Tonsillectomy

Learning objectives

Tonsillectomy is a surgical procedure to remove the palatine tonsils, which are lymphoid tissue covered in the respiratory epithelium and invaginated to create crypts
It is a common procedure in children to treat recurrent acute sore throat
Adenotonsillar hypertrophy can present with nasal obstruction, recurrent infections, secretory otitis media, deafness (secondary to Eustachian tube dysfunction), and obstructive sleep apnea (OSA)
The surgery is performed through the mouth using a Boyle-Davis gag → difficulties may be encountered due to a poorly placed gag, obstructing the tracheal tube or laryngeal mask airway

Absolute indications

Upper airway obstruction, dysphagia, and OSA
Peritonsillar abscess, which is unresponsive to adequate medical management and surgical drainage
Recurrent tonsillitis with associated febrile convulsions
Requirement for biopsy to confirm tissue pathology

Relative indications

Recurrent tonsillitis, which is unresponsive to medical treatment
- Sore throat secondary to tonsilitis
- >5 episodes of tonsillitis in one year
- Symptoms >1 year
- Episodes of sore throats are disabling
Persistent bad breath and taste in the mouth due to chronic tonsillitis
Persistent tonsillitis in streptococcus carrier, which is unresponsive to beta-lactamase-resistant antibiotics
Pathology thought to be neoplastic

Contraindications

Serious complication of tonsillectomy that can occur in the recovery or hours later
Emergency with limited time to optimize
Persistent swallowing can be an early indicator of bleeding from the tonsillar bed
Patient may be hypovolemic and require fluid resuscitation before induction → assess patient’s fluid status and cardiovascular parameters
Risk of aspiration due to potential full stomach with blood
Potential difficult airway due to blood in the airway and edema from recent intubation

Intraoperative management

Resuscitate patients and apply full monitoring
Assess previous anesthetic record
Suction must be immediately available
Head-down tilt helps to drain blood away from the larynx
Rapid sequence induction ensures quick intubation and protects the airway during induction
Intubation may require a smaller sized endotracheal tube than originally inserted
Continue fluid resuscitation throughout surgery
Empty the stomach with a wide-bore naso- or orogastric tube, and ensure that the stomach is empty before extubation
Extubate patients only when fully awake, in the head-down, left lateral position

Postoperative management

Patients have to stay in the recovery for an extended period to ensure that the bleeding has stopped
Check the hemoglobin and coagulation, and transfuse blood if necessary
Closely monitor patients for further bleeding