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Partial Tonsillectomy
Sarah Maurrasse MD, Vikash Modi MD
Weill Cornell Medicine, Department of Otolaryngology
Tonsillectomy is one of the most common surgical procedures performed in children. The main indication for partial tonsillectomy is sleep disordered breathing, which includes a spectrum of disorders from primary snoring to obstructive sleep apnea (OSA). This video includes 1) figures of the anatomy relevant to partial tonsillectomy 2) a discussion of the indications for partial tonsillectomy and 3) surgical videos and diagrams that explain the steps of the surgical procedure.
A Crowe-Davis or McIvor mouth gag is gently placed into the patient's mouth with the endotracheal tube fixed between the tongue and the blade. The endotracheal tube should fit securely into the groove in the blade. The soft palate is then retracted with catheters to stabilize the tonsil and to pull the uvula out of the way.
If tonsillectomy begins on the left, the microdebrider should be held in the right hand. A Hurd elevator is used to retract the anterior pillar laterally and the microdebrider is slowly moved from the inferior to the superior pole and from lateral to medial. The Hurd is also used to protect the posterior pillar, and additional lymphoid tissue can be debrided. When the majority of lymphoid tissue has been removed, the Hurd should be used to expose the superior pole. This area tends to be endophytic and if too much tissue is left behind, regrowth can occur.
Throughout the procedure, care is taken to leave a thin rim of lymphoid tissue on the tonsillar capsule. After resection is complete, pressure is held on the tonsillar fossa with an Afrin-soaked pack. Suction cautery is then used to control the bleeding from the tonsillar bed. To achieve hemostasis with suction electrocautery, the area of bleeding is initially suctioned and the tip of the suction electrocautery is positioned for several seconds on the bleeding site. The oral cavity is then irrigated and suctioned. Of note, after tonsillectomy the anterior and posterior muscular pillars should remain completely intact.
The main indication for partial tonsillectomy is sleep disordered breathing, which includes a spectrum of disorders from primary snoring to obstructive sleep apnea. In general, partial tonsillectomy is not recommended for recurrent infections, since tonsil tissue is left behind during this procedure and can continue to be a nidus for infection.
Relative contraindications include:
1) Recurrent infections (total tonsillectomy recommended in these cases as mentioned above)
2) Acute infection
3) Submucous cleft (increases risk of velopharyngeal insufficiency post-operatively)
4) Bleeding diathesis
5) Co-morbidities that increase anesthetic risk
Instrumentation:
1) Crowe-Davis mouth gag
2) Suspension with Mayo stand
3) Suction catheter (or red rubber) to retract the soft palate
4) Hurd elevator
5) Microdebrider
6) Afrin-soaked tonsil packs
7) Suction Bovie electrocautery
Preoperative workup should include a detailed history and physical exam. The history of present illness should address the presence of the following symptoms: snoring, witnessed apneas, daytime somnolence or hyperactivity, nocturnal enuresis. difficulty concentration, recurrent throat infections, throat pain, history of missed school days, and antibiotic usage. The physical exam should include a careful oral cavity exam to assess for tonsillar hypertrophy and/or signs of infection. Nasal endoscopy should also be considered if there is concern for coexisting adenoid hypertrophy.
1) Oral cavity
2) Palatine tonsils
3) Uvula
4) Anterior pillar (palatoglossus)
5) Posterior pillar (palatopharyngeus)
6) Soft palate
7) Tonsillar fossa
Advantages of partial tonsillectomy compared to total tonsillectomy include less post-operative pain (and subsequent dehydration and readmission) and a much lower risk of post-operative bleeding. The disadvantages of partial tonsillectomy compared to total tonsillectomy are related to leaving a small rim of lymphoid tissue and include 1) risk for regrowth and need for further surgery and 2) an increased risk of post-operative infection.
Complications and risks associated with partial tonsillectomy are very minimal. There is almost no risk of post-operative bleeding (as compared to a 1-2% risk with total tonsillectomy). In addition, pain is minimal with partial tonsillectomy and can usually be managed with acetaminophen and/or ibuprofen instead of narcotic medications, which are usually required for total tonsillectomy.
No conflicts of interest to disclose
Thank you to Vidal Maurrasse for providing voice over material.
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