OPEN ACCESS ATLAS OF OTOLARYNGOLOGY, HEAD &
NECK OPERATIVE SURGERY
PAEDIATRIC TONSILLECTOMY Joe Grainger and Nico Jonas
Tonsil surgery includes tonsillectomy facial artery, provides the main blood to
where the aim is complete removal of the the tonsil.
tonsil, compared to tonsillotomy where the
aim is to remove part of the tonsil in order Whilst the superior aspect of the tonsil is
to create more space in the oropharynx. usually well defined, inferiorly the tonsil
The indications for tonsillotomy are limit- often merges with lingual tonsil tissue
ed and includes surgery for sleep dis- around the base of the tongue.
ordered breathing in very young children
where the aim is to limit morbidity asso- Lymphatic drainage of the tonsil is to the
ciated with postoperative pain and jugulodigastric nodes and other upper deep
bleeding. cervical lymph nodes.
Anatomy Physiology
The palatine tonsils are located in the The palatine tonsils are part of Waldeyer’s
tonsillar fossae which are bounded by the ring, a ring of lymphoid tissue that forms
anterior and posterior faucal pillars. These an important first line of defence for the
comprise the palatoglossus and palato- respiratory and digestive systems.
pharyngeus muscles respectively (Figure Waldeyer’s ring is part of the mucosa
1). associated lymphoid tissue (MALT) and
plays a role in the production of B cells
following the ingestion or inhalation of
hazardous microorganisms.
Whilst the palatine tonsils and adenoids
form a significant component of this sys-
tem, removal of the tonsils (and adenoids)
does not seem to have a significant impact
on immunity; remaining lymphoid tissue in
Waldeyer’s ring and in other locations
continue to function and prevent immunity
problems.
Indications for tonsillectomy
Figure 1: Anterior (blue) and posterior
(yellow) faucal pillars The most frequent indications for tonsillec-
tomy in paediatric practice are:
Laterally, the tonsil is surrounded by a
• Recurrent tonsillitis and/or peritonsillar
fibrous capsule that separates the tonsil
abscess
from the superior constrictor muscle and
• Obstructive sleep apnoea syndrome
buccopharyngeal fascia. The glossopharyn-
(OSAS)
geal nerve and facial artery lie in close
• Suspected malignancy
proximity to the superior constrictor mus-
cle. The tonsillar artery, a branch of the • Halitosis caused by debris in the
tonsillar crypts
Occasionally an "acute” or “hot tonsillec- evidence based approach to tonsillectomy
tomy" might be indicated. This is reserved for recurrent tonsillitis. The Scottish
for patients requiring a general anaesthetic Intercollegiate Guideline Network advo-
to drain a quinsy abscess who already cates tonsillectomy for recurrent tonsillitis
qualify for tonsillectomy or patients who only in the following circumstances:
present with severe acute tonsillitis (usual- • Sore throats due to acute tonsillitis
ly glandular fever / infectious mononucleo- • Episodes of sore throat that are disab-
sis) causing acute airway obstruction and ling and prevent normal functioning
requiring airway intervention and not • Seven or more well documented,
responding to conservative management clinically significant, adequately treat-
(Figure 2). ed sore throats in the preceding year, or
• Five or more such episodes in each of
the preceding two years. or
• Three or more such episodes in each of
the preceding three years
Obstructive sleep apnoea syndrome
In obstructive sleep apnoea syndrome
(OSAS), children have a variable degree of
upper airway obstruction usually seconda-
ry to adenotonsillar hypertrophy. This may
be evident during the day as stertorous
mouth breathing but is usually more
noticeable when the child is asleep.
Reduced muscle tone during deep sleep
combined with adenotonsillar hypertrophy
causes upper airway obstruction and at
Figure 2: Enlarged tonsils secondary to times complete airway occlusion. Parents
glandular fever causing oropharyngeal will observe snoring and then periodically
obstruction obstructive apnoea evidenced by chest and
abdominal movement but no airflow.
