater the degree and the longer the duration of pain. Typically these procedures are performed as an outpatient unless there is a history of obstructive sleep apnea. In this case, overnight observation is often warranted. The focus of care at home needs to be on pain control and maintaining an adequate fluid status. Calorie intake post-operatively is not critical. Instead, maintaining a good fluid state is of primary importance. In general, the patient's throat will let them know what it is ready for. Although there are a few individuals who immediately post-operatively can eat a fairly normal diet, most individuals are comfortable with a variety of beverages and soft foods. It is important to avoid acidic or sour beverages, such as tomato juice or citrus beverages because they may cause more pain. Excessively hot or spicy foods may also increase the pain level and, therefore, should be avoided. The concern with rough or scratchy foods is that they may knock the scabs off in the back part of the throat and thus induce a post-operative hemorrhage. Therefore, it is prudent to avoid scratchy foods for at least 10 days post-operatively, as most cases of post-tonsillectomy hemorrhage occur within the first five to seven days after surgery.
Approximately 3% of patients after tonsillectomy have a post-operative hemorrhage that needs to be managed by observation or cauterization. Avoiding aspirin products is essential for fear of post-tonsillectomy hemorrhage. Although it is infrequent, bleeding may be a result of a dysfunctional coagulation status that first comes to light after tonsillectomy.
The pain is usually most intense in the first 48 hours after surgery, then starts to ease off but may re-intensify around four to six days after surgery. It is the second peak of pain that is often accompanied by severe ear pain. There is infrequently anything wrong with the ears – it just happens to be that this is where the pain radiates at this point in the post-operative period. Because of the scabs in the back part of the throat, there is often a foul taste in the mouth with very bad breath. Antibiotics may be useful in this regard.
WHAT DO THE RESULTS MEAN? A successful procedure resolves the symptoms that the patient has. After tonsillectomy, it is very unusual to have strep throat infections. In children, removal of the tonsils cures approximately 95% of sleep apnea syndrome, and for those patients with difficulty swallowing from enlarged tonsils, swallowing returns to normal. For those patients in whom a malignancy is identified, other surgical, chemotherapy, or radiation therapy treatments may be necessary.
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