Tonsillectomy

Tonsillectomy is a surgical procedure in which the tonsils are removed from their fossa. This is one of the most common surgical procedures performed in children and it is often done at the same time with the removal of the adenoids. However, in the past few years, the number of tonsillectomies in children has decreased (compared to several decades ago, when this kind of surgery was the first course of treatment).

The procedure is recommended in the following situations:

• Acute tonsillitis
  • Especially when the re-occurrence is frequent
  • The frequency standards for tonsillectomy are:
    • Seven or more in a year
    • Five or more per year for two years
    • Three or more per year for three years
• Symptoms that indicate the need for tonsillectomy include:
  • High fever
  • Cervical adenopathy
  • Result of tonsillar exudate (identification of infectious agent)
  • Strep throat (positive identification of streptococcus)
• Obstructive sleep apnea
• Snoring
• Obstruction of nasal airways
• Carrier of diphtheria
• Peritonsillar abscess
• Chronic tonsilloliths
  • Tonsil stones or calculi
  • Form in the crevices of the tonsils

Tonsillectomy Procedure

The procedure performed in the past was known as total or extra capsular tonsillectomy and it involved the dissection of the tonsil from the surrounding fascia. However, this procedure was gradually abandoned, as it led to increased bleeding and pain in the recently operated area. Today, the most common procedure for tonsil removal is the one of blunt dissection, performed with a simple scalpel. Laser removal has also become a popular choice and electrocautery started to be increasingly used in order to control the bleeding. Sutures are used for the ligation and the patients are administered specific medication (thrombin) post-operatively, to help with the blood clotting.

Below, you will find the most common procedures chosen for the removal of tonsils:

Dissection and snare method

• Forceps and scissors with a snare (wire loops) are used
• Not the most common method chosen today
• Procedure requires general anesthesia
• Complete removal of tonsils
• Electrocautery is used to control the bleeding
• Guarantees minimal post-operative bleeding

Electrocautery

• Uses electrical energy to remove the tonsils
• May cause damage to the surrounding tissues
• Increased post-operative discomfort

Radiofrequency ablation

• Probes are inserted into the tonsils
• Procedure requires local anesthesia
• Requires more than one session of treatment
• Advantages:
  • Reduced post-operative discomfort
  • Easy procedure
  • Immediate return to daily activities

• Does not completely remove the tonsils
• Indicated for tonsils that are enlarged
• Not recommended for chronically inflamed tonsils or recurrent infections

Coblation tonsillectomy

• Radiofrequency energy is combined with ionized saline solution
• Complete/partial removal of the tonsils
• Procedure requires general anesthesia
• Advantages:
  • Reduced post-operative pain
  • Healing process is faster
  • The post-operative care is reduced

• Risk of increased post-operative bleeding

Harmonic scalpel

• Uses ultrasonic energy
• Simultaneous cutting and coagulation
• Minimal thermal damage

Thermal welding

• Uses pure thermal energy
• Minimal post-operative pain
• No swelling or bleeding

Carbon dioxide laser

• Procedure requires local anesthesia
• Moderate post-operative pain
• More than one session required
• High cost of treatment
• Not recommended in young children or those who suffer from anxiety

Microdebrider

• Partial removal of the tonsils
• Less post-operative pain
• Faster healing process
• Reduced complications
• Indicated for enlarged tonsils.

How long does a tonsillectomy take?

The duration of the tonsil removal depends on the type of procedure that is chosen by the surgeon. On average, the procedure can last as little as twenty minutes and it can go as high as one hour. The duration of the procedure might increase if there are any complications or additional care measures that have to be taken.

Tonsillectomy Cost

The cost of the tonsillectomy is directly dependent on several factors, including the geographic area (prices may vary from one location to the other), the facility in which the surgery is performed and even the physician performing the surgery. The overall price depends on the type of surgical procedure that is chosen for the tonsil removal, the anesthesia (local or general) and the additional costs for the medical staff. It is important to understand that, if there are any complications during the procedure and additional care measures are taken, the price for the tonsillectomy will increase. It might be for the best to check out the insurance policy and see the exact coverage you have for this kind of procedure.

