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1.43: Tonsillotomy (Partial) and Complete Tonsillectomy Surgical Technique

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    OPEN ACCESS ATLAS OF OTOLARYNGOLOGY, HEAD & NECK OPERATIVE SURGERY

    TONSILLOTOMY (PARTIAL) & COMPLETE TONSILLECTOMY - SURGICAL TECHNIQUE

    Klaus Stelter and Goetz Lehnerdt


    Acute tonsillitis is treated with steroids e.g. dexamethasone, NSAIDs e.g. ibuprofen and beta-lactam antibiotics e.g. penicillin or cefuroxime. Only 10 days of antibiotic therapy has proven to be effective to prevent rheumatic fever and glomerulonephritis.

    Tonsillectomy is only done for recurrent acute bacterial tonsillitis, or for noninfectious reasons such as suspected neoplasia.

    Partial tonsillectomy (tonsillotomy) is the 1st line treatment for snoring due to tonsillar hyperplasia. It is low-risk, and postoperative pain and risk of hemorrhage are much less than with tonsillectomy. It is immaterial whether the tonsillotomy is done with laser, radiofrequency, shaver, coblation, bipolar scissors or monopolar electrocautery, as long as the crypts remain open and some tonsil tissue remains.

    Pain and hemorrhage are the main morbidity of tonsillectomy. Bleeding may occur anytime until the wound is completely healed, which is normally at 2-3 weeks. Patients have to be informed about what to do in case of hemorrhage. Life threatening hemorrhage often is preceded by smaller bleeds, which can spontaneously cease. That is why every hemorrhage, even the smallest, has to be treated as an inpatient. Massive hemorrhage is an extreme challenge for every paramedic or emergency doctor because of difficult airway management.

    Function and anatomical structure of tonsils in childhood and adolescence

    Tonsils allow one to acquire immunity and provide immune defense by antigen presentation. This is why they contain T-lymphocytes, germinal centers of B-lymphocytes 1 and macrophages. They are the first and easiest-to-reach station of the mucosa associated lymphoid tissue system (MALT)2-4. As the main phase of the immune acquisition continues until the age of 6 years, the palatine tonsils are physiologically hyperplastic at this time5, 6. This is followed by involution, which is reflected by regression of tonsil size until age 12 years7.

    The lymphoid tissue is separated by a capsule from the surrounding muscle (superior pharyngeal constrictor)8. The blood supply originates from four different vessels, the lingual artery, the ascending pharyngeal artery and the ascending and descending palatine arteries. These vessels radiate mainly to the upper and lower tonsillar poles, as well as to the center of the tonsil from laterally9. The tonsils have deep crypts that create a large surface area to provide a docking surface for potential antigens10.

    Tonsil diseases

    Sore throat episodes (R07.0)

    Synonyms include “acute sore throat”, and “throat infection”. "Sore throat" is an imprecise term and does not clinically distinguish between acute tonsillitis and pharyngitis. Neither the cause nor the exact location is determined11. In “sore throat” it remains unclear whether one is dealing with acute (bacterial) tonsillitis which, if recurrent, is an indication for tonsillectomy12.

    Acute tonsillitis (J03.0 - J03.9)

    Also known as “severe tonsillitis” 13, “true tonsillitis”, or “acute sore throat” 11, this refers to viral or bacterial tonsillitis with odynophagia, swelling and redness of the tonsils, possibly with a tonsillar exudate, cervical lymphadenopathy and fever >38.3°C (rectal)14, 15. Odynophagia for 24-48 hours, as part of prodromal symptoms of a common cold (viral infection of upper respiratory tract), is excluded from the term "acute tonsillitis" 11. Depending on the stage and appearance of the tonsillar deposits or exudate, one can distinguish catarrhal angina with redness and swelling of the tonsils (early stage), from follicular angina with stipple-like fibrin deposits, from lacunar angina with confluent deposits (late stage)16, 17. "Acute tonsillitis" can be diagnosed by a specialist purely on clinical grounds18. Smears, blood tests or viral evidence are unnecessary in most cases19-23. Penicillin or another beta-lactam antibiotic is the first line of treatment.

