Tonsillectomy – Indications, Contraindications and Complications

Tonsillectomy is a surgical procedure that involves the complete removal of both palatine tonsils from the back of the throat. This operation is primarily performed to treat recurrent tonsillitis, throat infections, and obstructive sleep apnea. Tonsillectomy is performed with or without adenoidectomy.

It is one of the oldest and most commonly performed surgical procedures, with over half a million tonsillectomies per annum performed in children under fifteen years of age in the United States alone. In UK tonsillectomy accounts for about 20% of all operations performed by otolaryngologists.

Indications for tonsillectomy

Tonsillectomy is most commonly performed for following reasons.

Infective causes

• Recurrent tonsillitis satisfying any of the criteria like – Paradise criteria, AAOHNS Criteria or SIGN – Scottish Intercollegiate Guidance Network Criteria (explained below)
• Recurrent tonsillitis associated with other conditions like:
  • Cardiovascular disease associated with recurrent streptococcal tonsillitis.
  • Recurrent febrile seizures.
• Chronic tonsillitis that are unresponsive to medical management and associated with halitosis (bad breath), persistent sore throat and cervical lymphadenitis.
• Tonsillitis associated with abscessed nodes.
• Quinsy / Peritonsillar abscess
• Infectious Mononucleosis (IMN) with severely obstructing tonsils, unresponsive to medical management.
• Streptococcal carrier state unresponsive to medical treatment.

Obstructive causes

• Obstructive Sleep Apnea (OSA)
• Adenotonsillar enlargement associated with cor pulmonale, and failure to thrive
• Dysphagia (difficulty in swallowing)
• Speech abnormalities (Rhinolalia clausa)
• Cranio facial growth abnormalities
• Occlusal abnormalities

Other causes

• Embedded foreign body in tonsil.
• Large symptomatic tonsilloliths (tonsil stones).
• As long term management of IgA nephropathy along with pulsed steroid therapy.
• As a biopsy/ As an oncological procedure for carcinoma tonsil.
• Tonsillar cysts
• As a surgical approach to another structures like – Styloid process, Glossopharyngeal nerve, Parapharyngeal space

Contraindications for tonsillectomy

• Tonsillectomy is usually not done in children under 4 years, except in OSA in fear of the significant morbidity and mortality associated with the procedure.
• Children with bleeding disorders or having anemia
• Poor anesthetic risk or uncontrolled medical illness
• “Hot tonsillectomy” or ‘tonsillectomy a chaud’ is tonsillectomy done at time of an acute infection. It is a relative contraindication for tonsillectomy.

Criteria’s for tonsillectomy

Paradise criteria for tonsillectomy is the most followed guidelines for tonsillectomy.

American Academy of Otolaryngology & Head and Neck Surgery (AAOHNS) Criteria

AAOHNS recommends tonsillectomy if there are 3 or more infections of tonsils and/or adenoids per year despite adequate medical therapy.

SIGN – Scottish Intercollegiate Guidance Network Guidelines

For tonsillectomy patients should meet all criteria

• Sore throat due to tonsillitis
• Five or more episodes of sore throat per year.
• Symptoms for at least a year.
• Episodes of disabling sore throat which prevents normal functioning.

Techniques of tonsillectomy

There are multiple ways in which tonsillectomy can be performed.

• Dissection technique
  • Cold steel / Conventional tonsillectomy
  •  Diathermy or electrocautery dissection with monopolar, Bipolar forceps, or bipolar scissors
  • Radiofrequency
    • Somnoplasty tonsillectomy/bipolar thermal radiofrequency ablation.
    • Coblation technique
    • Argon plasma coagulation tonsillectomy
  • Harmonic scalpel
  • Laser dissection
• Non dissection techniques
  • Guillotine tonsillectomy
  • Intracapsular tonsillectomy with micro-debrider, laser, Coblation

Types of tonsillectomy

There are two types of tonsillectomies.

Intracapsular tonsillectomy (ICT) / Tonsillotomy / Partial tonsillectomy

Intracapsular tonsillectomy (ICT) is a relatively newer technique in tonsillectomy where the entire visible tonsil tissue (>95%) is removed while leaving the capsule intact. This approach preserves the larger tonsil vessels and only exposes the more distal small vessels, significantly reducing the chances of postoperative bleeding. As a result, ICT is particularly recommended for very young children.

The intact capsule acts as a biological dressing, preventing the exposure of pharyngeal muscles to inflammatory pharyngeal secretions. Studies have indicated that ICT is associated with significantly less pain, shorter hospital stays, and a faster return to normal life, as patients experience reduced postoperative discomfort.

