Unfortunately, there may be a time when antibiotic therapy fails to resolve the chronic tonsillar infections that affect your child. In other cases, your child may have enlarged tonsils that cause loud snoring, upper airway obstruction and other sleep disorders. The best recourse for either of these conditions may be a tonsillectomy and adenoidectomy (surgical removal or reduction of the tonsils and adenoids). The American Academy of Otolaryngology - Head and Neck Surgery (AAO - HNS) recommends children who have three or more tonsillar infections a year undergo a tonsillectomy, with or without an adenoidectomy. Children with sleep disorders may also be a candidate for these procedures, according to the AAO-HNS.
The first report of tonsillectomy was made by the Roman surgeon Celsus in 30 A.D. He described scraping the tonsils, tearing them out or picking them up with a hook, and excising them with a scalpel. Today, the scalpel is still the preferred surgical instrument of many (otolaryngology) ear, nose, and throat specialists. However, other procedures are available. Which is the best choice depends on the extent of the procedure that is needed (complete tonsil removal versus partial tonsillectomy), along with other considerations such as pain and post-operative bleeding. A quick review of each procedure follows:
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Cold Knife (Steel) Dissection
Removal of the tonsils by use of a scalpel is the most common method practiced by otolaryngologists today. The tonsils are completely removed while the young patient is under general anesthesia. There is very minimal post-operative bleeding.
Electrocautery burns the tonsillar tissue and helps to reduce blood loss through cauterization. There is a downside, however. Research has shown that the heat of electrocautery (400 degrees Celsius) results in thermal injury to surrounding tissue. This may result in more discomfort after the surgical procedure.
This medical device uses ultrasonic energy to vibrate its blade at 55,000 cycles per second. Invisible to the naked eye, the vibration transfers energy to the tissue, providing simultaneous cutting and coagulation. The temperature of the surrounding tissue reaches 80 degrees Celsius. Use of a harmonic scalpel results in precise cutting with minimal thermal damage.
Monopolar radiofrequency thermal ablation transfers radio-frequency energy to the tonsil tissue through inserted probes. The procedure can be performed in-office using light sedation or local anesthesia. After the treatment is performed, scarring occurs within the tonsil causing it to decrease in size over a period of several weeks. The treatment can be performed several times. The advantages of this technique is that it causes minimal discomfort, the procedure is fairly easy to perform, and patients can immediately return to school or work. Tonsillar tissue remains after the procedure but is less prominent. This procedure is recommended for treating enlarged tonsils, rather than chronic or recurrent tonsillitis.
Carbon Dioxide Laser
Laser tonsil ablation (LTA) involves the otolaryngologist employing a hand-held CO2 or KTP laser to vaporize and remove tonsil tissue. This technique reduces tonsil volume and eliminates recesses in the tonsils that collect chronic and recurrent infections. This procedure is recommended for recurrent tonsillitis, chronic sore throats, severe halitosis and airway obstruction caused by enlarged tonsils.
An LTA is performed in 15 to 20 minutes in an office setting under local anesthesia. The patient leaves the office with minimal discomfort and returns to school or work the next day. Post-tonsillectomy bleeding may occur in 1 to 5 percent of patients. Research studies indicate that laser technology results insignificantly less pain during the post-operative recovery compared to other procedures, leading to better sleep, decreased morbidity, and less need for medications. On the other hand, some believe children may be adversely affected to outpatient procedures without sedation.
The microdebrider is a powered rotary shaving device with continuous suction that is often used during sinus surgery. It consists of a cannula or tube which is connected to a handpiece, and that in turn is connected to a motor with foot control and a suction device.
An endoscopic microdebrider is used to perform a partial tonsillectomy by shaving the tonsils. This procedure eliminates the portion of the tonsils that are causing an obstruction, while preserving the tonsillar capsule. A natural biologic dressing is left in place over the pharyngeal muscles to prevent injury, inflammation and infection. Compared to other techniques, this procedure results in less post-operative pain, a more rapid recovery and perhaps fewer delayed complications. However, a partial tonsillectomy is only recommended for enlarged tonsils, not for those that incur repeated infections.
Bipolar Radiofrequency Ablation (Coblation)
This procedure produces an ionized saline layer that disrupts molecular bonds without using heat. As the energy is transferred to the tissue, ionic dissociation occurs. This mechanism can be used to remove all or only part of the tonsillar tissue, with a thermal effect to 45 to 85 C°. It is performed under general anesthesia in the operating room, and can be used for enlarged tonsils and chronic or recurrent infections. This technique offers the advantages to patients of minimal pain, faster healing and less post operative care compared to other options.