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

Tonsillectomy — Detailed Indications

I. Infection-Based Indications

A. Recurrent Acute Tonsillitis — Frequency Thresholds

Adenotonsillectomy decreases the number of episodes of sore throat and days with sore throat in children in the first year after surgery, but its value in adults is less clear. Many adults improve spontaneously, and the potential benefit must be weighed against risks including hemorrhage and pain, which is more severe in adults. — Goldman-Cecil Medicine, 2e

B. Chronic Tonsillitis

• Whitish/yellow caseous material extruding from crypts (tonsilloliths)
• Foul taste and odor, chronic halitosis
• Chronic sore throat from persistent bacterial growth

• Frequent gargling with hydrogen peroxide mouthwash
• Manual expression of cryptic debris
• Long-term amoxicillin (500 mg TID × 21 days) or clindamycin (300 mg TID × 21 days)

• Presence of Actinomyces (commensal that colonizes tonsillar crypts) — even long-term antibiotics are unlikely to eradicate it
• Persistent symptoms despite maximal medical therapy
• Recurrent episodes with peritonsillar abscess

C. Peritonsillar Abscess (PTA / Quinsy)

1. Delayed (Interval) Tonsillectomy — after resolution of acute infection

• Recurrent peritonsillar abscess
• Recurrent/chronic tonsillitis
• Tonsillar hypertrophy with obstructive symptoms

2. Acute "Quinsy" Tonsillectomy — in the hot setting

• Recurrent PTA in a patient with strong indications (OSA, recurrent tonsillitis)
• Massive tonsils causing acute airway obstruction
• Patient already under general anesthesia (poor exposure or discomfort precludes adequate drainage)

"Quinsy tonsillectomy" should only be considered when patients have a strong independent indication for tonsillectomy, such as sleep apnea, recurrent tonsillitis, or recurrent peritonsillar abscess. — Tintinalli's Emergency Medicine

D. Streptococcal Carrier State

• Adult tonsils harbor mixed flora, with three-fourths containing beta-lactamase–producing organisms — explaining why standard penicillin fails in 7–37% of cases
• Theories of penicillin failure include protective beta-lactamase produced by commensal bacteria, poor tissue penetration, and lack of GABHS-inhibiting flora

E. Diphtheria Carrier State

II. Obstructive / Sleep-Disordered Breathing Indications

A. Pathophysiology Cascade — OSAS → Cor Pulmonale

1. Tonsillar hypertrophy → increased upper airway resistance
2. Repetitive obstruction → episodic hypoxemia + hypercarbia
3. Hypoxic pulmonary arteriolar/venule constriction
4. Sustained pulmonary artery hypertension
5. Cor pulmonale — right ventricular hypertrophy, ECG changes, cardiomegaly
6. Right-sided heart failure

• Neurobehavioral: OSAS duration correlates with irreversible prefrontal cortex neurochemical alteration; episodic hypoxia causes neuronal loss; hyperactivity and elevated C-reactive protein
• Metabolic: OSAS is a risk factor for metabolic syndrome (insulin resistance, dyslipidemia, hypertension) in obese children
• Cardiovascular: altered blood pressure regulation, endothelial dysfunction, systemic hypertension, changes in left ventricular geometry, systemic inflammation (interleukin elevation — reversed by tonsillectomy)

B. OSAS Classification and Types

• SDB affects 10% of the population; only 1–4% progress to frank OSAS
• OSAS in children peaks in preschool and school age (~10% prevalence), thought to decline after age 9
• BMI ≥ 95th percentile for age is an independent predisposing factor

C. OSAS Screening

• S: Snoring
• T: Trouble Breathing during sleep
• B/UR: Un-Refreshed after sleep

D. Role of Polysomnography (PSG) Before Surgery

E. Surgical Outcomes for OSAS

• Age > 7 years
• Obesity (obese children: 33–76% persistent OSA vs. 15–37% non-obese)
• Severe pre-operative OSA
• Chronic asthma
• Black race (CHAT trial)
• Craniofacial abnormalities

