Tonsillectomy: Tonsil Surgery Meaning, Procedure, Complication

Tonsillectomy is a surgical procedure performed to remove the tonsils. Tonsillectomy is a common operation and is also one of the most common major surgical procedures performed in children, but surgeons can also recommend it to adults if necessary.

Anatomy and Physiology of the Tonsils

Tonsils are two oval-shaped pads of lymphatic tissues located in the pharyngeal wall at the rear of the throat of humans - one on each side. Four types of tonsils are arranged into a ring around the pharynx (oropharynx and nasopharynx), known as Waldeyer’s ring of lymphoid tissue. The surface of the tonsils consists of numerous pits that lead to deeper lymphatic tissue. These pits get lodged frequently causing inflammation which leads to a condition known as tonsillitis.

Tonsils form a vital part of the immune system located at the gateway of the respiratory and digestive tracts. They act as the first line of defence against the pathogens that are ingested or inhaled.

Generally, tonsillectomy is performed to treat infection and inflammation of the tonsils (tonsillitis). However, tonsillectomy help treats certain conditions such as:

1. Breathing problems related to swollen tonsils
2. Frequent and loud snoring
3. Bleeding of the tonsils
4. Pharyngitis
5. Sleep apnea
6. Recurrent tonsillitis
7. Adenoid hypertrophy
8. Cancer of the tonsils 
9. Severe bad breath (halitosis)

Tonsillectomy is more commonly performed in children than adults. However, people of any age can experience trouble with their tonsils, and as a result, they may need tonsillectomy surgery. 

A tonsillectomy procedure can be performed in many ways. Usually, the procedure takes about 20 to 30 minutes to complete, depending on the patient’s age, other medical conditions and severity of the case. In children, the procedure is performed under general anaesthesia whereas, in adults, local anaesthesia is administered. All of the tonsils are usually removed, but some patients may benefit from a partial tonsillectomy. 

1. The patient will be placed in a supine position (lying face upwards).
2. The patient will then be administered a local or general anaesthesia based on the patient’s age and medical condition.
3. The patient will then be intubated orally with an endotracheal tube (a tube that goes through the mouth to the trachea to aid the patient with breathing).
4. A mouth gag will be attached to the patient’s jaw, which will keep their mouth in the open position.
5. Medical staff will monitor the blood pressure and heart rate throughout the procedure.
6. The surgeon will then use the best technique for the particular patient. The most common ways to take tonsils out include:
   1. Dissection method: 
      1. Sharp dissection will be used in this procedure. For the incision (cut), the surgeon will use a scalpel (a sharp-bladed instrument) on the sides of the tonsil. 
      2. A dissector will then completely remove the tonsils from the cavity.
      3. This procedure is done six weeks after the infection. Generally, the surgeon waits for six weeks after the episode of throat infection is clear to perform the surgery. If done within six weeks of infection, the chances of bleeding are higher.
   2. Bipolar cautery: 
      1. This procedure will be conducted using bipolar cautery forceps (electric current is used to dissect the tissue). 
      2. This procedure has a faster recovery time than the dissection method. Also, blood loss during the surgery is less in this method.
   3. Monopolar cautery: 
      1. This technique uses an electrical current, which creates a higher temperature. 
      2. The tonsils will be dissected utilising the generated heat. There will be minimal bleeding.
      3. This procedure is generally done immediately after infection.
   4. Laser coagulation technique: 
      1. A laser will be used to dissect the tonsillar tissue and coagulate (immediate solidification of blood, reducing excess blood loss) blood vessels. 
      2. This procedure involves lesser post-operative pain compared to the dissection method. However, wound healing is slower compared to the dissection method.
   5. Harmonic technology: 
      1. This procedure uses ultrasonic vibration for tissue dissection. 
      2. The tonsils will be cut and coagulated simultaneously in this procedure.
   6. Transoral robotic surgery: 
      1. This surgery is mainly performed in the case of cancer of the tonsils. 
      2. It offers fantastic results for removing tonsil cancers with acceptable low morbidity.
   7. Coblation: 
      1. This technique is used to remove the tonsil in the case of partial tonsillectomy (removal of a large portion of the tonsils). 
      2. In this method, radiofrequency energy will be applied for surgical tissue removal.
7. The surgeon will finally close the incision.
8. Then the patient is will be moved to the hospital ward so that he/she can recover.

Before the tonsillectomy, the doctor/surgeon will discuss and prepare the patient for the surgery. These steps often involve:

Before Tonsillectomy

Before undergoing the tonsillectomy procedure, the doctor will:

1. Ask the patient about prescription and over-the-counter medicines, supplements, and vitamins that he/she takes.
2. May advise the patient to stop taking specific anti-inflammatory medicines like ibuprofen (Advil, Motrin), aspirin or naproxen (Aleve) within one week of the operation. Anti-inflammatory drugs may make bleeding more difficult to stop.
3. May ask the patient not to eat or drink anything, including water, after midnight on the day of the surgery.
4. Recommend a routine preoperative evaluation to the patient that includes various tests including blood tests, physical exam and medical history.

