1 INTRODUCTION

Tonsillectomy remains one of the most common surgical procedures performed on children. In contrast to several decades ago when infectious indications were common, the reason most children undergo tonsillectomy today is to relieve upper airway obstruction. Traditional ‘extracapsular’ tonsillectomy remains a fairly morbid procedure. Children routinely require several days off from school and parents are often forced to take time off from work. Despite advances in surgical technology a significant reduction in postoperative pain following this procedure has eluded surgeons. This is evidenced by the wide array of techniques available to the surgeon. Furthermore, the rate of postoperative hemorrhage has remained fairly stable despite the technique practiced. Partial ‘intracapsular’ tonsillectomy seeks to significantly reduce postoperative pain and hemorrhage risk while effectively treating upper airway obstruction.

2 PATIENT SELECTION

Patients suffering from upper airway obstruction secondary to tonsil hypertrophy are candidates for partial tonsillectomy. Caregivers are fully informed of the differences between total and partial tonsillectomy and the rationale for each procedure. The potential for tonsil regrowth and the risk for development of chronic streptococcal tonsillitis need to be addressed (see Postoperative management and complications) during the informed consent process.

Relative contraindications to the performance of intracapsular tonsillectomy include a history of chronic tonsillitis and tonsil regrowth following a previous partial tonsillectomy.

The safety of intracapsular tonsillectomy in the young patient has been studied. Bent et al. found no significant difference in the rate of readmission, pain, oral intake or anal-gesic requirements in patients younger than 3 years of age who underwent partial tonsillectomy compared to a control group.¹

3 OUTLINE OF PROCEDURE

After general anesthesia is achieved, the patient is placed in the Rose position. According to surgeon preference the airway may be managed with a straight endotracheal tube, an oral RAE (Ring–Adair–Elwyn) tube or a laryngeal mask airway (LMA). The jaw is opened using a mouth gag, which can then be suspended. If concurrent adenoidectomy is to be performed, the soft palate is first inspected and palpated for the presence of a submucous cleft and then retracted using catheters that are placed through the nasal cavities and retrieved from the oropharynx. This maneuver also helps to stabilize the tonsillar pillars and pulls the uvula out of the surgical field.

With the microdebrider set at a rate of 1500 rpm on oscillating mode, dissection of the tonsil begins at the inferior pole (Fig. 68.1). This helps prevent blood from obscuring visualization of the anterior and posterior pillars. Dissection proceeds from a lateral to medial direction until the plane of the pillars is reached. At this point it is generally helpful to further stabilize and control the anterior pillar to maximize tissue removal and minimize injury to mucosa. A Hurd elevator is particularly helpful in this circumstance as it can also help to medialize the remaining tonsil tissue, making dissection easier. Dissection is carried down to but not through the capsule of the tonsil. The use of a mirror can facilitate dissection of the superior pole. Care is taken to avoid inadvertent injury to the uvula, which can occur rapidly given the suction associated with the microdebrider. After dissection is completed, hemostasis is achieved using suction cautery with settings generally between 20 and 40 watts according to surgeon preference (Fig. 68.2). The contralateral tonsil is then dissected in an identical fashion. Once the procedure is completed the pharynx is irrigated with sterile normal saline and the mouth gag is allowed to relax. After approximately one minute the gag is reopened and hemostasis is confirmed. A suction catheter is then passed under direct vision and the stomach and hypopharynx are suctioned free of any blood or irrigation fluid that may cause post-extubation laryngospasm.The mouth gag and nasal catheters (if present) are removed and the patient is turned over to anesthesia personnel for extubation.

Fig. 68.1 With the mouth gag in place and the anterior tonsillar pillar secured, the microdebrider is used to begin dissection.

Fig. 68.2 Final hemostasis is achieved using a suction electrocautery unit. Note tonsil capsule which remains intact at end of dissection.

Studies have shown that, when compared to total tonsillectomy, intracapsular tonsillectomy may produce slightly increased intraoperative blood loss and require slightly more operative time. A recent study of 300 patients found that intracapsular tonsillectomy was performed on average in 10 minutes while electrocautery tonsillectomy took 8 minutes.² This study also found no significant difference in overall blood loss but 15% of the intracapsular group lost more than 25 milliliters of blood compared to only 4% in the electrocautery group.