F. Hypertrophy Causing Physical Deformity or Developmental Problems

• Craniofacial bone malformation or dental malocclusion from chronic open-mouth posture and abnormal muscular forces — requires tonsillectomy before orthodontic/dental correction
• Dysphagia and poor weight gain — especially in young children; surgical relief is associated with normalization of weight gain
• Speech abnormalities — hyponasality and muffled "hot potato" voice quality from oropharyngeal crowding

III. Neoplastic Indications

A. Suspicion of Tonsillar Malignancy

• Unilateral tonsillar enlargement without symptoms of infection — particularly in adults
• Asymmetric, indurated, firm, or fixed tonsil
• Surface ulceration or irregular mucosa
• Rapidly enlarging tonsil
• Ipsilateral cervical lymphadenopathy without infectious cause

• HPV-related oropharyngeal squamous cell carcinoma (HPV-16 and -18; high p16 expression; often in non-smokers; favorable prognosis relative to non-HPV OPSCC)
• Standard variant OPSCC (smokers/drinkers)
• Lymphoma (tonsil and base of tongue)
• Minor salivary gland tumors

B. Search for Unknown Primary

C. Treatment of Early-Stage Tonsillar Cancer

IV. Miscellaneous / Special Indications

A. Febrile Convulsions

B. PFAPA Syndrome (Periodic Fever, Aphthous Ulcers, Pharyngitis, Adenopathy)

• Characterized by cyclical fevers every 3–6 weeks
• Corticosteroids (e.g., prednisolone) resolve episodes within 24 hours for most patients but may shorten intervals between episodes
• Cimetidine (H₂ antagonist) effective for prophylaxis in a minority
• NSAIDs are generally ineffective
• Tonsillectomy — small-scale studies show success in resolving periodic fevers, though at similar rates to medical treatment/observation; relapse after tonsillectomy has been documented. Tonsillectomy offers symptomatic benefit for pharyngitis in PFAPA patients and may be considered when pharyngitis symptoms are severe

C. IgA Nephropathy

D. Cardiac Valvular Disease with Recurrent Streptococcal Bacteremia

E. Nocturnal Enuresis with Adenotonsillar Hypertrophy

F. ADHD Resistant to Treatment with Coexistent OSAS

Tonsillectomy — Prevention in Detail

I. Pre-operative Prevention

A. Hematological and Coagulation Screening

• Personal or family history of abnormal bleeding
• Use of aspirin-containing OTC cold/allergy medications (many contain aspirin, which impairs platelet function — must be identified and stopped ≥ 7–10 days pre-operatively)
• Clinical suspicion of von Willebrand disease or other coagulopathy

B. Cardiac and Respiratory Pre-assessment

• Chest X-ray and ECG — not routine; indicated only with history of cor pulmonale, recent pneumonia, bronchitis, or URI
• Echocardiogram — children with history of cardiac abnormalities or suspected cor pulmonale from longstanding OSAS
• Polysomnography (PSG) — indicated when there is discordance between tonsillar size and severity of OSAS symptoms (AAO-HNS guideline), or when clinical screening is inconclusive (AAP guideline)

C. Airway Risk Assessment

• Observation for audible respirations, mouth breathing, chest retractions, nasal voice quality
• Inspection of the oropharynx for tonsillar size (Brodsky grade) — determines ease of mask ventilation and intubation
• Note elongated face, retrognathic mandible, high-arched palate — signs of craniofacial remodeling from chronic obstruction
• Inspiratory stridor or prolonged expiration — signals significant pre-existing partial airway obstruction

D. Medication Review

• Aspirin / NSAIDs — stop ≥ 7–10 days pre-operatively (platelet dysfunction increases intraoperative and post-operative bleeding)
• Anticoagulants — bridging strategy or temporary cessation discussed with prescribing clinician
• Antihistamines containing aspirin — common in OTC preparations; parents/patients must be specifically asked
• Antibiotics — if the patient is currently on antibiotics for active tonsillitis, defer elective surgery until infection fully resolves (inflamed, hyperemic tissue bleeds more)

