Operative Techniques in Otolaryngology (2005) 16, 224-228

FEATURE ARTICLES

Tonsillectomy
Anna H. Messner, MD

From the Departments of Otolaryngology/Head & Neck Surgery and Pediatrics, Lucile Packard Children’s Hospital at
Stanford, Stanford University, Palo Alto, California.

KEYWORDS Tonsillectomy is one of the most common surgeries performed in the United States of America. There
Tonsillectomy; is currently no consensus on which of the several techniques available is optimal. This article describes
Tonsillotomy; the various extracapsular (total tonsillectomy) and intracapsular (subtotal tonsillectomy) techniques that
Intracapsular; are currently available.
Extracapsular; © 2005 Elsevier Inc. All rights reserved.
Microdebrider;
Radiofrequency
ablation;
Harmonic scalpel

Tonsillectomy with or without adenoidectomy is one of Clinical Indicators Compendium lists under tests for tonsil-
the most common surgeries performed in the United States lectomy “Coagulation and bleeding workup if abnormality
of America, with more than 300,000 tonsillectomies per- suspected by history or genetic information unavailable.”2
formed annually.1 The most common indication for tonsil- However, many otolaryngologists recommend that their pa-
lectomy is a sleep-related breathing disorder (obstructive tients obtain some or all of the following tests before sur-
sleep apnea), followed by recurrent tonsillitis. Other possi- gery: complete blood count, platelet level, prothrombin
ble indications for tonsillectomy include peritonsillar ab- time, partial thromboplastin time, and bleeding time.1,3
scess unresponsive to medical treatment, persistent foul Other surgeons recommend obtaining a pertinent personal
taste or breath caused by chronic tonsillitis not responsive to and family history of bleeding, with a laboratory evaluation
medical therapy, unilateral tonsil hypertrophy presumed only if the bleeding history is positive.5,6
neoplastic, and hypertrophy causing dental malocclusion or Preoperative electrocardiogram and chest x-ray are not
adversely affecting orofacial growth documented by an necessary unless there is a history of heart disease.7 Other
orthodontist.2 preoperative evaluation needs to be decided based on the
medical conditions of each individual patient. For example,
a child with von Willebrand disease should have the input of
a hematologist regarding the use of desmopressin to mini-
Preoperative evaluation mize the risk of bleeding during the intraoperative and
postoperative periods. Flexion and extension x-rays of the
History alone is the most common method for diagnosing
cervical spine should be considered for patients with tri-
obstructive sleep apnea.3 When the diagnosis is at all in
somy 21 syndrome because they have an increased risk of
question, the child is younger than 2 years, or there is
subluxation of the cervical spine.
concern about the severity of the sleep apnea, a polysom-
nogram should be recommended.4 In the otherwise normal
child, once the recommendation for surgery has been made,
there is usually little other preoperative evaluation neces- Surgical procedure
sary. The American Academy of Otolaryngology 2000
The anesthesia induction and positioning of the patient is
similar for most patients undergoing tonsillectomy, re-
Address reprint requests and correspondence: Anna H. Messner,
MD, Otolaryngology/Head & Neck Surgery, 801 Welch Road, Palo Alto, gardless of which technique is used to remove the tonsils.
CA 94305-5739. The patient is placed in the supine position and orally
E-mail address: amessner@stanfordmed.org. intubated. The endotracheal tube is taped to the patient’s
1043-1810/$ -see front matter © 2005 Elsevier Inc. All rights reserved.
doi:10.1016/j.otot.2005.09.005
Messner Tonsillectomy 225