Recurrent tonsillitis These episodes can occur frequently
throughout the night and apnoea may last
Recurrent tonsillitis can be a significant several seconds on each occasion.
burden to child and family due to prolon- Obstruction results in a degree of arousal
ged episodes of illness, poor school atten- and the child then regains a patent yet still
dance and significant discomfort. Tonsil- compromised upper airway.
lectomy nearly always causes complete
resolution of recurrent acute tonsillitis. These repeated episodes lead to disturbed
However, this comes at the risk of primary sleep, poor sleep quality, daytime somno-
(within 24 hours) and secondary (after 24 lence and poor school performance. If
hours) haemorrhage which in some cases severe, OSAS can result in relatively
can be fatal. prolonged episodes of hypoxaemia and
hypercarbia, which may progress to
The decision when to perform a tonsil- pulmonary hypertension and cor pulmo-
lectomy for recurrent tonsillitis is contro- nale.
versial. Some healthcare systems adopt an
2
Other indications • Failure to thrive (weight <5th centile
for age)
Although malignancy of the tonsil in • Obesity
childhood is rare, consideration should be • Significant comorbidity
given to tonsillectomy to obtain a histo- o Severe cerebral palsy
logical diagnosis in a child with significant o Moderate to severe neuromuscular
tonsillar asymmetry. Malignancy is usually disorders
associated with cervical lymphadenopathy o Craniofacial abnormalities
and/or haematological abnormalities. o Storage diseases
o Congenital cardiac disease
Halitosis may occur from food debris o Chronic lung disease
collecting within tonsillar crypts, although Such children and those with proven
halitosis is most commonly caused by gin- severe OSAS or ECG changes are more
gival disease. Tonsillar halitosis can usual- likely to develop postoperative complica-
ly be managed with reassurance and tions and to require admission to intensive
mouthwashes. However, if severe or the care postoperatively.
child is being affected socially, tonsillec-
tomy may be considered.
Tonsillectomy procedure
Perioperative Evaluation There are several methods to do a tonsil-
lectomy and to obtain haemostasis. Meth-
General health ods are generally divided into ‘hot’ (using
some form of electrocautery) and ‘cold’
No perioperative investigations are gene- (using traditional instruments and ties)
rally required in an otherwise fit and (Figure 3).
healthy child undergoing tonsillectomy for
recurrent tonsillitis. Investigations should
be directed at areas of concern, particularly 1
bleeding diatheses. For most children a
preoperative blood grouping is not require- 6
2 7
ed; however, this is largely dependent on 8
local facilities and guidance.
3 9
Reason for tonsillectomy
4
Children undergoing tonsillectomy (with 10
or without adenoidectomy) for OSAS are
at increased risk of postoperative compli- 5
11
cations. Evaluation should consist of a
measure of the severity of the OSAS. This
may take the form of a clinical evaluation Figure 3: Basic set of instruments required
only in a low risk child. Overnight oxime- to perform a tonsillectomy: Drafton rods
try or polysomnography should be perfor- (1); Bipolar forceps (2); Silk ties (3);
med when the child falls into one or more Blades for Boyle Davis gag (4);
of the following categories: Boyle Davis gag (5); Knot pusher (6);
• < 2 years of age Pillar retractor (7); Tonsil dissector (8);
• <15kg Burkitt straight forceps (9); Curved Negus
3
Forceps (10); Luc’s tonsil holding forceps
(11)
The literature suggests that “hot”
techniques, using diathermy dissection
may have a higher rate of postoperative
haemorrhage although they may offer
other benefits such as reduced intra-
operative blood loss.
For the purposes of this description of
tonsillectomy, a ‘cold’ technique is descri-
bed using traditional dissection followed
by haemostasis with ties.
