Surgery to remove tonsils in adults and children: pros and cons

If you often suffer from tonsillitis, then after examining the tonsils, the ENT doctor, having weighed all the pros and cons, may recommend surgically solving this problem and removing the tonsils.

And although this operation, called tonsillectomy by doctors, is now performed less frequently than half a century ago, it remains one of the most common surgical procedures, especially the removal of tonsils in children. For example, about 400 thousand such surgical interventions are performed annually in the EU countries.

[ 1 ]

Indications for the procedure

Tonsils (tonsilla palatina) can be removed for various reasons. The most common in clinical otolaryngology is recurrent sore throat associated with frequent inflammation of the tonsils. And the main indications for tonsil removal surgery include both recurrent acute tonsillitis (purulent sore throats) and their chronic forms.

Since the size of the tonsils reaches its maximum at the age of three or four years and then gradually regresses, the removal of the tonsils in children is usually postponed for several years - unless the frequency of tonsillitis in the child during the year and their severity are critical. And one or two cases, even severe ones, are usually not sufficient grounds for surgery.

Currently, the following indicators are recognized as criteria for referring patients for tonsillitis removal (acute recurrent): at least seven tonsillitis episodes in the past year or at least five acute tonsillitis episodes per year for two years. Or three or more cases of tonsillitis per year for three years (mandatory recorded in the patient's medical document). ENT doctors also favor the appointment of surgery by: tonsillitis with high temperature (> 38.3 ° C), enlarged mandibular lymph nodes, the presence of purulent exudate and detection of beta-hemolytic streptococcus group A in a smear.

Much more often, tonsillitis is removed in chronic tonsillitis, especially in its so-called decompensated form: when neither antibiotics nor rinsing the tonsil lacunae (to remove purulent plugs) give a lasting effect, and a focus of strepto- or staphylococcal infection remains in the throat. Everyone knows how dangerous tonsillitis is, especially frequent purulent tonsillitis, therefore - in order to prevent bacterial toxins from spreading throughout the body and damaging myocardial cells, joint tissue, vascular walls and kidneys - the strategic solution is to remove the tonsils in adults and children.

Obstructive sleep apnea, in cases of its pathophysiological association with hypertrophy or hyperplasia of the tonsils, is also one of the most common indications for tonsil removal.

In addition, tonsils are removed in the following cases: a significant increase in their size due to the deposition of calcium salts in the lacunae (tonsil stones or tonsilloliths), which can cause dysphagia (difficulty swallowing); if large papillomas, fibromas or cysts have formed on the tonsils or palatine arches.

[ 2 ], [ 3 ], [ 4 ], [ 5 ]

Preparation

Preparation for this operation consists of laboratory blood tests, as well as a general therapeutic (for children - pediatric) examination and a cardiologist's report after an ECG.

The necessary tests for tonsil removal are a general and clinical blood test (hemogram), platelet level, and blood clotting factors (fibrinogen).

To avoid bleeding, according to the test results, patients may be prescribed calcium supplements or fibrinolysis inhibitors a week before tonsillectomy.

[ 6 ], [ 7 ]

Technique tonsillectomy

The traditional technique for performing this operation, as well as the surgical instrument used to remove the tonsils, are described in detail in the material - Tonsillectomy (Tonsillectomy) surgery

The duration of the operation is on average half an hour, but how long the removal of the tonsils lasts in each specific case depends on the method used, since in addition to the classical method, more technologically modern methods of removing the tonsils are used in ENT surgery.

As in many other areas of surgery, an ultrasonic surgical instrument (called an ultrasonic scalpel) can be used to simultaneously cut and coagulate tissue by vibrating its molecules at an ultrasound frequency (55 kHz), generating heat (t≤ +100ºC). Such tonsillectomy is performed under general anesthesia.

The positive aspect of tonsil removal by high-frequency bipolar electrocoagulation is minimal bleeding due to simultaneous cauterization of vessels. This method is used to remove tonsils under local anesthesia (by injecting an anesthetic into the paratonsillar areas). However, the high temperature created in the manipulation area can lead to thermal damage to the tissues surrounding the tonsils, which causes great discomfort to patients in the postoperative period.

Removal of tonsils by thermal welding method TWT (Thermal Welding Tonsillectomy) – using temperature of +300°C (at which the tonsil tissue captured with forceps sublimes) and pressure (for simultaneous coagulation of blood vessels). In this case, the tissues surrounding the tonsils are heated only 2-3 degrees above normal body temperature. According to patient reviews, postoperative pain is tolerable, and you can quickly switch to a normal diet.

