Overview of Tonsillectomy and Adenoidectomy
In the United States, a tonsillectomy, a surgery to remove the tonsils, is a very common procedure. In fact, it is done over 500,000 times a year for children under 15 years old. The two main reasons for getting this surgery are sleep-disordered breathing (or SDB, a condition that interferes with normal breathing during sleep) and recurring throat infections.
Sometimes, a tonsillectomy can lead to side-effects or complications such as bleeding, change in normal activity of muscles and tissues that keep food and fluids from going up into the nose region (a condition called velopharyngeal insufficiency), and dehydration.
The American Academy of Otolaryngology-Head and Neck Surgery states that during a tonsillectomy, the entire tonsil (an organ in the throat) and its outer layer is completely removed. This is done by carefully separating it from the surrounding muscle wall. In some cases, this surgery may also include the removal of the adenoids (small lumps at the back of the throat), particularly in relation to sleep-disordered breathing. This is then referred to as a tonsillectomy with adenoidectomy.
Anatomy and Physiology of Tonsillectomy and Adenoidectomy
The palatine tonsils are part of a group of lymphoid tissues known as Waldeyer’s ring. This cluster includes other components like adenoids, tubal tonsils, and lingual tonsils. Lymphoid tissues play a crucial role in your body’s immune system. The palatine tonsils can be distinguished from surrounding muscle tissue by a fibrous capsule, which develops from a layer of fibrous tissue called the pharyngobasilar fascia.
The space between this protective capsule and the surrounding muscle tissue is known as the peritonsillar space. These tonsils are located between two specific muscles, the palatoglossus and palatopharyngeal muscles which form the front and back pillars, respectively. The superior constrictor muscle, another important muscle, lies on the side of the tonsil.
Just underneath these muscles, the glossopharyngeal nerve can be found. This nerve is vulnerable to injury during a medical procedure known as tonsillectomy or removal of the tonsils. Swelling around this nerve after a tonsillectomy may lead to taste changes and ear pain.
The tonsils receive blood supply from several vessels that branch off from the external carotid artery: the lingual, facial, ascending pharyngeal, and internal maxillary arteries. Each of these arteries contributes to keeping the tonsils healthy. However, the structure of these blood vessels can sometimes differ form person to person.
Why do People Need Tonsillectomy and Adenoidectomy
There are two common reasons why someone might need a tonsillectomy, a surgical procedure to remove the tonsils. One reason is sleep-disordered breathing (SDB), which happens when someone has trouble breathing while they sleep due to a partially or fully blocked upper airway. This can disrupt sleep and normal breathing. A person with SDB might be very active, feel tired during the day, and show aggression. Other signs of SDB include loud, uneven snoring, not breathing for short periods during sleep, restlessness while sleeping, slower growth, poor performance at school, and wetting the bed at night.
Children who have SDB often have more health issues than other children. They might need to take antibiotics more frequently, visit the hospital more often, and have more upper respiratory infections. This adds up to an increase in healthcare usage. Enlarged tonsils and adenoids can be a main cause of SDB. But having bigger tonsils does not always mean a person will have severe SDB. If someone shows signs of SDB but their tonsils aren’t large, they might have to take a special sleep test known as a polysomnography for further evaluation.
Another reason for removing the tonsils is recurring infections, known as tonsillitis. If someone has up to seven infections in one year, or up to five infections a year for two years, or up to three infections a year for three years, doctors may recommend a ‘wait and see’ approach. But if infections happen more frequently than this, doctors might suggest a tonsillectomy. When documenting each infection, physicians check for a sore throat along with at least one other symptom, such as a high temperature, swollen glands in the neck, white patches on the tonsils, or a positive test for bacteria known as GABHS. If other factors come into play, like an allergy to antibiotics, PFAPA (a syndrome causing fever, mouth sores, sore throat, and swollen glands), or an abscess around the tonsils, doctors might suggest removing the tonsils sooner.
Sometimes the tonsils need to be removed for other reasons, like if one tonsil is much bigger than the other, which might indicate a cancer risk. The most common types of cancer that can develop in the tonsils are squamous cell carcinoma and lymphoma. In children, the most common type of cancer in this area is typically lymphoma.
When a Person Should Avoid Tonsillectomy and Adenoidectomy
There aren’t any strict rules that say who can’t have a tonsillectomy. However, there are some risks associated with this surgery, such as bleeding and reactions to anesthesia. So, before having this surgery where the tonsils are removed, it’s important for doctors to be aware if the patient has any risk factors for these complications.
These risk factors may include having a blood disorder or having a family history of a serious reaction to anesthesia known as malignant hyperthermia. Blood disorders can increase the risk of bleeding during or after the surgery, while malignant hyperthermia is a life-threatening reaction to certain drugs used during general anesthesia. If any of these risk factors are present, doctors will take necessary precautions before proceeding with the surgery.
Equipment used for Tonsillectomy and Adenoidectomy
When your doctor needs to remove your tonsils, a surgery called a tonsillectomy, they use various tools depending on the method they choose. For a “cold” tonsillectomy, they use a device to keep your mouth open, either a Crowe-Davis or McIvor mouth gag. They also use an Allis clamp, a no. 12 scalpel (a small, sharp blade), curved scissors for soft tissues known as Metzenbaum scissors, a Fisher’s tonsil knife/dissector for separating and cutting tissue, and a tool for snaring off the tonsils called Tyding snares. If they need to remove your adenoids (small lumps of tissue at the back of the throat), they’ll use an adenoidectomy curette (special tool for scraping tissue) and a St. Clair-Thompson adenoid forceps (used against the rear of the throat).
