Tonsils and Adenoids, Tonsillectomy Surgery

Tonsillectomy & Adenoidectomy

Tonsillectomy & Adenoidectomy (tonsil and adenoid surgery) is the most common major surgery performed in children. This section contains several graphic videos of tonsillectomy and adenoidectomy which should only be viewed by adults.

Five Top Myths of Tonsillectomy and Adenoidectomy

Alert - Health care professionals should prescribe an alternate analgesic for post-operative pain control in children who are undergoing tonsillectomy and/or adenoidectomy. Codeine should not be used for pain in children following these procedures. These children have evidence of being ultra-rapid metabolizers of codeine, which is an inherited (genetic) ability that causes the liver to convert codeine into life-threatening or fatal amounts of morphine in the body. Read More

Indications for Tonsillectomy and Adenoidectomy

Generally, there are two reasons why a child may need tonsils or adenoids removed. Most patients believe the most common reason to remove tonsils is to treat sore throats. However, the most frequent reason for tonsillectomy and adenoidectomy is airway obstruction. Seventy-five percent of patients have a tonsillectomy and adenoidectomy for this reason. See American Academy of Otolaryngology Indications for Tonsillectomy and Adenoidectomy Go To Top

A tonsillectomy is performed to treat recurrent infections, especially if it is associated with a "Strep Throat," which keeps coming back several times a year after antibiotic treatment. If medicine cannot treat or prevent the infections and the infections come back often, a tonsillectomy may be indicated. Several studies have shown that a tonsillectomy is an effective treatment for children with frequently recurring tonsillitis (chronic tonsillitis). View Abstract. Click on colored text for word definitions !!

The most common reason for tonsillectomy and adenoidectomy is is to remove enlarged tonsils and adenoids which block a child's breathing passages. The nose may be so blocked by the adenoid (which is located behind the nose and above the back of the throat--see the below pictures) that a child can't smell, has a congested nose, and talks like he has a cold all the time. If the tonsils are to large, a child may not eat well, taking only small, soft foods. The child may also have some choking and mouth breathing. Often, a child snores very loudly, may not breathe well while asleep, and may actually stop breathing for several seconds. If severe and not treated, this can put strain on the heart and lungs. It has been shown that removal of the tonsils and adenoids is effective in treating obstructive sleep apnea in children. View Abstract View Abstract.

The picture on the far right shows an enlarged adenoid blocking the nasal passage. The picture on the near right shows 4+ kissing tonsils blocking the oral airway. Both children needed to have these tissues removed to establish an adequate airway.
Tonsillar asymmetry without other indications (i.e.,abnormal appearance, symptoms or history) is often a benign finding and usually does not require treatment..
View Abstract


However, not all airway obstruction in children is caused by hypertrophic adenoids or tonsils. Here is a case of an 8 year old child with sleep apnea who had very small tonsils and adenoids but nasal airway obstruction due to a nasal septal spur and swollen nasal membranes.

The picture to the right shows an enlarged adenoid seen at the time of surgery. Mouse-over the picture to label the adenoid, click on picture to enlarge.

Graphic Videos - These Videos May Not Be Suited For All Viewers !!ewers !!

Peritonsillar Abscess (Quinsy Tonsillectomy): A tonsillectomy may also be performed to acutely treat a peritonsillar abscess. The picture to the right shows the physical findings of a peritonsillar abscess in a 5 year old child. Note the distention of the right peritonsillar pillar (blue arrows) and the deviation of the uvula to the left (red arrow). The child also had a "hot potato" voice and mild difficulty swallowing.

A peritonsillar abscess is often confused with severe exudative tonsillitis. In exudative tonsillitis, it is the tonsils which are enlarged and not the anterior tonsillar pillar. Often, needle aspiration is needed to make the diagnosis.

Most peritonsillar abscesses can be treated by incisional or needle drainage. However, in the young child this is usually not possible and a trip to the OR is necessary. Often there will also be a history of chronic tonsillitis. In this case, removing the tonsils is the preferred treatment.

Graphic Video - This Video May Not Be Suited For All Viewers !!

Search PubMed for Quinsy Tonsillectomy

Search PubMed for Peritonsillar Abscess

Surgical Techniques Go To Top

Adenotonsillectomy is major surgery. Children used to stay overnight but in the USA this surgery is commonly performed on an outpatient basis. Surgery usually lasts from 30 minutes to an hour, but sometimes takes longer. During this time, you can wait in the preoperative waiting room or other part of the hospital.

There are many different surgical techniques for removing the tonsils. Tonsils have been removed using a knife, electrocautery, laser, harmonic scalpel and coblation tonsillectomy. All of these techniques have their advantages and disadvantages. Some such as the laser was very popular in the 1980's but fell out of favor after it was shown to have delayed healing and increased the time the patient is under general anesthesia. The microdebrider is slow and does not control bleeding giving it little advantage over using a scalpel.