However, a disadvantage of this procedure is the potential for tonsil regrowth due to the remaining tissue.

There are different ways to perform an intracapsular tonsillectomy, but one of the most popular techniques is to use Coblation. Coblation uses a special plasma derived from saline which breaks down tissue at reasonably low temperatures, resulting in less pain and discomfort than some other techniques.

Extracapsular / Total tonsillectomy

Extracapsular tonsillectomy is the conventional and time tested method of tonsillectomy. This involves dissection between the plane of the pharyngeal muscles and the tonsillar capsule with removal of all tonsillar tissue. Here the pharyngeal muscles are exposed and hence this can lead to more post operative pain compared to intracapsular technique.

Complications of tonsillectomy

Bleeding remains one of the most common and feared complications following tonsillectomy, with or without adenoidectomy. Literature indicates a 4-6% incidence rate of bleeding within the first 14 days post-operation. However, intracapsular tonsillectomy, known for its lower bleeding rates of 0.1-2%, is considered a safer option, especially for children.

Primary / Reactionary hemorrhage

• It is the bleeding occurring with in first 24 hours of post op period.
• The estimated rate is 0.56% with a readmission rate of 4.5% and return to theatre rate of 1.4%.
• Immediate post op bleeding can occur due to wearing of hypotensive anesthesia, slipping of ligature etc.
• It is commoner in males, elder adults, patients with history of IMN, recurrent acute tonsillitis etc.
• All cases of primary hemorrhage in children should be taken back to theatre.
• In adults a short period of conservative treatment can be attempted prior to surgical reintervention.
  • If the surgeon is experienced and the patient is also co-operative
    • The patient is best examined in sitting position. 
    • If bleeding point is visualized injection of 1% lidocaine with 1:1lakh adrenaline to tissue can be given followed by cauterization with either electrocautery or silver nitrate. 
    • If these maneuvers fail, a figure of eight knot is put. 
  • If the patient is uncooperative / previous maneuvers fails / massive bleeding general anesthesia is needed.
    • If bleeding is diffuse and uncontrollable, pillar suturing can be done by suturing both the anterior and posterior pillars after placing a gauze or gelfoam in the tonsillar fossa. 
    • If gauze is used to pack the tonsillar fossa, silk is used to suture the pillars and these sutures must be removed after 48 hours and the gauze is removed. 
    • If absorbable material like gel foam is used the pillars can be sutured with chromic catgut and the sutures need not be removed.

Secondary hemorrhage

• Bleeding occurring after 24 hours of post op period, can be even up to 2 weeks.
• Estimated rate up to 16%. The incidence increases with age, peaking between 30-34 years with most presenting between day 4 and 7.
• Mostly due to infection by streptococcal organisms.
  • Presence of severe halitosis is most prominent feature, usually associated with fever.
  • Patients should be advised to have good oral intake of fluids and solids post operatively to clear tonsil bed.
• Prophylactic antibiotic therapy with penicillin is advised.

Postoperative nausea and vomiting (PONV) is a prevalent complication after tonsillectomy, affecting up to 70% of patients who do not receive prophylactic anti-emetics. It can result in higher admission rates, increased need for intravenous hydration, greater use of pain medication, and reduced patient satisfaction. To mitigate these effects, a single dose of intraoperative dexamethasone is recommended during tonsillectomy. Additionally, some clinicians routinely prescribe a single dose of ondansetron for outpatient surgeries, as PONV is most likely to occur within the first 24 hours post-surgery.

Pain is another leading cause of morbidity following tonsillectomy, often resulting in reduced oral intake, dehydration, dysphagia, and weight loss. Caregivers must be adept at monitoring for signs of dehydration and encouraging consistent hydration in their child. Alternating scheduled doses of acetaminophen and ibuprofen can effectively reduce oropharyngeal pain and support a smoother recovery.

Velopharyngeal insufficiency can occur following tonsillectomy and adenoidectomy. Symptoms may include hypernasal speech and food regurgitation through the nasal passages during feeding.

Other rare, but not so uncommon complications are:

• Complications associated with general anesthesia
• Temporo-mandibular joint dysfunction
• Small tears at commissure of mouth, cracks of lips, and teeth dislodge and aspiration.
• Dissection outside the pharyngeal musculature may traumatize adjacent structures which can cause injury to glossopharyngeal nerve, pharyngeal venous plexus, carotid sheath.
• Non traumatic atlantoaxial subluxation due to some inflammatory condition causing laxity of paraspinal ligaments termed as Grisel syndrome.