chin in the midline. Alternatively, some practitioners

prefer to use a laryngeal mask airway.8,9 The bed is
turned 90°-180° so that the surgeon can sit or stand at the
head of the bed. The patient is positioned at the edge of
the bed, and a small shoulder roll is placed. Either a
Crowe-Davis, McIvor, or Dingman mouth gag is inserted
and expanded to keep the mouth open for the duration of
the procedure. The tonsils are then removed using 1 of
the techniques described later.
Tonsillectomy techniques can be divided into 2 gen-
eral categories: extracapsular (total tonsillectomy, sub-
capsular) and intracapsular (partial tonsillectomy). Intra-
capsular is also termed “subtotal,” and this procedure is
listed as tonsillotomy in some publications. In an extra-
capsular tonsillectomy, dissection is performed lateral to
the tonsil in the plane between the tonsillar capsule and
the pharyngeal musculature, and the tonsil is generally
removed as a single unit. In contrast, an intracapsular
tonsillectomy involves removal of the tonsil in piecemeal
fashion, from medial to lateral, with care taken to pre-
serve the capsule. The most common extracapsular tech-
niques use a monopolar electrocautery, bipolar cautery
(or bipolar scissors), “cold” knife (sharp dissection), or
harmonic scalpel. Intracapsular techniques may use the Figure 1 Electrocautery tonsillectomy. Dissection is performed
microdebrider, bipolar radiofrequency ablation (which from superior to inferior in the plane between the tonsil and the
can also be used to remove the entire tonsil), and carbon underlying musculature. The entire tonsil with capsule is removed.
dioxide laser. Either extracapsular or intracapsular ton-
sillectomy can be performed for the pediatric patient with
obstructive sleep apnea, but only extracapsular tech- rounding tissue using scissors and/or knife, and the inferior
niques should be used for patients undergoing tonsillec- pole is amputated with a snare (Figure 2). Historically, a
tomy as a result of tonsillitis or peritonsillar abscess. In tonsillotome, or other guillotine-type device, was used to
addition, tonsils can be ablated using a laser or monopo- perform a total or partial “cold” tonsillectomy.10 Like the
lar radiofrequency (somnoplasty) in a cooperative adult electrocautery technique, hemostasis is obtained using
in a clinic setting. The tonsil ablation procedures will not packs, suction cautery, or absorbable ties.
be discussed in detail in this article.
Harmonic scalpel
Monopolar/bipolar electrocautery The harmonic scalpel can be used to perform an extra-
capsular tonsillectomy (Ethicon Endo-Surgery Inc, Cincin-
The most common technique used for removing tonsils nati, OH). This medical device uses ultrasonic energy to
in the United States today is monopolar electrocautery, also vibrate its blade at 55,000 cycles per second. The vibration
called a “hot” tonsillectomy.3 The superior pole of the tonsil transfers energy to the tissue, providing simultaneous cut-
is grasped with a curved or straight Allis clamp and re- ting and coagulation, so, typically, no additional instru-
tracted medially to identify the lateral edge of the tonsil ments are needed for hemostasis.
submucosally. Using an electrocautery setting of approxi-
mately 20 W (if using a standard electrocautery tip) or 6 W Bipolar radiofrequency ablation (aka coblation,
(if using a microdissection needle), the anterior tonsillar low-temperature plasma excision,
pillar is incised, and the entire palatine tonsil with the
ionized field ablation)
capsule is dissected from surrounding tissue. Typically,
dissection is performed from superior to inferior (Figure 1).
Bipolar radiofrequency ablation can be used to per-
Hemostasis is obtained using packing, a suction cautery, or
form an extracapsular or intracapsular tonsillectomy,
absorbable ties. A standard electrocautery tip or a microdis-
however, it is most commonly used to perform a partial
section needle can be used for the dissection. Alternatively,
tonsillectomy (Figure 3). The equipment includes a ra-
bipolar forceps or bipolar scissors can be used to remove the
diofrequency generator, foot control, saline irrigation
tonsils.
regulator, and the coblation wand (PlasmaCare Corp,
Sunnyvale, CA). During a bipolar radiofrequency abla-
“Cold” knife tion tonsillectomy, conductive saline solution is con-
verted into an ionized plasma layer, resulting in molec-
Another technique frequently used to remove completely ular dissociation with minimal thermal energy transfer.
the tonsils is the “cold” or sharp dissection technique. In this Hemostasis can usually be performed with the coblation
technique, the tonsil and capsule are dissected from sur- wand alone.
226 Operative Techniques in Otolaryngology, Vol 16, No 4, December 2005

