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Tonsillectomy

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Throat 1 day after a tonsillectomy.

A tonsillectomy is a 2,000 year-old [1] surgical procedure in which the tonsils are removed from either side of the throat. The procedure is performed in response to cases of repeated occurrence of acute tonsillitis or adenoiditis, obstructive sleep apnea, nasal airway obstruction, snoring, or peritonsillar abscess. Sometimes the adenoids are removed at the same time, a procedure called adenoidectomy. Although tonsillectomy is being performed less frequently than in the 1950s, it remains one of the most common surgical procedures in children in the United States.

Indications

Tonsillectomy may be indicated when the patient:

  • Experiences recurrent infections of acute tonsillitis. The number requiring tonsillectomy varies with the severity of the episodes. One case, even severe, is generally not enough for most surgeons to decide tonsillectomy is necessary. Lee (2008) suggests the following guideline: "3 per year for 3 years, 5 per year for 2 years, 7 or more in 1 year, or greater than 2 weeks of school or work missed in 1 year".[2]
  • Has chronic tonsillitis, consisting of persistent, moderate-to-severe throat pain.
  • Has multiple bouts of peritonsillar abscess.
  • Has sleep apnea (stopping or obstructing breathing at night due to enlarged tonsils or adenoids)
  • Has difficulty eating or swallowing due to enlarged tonsils (very unusual reason for tonsillectomy)
  • Produces tonsilloliths (tonsil stones) in the back of their mouth.
  • Has abnormally large tonsils with crypts (Craters or impacts in the tonsils)

The American Academy of Otolaryngology - Head and Neck Surgery (AAO-HNS) stated that "In many cases, tonsillectomy may be a more effective treatment, and less costly, than prolonged or repeated treatments for an infected throat...For the past several years, the Academy has been developing clinical guidelines based on evidence and outcomes research, including ‘Quality of Life after Tonsillectomy,’ a January 2008 supplement to the journal Otolaryngology—Head and Neck Surgery." This press release came out after the President of the United States, Barack Obama, stated that "Right now, doctors a lot of times are forced to make decisions based on the fee payment schedule that's out there. … the doctor may look at the reimbursement system and say to himself, 'You know what? I make a lot more money if I take this kid's tonsils out …". [3] The Wall Street Journal believes that pediatricians are not making money from doing tonsillectomies.[4] In the United States, otolaryngologists, not pediatricians, do tonsillectomies.[5]

Morbidity and mortality

The morbidity rate associated with tonsillectomy is 2% to 4% due to post-operative bleeding; the mortality rate is 1 in 25,000, due to bleeding, airway obstruction, or anesthesia.[6]

Effectiveness

The effectiveness of the tonsillectomy has been questioned in a 2009 systematic review of 7765 papers, published in the journal Otolaryngology—Head and Neck Surgery. The review found that it was most likely not effective all the time, but rather was modestly effective, and that "not a single paper reported that tonsillectomy is invariably effective in eliminating sore throats"[7]. Another systematic review of cases involving children found that there there was only a short-term benefit - "A child who meets these strict criteria will probably suffer from 6 throat infections in the next two years. A child who has surgery now will probably suffer from 3 throat infections. In two years there will probably be no difference."[8]

Post-operative care

The process of removing tonsils is very painful. A sore throat will persist for around two weeks. Most patients do not feel like swallowing anything during the first few days after surgery. Patients should try to get as much fluid down as possible, as it will help speed recovery. Very cold drinks will help bring down swelling. Ice cream, frozen yogurt and other dairy products are not recommended because they leave a film in the mouth that is difficult to swallow. Sherbert and popsicles, on the other hand, are recommended. Additionally, Icees/Slurpies are particularly helpful for sore throats and now come in sugar free flavors.

