Tonsillectomy

Oropharyngeal Anatomy — Tonsil Bed

• Superior pole — ascending pharyngeal artery, lesser palatine artery
• Inferior pole — tonsillar branches of the facial artery, dorsal lingual artery, ascending palatine artery

The inferior pole is the dominant vascular entry point; hemostatic effort directed here first controls most intraoperative bleeding.

Oropharyngeal Findings Warranting Tonsillectomy

• Tonsillar hypertrophy — enlargement that narrows the oropharyngeal airway; graded on the Brodsky scale (1–4+); 3+ to 4+ tonsils significantly reduce the airway lumen
• Asymmetric tonsil enlargement — raises concern for neoplasm (lymphoma, squamous cell carcinoma); requires biopsy
• Tonsillar exudate / cryptic debris — recurrent or chronic purulent exudates in the crypts suggest chronic bacterial tonsillitis (mixed flora, often with beta-lactamase-producing organisms in adults)
• Peritonsillar fullness or bulging — unilateral anterior displacement of the soft palate and tonsil with contralateral uvular deviation is classic for peritonsillar abscess
• Tonsillar surface irregularity or ulceration — hard, irregular, ulcerated, or fixed tonsil may represent malignancy
• Retrognathia / micrognathia or dental malocclusion — may be secondary to adenotonsillar hypertrophy causing craniofacial remodeling

Indications for Tonsillectomy

Absolute Indications

1. Tonsillar hypertrophy causing obstructive sleep symptoms (children or adults) leading to adverse pulmonary or cardiovascular consequences (cor pulmonale, pulmonary hypertension)
2. Hypertrophy with airway obstruction leading to craniofacial bone malformation or dental malocclusion
3. Hypertrophy causing dysphagia and poor weight gain
4. Recurrent peritonsillar abscesses requiring drainage that fail to resolve with appropriately dosed antibiotics
5. Febrile convulsions triggered by tonsillitis episodes
6. Suspected malignancy — suspect growth or anatomic characteristics requiring biopsy to exclude neoplasm

Relative Indications

1. Recurrent acute tonsillitis — 3 or more documented episodes per year causing missed work/school requiring medical treatment; some clinicians use the Paradise criteria (6–7 episodes in 1 year, 5/year × 2 years, or 3/year × 3 years) particularly in children
2. Chronic tonsillitis
3. Obstructive sleep apnea (OSA) — adenotonsillectomy is first-line in pediatric OSA
4. Persistent halitosis or foul taste not responding to medical therapy (tonsillar crypt disease)
5. Streptococcal carrier state with chronic bouts unresponsive to beta-lactamase–resistant antibiotics
6. Nocturnal enuresis with coexistent obstructive sleep disorder from adenotonsillar hypertrophy
7. ADHD resistant to treatment with coexistent upper airway obstructive sleep disorder

Acute "Quinsy" (Hot) Tonsillectomy Indications

• Recurrent peritonsillar abscess
• Massive tonsils causing acute airway obstruction
• Patient already under general anesthesia due to comfort/exposure issues

Contraindications

• Children < 3 years or with history of prematurity
• Seizure disorders, neuromuscular conditions, or asthma
• Severe obstructive sleep apnea (risk of post-obstructive pulmonary edema after removal of obstruction)
• Cardiovascular defects or heart murmurs (require perioperative antibiotic prophylaxis)

Prevention (Post-tonsillectomy Hemorrhage Prevention)

• Primarily — intraoperatively or immediately postoperatively
• Secondary — 5–7 days after surgery when eschar sloughs

1. Antibiotic prophylaxis — intraoperative IV antibiotics (e.g., ampicillin) followed by a 1-week oral course have been shown to significantly reduce postoperative morbidity
2. Local anesthetic injection — into the tonsillar bed at the start of surgery may decrease hemorrhage and improve postoperative recovery
3. Directed hemostasis — controlling the superior and inferior poles first (primary vascular entry points) before addressing the tonsillar bed at large
4. Surgical technique — gentle, careful removal of all tonsillar tissue reduces postoperative pain and recovery time; complete removal reduces risk of bleeding and recurrence (especially in intracapsular procedures)
5. Pre-operative workup — CBC, PT/INR, and bleeding time when there is any suspicion of a bleeding disorder
6. Avoid loose deciduous teeth — evaluate and remove extremely loose teeth that could be dislodged and threaten the airway intraoperatively

Types of Tonsillectomy and Prevention Implications

• Extracapsular (subcapsular) — removes tonsil and capsule entirely; pharyngeal muscles left to re-epithelialize; currently the favored technique
• Intracapsular (tonsillotomy) — removes tonsillar body only, capsule remains; theoretically less pain and faster recovery, but leaves residual tissue with risk of recurrence and bleeding if all tonsillar tissue is not removed