    1.png

    Figure 1: Hyperplastic tonsils in a child

    Chronic tonsillitis (J35.0 and J35.9)

    Also called “chronic (hyperplastic) tonsillitis”, it is not well-defined and thus should not be used24. It is better to speak of (chronic) recurrent tonsillitis25, 26, because true chronic tonsillitis with persistentsymptoms lasting >4 weeks with adequate treatment and recovery of the mucosa (as in rhinosinusitis) does not exist.

    Recurrent acute tonsillitis (J35.0)

    Also called “recurrent tonsillitis” or “recurrent throat infections” 27, this refers to recurrent bouts of acute tonsillitis. In contrast to a single attack of acute tonsillitis, it is usually caused by many different bacterial pathogens28, 29 and flare up again a few weeks after cessation of antibiotic therapy30. Depending on the frequency and severity of such episodes, this is an indication for tonsillectomy.

    Peritonsillar abscess (J36)

    This is also called “peritonsillitis”, or “quinsy” 31, 32, and is acute tonsillitis complicated by an abscess, typically unilateral33. The abscess may form in the intratonsillar, para/ peritonsillar or retrotonsillar spaces. The pathogens are typically staphylococci34, streptococci and fusobacterium necrophorum35. In contrast to acute tonsillitis, viruses play no role in abscesses36. A peritonsillar abscess is drained by aspiration or drainage or by unilateral tonsillectomy.

    Tonsil hyperplasia (J35.1 and J35.3)

    Tonsil hyperplasia37, also known as (idiopathic) tonsillar hypertrophy38, refers to abnormal enlargement of the palatine tonsil. It has to be distinguished from physiological pediatric palatine tonsil hyperplasia39, 40 which is not a sign or consequence of recurrent inflammation41, 42. Also, children with tonsil hyperplasia do not suffer from acute tonsillitis43, 44 or middle ear infections45. A pediatric tonsil is only "pathologically" hyperplastic if snoring (with or without obstructive sleep apnoea) or rarely dysphagia46 or even more rarely dysphonia47 occur.

    Surgical procedures

    Tonsillectomy

    (Extracapsular) tonsillectomy means that the entire tonsil, including its capsule, is removed from the tonsil fossa; no lymphatic tissue remains between the anterior and posterior palatal arches48. Since the late 1960s, with the realization that the tonsil is a focus of infection49-52, this form of tonsil operation has been the gold standard and is still the most common surgery done in the world53.

    Video 1: Extracapsular tonsillectomy

    Tonsillotomy (partial tonsillectomy)

    Only the medial part of the tonsil is removed. It requires that the (well-perfused) lymphatic tissue is resected, and that the remaining crypts remain open to the oropharynx54, 55. Active lymphatic tissue, with secondary follicles and crypts, is left in the tonsil fossae56. Tonsillotomy can be done with most dissecting and coagulating methods. The most common are laser tonsillotomy and radiofrequency tonsillotomy and are described in detail in this chapter.

    Video 2: Laser tonsillectomy

    Video 3: Radiofrequency tonsillectomy

    Intracapsular tonsillectomy

    Intracapsular, subcapsular or subtotal tonsillectomy describes a method in which the lymphatic tissue of the tonsil, including all crypts and follicles, is removed57, 58, but the capsule of the tonsil is preserved; thus the underlying muscles are not exposed59. At the end of the operation there is an empty tonsil fossa without typical subsequent scarring59. Indications for intracapsular tonsillectomy are foetor ex ore (halitosis) and recurrent detritus (debris) in the tonsillar crypts. It differs from tonsillotomy in which a lot more tonsillar tissue is left behind.

    Video 4: Intrascapular tonsillectomy with radiofrequency

    Thermal- or cryotherapy of palatine tonsil

    The tonsil tissue is heated (or cooled) interstitially; subsequent scarring causes shrinkage of the lymphoid tissue. No tissue is removed and a large part of the lymphoid tissue allegedly remains functional. The indication is mild tonsillar hyperplasia. Synonyms and different techniques include interstitial (electro)coagulation, laser coagulation, thermal coagulation, and cryocoagulation of the palatine tonsil60, 61, photodynamic therapy, ultrasound therapy62, radiofrequency-induced thermotherapy63, temperature-controlled tonsil treatment64, 65, and tonsil thermotherapy.