Pain following the procedure is significant and may include a hospital stay.[9] Recovery can take from 10 up to 20 days, during which narcotic analgesics are typically prescribed. Patients are encouraged to maintain diet of liquid and very soft foods for several days following surgery. Rough textured, acidic or spicy foods may be irritating and should be avoided. Proper hydration is very important during this time, since dehydration can increase throat pain, leading to a vicious cycle of poor fluid intake.[10][11]

At some point, most commonly 7–11 days after the surgery (but occasionally as long as two weeks (14 days) after), bleeding can occur when scabs begin sloughing off from the surgical sites. The overall risk of bleeding is approximately 1%–2% higher in adults.[12] Approximately 3% of adult patients develop significant bleeding at this time. The bleeding might naturally stop quickly or else mild intervention (e.g., gargling cold water) could be needed (but ask the doctor before gargling because it might bruise the area of the skin that has been cauterized). Otherwise, a surgeon must repair the bleeding immediately by cauterization, which presents all the risks associated with emergency surgery (primarily the administration of anesthesia particularly on a patient whose stomach may not be empty).

Generally Tonsils will be removed after a patient needing antibiotics to be prescribed 6 times in a year, GP's recomendation is based on how the quality of life will be improved after the operation. Tonsillectomies can be done while the patient is suffering from tonsillitis, however this increases the risk of bleeding.

Common causes, demographics

Infections requiring tonsillectomy are often a result of Streptococcus ("strep throat"), particularly Streptococcus pyogenes; some may be due to other bacteria, such as Streptococcus viridans, Staphylococcus aureus, and Hemopholus influenzae. However, the etiology of the condition is largely irrelevant in determining whether tonsillectomy is required.[13]

Most tonsillectomies are performed on children, although many are also performed on teenagers and adults; in the United States, it is the most common major surgical procedure performed on children.[14] The number of tonsillectomies in the United States has dropped significantly from over a million cases per year in the 1950s[14] to approximately 600,000 in the late 1990s.[citation needed] This has been due in part to more stringent guidelines for tonsillectomy and adenoidectomy (see tonsillitis and adenoid). Still, debate about the usefulness of tonsillectomies continues. Enlarged tonsils are removed more often among adults and children for sleep apnea (airway obstruction while sleeping), snoring, and upper airway obstruction. Children who have sleep apnea can do poorly in school, are tired during the day, may be bedwetters beyond what is normal, and have some links to ADHD.[15] [16]

Tonsillectomy in adults is more painful [citation needed] than in children, although each patient will have a different experience. Various procedures are available to remove tonsils, each with different advantages and disadvantages. Children and teenagers sometimes exhibit a noticeable change in voice[17] after the operation.[18]

Surgical procedure

The generally accepted procedure for tonsillectomy involves separating and removing the tonsils from the subcapsular plane – a fascia of tissue that surrounds the tonsils.[19] Removal is typically achieved using a scalpel or with electrocautery, although harmonic scalpels or lasers have also been used. Bleeding is stopped with electrocautery, ligation of sutures, and the topical use of thrombin, a protein that induces blood clotting.

The procedure is carried out with the patient lying flat on their backs, with the shoulders elevated on a small pillow so that the neck is hyperextended – the so-called 'Rose' position. A mouth gag is used to prop the mouth open; if an adenoidectomy is also being performed, the adenoids are first removed with a curette; the nasopharynx is then packed with sterile gauze. A tonsil is removed by holding it by the upper part, pulling it slightly medially, and making a cut over the anterior faucial pillar. After the tonsil is removed from its position, a snare can be used to make a small cut on the lower portion prior to removal of the tonsil. The use of electrocautery minimizes the blood loss.[20]

Other methods

The scalpel is the preferred surgical instrument of many ear, nose, and throat specialists. However, there are other procedures available – the choice may be dictated by the extent of the procedure (complete tonsil removal versus partial tonsillectomy) and other considerations such as pain and post-operative bleeding. A quick review of each procedure follows:

