Tonsillectomy in adults
- Marc J Gibber, MD
Marc J Gibber, MD
- Assistant Professor
- Albert Einstein College of Medicine
Tonsillectomy is a well-established operative procedure. Most patients have an uncomplicated course, but bleeding and pain can be significant perioperative issues.
The tonsils consist of lymphoid tissue covered by respiratory epithelium. "Tonsils" refers specifically to the palatine tonsils, and "adenoids" refers to the pharyngeal tonsils. In addition, there are lingual tonsils on the posterior tongue and tubal tonsils just posterior to the Eustachian tube opening. Waldeyer's ring is the ring of these four lymphoid tissues in the pharynx formed by the palatine tonsils ("tonsils"), pharyngeal tonsils ("adenoids"), tubal tonsils, and lingual tonsils (figure 1A-B).
The tonsils are positioned laterally in the pharyngeal wall between the palatoglossal arch and palatopharyngeal arch (the anterior and posterior tonsillar pillars) which merge superiorly to become the soft palate (figure 2). Each tonsil is contained within its own fascia. A potential space between the tonsil and the pharyngeal constrictor muscle can accumulate pus and become a peritonsillar abscess. The tonsil is innervated by branches from the glossopharyngeal nerve. Lymphatic drainage includes the upper jugular and jugulo-diagastric lymph nodes.
The tonsillar vascular supply is from branches of the external carotid artery (figure 3).
●Superior pole: Descending palatine artery
- Harley EH, Collins MD. Neurologic sequelae secondary to atlantoaxial instability in Down syndrome. Implications in otolaryngologic surgery. Arch Otolaryngol Head Neck Surg 1994; 120:159.
- Onerci M, Ogretmenoglu O, Ozcan OE. Atlantoaxial subluxation after tonsillectomy and adenoidectomy. Otolaryngol Head Neck Surg 1997; 116:271.
- Windfuhr JP, Chen YS, Remmert S. Unidentified coagulation disorders in post-tonsillectomy hemorrhage. Ear Nose Throat J 2004; 83:28, 30, 32 passim.
- Cole SM, Patterson MB, Cupp CL. Tonsillectomy in the anticoagulated patient. Ann Otol Rhinol Laryngol 2007; 116:589.
- Chan DK, Parikh SR. Perioperative ketorolac increases post-tonsillectomy hemorrhage in adults but not children. Laryngoscope 2014; 124:1789.
- Antimicrobial prophylaxis for surgery. Treat Guidel Med Lett 2012; 10:73.
- Weber RS. Wound infection in head and neck surgery: implications for perioperative antibiotic treatment. Ear Nose Throat J 1997; 76:790.
- Johnson JT, Kachman K, Wagner RL, Myers EN. Comparison of ampicillin/sulbactam versus clindamycin in the prevention of infection in patients undergoing head and neck surgery. Head Neck 1997; 19:367.
- Skitarelić N, Morović M, Manestar D. Antibiotic prophylaxis in clean-contaminated head and neck oncological surgery. J Craniomaxillofac Surg 2007; 35:15.
- Simo R, French G. The use of prophylactic antibiotics in head and neck oncological surgery. Curr Opin Otolaryngol Head Neck Surg 2006; 14:55.
- Iyer S, DeFoor W, Grocela J, et al. The use of perioperative antibiotics in tonsillectomy: does it decrease morbidity? Int J Pediatr Otorhinolaryngol 2006; 70:853.
- Schuster, GS, Burnett, GW. The microbiology of oral and maxillofacial infections. In: Management of Infections of the Oral and Maxillofacial Regions, 2nd ed, Topazian, RG, Goldberg, MH (Eds), WB Saunders, Philadelphia 1987. p.39.
- Velanovich V. A meta-analysis of prophylactic antibiotics in head and neck surgery. Plast Reconstr Surg 1991; 87:429.
- Keller C, Elliott W, Hubbell RN. Endotracheal tube safety during electrodissection tonsillectomy. Arch Otolaryngol Head Neck Surg 1992; 118:643.
- Randall DA, Hoffer ME. Complications of tonsillectomy and adenoidectomy. Otolaryngol Head Neck Surg 1998; 118:61.
- Kelley PE. Painless tonsillectomy. Curr Opin Otolaryngol Head Neck Surg 2006; 14:369.
- Lowe D, van der Meulen J, National Prospective Tonsillectomy Audit. Tonsillectomy technique as a risk factor for postoperative haemorrhage. Lancet 2004; 364:697.
- Burton MJ, Doree C. Coblation versus other surgical techniques for tonsillectomy. Cochrane Database Syst Rev 2007; :CD004619.
- Lowe D, Cromwell DA, Lewsey JD, et al. Diathermy power settings as a risk factor for hemorrhage after tonsillectomy. Otolaryngol Head Neck Surg 2009; 140:23.
- Timms MS, Temple RH. Coblation tonsillectomy: a double blind randomized controlled study. J Laryngol Otol 2002; 116:450.
- Walton J, Ebner Y, Stewart MG, April MM. Systematic review of randomized controlled trials comparing intracapsular tonsillectomy with total tonsillectomy in a pediatric population. Arch Otolaryngol Head Neck Surg 2012; 138:243.