    Preoperative evaluation, swabs & diagnosis

    Pathogens, biofilms, and normal findings

    With the discovery of rheumatic fever, group A streptococci (GAS) were primarily blamed for all ills in the upper respiretory tract in the 70’s 66-73. However more recently, anaerobes, e.g. Fusobacterium necrophorum, Streptococcus Intermedius and Prevotella Melaninogenica and Histicola have also been incriminated28, 74, 75.

    Children up to 8 years of age have a tendency towards diffuse intracellular pathogen enrichment with interstitial abscesses, while in adults or adolescents a more superficial bacterial accumulation at the edge of the crypts occurs. Particularly in the case of recurrent tonsillitis, several pathogens and microorganisms play a joint role. These can jointly form biofilms and bacterial clusters and thus evade antibiotics76. The oral cavity and especially the furrowed tonsil is a reservoir for multiple pathogens (viruses and bacteria), parasites77 and fungi78. However, all these microbes belong to resident flora with which we have lived symbiotically for aeons28, 79. Streptococci still play the largest role in acute tonsillitis (30%)80, followed by Haemophilus Influenzae and Neisseria28. Mostly, however, mixed infections (viral and bacterial initially) are responsible81.

    Diagnosis

    "Acute tonsillitis" in children and adults is a clinical diagnosis82. In viral tonsillitis, in addition to pain and fever, primarily cough, hoarseness, and rhinorrhoea occur, while in bacterial tonsillitis, in addition to pain with lymph node swelling, there is mainly a tonsillar exudate and fever >38.3°C 83. A streptococcal antigen test can confirm the diagnosis and is 98% specific for streptococci, although not particularly sensitive. A problem with these tests is the high number of asymptomatic chronic carriers of staphylococci and streptococci (10% of healthy children), who are definitely not in need of therapy84-89. In the early stages, a distinction between viral and bacterial tonsillitis is often difficult to make, especially when one considers that in 97.5% of cases, at least one virus, even in bacterial tonsillitis, is found (adenovirus and parainfluenza virus respectively in 47.5% 90, 91)81.

    Conservative Treatment

    Antibiotic therapy: In clinically apparent or proven bacterial tonsillitis associated with distress, antibiotics (beta-lactam) are justified. Beta-lactam antibiotic therapy also provides relatively reliable protection against the dreaded rheumatic fever and glomerulonephritis which often cause, especially in developing countries, arthritis, myocarditis and death. Studies have shown that antibiotic therapy can prevent sequelae such as peritonsillar abscesses, acute otitis and sinusitis. The penicillins, particularly in children and adolescents, have the greatest benefit at the lowest cost. There is no difference to cephalosporins. Macrolides and clindamycin have more side-effects with the same efficacy and should be reserved for patients with proven penicillin allergy92, 93.

    Postoperative antibiotic therapy is not indicated as it neither reduces pain nor postoperative bleeding94, 95.

    Steroids: In acute tonsillitis or after tonsillectomy, oral or intramuscular steroids (dexamethasone 10 mg), as well as betamethasone (8 mg) and prednisolone (60 mg), significantly improve symptoms with minimal side effects and no adverse effects relating to disease progression96-98.

    Analgesics: Nonsteroidal anti-inflammatory drugs have been used successfully for pain relief for >40 years 99. For acute tonsillitis, ibuprofen has the best efficacy with minimal side-effects compared to paracetamol and acetylsalicylic acid (ASA)100. Another advantage of ibuprofen is its longer duration of action (6-8 hours) compared to paracetamol. Both substances have a large therapeutic range and at the correct dosage, the safety is comparable 101, 102. Diclofenac and ketorolac are very effective, but in children have fewer docking sites and are metabolised more quickly, which is why the dose should be adjusted to a higher level than in adults)103. In postoperative management these substances play a role in opioid reduction, but as first-line therapy in paediatrics are not suitable for a sore throat 104, 105. Metamizol is not recommended as first or second choice analgesic in children due to a small but real risk of agranulocytosis106.

    Complications of tonsillitis

    In general, acute tonsillitis runs its course without complications and heals within 3-4 days. Rare but serious complications after streptococcal tonsillitis are glomerulonephritis and rheumatic fever, which triggers cardiomyopathies and rheumatic-like joint pain107. Early and a long course (10 days) of antibiotics (penicillin or cephalosporin) reduces the frequency of both these complications by 70% 108. In parts of the developing world where rheumatic fever is more common, preventing this complication is the main argument in favor of penicillin therapy108.