  • Dissection and snare method: Removal of the tonsils by use of a forceps and scissors with a wire loop called a 'snare' is the most common method practiced by otolaryngologists today. The procedure requires the patient to undergo general anesthesia; the tonsils are completely removed and the skin is cauterized. The patient will leave with minimal post-operative bleeding.
  • Electrocautery: Electrocautery burns the tonsillar tissue and assists in reducing blood loss through cauterization. Research has shown that the heat of electrocautery (400°C) results in thermal injury to surrounding tissue. This may result in more discomfort during the postoperative period.
  • Harmonic scalpel: This medical device uses ultrasonic energy to vibrate its blade at 55kHz. Invisible to the naked eye, the vibration transfers energy to the tissue, providing simultaneous cutting and coagulation. The temperature of the surrounding tissue reaches 80°C. Proponents of this procedure assert that the end result is precise cutting with minimal thermal damage.
  • Radiofrequency ablation: Monopolar radiofrequency thermal ablation transfers radiofrequency energy to the tonsil tissue through probes inserted in the tonsil. The procedure can be performed in an office (outpatient) setting under light sedation or local anesthesia. After the treatment is performed, scarring occurs within the tonsil causing it to decrease in size over a period of several weeks. The treatment can be performed several times. The advantages of this technique are minimal discomfort, ease of operations, and immediate return to work or school. Tonsillar tissue remains after the procedure but is less prominent. This procedure is recommended for treating enlarged tonsils and not chronic or recurrent tonsillitis.
  • Thermal Welding: A new technology which uses pure thermal energy to seal and divide the tissue. The absence of thermal spread means that the temperature of surrounding tissue is only 2-3 °C higher than normal body temperature. Clinical papers show patients with minimal post-operative pain (no requirement for narcotic pain-killers), zero edema (swelling) plus almost no incidence of bleeding. Hospitals in the US are advertising this procedure as "Painless Tonsillectomy". Also known as Tissue Welding.
  • Carbon dioxide laser: Laser tonsil ablation (LTA) finds the otolaryngologist employing a hand-held CO2 or KTP laser to vaporize and remove tonsil tissue. This technique reduces tonsil volume and eliminates recesses in the tonsils that collect chronic and recurrent infections. This procedure is recommended for chronic recurrent tonsillitis, chronic sore throats, severe halitosis, or airway obstruction caused by enlarged tonsils. The LTA is performed in 15 to 20 minutes in an office setting under local anesthesia. The patient leaves the office with minimal discomfort and returns to school or work the next day. Post-tonsillectomy bleeding may occur in 2-5% of patients. Previous research studies state that laser technology provides significantly less pain during the post-operative recovery of children, resulting in less sleep disturbance, decreased morbidity, and less need for medications. On the other hand, some believe that children are adverse to outpatient procedures without sedation.
  • Microdebrider: The microdebrider is a powered rotary shaving device with continuous suction often used during sinus surgery. It is made up of a cannula or tube, connected to a hand piece, which in turn is connected to a motor with foot control and a suction device. The endoscopic microdebrider is used in performing a partial tonsillectomy, by partially shaving the tonsils. This procedure entails eliminating the obstructive portion of the tonsil while preserving the tonsillar capsule. A natural biologic dressing is left in place over the pharyngeal muscles, preventing injury, inflammation, and infection. The procedure results in less post-operative pain, a more rapid recovery, and perhaps fewer delayed complications. However, the partial tonsillectomy is suggested for enlarged tonsils – not those that incur repeated infections.
  • Bipolar Radiofrequency Ablation (see Coblation tonsillectomy): This procedure produces an ionized saline layer that disrupts molecular bonds without using heat. As the energy is transferred to the tissue, ionic dissociation occurs. This mechanism can be used to remove all or only part of the tonsil. It is done under general anesthesia in the operating room and can be used for enlarged tonsils and chronic or recurrent infections. This causes removal of tissue with a thermal effect of 45-85 °C. It has been claimed that this technique results in less pain, faster healing, and less post operative care [21]. However, review of 21 studies gives conflicting results about levels of pain, and its comparative safety has yet to be confirmed [22]. This technique has been criticized for a higher than expected rate of bleeding presumably due to the low temperature which may be insufficient to seal the divided blood vessels.