If you do not have insurance, then you should expect to pay somewhere from $4000 to $7000 for tonsillectomy. If the procedure is performed in an outpatient setting, then the price might be reduced by $1000-$2000. If you have insurance, then you should expect to pay somewhere around $200-$1000 for the procedure.

What are the Complications of Tonsillectomy?

These are the most common complications of tonsillectomy:

• Excessive post-operative bleeding
  • The patient might require a blood transfusion to avoid vascular collapse
• Infection to the site of the operation
  • May be accompanied by fever
  • The fever might appear as a response to the infection but also because of pulmonary complications or as a reaction to the administered anesthetic
  • If the fever lasts for more than a day and the patient presents severe pain in the throat, then the diagnosis of infection is more than certain
  • Rare complication – neck infection (suppurative lymphadenitis)
• Prolonged post-operative pain and discomfort
• Permanent change of the voice
• Nasal regurgitation (in rare cases)
• In adults, a rare complication is the dislocation of cervical vertebrae (the atlanto-axial joint presents the highest risk for dislocation or even subluxation). This is an increased risk in patients who already suffer from joint hyperlaxity, such as the patients diagnosed with Down’s syndrome.
• Complications related to anesthesia
• Pulmonary complications
  • Airway risk
  • Aspiration pneumonia – Blood is aspirated into the lungs
• Pulmonary edema – Negative pressure pulmonary edema is a common complication in children who have undergone tonsillectomy
• Edema of the uvula
• Mandible condyle fracture – Forceful opening of the mouth
• Injury to the Eustachian tube
• Temporary tongue edema
• Damage to the glossopharyngeal nerve
  • During dissection or electrocautery
  • May lead to taste disorder
  • Can heal spontaneously

Side effects

These are the most common side-effects of tonsillectomy:

Post-operative nausea and vomiting

Can be reduced by administering a dose of corticosteroids before the actual surgical procedure

Otalgia

• Pain felt in the ears

Difficult post-operative swallowing

• The patient is recommended to drink a lot of fluids, in order to keep the throat hydrated
• Dehydration occurs most commonly in children who have a hard time swallowing
• Vomiting can worsen the situation
• Soft and cold foods are recommended during the post-operative recovery period
• More severe cases might require intravenous fluids to be administered

Excessive hyperextension of the neck

• Muscular tension
• Severe post-operative neck pain

Obstruction of the airways

• This may happen because of the intubation
• May be a result of the edema of the surrounding tissues
• Acute airway obstruction – happens when blood clots accumulate in the hypopharynx
• Dislodged tonsillar tissue is not fully removed
• Loose teeth or parts of surgical instruments can block the airways.

Recovery time

The recovery time after tonsillectomy usually takes between ten days and two weeks. The necessary time for recovery can be maintained to the said period of time if there are no complications to the surgery and if the patient follows the recommended post-operative care measures. Proper hydration during the post-operative period guarantees a faster recovery time and taking the necessary amount of rest is also important. Studies have found that the recovery time is faster in children, not only because they heal faster but also because they take the necessary time to recover, as imposed by the parents. Adults, on the other hand, tend to immediately get back to work.

The recovery time varies according to the age:

Children (2-5 years)

• Recovery time – few days
• Rest period recommended – seven to ten days

Children (5-12 years)

• Recovery time – one weeks
• Solid foods – after two weeks
• Return to normal activities – after two weeks

Teenagers (12-19 years)

• Recovery time – two weeks
• Solid foods – after two weeks
• Return to normal activities – after two weeks
• Remember, it takes one year for the lesion to be completely healed

Adults (over 19 years)

• Recovery time – two weeks
• Solid foods – after two weeks
• Return to normal activities – after two or three weeks
• Remember, it takes one year for the lesion to be completely healed.