    Peritonsillar abscess is a second, more frequent complication. It is typically unilateral, although bilateral abscesses occur in up to 4% 109. It is preceded by acute tonsillitis in only 1/3 of cases110. Even correctly administered antibiotic treatment of acute tonsillitis cannot really prevent peritonsillar abscesses (in contrast to rheumatic fever)111. Since peritonsillar abscesses can rapidly spread to the soft tissues of the neck and are potentially life-threatening, the primary therapy is urgent and surgical112-114. It does not matter whether the abscess is needle aspirated, incised or treated by tonsillectomy115. But the surgeon has to keep in mind that a stab incision can fail to drain inferiorlylocated abscesses109, 116. Before the operation, high-dose steroid therapy, as well as penicillin should be administered, as is often done for mixed infections117.

    Indications for tonsil surgery

    Surgery is done for infections, to relieve airway obstruction, for halitosis and for diagnosis when a tumor is suspected. Surgery for recurrent tonsillitis depends on its frequency and severity, and the presence of additional diseases (antibiotic allergies, immunosuppression and PFAPA syndrome).

    Paradise criteria for tonsillectomy118

    Paradise (1984) reported that tonsillectomy significantly lowers the frequency of severe recurrent sore throats in children aged 3-15 years. Most published guidelines incorporate the so-called Paradise criteria for tonsillectomy:

    • 7 episodes of tonsillitis per year in one year or,
    • 5 episodes of tonsillitis per year in 2 consecutive years or,
    • 3 episodes of tonsillitis per year in 3 consecutive years

    A diagnosis of "purulent tonsillitis" must however be documented and confirmed by an elevated temperature (>38.3°C), tonsillar exudate, enlarged lymph nodes at the angle of the jaw, and antibiotic treatment119, 120. The authors also reported that on average only a few (not all) throat infections can be prevented by tonsillectomy in the following 2 years; 47 of 187 patients withdrew from the planned three-year follow-up121. For less severe sore throat inflammation or less frequent throat inflammation, the risk of tonsillectomy does not outweigh the benefits122.

    While tonsils contribute to immune competence until 12 years, a negative long-term effect on the immune system cannot be proven123. Nevertheless, in children under 8 years, the indications for complete removal must be strictly adhered to, as the risks of serious or fatal bleeding are higher124.

    With tonsillotomy (unlike tonsillectomy), some active lymphatic tissue is retained; it continues to grow in about 15% of cases, but rarely causes problems such as renewed snoring or recurrent tonsillitis125. The fear that frequent tonsillitis or peritonsillar abscesses will occur after tonsillotomy is unfounded126-128. All crypts remain open during laser, ultrasound, shaver, high- and radiofrequency technique129, 130.

    Surgical technique

    Extracapsular tonsillectomy

    Cold steel dissection is the most commonly performed surgical technique in children and adults, and is described in detail in the chapter on Pediatric Tonsillectomy. The technique is similar in adults.

    The tonsils are dissected from the tonsil bed partly sharply and partly bluntly with a raspartorium and scissors. The feeding vessels, especially at the upper and lower tonsil pole, are pinched off and then selectively ligated. After removal of the tonsil, a dry swab is pressed for about 1 minute into the tonsil bed to stop bleeding from small vessels. Some surgeons perform additional suturing of the lower pole (so-called “pole suturing”, a controversial method131).

    This method of tonsillectomy has been known for decades and has been very commonly used, especially in the 70s and 80s with the discovery of that tonsils are a source of infection132. Optical magnification (microscope or loupes), makes it possible to specifically identify the smaller vessels and perform bipolar coagulation before dissection133.

    Due to its good long-term results and low morbidity and mortality, cold steel dissection is still the most common method of tonsillectomy134.

    Tonsillotomy (partial tonsillectomy)

    The tonsil is not completely removed, but only the portion that bulges into the throat, which due to its size causes functional problems. By preserving some tonsil tissue a lymphatic and immunologically active rudiment is retained.

