Surgical advances in tonsillectomy: report of a roundtable discussion

Ear, Nose & Throat Journal, August, 2004 by Kelvin C. Lee, John P. Bent III, Jay N. Dolitsky, Annette M. Hinchcliffe, Eric L. Mansfield, Ann K. White, Ramzi Younis

Tonsillar surgery dates back to antiquity, and both its indications and techniques continue to evolve. During the past 10 years, the large number of articles on tonsillar surgery published in the literature is a testament to the ongoing growth, development, and controversies involved with this procedure.

Based on observations made during a roundtable discussion, this supplement contains a review of several recent advances in the surgical management of tonsillar disease. In particular, the seven participating physicians discuss three of the newer surgical tools that are available to otolaryngologic surgeons: the harmonic scalpel, the powered tissue microdebrider, and the plasma excision (Coblation[R]) device. They also share some practical surgical pearls that will help surgeons maximize their use of these modalities.

Indications and rationale for tonsillectomy

As far as we know, Celsus was the first to recognize tonsillar disease and its relationship to infection, and he performed the first tonsillectomy in 40 A.D. (1) The popularity of tonsillectomy peaked in the 1930s, but after the use of antibiotics became widespread, enthusiasm for the procedure waned and its use had decreased dramatically by the 1960s. Concerned about the morbidity inherent in the surgical procedure, pediatricians began to question its value relative to medical management with antimicrobials. The tide turned again in the 1980s, when Paradise et al demonstrated that surgery significantly improved patient outcomes compared with medical therapy. (2) They also identified specific indications for which tonsillar surgery had proved to be beneficial.

The traditional indication for tonsillectomy is recurrent tonsillar infection. More recently, awareness of the incidence of obstructive adenotonsillar hypertrophy with associated obstructive sleep apnea has increased; in fact, in many practices, it has become the most common indication for tonsillar surgery. Other relative indications include craniofacial and dental growth abnormalities, chronic irritation, biopsy for suspicious neoplasms, and halitosis. For all these indications, most clinicians advocate the complete removal of the tonsillar tissues via standard dissection.

Another procedure--intracapsular (partial) tonsillectomy--has been shown to be as beneficial as total tonsillectomy in some cases, particularly in patients with obstructive adenotonsillar hypertrophy. By preserving the tonsillar capsule, the surgeon avoids interrupting the deeper tissue layers (e.g., the pharyngeal muscles) and leaves in place a biological dressing that keeps the muscles isolated from inflammatory secretions. (3) Compared with total tonsillectomy, tissue-sparing intracapsular tonsillectomy decreases the risk associated with exposing the larger blood vessels. It is also associated with reductions in postoperative pain, recovery time, and delayed postoperative bleeding. (3,4) The lower risk of bleeding may be attributable to the fact that the tonsil is removed from the outside in; the resection is performed distal to the arborization of the primary tonsillar vessels, exposing only the smaller branched arterioles. (3)

Even so, experience with intracapsular tonsillectomy suggests that allowing tonsillar tissue to remain after surgery may pose limited risks of recurrent infection and tonsillar regrowth. Tonsillar tissue is different from other lymphoid tissues because the tonsillar surface contains deep crypts. Some authors have suggested that accumulated debris in the tonsillar crypts can cause chronic irritation and subsequent infection. The crypts protect the bacteria from the effects of both the body's immune response and systemic antibiotics. In addition, the bacteria in these crypts have been found to produce biofilms. These biofilms may be a principal reason that tonsillar infections recur despite the aggressive use of oral antibiotics. This finding suggests that if intracapsular tonsillar procedures are to be an effective treatment, they must be designed to include the removal of the tonsillar crypt tissue.

Another significant disadvantage of intracapsular tonsillectomy is that it may take longer to perform than total tonsillectomy. Because larger tonsils have more volume, tissue removal often takes longer to perform. The advantages and disadvantages of intracapsular tonsillectomy must be discussed with patients or their parents so that they can make an informed decision.

The effectiveness of the intracapsular procedure continues to be studied, but in the meantime, total tonsillectomy remains the procedure of choice for most surgeons. During the panel discussion, Dr. Dolitsky emphasized that he prefers total tonsillectomy for patients with chronic or recurrent tonsillar infection because it obviates the risk that a patient will require additional tonsillar surgery in the future, which is a possibility associated with intracapsular tonsillectomy. He also pointed out that some parents have the misconception that the tonsils are a functioning part of the immune system. They erroneously believe that if the tonsils are removed, their child will be at increased risk of developing asthma, bronchitis, or pulmonary infection. He points out that there are no data to support this belief.