E. Dental Assessment

F. Anaesthetic Pre-medication Caution

• Sedative premedication should be avoided in children with OSAS, intermittent airway obstruction, or very large tonsils — blunts pharyngeal dilator muscle tone and can precipitate complete obstruction
• Antisialagogue (e.g., glycopyrrolate) may be used to minimize secretions in the operative field
• IV access and hydration established before induction — vigorous intraoperative IV hydration offsets reduced postoperative oral intake

G. NPO (Nil Per Os) Fasting

• Solid foods: nil ≥ 8 hours before surgery
• Standard clear fluid fasting applies per anaesthetic guidelines

H. Pre-operative Antibiotic Prophylaxis

• Intraoperative IV antibiotics (e.g., ampicillin) followed by a 1-week oral antibiotic course have been shown to significantly reduce postoperative morbidity
• Children with cardiovascular defects or heart murmurs must receive appropriate perioperative antibiotic prophylaxis against infective endocarditis

II. Intraoperative Prevention

A. Anaesthetic Management — Key Preventive Steps

1. Avoid sedative premedication in OSAS patients (see above)
2. Induction: Volatile inhalation induction is standard in children; propofol can be used as an alternative to neuromuscular blockade by deepening anaesthesia
3. Airway protection options:
   • Cuffed endotracheal tube — provides best airway protection; cuff inflation pressure must be carefully monitored to prevent post-extubation croup
   • Flexible LMA — increasingly used; protects vocal cords from blood/secretions; the standard rigid LMA does not fit under the mouth gag and is easily compressed
4. Supraglottic packing with petroleum gauze OR use of a cuffed ETT — prevents blood from entering the trachea intraoperatively
5. Throat pack with retrieval string — prevents swallowed blood from reaching the stomach; reduces post-operative nausea; string is taped to face with a small hemostat and must be documented and removed before extubation
6. Orogastric tube decompression — decompresses the stomach of swallowed blood and insufflated air, reducing post-operative nausea and vomiting (PONV)
7. Monitoring: precordial stethoscope, ECG, automated NIBP, pulse oximetry, end-tidal capnography (EtCO₂)

• Standard opioid doses reduced by 50% due to increased opioid sensitivity in OSAS patients
• Avoid sedative premedication and heavy opioid loading
• Dexmedetomidine 0.5–1 mcg/kg infused during the procedure — attenuates emergence delirium in toddlers; also useful in DISE procedures

B. Surgical Technique to Prevent Hemorrhage

The inferior pole receives the dominant blood supply (facial artery branches, dorsal lingual artery, ascending palatine artery). Directing hemostatic effort here first controls the majority of potential intraoperative bleeding. Only two minor branches enter the superior pole.

C. Local Anaesthetic Injection — Pre-incision

• Pre-incision peritonsillar infiltration with local anaesthetic + adrenaline/epinephrine:
  • Reduces intraoperative blood loss
  • Reduces bleeding through vasoconstrictive effect
  • Shown to provide a more rapid return to activity compared with general anaesthesia alone
  • Does not significantly decrease postoperative pain (post-hoc operative site anaesthesia has limited duration)

D. Emergence from Anaesthesia

• Emergence should be rapid — child should be alert and able to protect the recently instrumented airway before transfer to recovery
• Child must be awake and able to clear blood and secretions from the oropharynx before extubation
• Maintenance of pharyngeal and airway reflexes is essential to prevent aspiration, laryngospasm, and airway obstruction
• There is no difference in airway complication rates between awake vs. deep extubation — both acceptable
• Avoid stimulating the larynx during emergence

III. Pharmacological Prevention

A. Pain Prevention (Multimodal Analgesia)

1. Acetaminophen (Paracetamol) — First-Line

• IV acetaminophen — faster onset than oral (analgesia within 15 minutes, fever reduction within 30 minutes); reduces need for rescue opioid after tonsillectomy; higher cost limits routine use
• Oral: effective for mild–moderate pain; give regularly (not PRN) for best results
• Rectal: 40 mg/kg rectal vs. 15 mg/kg IV — study showed median time to rescue analgesia of 10 and 7 hours respectively when combined with fentanyl 1–2 mcg/kg
• Safe in all age groups including children post-tonsillectomy