    The tonsil has a rich blood supply and has to be sufficiently cut and coagulated (not crushed) during surgery so that there is no postoperative bleeding, infection or pain. To this end, several dissection procedures have been developed (in principle, a tonsillectomy can also be performed with all these methods):

    • CO² laser 135 136
    • Monopolar high frequency current 137
    • Ultrasound scalpel 138
    • Bipolar radiofrequency coblation 139
    • Bipolar scissors 140
    • Argon gas-assisted monopolar needle 141
    • Microdebrider 142

    Advantages of tonsillotomy (regardless of what method is used to reduce the tonsils) are significantly less pain 143 and a lower postoperative bleeding rate 144 compared with tonsillectomy.

    2.png

    Figure 2: Instruments to perform radiofrequency dissected tonsillotomy / partial tonsillectomy

    The quickest and easiest way to perform tonsillotomy is with monopolar high frequency dissection (Video 3). Instrumentation is shown in Figure 2.

    • Following induction of general anesthesia the patient is positioned supine with neck slightly extended
    • Select an appropriate length Boyle Davis blade and insert the gag to retract the tongue and expose the tonsils (Figure 1)
    • Grasp a tonsil with a broad tonsil holding forceps and gently pull it toward the midline. Avoid pulling too hard to avoid doing a complete tonsillectomy
    • Insert a Colorado needle into the tonsil at the edge of the anterior faucal pillar
    • Spare the mucosa of the velopalatinal arch to avoid bleeding and pain in the incision line
    • Amputate the protruding part of the tonsil by dissecting with continuous movements of the needle. Do not remain too long in the same place with the cutting needle as it may burn holes in the tonsil
    • Pack the wound with a gauze swab for at least 1 minute
    • Minor bleeding stops spontaneously. Larger bleeding vessels can be coagulated with bipolar forceps. A suture or ligature is not required
    • Repeat the process on the contralateral side

    Intracapsular (subtotal) tonsillectomy

    The tonsil capsule covering the underlying muscle remains in the tonsil fossa145. Slightly less postoperative pain and earlier food intake have been reported146. The instrumentation and technique is similar to tonsillotomy. All the methods of tonsillotomy previously listed may also be used. The microdebrider has been reported to be a useful tool147-152.

    • The surgeon has to pull harder on the tonsil to subluxate the capsule, but the capsule itself has to remain in place and not be breached
    • It may be very difficult to determine the exact proportion of residual tonsil that remains in the fossa
    • After tonsillitis with subsequent scarring it is difficult even with loupes or a microscope to identify the exact plane of the tonsil capsule and only to remove only the active lymphatic tissue
    • Because the vessels are bigger in the abyss of the crypts and near the capsule, bleeding has to be controlled with bipolar forceps more often than with (more superficial) tonsillotomy

    Postoperative pain

    Tonsillectomy is very painful, especially if the capsule is breached and the muscle is exposed. Severe pain and superinfection of the wound bed can cause delayed healing and prolong hospital stay. Especially adolescent and adult patients report pain, exhaustion and fatigue weeks after surgery. In tonsillectomy the wound remains open and heals in 2-3 weeks secondarily by granulation. Sealing the wound beds postoperatively e.g. with fibrin glue153 or sucralfate154 has no advantage in terms of postoperative bleeding or pain.

    With tonsillotomy, however, pain was reported as only around 2-3 on the numerical analogue scale.

    Intracapsular tonsillectomy is allegedly less painful than tonsillectomy155. However, it is unlikely that intracapsular tonsillectomy produces as little pain as tonsillotomy. Pain is perceived very differently by individuals. In children and adults, the differences, regardless of surgeon and method, can be enormous156-158. Children of African descent have more postoperative pain than Europeans and respond better to opiates159. This complicates both objective pain measurement (which does not exist), as well as a standard therapy. Pain therapy must therefore be individualized and adjusted, especially in children. Questionnaires (e.g. Ramsay Sedation Scale160) for analgesic use, food intake, otalgia, and downtime use popular surrogate parameters.

    Because pain is perceived and processed multimodally, the treatment must be multimodal. Firstly, a local long-lasting pain reliever (e.g. Bupivacaine or Ropivacaine161) should be injected into the wound postoperatively or perioperatively to pre-vent activation of the early pain pathway162-164. Then already perioperatively it should be cooled locally by a cold compress165 and later a lot of ice should be eaten (local cooling and calorie intake)166. Mouth-washes with gingicaine, benzocaine or tetracaine also provide pain relief, but also numb the taste buds and respiratory flow receptors, which is often perceived as very unpleasant.