In the pediatric patient, adenoidectomy is routinely combined with tonsillectomy in an attempt to remove potentially obstructing lymphoid tissue. Various techniques exist to remove the adenoids (see Chapter 66: Current techniques of adenoidectomy). Our preference is to perform microdebrider-assisted adenoidectomy. The addition of adenoidectomy does not add significantly to the overall morbidity of the operation. As children age, the adenoids undergo regression and so in the older child performance of both procedures may not be necessary. Obviously, each procedure must be tailored to the individual patient’s needs and direct visualization of the adenoid pad to assess its size is recommended. This may be performed either preoperatively in the office setting or during surgery at the time of tonsillectomy. Lateral plain films of the nasopharynx may also be used to assess the size and degree of obstruction produced by the adenoids.

4 POSTOPERATIVE MANAGEMENT AND COMPLICATIONS

In the recovery room patients are appropriately monitored. Oral diet is resumed, generally in the form of clear liquids, once an adequate level of consciousness is reached. Pain medicine may be administered either via an intravenous route or orally. The use of non-steroidal anti-inflammatory drugs in the postoperative period is controversial and may lead to an increased risk of postoperative hemorrhage. It is our practice to use either acetaminophen or acetaminophen/narcotic combinations. The use of narcotic medication in the child with sleep apnea must be carefully considered. This population may have reduced respiratory drive in the presence of even low doses of narcotics. Patients who are observed in the hospital overnight should have continuous pulse oximetry. Consideration can also be given to temporary observation in an intensive care unit setting for patients with craniofacial abnormalities, severe preoperative sleep apnea, young age, history of bleeding disorder or other significant medical co-morbidities. It is our practice to routinely observe healthy patients less than 4 years of age overnight prior to discharge following tonsillectomy.

The most common and potentially life-threatening complication of tonsillectomy is hemorrhage. Generally bleeding will occur at two distinct time periods after surgery. Rarely patients will hemorrhage within the first 24 hours following surgery and this is generally ascribed to incomplete hemostasis at the time of the operation. More commonly hemorrhage occurs several days after surgery. Management of post-tonsillectomy hemorrhage varies and depends on multiple factors including the age and co-operativeness of the child, degree of hemorrhage, and hemodynamic stability of the patient, among others. Cautery in the awake and co-operative patient is certainly an option but in the young or unco-operative patient this may prove an impossible task. In that case, general anesthetic is required. In patients who have had minor bleeding without an obvious source, observation may be a viable option. Children are generally observed for approximately 12−24 hours prior to discharge home following a minor episode of bleeding.

One potential advantage of intracapsular tonsillectomy is a potentially decreased risk of postoperative hemorrhage compared to traditional procedures. A recent multi-center retrospective review of 870 patients found a 0.7% rate of delayed postoperative hemorrhage.³

As mentioned earlier in this text, the risk of potential tonsil regrowth must be discussed with patients and their families preoperatively. A recent study reviewed 278 children who underwent intracapsular tonsillectomy.⁴ Nine patients (3.2%) experienced regrowth of tonsil tissue associated with snoring and two of these required revision surgery. We are currently in the process of reviewing a large series of patients who are several years removed from their intracapsular procedures to better understand the rate and severity of regrowth that does occur.

Because the intracapsular procedure does leave tonsil tissue behind it should have no influence on the future development of streptococcal tonsillitis.

5 SUCCESS RATE OF PROCEDURE AND WHAT TO DO IF THE PROCEDURE FAILS

Fortunately, in children, tonsillectomy with or without adenoidectomy to treat obstructive sleep apnea has an excellent success rate. Intracapsular procedures appear to have equally effective results when compared to traditional methods.

As with adults, children can have obstruction at multiple levels of the upper aerodigestive tract. This is especially true for children with associated craniofacial malformations. If symptoms do not resolve in the postoperative period, a sleep study is recommended as snoring can exist without apnea. Recalcitrant apnea needs to be addressed based on the anatomic level of obstruction occurring. Tracheotomy remains the gold standard to treat sleep apnea.

In patients who experience recurrent symptoms in a delayed fashion after undergoing partial tonsillectomy with or without adenoidectomy, one must consider the possibility of regrowth at either of these anatomic locations.