History

The tonsillectomy has been practiced for 2000 years, with varying popularity over the centuries."[1] The procedure is first mentioned in "Hindu medicine" about 1000 BC; roughly a millennium later the Roman aristocrat Celcus (25 AD – 50 AD) described a procedure whereby using the finger (or a blunt hook if necessary), the tonsil was separated from the neighboring tissue prior to being cut out.[1] Galen (121 – 200 AD) was the first to advocate the use of the surgical instrument known as the snare, a practice that was to become common until Aetius (490 AD) recommended partial removal of the tonsil, writing "Those who extirpate the entire tonsil remove, at the same time, structures that are perfectly healthy, and, in this way, give rise to serious Hæmorrhage".[1] In the 7th century Paulus Aegineta (625 – 690) described a detailed procedure for tonsillectomy, including dealing with the inevitable post-operative bleeding. 1,200 years pass before the procedure is described again with such precision and detail.[1]

The Dark Ages saw tonsillectomy fall into disfavor; Ambroise Pase (1509) wrote it to be "a bad operation" and suggested a procedure that involved gradual strangulation with a ligature. This method was not popular with the patients, however, due to the immense pain it caused, and the infection that usually followed. Scottish physician Peter Lowe in 1600 summarized the three methods in use at the time, including the snare, the ligature, and the excision.[1] At the time, the function of the tonsils was thought to be to absorb secretions from the nose; it was assumed that removal of large amounts of tonsillar tissue would interfere with the ability to remove these secretions, causing them to accumulate in the larynx, resulting in hoarseness. For this reasons physicians like Dionis (1672) and Lorenz Heister censured the procedure.

In 1828, physician Philip Syng Physick modified an existing instrument originally designed by Benjamin Bell for removing the uvula; the instrument, known as the tonsil guillotine (and later as a tonsillotome), became the standard instrument for tonsil removal for over 80 years.[1] By 1897, it became more common to perform complete rather than partial removal of the tonsil after American physician Ballenger noted that partial removal failed to completely alleviate symptoms in a majority of cases. His results using a technique involving removal of the tonsil with a scalpel and forceps were much better than partial removal; tonsillectomy using the guillotine fell out of favor in America.[1]

Tonsils, tonsilitis and tonsillectomy
  • Throat with tonsillitis.
    Throat with tonsillitis.
  • Two removed tonsils.
    Two removed tonsils.
  • Throat 1 day after a tonsillectomy.
    Throat 1 day after a tonsillectomy.
  • Throat some days after a tonsillectomy.
    Throat some days after a tonsillectomy.
*All images from Wikimedia Commons. Please check their respective copyrights before using then on external websites.