2. NSAIDs — Safe When Used Appropriately

• Cochrane meta-analysis (36 studies; 1747 children + 1446 adults): no increased risk of bleeding with NSAIDs after tonsillectomy — no increase in general bleeding, most severe bleeding, secondary hemorrhage, readmission, or re-operation for bleeding
• Results consistent across: single vs. multiple doses, pre- vs. post-operative administration, and different NSAID types
• Intraoperative NSAIDs should be avoided to decrease hemorrhage risk during surgery; safe and effective in the post-acute recovery period
• Recommended by both AAO-HNS and PROSPECT guidelines as part of standard analgesic regimen

3. Corticosteroids — Dexamethasone

• Single intraoperative dose of dexamethasone is recommended by AAO-HNSF for all children undergoing tonsillectomy
• Benefits: reduces oedema formation, reduces PONV, decreases postoperative discomfort, shortens time to oral intake
• Dose: 0.5 mg/kg IV (with or without ondansetron)
• Concern about increased bleeding risk has not been consistently confirmed — current guidelines support its use
• Post-operative oral dexamethasone: 0.03–0.3 mg/kg/day (children), 0.75–9 mg/day (adults), divided into two doses
  • Greatest benefit when given on post-operative day 3 (when most patients experience peak discomfort)
  • Instituting for 3–4 days at this point reduces pain and increases oral intake with minimal side effects

4. Codeine — Contraindicated in Children

• Codeine is metabolized by CYP2D6 to morphine (active metabolite)
• Two pharmacogenomic variants are dangerous:
  • Poor metabolizer — codeine is ineffective (one polymorphism)
  • Ultra-rapid metabolizer — dangerous morphine accumulation occurs (different polymorphism)
• FDA 2013 Black Box Warning: following review of 10 deaths and 3 overdoses (8 occurring after adenotonsillectomy, 1969–2012)
• FDA 2017: Codeine contraindicated in children < 12 years; warned against use in adolescents aged 12–18 with obesity or OSA
• AAO-HNS guidelines: codeine strictly contraindicated in pediatric tonsillectomy
• Acetaminophen with codeine has NOT been shown to be superior to acetaminophen alone in post-tonsillectomy pain

5. Gabapentinoids

• Gabapentin 600 mg twice daily on the day of surgery, then 600 mg three times daily for 5 subsequent days → significant opioid-sparing effect after tonsillectomy; potential adverse effects: sedation, dizziness, gait disturbance
• Gabapentin 1200 mg orally pre-operatively showed intraoperative and post-operative analgesic effects in head and neck surgery
• Pregabalin reduces early post-operative pain scores and opioid consumption after tonsillectomy
• Lower doses (300 mg BD) did not reduce opioid use but showed meaningful pain score reductions with comparable side-effect profiles

6. NMDA Receptor Antagonists — Ketamine

• Low-dose ketamine: acts as an antihyperalgesic (limits central sensitization) rather than a primary analgesic
• Cochrane review: IV ketamine reduces both post-operative analgesic requirement and pain intensity, with possible reduction in PONV, without significant CNS adverse effects at low doses
• Useful for severe post-operative pain and in opioid-tolerant patients
• Requires skilled supervision; safe use requires careful planning

7. Ondansetron — Prevention of PONV

• Ondansetron 0.10–0.15 mg/kg IV (with or without dexamethasone) — highly effective in reducing:
  • Post-tonsillectomy nausea and vomiting
  • Post-operative pain
  • Time to first oral intake
• Adult dose: 6–8 mg IV every 6 hours
• Children: 0.15 mg/kg IV every 4–6 hours
• Promethazine is an alternative: 12.5–25 mg IV q4–6h (adults); 0.25–1 mg/kg IV q4–6h (children)

