An 11-year-old boy presents to the office with a chief complaint of difficulty breathing through the nose for the past 7 years. At night his parents have noticed that he sleeps with an open mouth and has episodes of restlessness. He complains of tiredness during the day and has had declining performance in his 6th grade class. His schoolteacher has also complained to his parents about moments of aggressive behavior with his peers. He has received multiple courses of antibiotics for recurrent episodes of pharyngitis. There is no history of headaches in the morning, vomiting, or diarrhea. He currently has no fever, sore throat, or cough.
Exam: VS T 37.1, P 80, RR 14, BP 118/74, oxygen saturation 99% in room air. He is alert but appears tired. HEENT shows enlarged tonsils with pink and moist oral mucosa. There is no exudate, erythema, or tenderness over the sinuses, or bleeding inside his mouth. There are no visible nasal polyps. His eyes and ears are normal. The remainder of his physical exam is normal.
Due to his history of recurrent pharyngitis and description consistent with sleep-disordered breathing (SDB), his pediatrician refers him to an otolaryngologist and the decision is made to perform a tonsillectomy and adenoidectomy. On the day of surgery, an anesthesiologist assesses his airway and he is placed under general anesthesia, intubated with an oral right angle endotracheal (RAE) tube. The otolaryngologist uses monopolar cautery to successfully perform an extracapsular tonsillectomy and adenoidectomy. No complications are noted following the procedure. Anti-emetics are prescribed to minimize vomiting and nausea postoperatively. He recovers post-operatively and is discharged and encouraged to stay hydrated and eat soft foods.
Tonsillectomy and adenoidectomy, surgical removal of the palatine and adenoid tonsils respectively, have become the second most common pediatric surgical procedure with over 500,000 surgeries performed annually in children less than 15 years old (1). Indications for this surgery range from sleep-disordered breathing caused by tonsillar hypertrophy to chronic infectious tonsillitis. Other less common indications include tonsillar neoplasm, antibiotic intolerance, and peritonsillar abscess (2).
Waldeyer’s ring is composed of partly encapsulated lymphoid tissue located in the pharynx that has four different sections: 1) nasopharyngeal (also known as the adenoid tonsils), 2) tubal, 3) palatine, and 4) lingual tonsils. 1) The nasopharyngeal tonsil (adenoids) functions as the superior portion of Waldeyer’s ring as it is located on the roof and posterior wall of the nasopharynx. 2) The tubal tonsils are located just lateral to the nasopharyngeal tonsils and surround the eustachian tube in the nasopharynx. 3) The palatine tonsils form the lateral walls of Waldeyer’s ring as they are bordered by the palatoglossal arch anteriorly and the palatopharyngeal arch posteriorly in the oropharynx. The palatine tonsils are the only ones that can be visualized unaided when observing the oropharynx. To operate on the palatine tonsils in a tonsillectomy or peritonsillar abscess drainage, the surgeon must delineate a clear surgical place to prevent damage to the internal carotid artery and glossopharyngeal nerve which are located nearby to the stylopharyngeus and pharyngeal constrictor muscles. 4) The lingual tonsils create the base of Waldeyer’s ring and are located at the base of the tongue (3).
Tonsils are classified as mucosa associated lymphoid tissue (MALT) and contain three different layers. The cortex makes up the outermost layer and houses the follicles. The paracortex becomes the middle layer and is where the T-cells reside. The medulla functions as the innermost layer and contains the sinus for final lymph drainage. Lymph fluid enters the cortex via multiple afferent lymph vessels and exits through a single efferent lymphatic vessel near the medulla. As lymph fluid enters the cortex, the follicular dendritic cells (FDCs) and free antigens can activate B-cells inside the follicles. T-cells become activated by FDCs in the paracortex. Venules in the paracortex are composed of spaced-out endothelial cells that allow for T-cells and B-cells to exit the systemic system and localize in the tonsils. During an active infection, the paracortex can become swollen due to the adaptive immune response. Finally, the medulla is divided into the medullary sinuses and chords. The chords house the plasma cells that secrete antibodies specific to the invading pathogen and the sinuses have macrophages that continuously filter the lymph fluid through phagocytosis (4).
