Continuing Education Activity

Tonsillectomy remains one of the most frequently performed surgical procedures in the United States, with more than 500,000 operations conducted annually in children younger than 15 years. This course outlines this procedure, which involves the complete removal of the palatine tonsil and its capsule from the peritonsillar space and may be performed with or without adenoidectomy, as well as anatomical structures, including the palatine tonsils, which form part of Waldeyer’s ring and lie between the palatoglossus and palatopharyngeal muscles, with the superior constrictor muscle and glossopharyngeal nerve located laterally. Indications for tonsillectomy, most commonly including sleep-disordered breathing caused by tonsillar and adenoid hypertrophy, recurrent tonsillitis meeting established clinical criteria, tonsillar asymmetry, and suspected malignancy, are also discussed. Although generally safe, the procedure carries potential complications, eg, postoperative hemorrhage, pain, dehydration, and postoperative nausea and vomiting.

This activity reviews tonsillar anatomy, indications for surgery, operative techniques, and postoperative management. Participants will also gain an understanding of appropriate surgical candidates, perioperative risks, and early identification of complications. This activity for healthcare professionals is designed to enhance the learner's competence in performing tonsillectomies, applying common surgical approaches, selecting pain control strategies, employing preventive measures for complications, supporting safer patient counseling, improving perioperative care, and implementing an appropriate interprofessional approach to achieve better clinical outcomes in pediatric and adult populations undergoing tonsillectomy.

Objectives:

• Identify the indications for tonsillectomy.
• Select the appropriate technique for a tonsillectomy.
• Assess for complications following a tonsillectomy.
• Collaborate with interprofessional team members to improve care coordination and outcomes in patients undergoing tonsillectomy.

Introduction

In the United States, tonsillectomy is one of the most commonly performed surgical procedures. Over 500,000 cases are performed annually in children younger than 15 years of age. Common reasons for this surgery are sleep-disordered breathing (SDB) and recurrent throat infections. Several complications are documented with tonsillectomy and include bleeding, throat pain, and dehydration. According to the American Academy of Otolaryngology-Head and Neck Surgery, the definition of tonsillectomy is a “surgical procedure performed with or without adenoidectomy that completely removes the tonsil, including its capsule, by dissecting the peritonsillar space between the tonsil capsule and the muscular wall. Depending on the context in which it is used, it may indicate tonsillectomy with adenoidectomy, especially in relation to SBD.”[1]

Anatomy and Physiology

The palatine tonsils are a component of the Waldeyer ring of lymphoid tissue. Other components include the adenoids, tubal tonsils, and the lingual tonsils. The demarcation of the lymphoid tissue from the surrounding musculature is by a fibrous capsule that develops from the pharyngobasilar fascia. The potential space between the capsule and muscle is called the peritonsillar space. The tonsils are located between the palatoglossus and palatopharyngeus muscles, which form the anterior and posterior pillars, respectively (see Image. Oral Cavity and Palatine Tonsils).

The superior constrictor muscle lies lateral to the tonsil. Immediately deep to these muscles is the glossopharyngeal nerve, which is susceptible to injury during tonsillectomy. Transient swelling around this nerve can cause taste alterations and referred otalgia. The tonsils have multiple blood vessels providing their vasculature. The main vessels come from branches of the external carotid artery, and they are as follows: lingual, facial, ascending pharyngeal, and the internal maxillary arteries. The lingual artery gives off the tonsillar branch. The facial artery gives off a tonsillar and ascending palatal branch. The internal maxillary artery supplies the tonsil via the descending palatal artery. The surgeon needs to understand the anatomy of the oropharynx to perform safe surgery and reduce postoperative complications. Additionally, numerous anomalies can arise from this architecture.[2][3][4][5]

Indications

The 2 most common indications for tonsillectomy are SDB and recurrent tonsillitis. Sleep-disordered breathing is recurrent partial or complete upper airway obstruction during sleep, disrupting normal ventilation and sleep patterns. SDB can be diagnosed based on clinical findings. Symptoms of SBD include hyperactivity, daytime tiredness, and aggression. Signs of SBD include habitual snoring, witnessed apnea, restless sleeping, growth retardation, poor school performance, and nocturnal enuresis. Children with SDB have significantly higher rates of antibiotic use, 40% more hospital visits, and a 215% elevation in healthcare usage from increased upper respiratory infections compared to children without SDB. Tonsillar and adenoid hypertrophies are the most common cause of SDB. Tonsillar size does not always correlate with the severity of SDB, and polysomnography can further evaluate patients with signs and symptoms of SDB who are without tonsillar hypertrophy.

