Intracapsular tonsillectomy (tonsillotomy) offers significant advantages over the extracapsular approach. By preserving residual tonsillar tissue and the capsule as a biological dressing, it protects the underlying musculature with its vessels and nerves, while delivering equivalent clinical outcomes with reduced complications of postoperative pain, dehydration, and bleeding. There is no standardized approach in performance of a tonsillotomy , unlike the extracapsular approach. Additionally, when performing a tonsillotomy on large hypertrophied tonsils, visualizing the posterior pillar—often hidden behind tonsillar tissue—can be challenging, potentially putting this muscular structure at risk for damage and negating the advantages of a tonsillotomy. We describe a standardized technique for tonsillotomy using a midline split within the tonsillar tissue, creating a “coffee bean” appearance that serves as a pivot point for retraction. This approach allows for more accurate distinction between the posterior tonsil and the pillar, resulting in more precise ablation.
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There is no standardized approach in performance of a tonsillotomy , unlike the extracapsular approach. When performing a tonsillotomy on large hypertrophied tonsils, visualizing the posterior pillar—often hidden behind tonsillar tissue—can be challenging, potentially putting this muscular structure at risk for damage and negating the advantages of a tonsillotomy. We desribe a standardized technique for tonsillotomy using a midline split within the tonsillar tissue, creating a “coffee bean” appearance that serves as a pivot point for retraction. This approach allows for more accurate distinction between the posterior tonsil and the pillar, resulting in more precise ablation.
This approach particularly useful for large hypertrophied tonsils allows for standardization for performance of an intracapsular tonsillectomy and more accurate distinction between the posterior tonsil and the pillar, resulting in more precise ablation.
Very small tonsils where creating a midline split could risk damaging the tonsil capsule
Standardized tonsillectomy setup with Crowe-Davis mouth retractor
BONSS coblator with an ablate setting of 8, coblate setting of 5
Standard pre-operative workup for a tonsillectomy, if required
Anterior and posterior tonsillar pillars
Tonsil bed with capsule
Superior and inferior poles of the tonsil
1. Allows standardization for performance of a tonsillotomy, particularly for large hypertrophied tonsils
2. Allows for more accurate distinction between the posterior tonsil and the pillar, reducing risk of damage to the pillar and resulting in more precise ablation.
Identify damage to tonsil capsule and use of coblate function for hemostasis as necessary
None
Sarah Shamsi, RN, who assisted with handling of the endoscope for the video recording
Russo E, Festa BM, Costantino A, Bernardocchi A, Spriano G, De Virgilio A. Postoperative Morbidity of Different Tonsillectomy Techniques: A Systematic Review and Network Meta-Analysis. Laryngoscope. 2024 Apr;134(4):1696-1704. doi: 10.1002/lary.31116. Epub 2023 Oct 16. PMID: 37843298.
Review ‘Coffee Bean’ Tonsillotomy.