The adenoids (nasaopharyngeal tonsils) have a pyramidal structure and are in the posterior wall of the nasopharynx. A layer of connective tissue containing many sero-mucous glands cover the pseudostratified ciliated columnar epithelium lining most of the tissue. The glossopharyngeal nerve and branches from the maxillary and mandibular nerve innervate the adenoids. The lymph fluid from the adenoids drain to the retropharyngeal and pharyngomaxillary space lymph nodes. The blood supply comes from the ascending pharyngeal artery, ascending palatine artery, tonsillar branch, pharyngeal branch, basisphenoid artery, and artery of pterygoid canal. The internal submucous and external pharyngeal venous plexus provide venous drainage for the adenoids (3).
The palatine tonsils (the visible tonsils on inspection of the oropharynx) attach to the wall between the palatoglossal and palatopharyngeal arches with a fibrous capsule. Stratified squamous epithelium and numerous crypts cover the remainder of the tissue. The maxillary division of the trigeminal nerve and the tonsillar branch of the glossopharyngeal nerve innervate the palatine tonsil. The lingual branch of the glossopharyngeal nerve, located 6.5 mm from the posteroinferior tonsillar fossa, provides taste and sensation to the posterior 1/3rd of the tongue. The lymph fluid from the palatine tonsils drain to the jugulodigastric lymph node. The blood supply comes from the tonsillar branch of the facial artery, ascending pharyngeal branch of the external carotid artery, ascending palatine branch of the facial artery, dorsal lingual branch of the lingual artery, and the lesser palatine branch of the descending palatine artery. The peritonsillar plexus functions to drain venous blood from the palatine tonsils into the internal jugular vein (3).
Tonsillectomy and/or adenoidectomy is indicated for sleep-disordered breathing, chronic sinusitis, recurrent pharyngitis, tonsilitis and/or adenoiditis, and persistent otitis media with effusion. Sleep-discorded breathing results from obstruction of the upper airway passage due to inflamed or enlarged tonsils. Physical exam signs such as tonsil hypertrophy combined with a history of daytime fatigue and restlessness can help point towards this diagnosis. As the degree of obstructive sleep apnea is not strictly predictive by the degree of tonsillar hypertrophy, polysomnography (a sleep study) can be a useful tool in evaluating and characterizing the degree of sleep-disordered breathing (5).
In patients with recurrent tonsillitis the required indications for tonsillectomy include: 1) >7 episodes annually 2) >5 episodes annually for the past two years 3) >3 episodes annually for the past three years . When patients do not meet the criteria listed previously, the clinical approach of watchful waiting/monitoring is appropriate except in some circumstances such as: inability to tolerate antibiotic courses (allergy, intolerance), PFAPA (periodic fever, aphthous stomatitis, pharyngitis, and adenitis), or tonsillar abscess (or tonsillar infection refractory to medical management). Tonsillectomy is also indicated for evaluation of malignancy, commonly caused by squamous cell carcinoma and lymphoma (5).
Extra precautions should be taken with patients having a high risk of bleeding (1). Adenoidectomy is contraindicated in patients with cleft palate, submucous cleft palate and velopharyngeal insufficiency (VPI), and irreversible coagulopathy due to hematological conditions (6).
There are several procedure techniques available to perform this surgery. Before the surgery anesthesia is administered with the patient in a supine position. An oral right angle endotracheal (RAE) tube inserted, and the Crowe-Davis device is placed at the groves of the tongue to keep the mouth open. Surgeons can perform a total or subtotal removal of the tonsils by sparing the surrounding capsule. For a total removal, the Allis clamp grasps the superior pole of the tonsil, and the tonsil is medialized. A monopolar cautery with 20W of power is used to remove the entire tonsil from a superior to inferior incision (1).