8. Sucralfate

• 1 teaspoon orally four times daily may benefit both children and adults in reducing mucosal pain during healing (topical mucosal protectant)
• Role is still debated but widely used as adjunct

IV. Post-operative Prevention and Management

A. Immediate Post-operative Care

B. Diet and Activity Restrictions

• Soft diet for 10–14 days — critical for preventing secondary (delayed) hemorrhage by avoiding disruption of the healing eschar
• Gradual return to normal activities over the same period
• Avoid strenuous physical activity during the healing period (Valsalva manoeuvre can dislodge eschar)
• Patients and carers must be counselled that a grayish-white eschar in the tonsillar fossa is normal — not a sign of infection

C. Post-operative Antibiotic Policy

D. Inpatient Admission Criteria (Prevention of Catastrophic Complications)

• Age < 8 years (higher respiratory complication risk)
• Pulmonary hypertension or other cardiac abnormalities
• Craniofacial syndromes
• Failure to thrive
• Hypotonia or neuromuscular disease
• Morbid obesity
• Severe pre-operative sleep study indices

• Narcotic analgesics should be avoided or severely limited
• May require: supplemental oxygen, steroids, nasopharyngeal airway, CPAP/BiPAP, or endotracheal intubation
• Neck pain after adenoidectomy persisting > 2 weeks → suspect C1–C2 subluxation (Grisel syndrome)

E. Prevention of Post-obstructive Pulmonary Oedema

• Pre-operatively, inspiratory efforts against obstruction generate intrapleural pressures of −30 cmH₂O (vs. normal −2.5 to −10 cmH₂O)
• These negative pressures disrupt pulmonary microvascular capillary walls → fluid transudation into alveoli
• Concurrent expiratory "grunt" (similar to Valsalva) had been limiting pulmonary venous return — this protective mechanism is lost when obstruction is relieved
• Relief → increased venous return → pulmonary hydrostatic hyperaemia → frank pulmonary oedema

V. Emergency Management of Post-tonsillectomy Hemorrhage

Timing

• 75% of post-operative tonsillar hemorrhage within 6 hours
• Remaining 25% within 24 hours
• Late bleeding possible up to post-operative day 6
• 67% bleeds from tonsillar fossa; 26% nasopharynx; 7% both
• Incidence: 0.1–8.1% overall; up to 11.1% with coblation technique

Immediate Emergency Steps

1. Keep patient NPO — treat as full stomach (significant blood may have been swallowed)
2. Sit patient upright with head forward — facilitates drainage and prevents aspiration
3. Pulse oximetry and IV access — mandatory
4. CBC, coagulation studies, type and cross-match blood
5. Examine oropharynx — identify active bleeding site; note presence of normal gray-white eschar vs. active ooze/arterial jet
6. Apply direct pressure to the bleeding tonsillar bed:
   • Tonsillar pack or 4×4 gauze on a long clamp, moistened with thrombin or lidocaine with epinephrine
   • Place a suture through the pack and tape to the face — prevents loss of pack into the airway
   • Apply pressure to the lateral pharyngeal wall (avoid midline — stimulates gag reflex)
7. Pressure alone can achieve control until otolaryngologist arrives

Pharmacological Haemostasis

Surgical and Advanced Management

• Cautery: if a specific bleeding point is visualised, cauterisation after local anaesthetic infiltration
• Return to OR: if initial measures fail — surgical haemostasis under general anaesthesia
  • Treat as full stomach / rapid-sequence induction (blood swallowed; aspiration risk)
  • Assess for orthostatic BP changes to estimate volume depletion
  • Prepare duplicate laryngoscope blades, ETT sizes, and suction apparatus — blood may obscure cords and plug ETT
  • Supraglottic airway (SGA/LMA) may serve as a rescue device if intubation is compromised
  • In cases of massive bleeding where intubation is impossible: emergent cricothyrotomy must be planned before attempting intubation
• Endovascular embolisation: a definitive option for recurrent or surgically inaccessible bleeding
• Patients may suffer second or third hemorrhage — otolaryngology consultation in the ED is always required; discharge without specialist review is inappropriate