Contributors: Conor Smith (Arkansas Children’s Hospital) and Gresham Richter M.d. (Arkansas Children’s Hospital)
The removal of tonsils is most often indicated by tonsillar hypertrophy contributing to obstructive sleep apnea or chronic/recurring throat infections from pathogens such as streptococcal bacteria. Electrocautery is the most commonly used technique to safely and effectively excavate the tonsils.
After induction of general anesthesia and placement of a shoulder roll, the patient is situated in the Rose position so that the head and neck are extended. Once draped, the patient is suspended with the Crowe-Davis mouth gag to retract the tongue. The palate is palpated in order to attempt to identify a submucosal cleft. Then two red rubber catheters are inserted intranasally and brought out through the oral cavity for palatal retraction. The right tonsil is then retracted medially with the tonsil forceps in order to identify the lateral extent of the tonsil. A semilunar mucosal incision is made with the electrocautery in the anterior tonsil pillar. The tonsil is removed in a sub-capsular plane with the electrocautery to prevent bleeding (hemostasis). The contralateral tonsil is removed in a similar fashion. Hemostasis in the tonsillar fossae is obtained via cautery of exposed vessels. Risk of bleeding ranges from 1-4% within the next 14 days postoperatively as eschar sloughs off the tonsillar fossa.
Obstructive sleep apnea as well as chronic/recurring throat infections
bleeding disorders, cleft of the soft palate, acutely infected tonsils
Crowe Davis mouth gag is placed to retract the tongue and place patient in the Rose (sniffing) position.
Inquire about history of bleeding disorder in patient or family.
Palatine tonsils bound by the palatoglossus (anterior pillar) an palatopharyngus (posterior pillar).
Advantages: improved quality of life via elimination or reduction of obstructive sleep apnea and recurring throat infections. Disadvantages: general risks of surgery and anesthesia including but not limited to postoperative bleeding and 1-2 weeks of discomfort.
Hemorrhage (perioperative and postoperative), airway obstruction secondary to postoperative edema, anesthesia complications, as well as, the rare nasopharyngeal stenosis.
Paradise JL (1983) "Tonsillectomy and Adenoidectomy" Pediatric otolaryngology: 122-6