They may also perform a “hot” tonsil removal, where they use a monopolar cautery, a tool that uses electric current to cut and seal tissues. Another option is using what’s known as coblation, this involves use of bipolar radiofrequency ablation (controlled heating of tissues using radiofrequency energy). There’s also a microdebrider method that doctors use mainly for a specific type of tonsillectomy called intracapsular – this involves a medical device for careful tissue removal.
Who is needed to perform Tonsillectomy and Adenoidectomy?
In a tonsillectomy (procedure to remove tonsils), there are a few key people involved. The first one is a surgeon, a specially trained doctor who performs the operation. Alongside the surgeon, there is an anesthesiologist who is responsible for giving you medicine that helps you sleep so you don’t feel any pain during the procedure. A surgical technician is also there to assist the surgeon by handling the medical tools and equipment. A circulating nurse is necessary too, they help with various tasks during the operation, like providing additional supplies or helping the anesthesiologist monitor you. All these roles ensure your procedure is safe and smooth.
Preparing for Tonsillectomy and Adenoidectomy
No matter what method is used for the surgery, the process of putting the patient to sleep, or ‘inducing anesthesia’, is usually the same. The patient lies down on their back and a tube is gently placed into their mouth. This tube helps control the patient’s breathing during the operation. Many surgeons like to use a specific type of tube called an ‘oral RAE endotracheal tube’.
Once the patient is asleep and the tube is in place, it is secured to avoid any movement. The operating table is then rotated anywhere from 45 to 180 degrees. This allows the surgeon to either sit or stand at the head of the bed, in the most comfortable and effective position for the surgery. Also, a special device called a ‘McIvor’ or ‘Crowe-Davis mouth gag’ is used to keep the patient’s mouth open throughout the procedure.
How is Tonsillectomy and Adenoidectomy performed
A tonsillectomy, the procedure where your tonsils are removed, can be done in a few different ways. This operation can be either extracapsular or intracapsular. In simple terms, extracapsular means that the whole tonsil is removed, and intracapsular means only a part of it is taken out.
The “hot” extracapsular method is most commonly used in the US. This technique uses an instrument that cauterizes (burns) to control bleeding while cutting. The top of the tonsil is gripped with a special clamp, and the tonsil is brought into the middle. The outer edge is cut under the surface, starting at the top. The procedure moves down, separating the tonsil from the surrounding muscle. Once the entire tonsil is cut free, different methods can be used to stop any bleeding.
The “cold” tonsillectomy uses sharp instruments, like scalpels or scissors, instead of heat. The process is similar to the “hot” method but done with a scalpel. Once the avascular plane (the area between the tonsil and muscle where there are no blood vessels) is reached, a special tool called a Fisher tonsil dissector is used to free the tonsil. The final attachment at the bottom is removed with the help of a snaring tool. Again, there are several methods to control the bleeding.
Coblation is another technique that can be used for both full and partial tonsillectomies. This process uses a saline solution that changes into a plasma layer, resulting in breaking down the tissue. This technique generates minimal heat and is often used for partial removals. A device called a micro-debrider can also be used for partial removals.
What tonsillectomy technique is best often depends on various factors, such as cost, potential for complications like bleeding, length of the operation, and postoperation pain. For example, some patients find the “cold” method leads to less pain after surgery, while others find the “hot” technique results in less blood loss and a shorter operation. The decision on which method to use often depends on the surgeon’s experience and comfort with the technique.
Possible Complications of Tonsillectomy and Adenoidectomy
After a child has their tonsils (and possibly adenoids) removed, there are some common complications that may occur. One of them is bleeding – about 2.8% of children had to go back to the doctor due to bleeding after the surgery. This is especially likely to happen at night between 10pm-1am and 6am-9am, due to natural body rhythm changes, the vibrations caused by snoring, or the mouth drying out due to breathing through the mouth. Children who already have problems with their blood clotting might be more at risk.
Another complication is postoperative nausea and vomiting (PONV) – this means a child might feel sick or throw up after the operation. It can happen to almost 70% of children who don’t get medicine to stop it from happening. PONV can lead to more kids having to stay in the hospital than planned, needing more fluids through a drip, more pain relief and also means the child and their parents might not be as happy with the way their treatment went. In order to stop this from happening, children can get a single dose of a medicine called dexamethasone during their tonsil operation. Also, some doctors might prescribe a dose of ondansetron for kids who are having their operation and going home on the same day, as this is when PONV is most likely to happen.
Pain is another common complication, and this can mean a child may eat and drink less, meaning they might get dehydrated, have trouble swallowing, and lose weight. Parents should watch out for signs of dehydration and make sure their child drinks lots of fluids. Giving doses of common painkillers like acetaminophen and ibuprofen can help reduce the pain.
Sometimes, a condition called velopharyngeal insufficiency can occur after a tonsil and adenoid operation. This can make a child’s speech sound nasal and they might find food coming back up in their nose when they are eating.
What Else Should I Know About Tonsillectomy and Adenoidectomy?
Tonsillectomy, an operation to remove tonsils, is one of the most common surgeries performed on children in the United States. It’s crucial for healthcare providers such as your family doctor, and ear, nose, and throat specialists (or otolaryngologists) to be acquainted with reasons to perform this surgery, prohibitions against it, and potential risks involved. They need this knowledge to educate their patients or patient’s caregivers effectively.
The surgery is done in the back of the throat, an area known as the oropharynx. The operating surgeon needs to have a thorough understanding of the oropharynx to ensure the patient’s safety and reduce the risk of complications after the operation.