In this procedure, the adenoid tissue is ablated and both tonsils are resected. There are multiple techniques of performing adenotonsillectomy, including cold steel (scissors) dissection, electrocautery, microdebrider, and Coblation™.
Indications for Surgery:
- Recurrent acute tonsillitis (7 or more episodes over 1 year, 5 or more episodes a year for 2 years, or 3 or more episodes a year for 3 years)
- Recurrent acute tonsillitis in patients with cardiac valvular disease or febrile seizures
- Two or more episodes of peritonsillar abscess
- Obstructive sleep apnea
- Adenotonsillar hypertrophy associated with cor pulmonale, failure to thrive, dysphagia, speech abnormality, or craniofacial growth abnormality
- Chronic tonsillitis refractory to medical therapy and associated with significant symptoms
- Asymmetric tonsillar hypertrophy (concern for neoplasia)
- Adenoid hypertrophy associated with recurrent acute otitis media or otitis media with effusion
- Adenoid hypertrophy associated with obstructive sleep apnea
- Adenoid hypertrophy associated with cor pulmonale, failure to thrive, dysphagia, speech abnormality, or craniofacial growth abnormality
- Adenoid hypertrophy associated with chronic sinusitis
- Concern for neoplasia
Contraindications to Surgery:
- Medical comorbidities that would preclude surgical or anesthesia risk
- Adenotonsillectomy should not be performed in the setting of active acute infection
- Adenoidectomy is relatively contraindicated in patients with cleft palate or submucous cleft, as it increases the risk of velopharyngeal insufficiency
If tonsillectomy is performed for obstructive sleep apnea, a polysomnogram may be considered, but is not necessary if tonsillar hypertrophy is prominent and the history is consistent with OSA.
- The patient is placed supine on the operating table and general anesthesia is induced via endotracheal intubation.
- The table is rotated 45-90 degrees, a shoulder roll is placed, and the neck is extended.
- A retractor is placed in the mouth to depress the tongue and hold the mouth open so that the oropharynx is in view. The palate is checked to make sure there is not a bifid uvula or other evidence of a submucous cleft palate.
- One end of a rubber catheter may be inserted through the nostril and the other end pulled out through the mouth; the ends are then secured together, elevating the soft palate. This may be done on both sides, if desired.
- The adenoid pad is visualized using a mirror inserted into the oral cavity.
- The adenoid tissue is removed with a microdebrider, curette, or suction monopolar cautery in a posterior-to-anterior fashion. Care is taken to avoid resecting too far anteriorly to prevent velopharyngeal insufficiency, or too far laterally to prevent nasopharyngeal stenosis.
- The nasopharynx may be packed while the surgeon proceeds to the tonsils (if indicated).
- The tonsils are removed one at a time. An incision is made superiorly in the anterior and posterior pillars and the tonsil is dissected away from the tonsillar bed. The tonsil may then be snared with a wire loop, or the dissection may be completed using cold steel, electrocautery, or Coblation™.
- Alternatively, for the treatment of airway obstruction, a partial intracapsular tonsillectomy may be performed, in which the microdebrider or Coblator™ is used to remove the majority of the tonsillar tissue, leaving a thin rim intact. Because the capsule is not violated, recovery time may be shorter and the risk of hemorrhage is thought to be decreased.
- Packs are placed in the tonsillar beds. Hemostasis is then achieved in the adenoid and tonsillar beds with ties or sparing use of electrocautery. Overcautery of the tonsillar bed should be avoided, as it may increase postoperative pain.
- The nares and oral cavity are irrigated and suctioned; an orogastric tube is passed to clear the stomach of any blood to decrease postoperative nausea.
- The rubber catheters and retractor are removed and care of the patient is returned to the anesthesiologist for recovery.
- Adenotonsillectomy is typically performed on an outpatient basis if the patient is three years of age or older. Patients younger than three years or with severe OSA are admitted for overnight monitoring.
- No postoperative antibiotics are prescribed.
- The child may eat a normal diet, as tolerated.
- Younger children are advised to take ibuprofen and acetaminophen on an alternating schedule around the clock for the first 48 hours after surgery; narcotic pain medication may be prescribed for older children.
- Parents are advised to watch for post-operative bleeding and to seek medical attention immediately if it occurs.
- Velopharyngeal insufficiency
- Nasopharyngeal stenosis
- Airway obstruction from post-operative edema
- Atlantoaxial subluxation (Grisel's syndrome)