Figure 5: View of tonsils and oropharynx
• Following induction of general following insertion of Boyle Davis gag
anaesthesia, the patient is positioned
supine on the operating table with the
• The tonsil gag is fitted with rubber
neck slightly extended using a shoulder
tooth protectors (can be made from
roll
sections of soft rubber tubing) which
• Select an appropriate length Boyle can be removed in edentulous patients
Davis blade and insert the gag to to avoid the gag slipping off the gum
retract the tongue and expose the (Figure 4)
oropharynx (Figure 3, 4, 5)
• Drafton rods are then placed to suspend
and stabilise the gag (Figures 3 and 6)
Figure 4: Boyle Davis tonsil gag and tonsil
swabs; the tonsil gag has been fitted with Figure 6: Boyle Davis gag in place
rubber tooth protectors suspended and held in place by Drafton
rods
4
• The tonsil is grasped with tonsil
holding forceps and pulled towards the
midline (Figures 7 and 8)
Figure 9: Site of initial incision
• The capsule of the tonsil is identified
Figure 7: Gripping the right tonsil with (Figure 10)
tonsil holding forceps
Figure 10: Extend the initial incision and
Figure 8: Pulling the tonsil medially to define the lateral border of the tonsil by
demonstrate the lateral border of the tonsil spreading the blades of the scissors
deep to the palatoglossal fold
• A tonsil dissector is used to strip the
• Scissors are used to incise the mucosa pharyngeal muscle fibres laterally
of the anterior faucal pillar as shown away from the tonsil (Figure 11). This
(Figures 9 and 10). An incision placed process usually commences superiorly
too laterally will leave only a small and progresses inferiorly. Medial trac-
residual anterior pillar and is likely to tion should be maintained on the tonsil
cause additional postoperative discom- at all times to facilitate this
fort
5
Figure 11: While maintaining medial Figure 13: After the tonsil has been
traction, the tonsil dissector is used to strip removed the vascular bundle is tied using
the pharyngeal muscle fibres laterally and a silk or linen ligature and knot-pusher
away from the tonsil (left lower corner of picture)
• As this dissection process continues • The tonsil fossa is packed with a gauze
inferiorly, the tonsil ends up being swab (Figure 14)
attached only by a vascular bundle at • The process is repeated on the
the tonsillolingual sulcus. This vascular contralateral side
bundle is clamped with curved vascular
forceps (Figure 12)
Figure 14: The tonsil fossa is packed with
a gauze swab
Figure 12: The vascular bundle is
clamped inferiorly with curved • Each tonsil fossa is revisited, the gauze
vascular forceps (Curved Negus) packing removed, and inspected for
bleeding. Minor bleeding from muscle
• The vascular bundle is tied to reduce and small vessels will stop sponta-
bleeding using a silk or linen ligature neously. Larger bleeding vessels are
and knot-pusher, and the tonsil is clipped with straight vascular forceps,
removed (Figure 13). and gentle traction is applied to elevate
6
the vessel from the tonsil bed (Figure haemostasis. If monopolar diathermy is
15). used care must be taken to avoid burn
injuries to the lips
• The tension on mouth gag is then
released for a short period as further
bleeding points may then become
apparent
• The postnasal space is suctioned clear
of blood clots
• Postoperative analgesia is prescribed
• Antibiotics are not usually indicated
Complications
Figure 15: The vessel is clipped with Accidental extubation
straight vascular forceps
Care must be taken when the gag is
• The vessel is then cross-clamped with removed as the endotracheal tube can get
curved forceps placed below the tip of trapped in the groove in the centre of the
the straight vascular forceps (Figure gag hence causing accidental extubation
16). This technique facilitates the use when the gag is removed (Figure 17).
of ligatures in a fashion similar to that Entrapment of the tube in the tonsil blade
employed for the vascular bundle at the can be avoided by initially wrapping
inferior tonsillar pole adhesive tape around the blade to cover the
groove where the tube can get stuck
Figure 16: Gentle traction applied to the
straight forceps elevates the vessel from
the tonsil bed so that the vessel can be
cross-clamped with curved forceps Figure 17: Picture illustrating endotra-
cheal tube stuck in Boyle Davis gag caus-
• This process is continued until haemo- ing accidental extubation when removing
stasis is achieved. Bipolar diathermy, if the gag at the end of the procedure
available, can be used to facilitate
7
Uncontrolled bleeding managed with a nasopharyngeal airway.