On the day of Tonsillectomy

1. The patient needs to reach the hospital before the scheduled time for surgery.
2. The patient will be asked to sign the consent form before the surgery.
3. The patient will be instructed to remove his/her street clothes and jewellery and wear a hospital gown.
4. The parents can bring a comforting toy or blanket for their child.
5. A nurse will place an intravenous catheter in the patient’s hand or forearm, and then general anaesthesia will be administered.
6. The vitals of the patient will also be monitored.
7. The patient will be shifted to the operation theatre for the procedure.

A patient who has undergone a tonsillectomy can expect the following after the surgery:

The recovery process at the hospital

1. Post-surgery, the patient will be taken to a recovery area so that he/she can recover.
2. The patient will be kept in observation until the after-effect of anaesthesia wears off.
3. Pain will be worse for the first three to four days after the surgery. The doctors will design a medication plan to relieve the pain.
4. Discolouration on the skin of the patient’s throat may be observed post-surgery. It will disappear 3 to 4 weeks after the surgery when the area is completely healed.
5. The patient will only be discharged from the hospital when the condition of the patient stabilises. The doctor will recommend the patient stay in the hospital for at least one day to watch for reactionary haemorrhage (bleeding that takes place within 24 to 48 hours of surgery).

Recovery process/expectation after hospital discharge

1. Activity:
   1. For three days, the patient should engage in only quiet activities.
   2. For two weeks, the patient should refrain from sneezing, coughing, clearing the throat, or blowing the nose vigorously.
   3. In the case of children, he/she may go back to school after five to seven days.
   4. Adults may return to work after three days if the work does not involve strenuous physical activity.
   5. It is possible to have tarry stools for a few days because of ingested blood.
2. Diet:
   1. The patient can consume clear liquids in the initial days (water and non-citrus juices).
   2. After a few days, the patient could consume soft foods (pudding, noodles, and applesauce) for 10 days before resuming a normal diet.
   3. The patient must avoid spicy and hot foods.
   4. The patient should not consume toast, chips, and other dry foods.
3. Medication:
   1. Follow the surgeon’s prescription for medicines, such as pain medicine or an antibiotic.
   2. The patient must take the pain medicine an hour before food regularly (every four hours generally) for the first three days. This will make swallowing easier. 
   3. The patient must avoid aspirin or ibuprofen for two weeks after the operation.
4. General: 
   1. A little nosebleed can occur on the first or second postoperative day.
   2. The patient might observe a foul odour coming from the nose or mouth for 7 to 10 days during the recovery process. The antibiotic will reduce this smell.
   3. To help reduce mouth pain, the patient can use a humidifier while sleeping.
   4. Throat and ear pain are not uncommon after the surgery. The patient can place warm towels over the ears to relieve the pain, in addition to taking the pain medicines.
   5. Spitting up a slight amount of blood is normal. However, it should not be more than that.

First follow-up appointment

1. The first follow-up appointment with the doctor will usually be scheduled 1 to 2 weeks after the surgery. 
2. During the follow-up, the doctor will do a thorough check-up of the surgical site to check for the recovery process.
3. The doctor might also change the medication or advise the patient to continue with the previous medication for some more time, depending on the condition and recovery of the surgical area.
4. The doctor will advise the patient for further timely follow-ups as well.

Tonsillectomy is a safe procedure that helps improve the quality of life of an individual. The benefits of tonsillectomy include:

1. Reduce the frequency and severity of strep throat and other bacterial infections
2. Lesser dependency on medications for tonsil pain
3. Improved sleep

Like any other surgical procedure, tonsillectomy also has risks and complications associated with it. These include:

1. Reactions to anaesthesia
2. Swelling
3. Bleeding during surgery
4. Bleeding during healing
5. Infection

When is consultation with the doctor needed?

The patient must consult the doctor immediately if he or she notices the following symptoms:

1. Bright red bleeding from the mouth
2. A fever higher than 101⁰F 
3. Uncontrolled pain
4. Becoming dehydrated

Delaying tonsillectomy can increase the severity of the pain and discomfort leading to reduced quality of life. Below mentioned are some of the common risks of delayed tonsillectomy:

1. Recurrent pharyngitis (swelling of the throat)
2. Swelling of the tonsils
3. Recurrent pharyngotonsillitis (swelling of both tonsils and throat).
4. Intratonsillar abscess (pus formation inside the tonsils)
5. Dysphagia (difficulty in swallowing)
6. Odynophagia (pain while swallowing)
7. Occasionally, swelling of the neck and cheek region with fever.

The cost of tonsillectomy ranges from ₹20,000 to ₹70,000. The cost varies based on the following factors:

1. Age of the patient
2. Type of the procedure done
3. Technique and equipment used
4. The medical condition of the patient
5. The type of hospital facility availed - individual room or shared.