DOI: 10.1051/odfen/2011402 J Dentofacial Anom Orthod 2012;15:102� RODF / EDP Sciences

1

Author’s conflicts of interest: NONEArticle received: 12-2010.

Accepted for publication: 03-2011.

Current views on theindications and techniquesfor tonsillectomiesin children

Martine FRANÇOIS

ABSTRACT

There are two principal indications for tonsillectomies or ablation of palataltonsillar tissue: repeated episodes of tonsillitis (at least 5 times per year in twosuccessive years) and obstructive tonsillar tissue as well as another, more rare,indication, highly asymmetrical blocs of tonsillar tissue that may suggestpresence of a lymphoma. When tonsils are obstructive in patients suffering fromsleep apnea, the indication for excision is formal and requires prompt attention.In other cases of enlarged tonsils the indication for surgery can be discussed butpractitioners must inform parents of the possible maxillofacial complicationsthat may develop because of chronic pharyngeal blockage.

Surgeons perform tonsillectomies on children under general anesthesia,protecting the lower airways by intubation. Post-operative pain after surgery isconstant and practitioners must be prepared to manage it in conformity with theage of patients and the difficulties they have in swallowing.

KEY WORDS

Tonsillectomy,

Hypertrophied tonsillar tissues,

Recurrent tonsillitis,

Lymphoma,

Pain,

Sleep apnea.

Address for correspondence:

Martine FRANC�OISENT Service, Hospital Robert Debre,48 boulevard Serurier, 75019 Paris.martine.francois@rdb.aphp.fr

Article available at http://www.jdao-journal.org or http://dx.doi.org/10.1051/odfen/2011402

1 – INTRODUCTION

A tonsillectomy is an excision ofpalatal tonsillar tissue. This lymphoidtissue together with other compo-nents of Waldeyer’s ring, adenoidaltissue and lingual tonsils, constitutesan individual’s first line of defenseagainst bacterial and viral invasionsthrough the nasal and oral cavities butcan, nevertheless, be removed with

no resultant unfavorable immuno-aller-gic consequences7. Still, the surgicalintervention can be painful and en-cumbered by some risks, essentiallyhemorrhagic. Therefore, the treatmentteam, in consultation with familymembers, must conduct a scrupulouscost/benefit analysis.

2 – INDICATIONS FOR TONSILLECTOMY IN INFANTS

2 – 1 – Hypertrophied tonsils

Practitioners must suspect any clearunilateral tonsillar hypertrophy, andassume it is pathological when it istriple the size of its contralateral mate,of being a lymphoma2, requiring rapidremoval, within the week, for anato-mo-pathological examination (fig. 1).

Bilateral tonsillar hypertrophy is abenign growth of excess tissuecaused by lack of timely apoptosis,or appropriate death of cells. Thisparticular malady first widely recog-nized in the 1970s today constitutesalmost half of the indications fortonsillectomy in infants15. It is primar-ily seen in children younger than 5who otherwise enjoy good health. Butindications for surgical interven-tion6,18,19,20 are clear for children withenlarged tonsils who also suffer fromsleep apnea. Tonsillectomy is alsoadvisable for children who are mouthbreathers in order to prevent unwel-come maxillofacial consequencessuch as opening the mandibular angleand creating an anterior open bite.When symptoms are minor, practi-tioners should adopt a posture ofwatchful waiting.

Critical signs include snoring andother nocturnal problems such asagitated sleep, with frequent legmovements and changes of position,adopting abnormal sleep posturessuch as genu pectoral or extremehyperextension of the head, frequentcalls to parents or visits to their bed-rooms, sweating, or drooling. Practi-

Figure 1A computed tomodensitometric coronal section show-ing a very bulky right tonsillar mass that is a lymphoma.

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2 Francois M. Current views on the indications and techniques for tonsillectomies in children

tioners should ask if patients some-times stop breathing and then resumeit with a noisy inspiration of air. Someparents have hit upon the good idea ofmaking videos of their children’snocturnal behavior that can be effec-tively revelatory. Other, less noticeablesymptoms, like morning headaches,agitated somnolence, difficulty in swal-lowing solids, and problems with main-taining attention may also be present.Severe cases of hypertrophied tonsilsmay cause interruption with the steadyprogress of weight gain and staturalgrowth14 (fig. 2).

Examiners may find the volume oftonsils of the oropharynx difficult toassess because of a child’s naturalgagging reflex that causes them topivot inwards and appear larger thanthey actually are.

A diagnosis of pathological, butbenign, enlargement can be madewhen tonsils are hypertrophied en-ough for right and left masses to abutor have less than a centimeter ofseparation in the absence of a nause-ous reflex6 and are associated withtypical symptoms (fig. 3). It is only incases of imprecision of clinical signs,of neurological problems, or of themajor operative risks associated withsystemic disorders like hemophiliathat practitioners need to order anocturnal polysomnograph study toclarify the severity of obstructive sleepapnea with desaturation (fig. 4).

When the decision not to perform atonsillectomy is made, after severalmonths, or years, symptoms diminishbecause growth of the oropharynx hasmade the enlarged tissues occupyrelatively less space or because the

tonsils themselves have shrunken asadolescence progresses. However, aslong as the tonsils remain hypertro-phied they block pharyngeal respira-tion and have a deleterious effect onthe heart and brain that could causeirreversible lesions. And continuedmouth breathing could have deleter-ious maxillofacial consequences18,20.