Figure 2 “Cold” knife tonsillectomy. (A) Scissors are used to identify the plane between the tonsil and underlying musculature. The
anterior tonsillar pillar is incised at the superior edge of the tonsil. (B) Within the exposed plane, the tonsil is separated from the surrounding
tissue using a Fisher knife. (C) The inferior pole is amputated with a snare.

Microdebrider tonsillectomy Advantages and disadvantages of

aforementioned techniques
Another method of intracapsular tonsillectomy uses the
microdebrider. The microdebrider is a powered rotary shav- There is great debate about the relative merits of the
ing device with continuous suction, made up of a tube, various tonsillectomy techniques, and many studies have
connected to a hand piece, which, in turn, is connected to a been published, with many more ongoing that compare
motor with foot control and a suction device. A partial the techniques. The existing literature consistently re-
tonsillectomy is completed with the removal of approxi- ports that the intracapsular (partial) techniques result in
mately 90% to 95% of the tonsil, while preserving the less postoperative pain, however, the degree of lessened
tonsillar capsule. pain continues to be much debated.11-18 In addition, there
Messner Tonsillectomy 227

is a small risk of tonsil regrowth and the necessity for an Table 1 Cost of tonsillectomy equipment*
additional procedure with the intracapsular techniques.
Of the extracapsular techniques, “cold” tonsillectomy Equipment Cost
results in less postoperative pain compared with an elec- Electrosurgical pencil $2.93 each
trocautery or “hot” tonsillectomy, however, the latter Snare wire $1.71 for 2 wires
procedure is typically faster and has less intraoperative Suction cautery $7.60
blood loss.19-21 Although not extensively researched thus Powered T&A set $111.40
Coblator T&A set $180.00
far, a total tonsillectomy with the coblation unit may have Harmonic scalpel T&A set $237.00
slight advantages over electrocautery tonsillectomy.22
*These numbers are an average of the cost to the hospital at
The studies on outcomes of surgeries completed with the
Lucile Packard Children’s Hospital at Stanford (Palo Alto, CA) and The
harmonic scalpel do not show any definitive advantage to Children’s Hospital of Denver (Denver, CO). The cost to the patient
the scalpel.23-27 It is not clear which technique, if there is would be considerably higher.
one, results in the lowest rate of postoperative hemor-
rhage.28-30 The data available to date suggest that there is
not a difference in the bleeding rates between extracap-
Postoperative care
sular and intracapsular tonsillectomy.30 The equipment
involved with various techniques varies in price (Table 1), A majority of children can safely be discharged home on the
although the largest cost factor in any tonsillectomy is the same day of surgery, regardless of the surgical technique
operating time. used.3,33 Children younger than 2 years or who live far from
a hospital should be kept overnight for observation. Pain
medication should be recommended, and most physicians
prescribe either acetaminophen or acetaminophen with co-
Complications deine postoperatively.34 Some physicians recommend a soft
The primary complication with all tonsillectomy techniques diet postoperatively, others recommend “diet as tolerated.”3
is postoperative bleeding. The risk of postoperative bleed- Studies have not shown any difference in recovery between
ing is generally in the range of 4%, with a wide range of children who have a restricted versus those who have non-
reported values.28-32 The variation in the reported incidence restricted diets postoperatively.35,36
is most likely related to the definition of “bleeding” and the
data collection systems used in various studies. The inci-
dence of bleeding has increased with the age of the pa- Long-term follow-up
tient.31,32
Typically, the patient will be seen in the office in 1 month
of the tonsillectomy to confirm adequate healing, although it
is also acceptable to follow-up with a phone call only.3,37

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