CHAPTER 83 Tonsillectomy and Adenoidectomy

Tonsillectomy is one of the oldest surgeries known. It was first described in 50 A.D. by Celsus, who used a hook to grasp the tonsil and his finger to excise the bulk of the tonsillar tissue. By the 6th century, hygienic concerns had led to the use of knives and other instruments to complete the surgery. These early surgeons were quick to recognize the importance of following the correct tissue planes to be successful, a fact that holds true today. The pain of doing surgery without anesthesia led to the development of instruments that would remove the tonsils quickly. These methods often failed to remove all the tonsillar tissue and obstruction would recur. Throughout the first half of the 20th century, tonsillectomy was performed under local anesthesia and later general anesthesia without airway protection. The procedure was often performed with very few indications in healthy individuals. Adenotonsillectomy reached its peak when 1.4 million procedures were performed in the United States in 1959.

Over the last 50 years the frequency of tonsillectomy and adenoidectomy has declined among American clinicians; however, it still remains the most common surgery performed on children younger than 15 years of age. There are many techniques and innovations that have been tried through the years, from snares to lasers. Many fell out of favor because of concerns over excessive blood loss, tissue damage, excessive postoperative pain, or extended intraoperative time.

This chapter focuses on three of the most popular techniques used today. These are cold knife and snare with or without electrocautery, harmonic ultrasonic scalpel (Ethicon Endosurgery), and bipolar radiofrequency ablation or Coblation (Arthrocare).

Most studies agree that the less heat introduced into the pharyngeal tissue, the less postoperative pain experienced by the patient. Cold knife and snare removal puts no heat into the system, but cold steel does nothing to stop the bleeding. Bleeding is the most feared complication of tonsillectomy, and electrocautery or sutures must be used as a supplemental measure to control the brisk bleeding. Electrocautery produces considerable heat at the operative site (400° C; Fig. 83-1A). Electrocautery and figure-of-eight sutures also cause collateral tissue damage for several millimeters around the bleeding site. This heat and tissue damage nullifies any benefits the cold knife procedure may have had with respect to lower pain levels or prompter healing rates. Both the harmonic ultrasonic scalpel and the radiofrequency Coblation wand cut and coagulate at the same time, resulting in very little blood loss. Hemostasis is achieved by the production of a protein plug in the end of the cut vessel from the ultrasonic or plasma energy of the devices. The harmonic scalpel generates operative site temperatures of 70° C to 80° C, and the radiofrequency Coblation wand produces a slightly lower temperature of 60° C (Fig. 83-1B). Less heat translates into slightly lower postoperative pain scores for the Coblator compared with the harmonic ultrasonic scalpel. However, recovery time is nearly identical, so the temperatures should not be a significant factor when deciding between these two techniques. All studies agree that lower pain scores and decreased recovery time also come from gentle and careful removal of all of the tonsillar tissue. Therefore, the best method for tonsillectomy is the technique with which the operating clinician is most comfortable, or has the most experience.