Tomkinson et al. Cold dissection tonsillectomy has a lower rate of delayed bleeding than dissection with bipolar diathermy or coblation. View Abstract

What is most important is the experience of your surgeon. This is one surgery you do not want to go to the lowest bidder. Find an experienced surgeon who is skilled with a particular technique and has good outcomes. Do not worry so much about the exact technique used.

The video on the right shows
The use of the ENTcepts to remove
tonsils and control bleeding.

Time Tested: The oldest and most time tested techniques are HOT and COLD tonsillectomy. In HOT dissection the tonsils are removed with an electrocautery. In COLD dissection, a surgical knife is used to remove the tonsils. Both techniques have comparable post-operative bleeding rates but COLD dissection has been shown to produce less pain. View Abstract However, Lee, et.al, found that the HOT dissection had a significantly higher secondary bleeding rate View Abstract and has more post-operative pain than COLD dissection. Ferreira et. al found less intra-operative bleeding but more pain with a hot technique. View Abstract

Graphic Videos - These Videos May Not Be Suited For All Viewers !!

Newer Techniques Which Control Bleeding During the Operation and Reduce Pain. Coblation tonsillectomy and adenoidectomy was introduced in 2001. In this technique, a wand is used to coagulate and ablate tissue using a cool electrical current at the tip of the wand. It produces cooler tissue temperatures and less adjacent tissue destruction than in a HOT tonsillectomy. Timms (2002) reported coblation produces less pain than a HOT tonsillectomy View Abstract. Bleeding rates have been reported to be similar to non-coblation tonsillectomy ( Divi and Benninger 2005 ) View Abstract . Belloso, et.al.(2003) reported that coblation tonsillectomy had a lower rate of secondary hemorrhage than non-coblation tonsillectomy in both children and adults. View Abstract . Lowe D, Van der Meulen J in the Lancet (2004) reported that the risk of hemorrhage was greater for HOT (diathermy ) tonsillectomies and coblation than for COLD techniques using knife dissection and suture ligatures to control bleeding. View Abstract Gustavii et al. also reported an increase in post-operative bleeding using coblation. View Abstract

View Analysis of Post Operative Bleeding of Coblation Tonsillectomy VS Cold Steal Tonsillectomy WAENT Article

Graphic Video - This Video May Not Be Suited For All Viewers!!s!!

The harmonic scalpel is very useful in young patients, especially those at risk of rapid dehydration due to poor oral intake secondary to postoperative pain. The harmonic scalpel controls bleeding from small vessels and several studies have reported that patients experience less postoperative pain. View Abstract View Abstract View Abstract. The cost of the procedure is increased and in older patients more brisk bleeding may be encountered which may require the use of electrocautery. Cauterization will increase postoperative pain and tends to negate the advantage of using the harmonic scalpel. However, in this case the ability of the harmonic scalpel to reduce the bleeding aids in the performance of the surgery.   Scotch, et.al., has reported that complication rates are comparable to (in this study actually less than) other techniques.   View Abstract     Search PubMed for Harmonic Scalpel Tonsillectomy

In a recent article by Mehta et. al. Three techniques for removing tonsils were compared (electrocautery, harmonic scalpel and coblation). The authors found that pain after the operation was similar using the harmonic scalpel and electrocautery but was significantly less using coblation. It also appeared that patients undergoing coblation tonsillectomy returned more quickly to a normal diet. View Abstract

Graphic Video - This Video May Not Be Suited For All Viewers !!a

Graphic Video - This Video May Not Be Suited For All Viewers !!

(Note: You may have noticed that I have quoted one article that says HOT and COLD techniques have the same post- operative bleeding rates and another which states that a HOT tonsillectomy has more bleeding than a COLD tonsillectomy. Such discrepancies are commonly found in the medical literature and are thought to be due to the differences in skill between surgeons using the various technique. Thus, if a surgeon has performed 6,000 operations in technique "A" this technique may have better results for him than technique "B" even though technique "B" may produce better results for the average surgeon. The most important thing you need to do is to find an experienced surgeon who is skilled with a particular technique and has good outcomes. Don't worry so much about the exact technique used.)

After surgery, your child will be in the recovery room for about an hour. He or she will then be brought to the room to see you and spend some time slowly waking up.

Complications View a discussion of possible tonsillectomy complications Go To Top

-- Bleeding occurs in 1 to 4% of patients who undergo a tonsillectomy.
-- Poor speech (hypernasal speech) occurs in 1/3000 patients. A higher rate occurs in patients with mental retardation or cranio-facial deformities.
-- Nasopharyngeal Stenosis: This is scaring and occlusion of the back part of the nose. This is a rare complication which can occur after the tonsils and adenoids are removed.
-- Chipped teeth: This may be caused by slippage of the mouth-gag retractor.
-- Electocautery burns
-- Death

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Tonsil and Adenoid Surgery - T & A