For recurrent tonsillitis, watchful waiting is recommended for patients who do not meet the Paradise Criteria. A patient with fewer than 7 episodes in the prior year, fewer than 5 episodes annually in the past 2 years, or fewer than 3 episodes annually in the past 3 years does not meet the criteria for tonsillectomy.[6] If the frequency of infections exceeds these thresholds, tonsillectomy may be recommended as a treatment option. Documentation of each infection should include a sore throat and 1 or more of the following:

• Temperature >100.4 °F (37 °C)
• Cervical adenopathy
• Tonsillar exudates
• A positive group A beta-hemolytic streptococcus test

Modifying factors, eg, antibiotic allergy/intolerance, PFAPA (periodic fever, aphthous stomatitis, pharyngitis, and adenitis), or peritonsillar abscess, could warrant earlier surgical intervention in patients with recurrent tonsillitis.[1] Additional indications for tonsillectomy include tonsillar asymmetry (to rule out malignancy) and malignancy. The most common malignancies of the palatine tonsils are squamous cell carcinoma and lymphoma. Most malignant neoplasms in children are lymphoma.[7]

Contraindications

No absolute contraindications to tonsillectomy have been established. The major complications related to tonsillectomy are bleeding and anesthetic risks. Therefore, patients undergoing tonsillectomy should have any risk factors for these complications (ie, bleeding disorders, family history of malignant hyperthermia) identified and addressed preoperatively with necessary precautions.[8]

Equipment

The equipment required for tonsillectomy depends on the technique used. “Cold” tonsillectomy is performed using a Crowe-Davis or McIvor mouth gag, Allis clamp, number 12 scalpel, curved Metzenbaum scissors, Fisher tonsil knife/dissector, and Tyding snares. “Hot” tonsil dissections are performed using monopolar cautery. Bipolar radiofrequency ablation (ie, coblation) is also an option. Mircodebrider techniques are also used (especially when performing intracapsular tonsillectomies).

Personnel

Personnel required for a tonsillectomy include a surgeon, an anesthesiologist, a surgical technician, and a circulating nurse.

Preparation

Anesthesia is induced similarly regardless of the technique used. The patient is positioned supine and orally intubated. Most surgeons prefer oral RAE endotracheal tubes.[9] The tube is taped at the midline. The bed is then turned 45 to 180 degrees to allow the surgeon to sit or stand at the head of the bed, and the shoulder roll is then placed. A McIvor or Crowe-Davis mouth gag maintains the patient’s mouth in the open position.

Technique or Treatment

Tonsillectomy Approaches

Tonsillectomy can be performed either extracapsularly or intracapsularly. The “hot” extracapsular technique with monopolar cautery is the most popular technique in the United States. The superior pole of the tonsil is grasped with the Allis clamp, and the tonsil is medialized. The lateral edge of the tonsil is identified submucosally. The superior pole is incised using around 20 Watts of power if a traditional tip is used. The avascular plane between the tonsil and musculature is identified. The entire palatine tonsil is removed typically from the superior to the inferior pole. Maintenance of hemostasis is by packing, suction cautery, or ties. 

“Cold” tonsillectomy is performed using sharp dissection. The tonsil is grasped with the Allis clamp and medialized. The lateral aspect of the tonsil is again identified and incised using a number 12 scalpel. A Metzenbaum scissors is then used to identify the avascular plane. Once within the plane, a Fisher tonsil dissector removes the tonsil from the fossa until the tonsil attachment remains only at the inferior pole. A Tyding snare is then used to separate the tonsil from its inferior pole. Maintenance of hemostasis is with pressure from a tonsil sponge, suction cautery, or ties. 

Coblation can be used to remove the tonsil using a technique similar to monopolar cautery. Coblation utilizes saline irrigation that converts into an ionized plasma layer, resulting in a molecular breakdown of tissue. Minimal heat generation takes place, and this is a common technique for partial/intracapsular tonsillectomies. A microdebrider can also be used to perform a partial tonsillectomy.[10][11]

The debate remains between the advantages of one technique over the other.[12] Overall, the benefits of a technique depend on the cost, decreased complication rates (ie, bleeding rates), time in the operating room, and postoperative pain. “Cold” tonsillectomy is thought to result in less postoperative pain, while some studies show “hot” tonsillectomy results in less intraoperative blood loss and surgical time.[13][14] Choice of technique depends on the surgeon’s experience and comfort level.

Clinical Practice Guidelines

The following guidelines are from the 2018 Clinical Practice Guideline: Tonsillectomy in Children from the American Academy of Otolaryngology-Head and Neck Surgery:

• Clinicians should recommend watchful waiting for recurrent throat infections if fewer than 7 episodes have occurred in the past year, fewer than 5 in the past 2 years, or fewer than 3 in the past 3 years.
• Clinicians may recommend tonsillectomy for recurrent throat infection with a frequency of at least 7 episodes in the past year or at least 5 episodes per year for 2 years or at least 3 episodes per year for 3 years with documentation in the medical record for each episode of sore throat and 1 or more of the following: temperature >38.3 °C, cervical adenopathy, tonsillar exudate, or a positive test for group A beta-hemolytic streptococcus.
• Clinicians should assess the child with recurrent throat infection who does not meet criteria in Statement 2 for modifying factors that may nonetheless favor tonsillectomy, which may include but are not limited to multiple antibiotic allergy/intolerance, PFAPA (periodic fever, aphthous stomatitis, pharyngitis, and adenitis), or history of more than 1 peritonsillar abscess.
• Clinicians should ask caregivers of children with obstructive sleep-disordered breathing and tonsillar hypertrophy about comorbid conditions that may improve after tonsillectomy, including growth retardation, poor school performance, enuresis, asthma, and behavioral problems.
• Clinicians should counsel caregivers about tonsillectomy as a means to improve health in children with abnormal polysomnography who also have tonsil hypertrophy and sleep-disordered breathing.
• Clinicians should counsel caregivers and explain that SDB may persist or recur after tonsillectomy and may require further management.
• Clinicians should administer a single, intraoperative dose of intravenous dexamethasone to children undergoing tonsillectomy.
• Clinicians should not administer or prescribe perioperative antibiotics to children undergoing tonsillectomy.
• The clinician should counsel patients and caregivers on the importance of managing postoperative pain as part of perioperative education and reinforce this counseling at the time of surgery, with reminders to anticipate, reassess, and adequately treat pain after surgery.
• Clinicians who perform tonsillectomy should determine their rate of primary and secondary posttonsillectomy hemorrhage at least annually.[1]

Complications

Bleeding is one of the most common and feared complications following tonsillectomy with or without adenoidectomy. A study from 2009 to 2013 involving over 100,000 children showed that 2.8% of children had unplanned revisits for bleeding following tonsillectomy, 1.6% percent of patients came through the emergency department, and 0.8% required a procedure.[15] Treatment of postoperative tonsillectomy hemorrhage is leaning in favor of using tranexamic acid, whether intravenously or nebulized.[16][17][18] Frequency is higher at night, with 50% of bleeding occurring between 10 pm and 1 am and 6 am and 9 am; this is thought to be from changes in circadian rhythm, vibratory effects of snoring on the oropharynx, or drying of the oropharyngeal mucosa from mouth breathing.[19] The risk of bleeding in patients with known coagulopathies may be significantly higher.[20]

Postoperative nausea and vomiting (PONV) is another common complication following tonsillectomy. This complication occurs in up to 70% of patients who did not receive prophylactic antiemetics. PONV can lead to increased admission rates, increased need for intravenous hydration, increased need for pain medicine, and decreased patient satisfaction. The recommendation to counter these sequelae is to administer a single dose of intraoperative dexamethasone during tonsillectomy. Some clinicians will routinely prescribe a single dose of ondansetron for outpatient surgeries, as PONV is most likely within the first 24 hours after surgery.

The leading cause of morbidity following tonsillectomy is pain, subsequently leading to diminished oral intake and dehydration, dysphagia, and weight loss. Caregivers should be competent in monitoring for signs of dehydration and should continuously encourage their child to stay hydrated. One method to decrease oropharyngeal pain is alternating scheduled doses of acetaminophen and ibuprofen.[1]

Clinical Significance

Tonsillectomy is among the most frequent surgical procedures performed on children in the United States. Primary care clinicians and otolaryngologists must understand the indications, contraindications, and risks associated with this procedure to educate their patients or the patient’s caregiver. Surgeons need to understand the anatomy of the oropharynx to perform safe surgery and reduce postoperative complications.

Enhancing Healthcare Team Outcomes

Tonsillectomy is one of the most commonly performed surgical procedures in the United States, particularly in children younger than 15 years of age. The procedure involves complete removal of the palatine tonsils, with or without adenoidectomy, by dissecting the peritonsillar space between the tonsillar capsule and the muscular wall of the oropharynx. The most common indications include sleep-disordered breathing caused by tonsillar and adenoid hypertrophy and recurrent tonsillitis meeting established clinical criteria. Additional indications include tonsillar asymmetry and suspected malignancy. Understanding the complex anatomy of the tonsils, surrounding musculature, neurovascular structures, and blood supply is essential for safe surgical execution and minimizing complications. Although tonsillectomy is generally safe, potential complications include postoperative hemorrhage, pain, dehydration, and postoperative nausea and vomiting.

Optimal management of patients undergoing tonsillectomy requires coordinated interprofessional collaboration. Physicians and otolaryngologists evaluate surgical indications, perform the procedure, and manage perioperative risks. General practitioners and advanced practitioners contribute by identifying appropriate candidates, applying guideline-based criteria, and coordinating referrals. Nurses monitor patients perioperatively, provide education on hydration, pain control, and signs of postoperative complications, and support recovery. Pharmacists assist with medication management, including analgesics, antiemetics, and, when indicated, agents such as tranexamic acid. Effective communication among team members ensures accurate documentation of infection episodes, careful preoperative risk assessment, and timely recognition of complications. Coordinated care and patient-centered education improve safety, reduce postoperative morbidity, and enhance overall outcomes and team performance.

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Disclosure: Olivia Matz declares no relevant financial relationships with ineligible companies.

Disclosure: Carl Shermetaro declares no relevant financial relationships with ineligible companies.