Rarely, postoperative pulmonary oedema
Failure to stem bleeding with ligatures or may develop. The patient is then admitted
cautery may occur at the time of tonsillec- to intensive care and supportive manage-
tomy, or with a primary or secondary post- ment instituted with continuous positive
operative haemorrhage. This necessitate airways pressure.
one to suture the tonsil pillars together
after packing the tonsil fossa with surgicel Sore throat and otalgia
haemostatic dissolvable gauze. It is impor-
tant to place the pillar sutures through the Patients experience significant pain,
surgicel to prevent it dislodging and being odynophagia and referred otalgia. The
aspirated. If surgicel haemostatic dissolva- most severe pain is experienced around
ble gauze is not available, then a standard Day 5-6. Regular analgesia in the form of
surgical gauze swab can be packed and paracetamol and anti-inflammatory drugs
sutured into the tonsil fossa for a few days will usually be sufficient.
before removing it.
Further Reading
Primary postoperative haemorrhage
• Clarke RW. 2007. The causes and
This may occur at the time of surgery effects of obstructive sleep apnoea in
when a bleeding disorder has not been children. In Graham JM, Scadding GK
identified. Treatment should be directed at and Bull PD ed. Pediatric ENT. 2007.
the underlying cause; fresh frozen plasma Springer, New York, pp 141-151.
transfusion or coagulant drugs may be • Robb PJ, Bew S, Kubba H, Murphy N,
required. Fluid replacement should be Primhak R, Rollin A-M and Tremlett
initiated and packing of the tonsil fossae M. 2009. Tonsillectomy and Adenoid-
may be required for a prolonged period. ectomy in Children with Sleep-Related
Breathing Disorders: Consensus State-
Secondary postoperative haemorrhage ment of a UK Multidisciplinary Work-
ing Party. Ann R Coll Surg Engl. 2009
This occurs more commonly (approx. 5% July; 91(5): 371–373.
of children) and can occur up to 10 days • Royal College of Surgeons of England.
postoperatively. Poor postoperative oral 2005. National Prospective Tonsillec-
intake due to pain and infection is likely to tomy Audit. Royal College of Surgeons
play a role. If bleeding settles sponta- of England, London.
neously, children should be observed in • Scottish Intercollegiate Guidelines Net-
hospital as the bleed may represent a work. 2010. Guideline 117: Manage-
‘herald bleed’. If bleeding fails to settle ment of sore throat and indications for
following fluid resuscitation, the child tonsillectomy. Scottish Intercollegiate
should be returned to the operating room. Guidelines Network, Edinburgh.
Antibiotics are usually administered due to
a presumed element of infection. Open Access Atlas chapter on
Tonsillotomy:
Respiratory compromise https://vula.uct.ac.za/access/content/group/
ba5fb1bd-be95-48e5-81be-
Children with OSAS are at higher risk of 586fbaeba29d/Tonsillotomy%20_partial_
complications following tonsillectomy. %20and%20complete%20tonsillectomy%2
Postoperative airway obstruction may be 0surgical%20technique.pdf
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Author THE OPEN ACCESS ATLAS OF
OTOLARYNGOLOGY, HEAD &
Joe Grainger FRCS, DCH, MedSci
Consultant Paediatric ENT Surgeon NECK OPERATIVE SURGERY
www.entdev.uct.ac.za
Birmingham Children’s Hospital
Birmingham
United Kingdom
[email protected]
The Open Access Atlas of Otolaryngology, Head &
Neck Operative Surgery by Johan Fagan (Editor)
Author and Paediatric Section Editor [email protected] is licensed under a Creative
Commons Attribution - Non-Commercial 3.0 Unported
License
Nico Jonas MBChB, FCORL, MMed
Paediatric Otolaryngologist
Addenbrooke’s Hospital
Cambridge, United Kingdom
[email protected]
Editor
Johan Fagan MBChB, FCORL, MMed
Professor and Chairman
Division of Otolaryngology
University of Cape Town
Cape Town, South Africa
[email protected]