See also

Footnotes

  1. ^ a b c d e f g h McNeill RA. (1960). "A History of Tonsillectomy: Two Millenia of Trauma, Hæmorrhage and Controversy". Ulser Medical Journal. 29 (1): 59–63. {{cite journal}}: Unknown parameter |day= ignored (help); Unknown parameter |month= ignored (help)
  2. ^ Lee KL, p. 543.
  3. ^ http://www.businesswire.com/portal/site/google/?ndmViewId=news_view&newsId=20090723006009&newsLang=en
  4. ^ http://online.wsj.com/article/SB10001424052970204886304574308472181248330.html
  5. ^ http://pedsent.com/surgery/tonsillectomy.htm
  6. ^ Lee KL, p. 544.
  7. ^ Hornibrook J (2009). "Response to: The role of tonsillectomy in reducing recurrent pharyngitis: A systematic review, from Jeremy Hornibrook". Otolaryngology - Head and Neck Surgery. 141 (1): 155–156.
  8. ^ Marshall T (2002). "Effectiveness of tonsillectomy? A reply to Howel et al". Family Practice. 19 (6): 707–708.
  9. ^ Graham, John M. (2008). Pediatric ENT. Springer. p. 136. ISBN 3540699309. {{cite book}}: Unknown parameter |coauthors= ignored (|author= suggested) (help)
  10. ^ Timby, Barbara Kuhn (2006). Introductory medical-surgical nursing. Lippincott Williams & Wilkins. p. 357. ISBN 0781780322. {{cite book}}: Unknown parameter |coauthors= ignored (|author= suggested) (help)
  11. ^ Pemberton, Cecilia M. (1988). Mayo Clinic diet manual. B.C. Decker. ISBN 1556640323.
  12. ^ Windfuhr JP, Chen YS, Remmert S. (2005). "Hemorrhage following tonsillectomy and adenoidectomy in 15,218 patients". Otolaryngology-Head & Neck Surgery. 132 (2): 281–86. doi:10.1016/j.otohns.2004.09.007. PMID 15692542.{{cite journal}}: CS1 maint: multiple names: authors list (link)
  13. ^ http://www.ivillage.com/topics/health/0,,232762,00.html
  14. ^ a b Cramer and Pasha, p. 176.
  15. ^ Avior G, Fishman G, Leor A, Sivan Y, Kaysar N, Derowe A (2004). "The effect of tonsillectomy and adenoidectomy on inattention and impulsivity as measured by the Test of Variables of Attention (TOVA) in children with obstructive sleep apnea syndrome". Otolaryngology-Head & Neck Surgery. 131 (4): 367–71. doi:10.1016/j.otohns.2004.04.015. PMID 15467601.{{cite journal}}: CS1 maint: multiple names: authors list (link)
  16. ^ Ray RM, Bower CM. (2005). "Pediatric obstructive sleep apnea: the year in review". Curr Opin Otolaryngol Head Neck Surg. 13 (6): 360–5. doi:10.1097/01.moo.0000186076.53986.71. PMID 16282765.
  17. ^ Hoffman D. "Tonsillectomy and Adenoidectomy for Obstructive Sleep Apnea". Retrieved 2009-04-08.
  18. ^ "MedlinePlus: Tonsils and Adenoids". U.S. National Library of Medicine and the National Institutes of Health. Retrieved 2009-04-08.
  19. ^ Snow and Wackym, p. 777.
  20. ^ Jaffe et al., p. 143
  21. ^ Friedman M, LoSavio P, Ibrahim H, Ramakrishnan V (2003). "Radiofrequency tonsil reduction: safety, morbidity, and efficacy". Laryngoscope. 113 (5): 882–7. doi:10.1097/00005537-200305000-00020. PMID 12792327.{{cite journal}}: CS1 maint: multiple names: authors list (link)
  22. ^ Windfuhr JP. (2007). "[Coblation tonsillectomy: a review of the literature.]". HNO. 55: 337. doi:10.1007/s00106-006-1523-3. PMID 17431570.

References

  • Kramer SP, Pasha R. (2005). Otolaryngology: Head and Neck Surgery--A Clinical & Reference Guide, Second Edition. Plural Publishing. ISBN 1-59756-023-5.
  • Lee KL. (2008). Essential Otolaryngology: Head and Neck Surgery, Ninth Edition. McGraw-Hill Professional. ISBN 0-07-148270-9.
  • Montgomery WR. (1996). Surgery of the Upper Respiratory System. Baltimore: Williams & Wilkins. ISBN 0-683-06121-6.
  • Nsow JB., Wackym PA. (2009). Ballenger's Otorhinolaryngology Head and Neck Surgery, 17th edition (Otorhinolaryngology: Head and Neck Surgery (Ballenger)). pmph usa. ISBN 1-55009-337-1.
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