    The perioperative and postoperative administration of high-dose steroids (dexamethasone or prednisolone) is clearly recommended in all guidelines. This reduces postoperative nausea and analgesic consumption significantly167-169.

    A fixed analgesic regimen with ibuprofen or diclofenac makes sense in adults and adolescents, but for children and infants rescue medication is often enough170, 171. An increased risk of bleeding due to nonsteroidal anti-inflammatory drugs, (except for aspirin) should not be feared172, 173. One should therefore adhere to the WHO staging system174 (http://www.who.int/cancer/palliative/painladder/en/). After tonsillectomy, it may well be that in the first days WHO stage III drugs (strong opioid, e.g. piritramide iv) or even a pain pump must be administered to ensure pain under 4 on the visual analogue scale and adequate food intake175. Pain and nausea (with and without vomiting) after tonsillectomy are often trivialized by both nurses as well as physicians and therefore it is more likely that few analgesics will be administered postoperatively176-178.

    Post-tonsillectomy bleeding

    Early and late postoperative bleeding

    Postoperative bleeding can occur anytime until the wound is completely healed, despite careful intraoperative hemostasis and dissection; usually after 2-3 weeks.

    Postoperative bleeding occurs either as socalled early bleeding within the first 24 hours, or in the form of late bleeding with a peak incidence between the 5th and 8th day after surgery. From the 3rd postoperative week bleeding occurs only very rarely. Therefore late postoperative bleeding presents a special problem because it often occurs only at home and therefore the time factor to get a professional play a major role.

    3.png

    Figure 3: Rigid tonsil or thoracic suction device manufactured by Cardinal Health, IL, USA (Medi-Vac ® Yankauer Suction Handle, REF KEX80)

    The most common cause of late bleeding is the physiological detachment of the fibrin layer from the open wound bed and usually results in harmless bleeding. This bleeding almost always ends spontaneously, or due to local icing (sucking ice cubes, applying an ice cravat) or by tranexamic acid intravenously or locally (rinsing)179. If bleeding does not spontaneously subside because a larger vessel is bleeding, vessel ligation or suturing under anesthesia is required. Massive hemorrhage is an extreme challenge for every paramedic or emergency doctor because of the difficult airway management. Intubation is only possible with suctioning the airway with suction tubes (Figure 3).

    During induction and intubation, the ENT doctor should be present and prepared to perform emergency Cricothyroidotomy. Aspirated blood or incorrect intubation is the most common clinical complication of postoperative bleeding. Intraoperatively the surgeon must decide whether targeted bipolar coagulation and swab pressure are sufficient or whether suturing or ligation are necessary. If that fails, either the lingual artery, ascending pharyngeal artery, facial artery or even the external carotid artery must be ligated from externally or embolisation the feeding vessels by interventional radiology should be done. Such massive bleeding is signalled in most cases by a minor "warning bleeding"180, 181, so any bleeding must be taken seriously and the patient must be hospitalized.

    Postoperative bleeding depending on method of surgery

    In principle, intraoperative and postoperative bleeding can occur with all intervenetions involving the tonsils. However, for the tonsillotomy the postoperative bleeding rate is, by a factor of 5-10, lower than that for tonsillectomy182. In cryptolysis and thermotherapy of the tonsils postoperative bleeding is a rarity183, 184. Only extracapsular tonsillectomy remains problematic. "Cold dissection" with ligature or suturing has the lowest postoperative bleeding rates. Significantly more severe late bleeding has been reported after laser, coblation, monopolar or bipolar techniques185-187.

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    Authors

    PD Dr. med. Klaus Stelter
    Dep. of Otorhinolaryngology, Head and Neck Surgery
    RoMed Clinic Bad Aibling
    Harthauser Str. 16
    83043 Bad Aibling
    info@alpenpraxisklinik.de

    Prof. Dr. med. Götz Lehnerdt
    Dep. of Otorhinolaryngology, Head and Neck Surgery
    St. Anna Clinic Wuppertal
    Vogelsangstr. 106
    42109 Wuppertal
    Hno.kh-anna@cellitinnen.de

    Editor

    Johan Fagan MBChB, FCS(ORL), MMed
    Professor and Chairman
    Division of Otolaryngology
    University of Cape Town
    Cape Town, South Africa
    johannes.fagan@uct.ac.za