Similarly, for a cold tonsillectomy the Allis clamp is also used to medialize the tonsils. A scalpel helps identify the lateral side of the tonsil and then the Metzenbaum scissors helps detect the avascular plane. Then a Fisher tonsil dissector cuts through the tonsil until the inferior pole is reached. Finally, a Tyding snare makes the final separation from the inferior attachment (6).
Coblation is another technique that can be used for tonsillectomy and adenoidectomy. This technology creates a powerful energy field that is conducted through saline to dissolve tissue in a more controlled setting (1).
The preferred technique for tonsillectomy and adenoidectomy depends on the experience and comfort of the surgeon.
Bleeding is the most common complication following this procedure. Postoperative hemorrhage occurs in approximately 12% of pediatric cases (ages 1 to 17). This bleeding can sometimes be significant and require return to the operating room for surgical intervention. Older age and female sex were factors associated with increased bleeding risk (7). Postoperative nausea and vomiting (PONV), which can result in severe dehydration, has the greatest incidence in children after procedures such as tonsillectomy, with a 70% occurrence in high-risk individuals. Prophylactic treatment with dexamethasone and ondansetron are often used to minimize the development of PONV. Risk factors for children include older than 3 years, history of PONV or motion sickness, and post-pubertal female (8). Both bleeding and PONV with moderate-severe dehydration account for most post operative complications that result in re-presentation to the emergency room or hospitalization.
Questions
1. Which nerve, if damaged during tonsillectomy, could lead to taste alterations postoperatively?
a. glossopharyngeal nerve
b. trigeminal nerve
c. vagus nerve
d. mandibular nerve
e. maxillary nerve
2. Which of the following descriptions meets the recommended requirements to receive a tonsillectomy?
a. 6 episodes of tonsillitis in the past year
b. 4 episodes of tonsillitis annually for the past 3 years
c. 4 episodes of tonsillitis annually for the past 2 years
d. 3 episodes of tonsillitis in the past 6 months
3. Which tonsil from Waldeyer’s ring is removed in a tonsillectomy?
a. Lingual
b. Nasopharyngeal
c. Palatine
d. Tubal
References
1. Huyett P, Dohar JE. Chapter 192. Tonsillectomy. In: Bluestone CD (ed). Operative Otolaryngology Head and Neck Surgery, 3rd edition. 2018. Elsevier, Philadelphia. pp: 1347-1355.
2. Wetmore RF. Chapter 411. Tonsils and Adenoids. In: Kliegman RM, St. Geme JW, Blum NJ, et al (eds). Nelson Textbook of Pediatrics, 21st edition. 2020, Elsevier, Philadelphia, PA. pp: 2198-2202.
3. Arambula A, Brown JR, Neff L. Anatomy and physiology of the palatine tonsils, adenoids, and lingual tonsils. World J Otorhinolaryngol Head Neck Surg. 2021;7(3):155-160.
4. Brandtzaeg P. Immunology of tonsils and adenoids: everything the ENT surgeon needs to know. Int J Pediatr. Otorhinolaryngol. 2003;67(1):S69-S76
5. Mitchell RB, Archer SM, Ishman SL, Rosenfeld RM, et al. Clinical practice guideline: Tonsillectomy in children (update). Otolaryngol. Head Neck Surg. 2019;160(1_suppl):S1-42.
6. Ungkanont K. Chapter 191. Adenoidectomy. In: Choi S (ed). Operative Otolaryngology Head and Neck Surgery, 3rd edition. 2018. Elsevier, Philadelphia. pp: 1341-46.
7. Dhaduk N, Rodgers A, Govindan A, Kalyoussef E. Post-Tonsillectomy Bleeding: A National Perspective. Ann Otol Rhinol Laryngol. 2021;130(8):941-947.
8. Gan TJ, Belani KG, Bergese S, Chung F, et al. In: Fourth Consensus Guidelines for the management of postoperative nausea and vomiting. Anesth Analg. 2020;131(2):411–448.
Answers to questions
1.a, 2.b, 3.c