Total Tonsillectomy

Total 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 two main indications for tonsillectomy are sleep disordered breathing and recurrent infections, both of which are common in the pediatric population. This video includes 1) a detailed introduction including relevant anatomy 2) a discussion of the indications for total tonsillectomy 3) surgical videos and diagrams to explain the steps of the surgical procedure and 4) an explanation of possible post-operative complications.

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. A debakey forcep or alice clamp is used to retract the tonsil medially and a flat tip or needle tip bovie is used to dissect in the capsular plane. A total tonsillectomy requires careful dissection in the subcapsular plane between the tonsil and the underlying muscular bed. After removal of the tonsil, a suction bovie is used to achieve complete hemostasis. After removal of the right tonsil, the same procedure is carried out on the left side. Total tonsillectomy leaves the musculature of the pharynx exposed to heal by secondary intention. Patients can experience significant pain, and approximately a 2% risk of post-operative bleeding, as the exposed muscle remucosalizes.
1) Sleep disordered breathing including a spectrum of disorders from primary snoring to obstructive sleep apnea 2) Recurrent throat infections, which are defined as 7 or more throat infections in 1 year, 5 infections per year for 2 consecutive years, or 3 infections per year for 3 consecutive years 3) Tonsillar asymmetry 4) Concern for malignancy
Relative contraindications include: 1) Acute infection or presence of a peritonsillar abscess 2) Submucous cleft 3) Bleeding diathesis 4) Comorbidities that would increase anesthetic risk
Preoperative workup includes 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
The advantages of total tonsillectomy compared to partial tonsillectomy are related to the removal of all of the lymphoid tissue and include 1) mininmal risk for regrowth and need for further surgery and 2) a decreased risk of recurrent post-operative infection. Disadvantages of total tonsillectomy compared to partial include more post-operative pain (and subsequent dehydration and readmission) and a risk of post-operative bleeding.
Complications of tonsillectomy include damage to nearby structures--such as tooth trauma, lip lacerations or burns, injury to the pharyngeal wall, or injury to the soft palate--and bleeding. Post-operative complications include pain, nausea, vomiting, dehydration, otalgia, or neck pain. Post operative complications may also result in readmission or further surgery, such as control of hemorrhage. Velopharyngeal insufficiency is a long-term complication that should be considered, especially in the presence of a submucous cleft, or when adenoidectomy is performed at the same time.
No conflicts of interest to disclose
Thank you to Vidal Maurrasse for providing voice over material.

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