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2/4/18 in Blog Posts
In my practice as a pediatric otolaryngologist for almost 30 years, I have been impressed by the benefits of partial tonsillectomy for both the patient and the surgeon. After overcoming my initial skepticism and fear of tonsil regrowth and recurrent symptoms, the technique has become the most common operation that I perform in children. The following FAQs summarize my experience.
Why partial tonsillectomy in children?
The majority of kids who need tonsil surgery are seeking relief for sleep and breathing problems, and are under the age of six. Their breathing and sleep issues can be alleviated in most cases by removing the adenoids and shaving the tonsils, the so-called partial or intracapsular tonsillectomy. The advantages include a quicker and less painful recovery and one that usually avoids the need for narcotic pain medications and their attendant risks (an important consideration now that the FDA has banned the use of codeine for children after T and A.)
In addition, the risk of bleeding postop is reduced, and the children are much less likely to get dehydrated and be readmitted to the hospital for pain control and IV fluids.
How do patients feel about the surgery?
Most families are relieved to know that there is an effective surgery, which is potentially safer. Some children have recurrent strep in addition to tonsil and adenoid hypertrophy, and parents in that situation might opt for total tonsillectomy. Some parents prefer the traditional total tonsillectomy, based on personal or family experience. On the other hand, many parents like the idea of leaving a little tonsil tissue in the throat, especially if they have read that the lymphoid tissue may afford some immune protection.
Is there a best technique?
The surgical microdebrider is my preferred instrument, but others use a coblator. The key in my experience is not to just trim the tonsil back to the pillars, but to evert the tonsil and debulk the tonsil mass; my goal is to leave less than 10% of the lymphoid tissue over the muscle bed. The suction cautery is then used to control surface oozing, and can be used to shrink the tissue further, especially in the upper pole region where the tonsil is often thicker.
What is the risk of tonsil regrowth?
My personal experience in following patients for approximately 15 years is that the risk of both tonsil regrowth and recurrence of sleep and breathing symptoms is exceedingly low. Since the surgery is most commonly performed in children less than age 6, their growth in the ensuing years helps to minimize the risk. I have also observed that children get strep throat infections less frequently after the surgery.
What if a sleep study shows obstructive sleep apnea?
Severe sleep apnea demonstrated on a sleep study probably warrants a complete tonsillectomy, or at least a discussion of the risks and benefits of the two techniques. A child with mild OSA will probably do well with either technique.
When is a total tonsillectomy warranted?
In my practice, I still recommend total tonsillectomy for recurrent or chronic strep tonsillitis; in children with PANDAS or suspected PANDAS, especially if they have high ASO titers; in children with Trisomy 21 and other craniofacial abnormalities; in children who have had previous tonsil surgery, and symptoms have recurred; in patients with a history of peritonsillar abscess; and in patients with OSA who are overweight, or who have other anatomic or family predisposition to suggest that recurrent symptoms might be a future problem.