Figure 2Stature and weight curves of a young boy with tonsillarobstruction. The weight curve began to flatten whenhe was 9 months old, the growth curve a little later.The child had a tonsillectomy at the age of 18 monthsand the weight and growth curves started to improve inthe next few months.

CURRENT VIEWS ON THE INDICATIONS AND TECHNIQUES FOR TONSILLECTOMIES IN CHILDREN

J Dentofacial Anom Orthod 2012;15:102 3

Treatment with corticoids will re-duce tonsillar bulk, but only tempora-rily1. They are used to removerespiratory blockage from the en-larged tonsils that are caused byinfectious mononucleosis. But nomedication is capable of reducing thesize of tonsils permanently so that theonly solution to their hypertrophy issurgical excision19.

2 – 2 – Repeated attacksof tonsillitis

Tonsillectomy is indicated when achild has had 7 episodes of tonsillitisin a single year or 5 in each of twosuccessive years4,12,19. In their inter-view, practitioners should ask howmany times children’s’ sore throats

have required antibiotic treatment ortheir missing school.

In such cases surgical interventionis not obligatory but the practitionershould suggest its possibility. Parentsmay opt for symptomatic treatment ofinfections if the rapid strep test, RST,is positive. If operations are notperformed, episodes of infection maybegin to occur less frequently afterseveral years.

3 – TECHNIQUES FOR TONSILLECTOMY IN INFANTS

No matter what technique is em-ployed, surgeons perform all tonsillec-tomies for children under generalanesthesia with oral or naso-tracheal

intubation to protect the lower airways,gaining access through the mouth toavoid external scarring.

Figure 3Normal sized palatal tonsils in a five year-old boy. Thereis more than a centimeter of space between the rightand left free margins.

Figure 4Polysomnograph registration showing desaturationassociated with obstructive sleep apnea.

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4 Francois M. Current views on the indications and techniques for tonsillectomies in children

3 – 1 – Dissection is thetechnique most oftenutilized

The surgeon gains access to thetonsils by passing instrumentsthrough the gap between the tonsillarcapsule and the muscles that sur-round it9. Surgeons have the choiceof making incisions with scissors, aJost comb (peigne de Jost), a curette,or an electric bistoury11,17. They canachieve hemostasis with a bipolarelectric bistoury (the monopolarbistoury is not advisable) but some-times supported sutures or pillar liga-tures may also be needed.

Children operated on for repeatedsore throats are considered ambula-tory, that is they can return home ifconditions are acceptable, meaningthat two responsible adults should bepresent with access to a telephone ina site located where the hospital orclinic can be reached in less than halfan hour5,15. But patients who havebeen operated on for removal ofobstructive tonsils should not beconsidered ambulatory.

After the tonsillectomy patientssuffer constant pain that is aggravatedby swallowing2,13. So level 2, of theWorld Health Organization scale, an-algesics should be prescribed to makethe pain bearable and to allow thechild to eat. Acetaminophen is insuffi-cient and anti-inflammatories are con-tra-indicated.

Parents should provide their chil-dren with acceptable nourishment,cold, liquid or sometimes liquid mixedwith solids. At the slightest indicationof bleeding, parents should bring theirchildren to the clinic or hospitalpromptly because unpredictable

bleeding is always a risk in the first15 days after the tonsillectomy8

(fig. 5).

3 – 2 – Other techniques

Tonsillectomies accomplished byCO2 laser, with micro-debridement orby coblation are, in fact, partial tonsil-lectomies. With CO2 lasers surgeonscan, in a step-by-step procedure,vaporize 30 to 40 % of palatal tonsillartissue, removing everything in thezone of the tonsillar crypts11 but byadding micro-debridement they canincrease the extent of tonsillar re-moval to 80 to 90 %. The procedureis an intra-capsular exeresis thatgreatly reduces the risk of post-opera-tive hemorrhage and the degree ofpost-operative pain because the peri-tonsillar muscles are neither stretchednor denuded10,17. Coblation combinesthe action of radio frequency with aconducting saline solution that trans-fers energy without producing heat.With this technique surgeons make an

Figure 5Hemorrhage occurring 10 days after a surgical tonsil-lectomy. A blood clot is visible in the upper pole of the lefttonsillar fossa. Note that the right tonsillar fossa has notyet healed completely: false membranes are present.

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J Dentofacial Anom Orthod 2012;15:102 5

extra-capsular excision or simply re-duce tonsillar volume. According toseveral published studies of smallsamples, this procedure is less painfuland less likely to cause hemorrhage inpatients than surgical dissection.

Repeated episodes of sore throatare the principal indication for the newtonsillectomy techniques and parentsare likely to welcome them becausethey have heard of the pain andcomplications that frequently followtraditional surgical tonsillectomies.However, no technique can promisethat it will not be followed by some

post-operative pain or risk of bleeding.And it is important to note that in 15 %of cases symptoms do not disappearor reappear later. Parents should begiven the option of selecting a surgicaldissection for removal of tonsils. Andit should be remembered that sur-geons cannot bill for two tonsillec-tomies in the same patient, so theywill not want to perform any correctiveprocedures for a not entirely success-ful first intervention. There is also aproblem of how to finance the invest-ment required for executing the newtechniques.

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