- Sarny S, Ossimitz G, Habermann W, Stammberger H. Hemorrhage following tonsil surgery: a multicenter prospective study. Laryngoscope 2011; 121:2553.
- Mathews J, Lancaster J, Sherman I, Sullivan GO. Guillotine tonsillectomy: a glimpse into its history and current status in the United Kingdom. J Laryngol Otol 2002; 116:988.
- Schmidt R, Herzog A, Cook S, et al. Complications of tonsillectomy: a comparison of techniques. Arch Otolaryngol Head Neck Surg 2007; 133:925.
- Chidambaram A, Nigam A, Cardozo AA. Anticipated absence from work ('sick leave') following routine ENT surgery: are we giving the correct advice? A postal questionnaire survey. Clin Otolaryngol Allied Sci 2001; 26:104.
- Dhiwakar M, Clement WA, Supriya M, McKerrow WS. Antibiotics to reduce post-tonsillectomy morbidity. Cochrane Database Syst Rev 2008; :CD005607.
- Lachance M, Lacroix Y, Audet N, et al. The use of dexamethasone to reduce pain after tonsillectomy in adults: a double-blind prospective randomized trial. Laryngoscope 2008; 118:232.
- Cardwell M, Siviter G, Smith A. Non-steroidal anti-inflammatory drugs and perioperative bleeding in paediatric tonsillectomy. Cochrane Database Syst Rev 2005; :CD003591.
- Park SK, Kim J, Kim JM, et al. Effects of oral prednisolone on recovery after tonsillectomy. Laryngoscope 2015; 125:111.
- Seshamani M, Vogtmann E, Gatwood J, et al. Prevalence of complications from adult tonsillectomy and impact on health care expenditures. Otolaryngol Head Neck Surg 2014; 150:574.
- Windfuhr JP, Chen YS. Post-tonsillectomy and -adenoidectomy hemorrhage in nonselected patients. Ann Otol Rhinol Laryngol 2003; 112:63.
- Lowe D, van der Meulen J, Cromwell D, et al. Key messages from the National Prospective Tonsillectomy Audit. Laryngoscope 2007; 117:717.
- Windfuhr JP, Chen YS, Remmert S. Hemorrhage following tonsillectomy and adenoidectomy in 15,218 patients. Otolaryngol Head Neck Surg 2005; 132:281.
- Wei JL, Beatty CW, Gustafson RO. Evaluation of posttonsillectomy hemorrhage and risk factors. Otolaryngol Head Neck Surg 2000; 123:229.
- Windfuhr JP, Schloendorff G, Baburi D, Kremer B. Life-threatening posttonsillectomy hemorrhage. Laryngoscope 2008; 118:1389.
- Pinder D, Hilton M. Dissection versus diathermy for tonsillectomy. Cochrane Database Syst Rev 2001; :CD002211.
- Boies, LR. Tonsillectomy. In: Boies Fundamentals of Otolaryngology: A Textbook of Ear, Nose, and Throat Diseases, 6th ed, Adams, GL, Boies, LR, Hilger, PA (Eds), WB Saunders, Philadelphia 1989.
- DeDio RM, Hendrix RA. Postobstructive pulmonary edema. Otolaryngol Head Neck Surg 1989; 101:698.
- Hirth K, Welkoborsky HJ. [Grisel's syndrome following ENT-surgery: report of two cases]. Laryngorhinootologie 2003; 82:794.
- Mora R, Jankowska B, Mora F, et al. Effects of tonsillectomy on speech and voice. J Voice 2009; 23:614.
- Obiako MN. Speech defects as an unusual complication of adenotonsillectomy. Ear Nose Throat J 1988; 67:752.
- Mueller CA, Khatib S, Landis BN, et al. Gustatory function after tonsillectomy. Arch Otolaryngol Head Neck Surg 2007; 133:668.
- Windfuhr JP, Sack F, Sesterhenn AM, et al. Post-tonsillectomy taste disorders. Eur Arch Otorhinolaryngol 2010; 267:289.
- Randall DA. Taste impairment following tonsillectomy and adenoidectomy: an unusual complication. Ear Nose Throat J 2010; 89:E15.
- Heiser C, Landis BN, Giger R, et al. Taste disturbance following tonsillectomy--a prospective study. Laryngoscope 2010; 120:2119.
- Leong SC, Karkos PD, Papouliakos SM, Apostolidou MT. Unusual complications of tonsillectomy: a systematic review. Am J Otolaryngol 2007; 28:419.
- PATIENT SELECTION
- PREOPERATIVE EVALUATION
- Medical risk assessment
- Medication review
- Anatomic risk assessment
- PROPHYLACTIC ANTIBIOTICS
- OPERATIVE MANAGEMENT
- Measures to prevent complications
- - Instrumentation
- - Technique
- POSTOPERATIVE MANAGEMENT
- Postoperative antibiotics
- Pain management
- Nausea and vomiting
- Minor bleeding
- - Patient education
- - Return to work
- Major bleeding
- - Primary and secondary hemorrhage
- - Control of life-threatening hemorrhage
- Pulmonary complications
- Postoperative tonsillar bed infection
- Other complaints and complications
- SUMMARY AND RECOMMENDATIONS