Cryoablation or cryotonsillectomy is the removal of tonsils with nitrogen (which has a liquid temperature of < -190°C), which is supplied to the tissues to be removed by a cryoprobe and freezes them to the point of necrosis.

Laser tonsillectomy – ablation using medical lasers of various modifications (usually carbon dioxide) – is considered an effective and safe procedure, the duration of which is on average 25 minutes; it is performed under local anesthesia. However, it is often necessary to repeat it, and the pain after laser ablation can be more intense compared to other methods. Since the procedure requires complete immobility of the patient, this method of tonsillectomy is not suitable for young children.

The cold plasma method – removal of tonsils with a coblator – is performed only under general anesthesia. This technology involves passing radiofrequency energy through an isotonic sodium chloride solution (saline), which creates a plasma field capable of destroying molecular bonds of tissues without increasing their temperature above +60-70°C. This factor makes it possible to minimize or even avoid damage to surrounding healthy tissue. COBLATION technology, according to surgeons, reduces pain and swelling after surgery and is characterized by a lower incidence of intraoperative or delayed bleeding, as well as secondary infections.

Finally, monopolar radiofrequency thermal ablation or radio wave tonsillectomy, performed under local anesthesia, is actually recommended and used to reduce the size of hypertrophied tonsils – due to the processes of scar tissue formation in the tonsils at the site of the removed lymphoid tissue.

Contraindications to the procedure

Tonsillectomy operations are contraindicated in the following cases:

• hemophilia, leukemia, thrombocytopenia and/or agranulocytosis, pernicious anemia;
• acute forms of cardiovascular, pulmonary or hepatic failure;
• thyrotoxicosis;
• diabetes mellitus of the third degree;
• active form of tuberculosis;
• acute infections of various etiologies and localizations, as well as exacerbation of chronic diseases;
• serious mental disorders;
• oncological diseases.

Tonsil removal is not performed during pregnancy. A relative contraindication is the age of children under five years.

[ 8 ], [ 9 ], [ 10 ], [ 11 ]

Consequences after the procedure

There are certain risks of this operation and consequences after the procedure.

When considering the pros and cons of tonsillectomy, otolaryngologists, first of all, point out the real benefit of the operation – getting rid of the source of infection in the throat and the associated tonsillitis, and, therefore, eliminating pain.

Indeed, tonsillitis after tonsillectomy no longer bothers, but life after tonsillectomy can present an unpleasant "surprise": tonsillitis can be replaced by inflammation of the mucous epithelium of the pharynx - pharyngitis. According to research by Finnish otolaryngologists who studied this problem, 17% of patients experienced six or more episodes of acute pharyngitis within a year after tonsillectomy.

According to experts from the American Academy of Otolaryngology, patients experience the benefits of this surgical procedure only for 12-15 months: the average number of episodes of sore throat decreases, and, accordingly, the number of visits to the doctor and the amount of analgesics and antibiotics taken decreases. But there is insufficient clinical evidence to support the long-term benefits of tonsillectomy.

However, as noted above, tonsils can be removed not only because of constant sore throats, but also to treat sleep apnea. And in this case, the advantage of such an operation is obvious, especially in young men with excess weight.

According to many experts, the biggest disadvantage is the possible weakening effect of tonsil removal on immunity. As an active immunological organ, the palatine tonsils (along with other tonsils of the nasopharynx) are part of the Waldeyer lymphoepithelial ring, which protects the body from bacterial and viral infections through the mucous membranes of the respiratory tract and gastrointestinal tract. And the lymphoepithelial tissue cells of the tonsils produce T and B lymphocytes, immunomodulatory cytokines, and immunoglobulins (IgA).

But the counterarguments of opponents of this point of view are also not without logic, because the tonsils are removed, which, due to recurrent infections and inflammation, are no longer able to perform a protective function. So the discussions on this issue continue.

Complications after the procedure

The blood supply to the palatine tonsils is provided by the tonsillar branches of several arteries, so bleeding after tonsil removal can be quite intense. And this is one of the key complications of this procedure. Moreover, increased bleeding can be noted both immediately after the operation and after 7-12 days (noted in about 2-3% of patients) - if the scab on the wound surface falls off prematurely. In some cases, real bleeding begins, which may require surgical intervention to stop.

Complications after the procedure - swelling of the mucous membrane in the throat and severe pain after tonsillectomy - occur with any method of tonsillectomy: the most modern surgical technologies simply reduce their intensity and shorten their duration. Usually, the throat hurts after tonsillectomy for the entire time the scab forms (up to two weeks or a little longer); the pain goes away when the scab comes off. Tonsil removal in children can cause postoperative ear pain, and this is pain irradiation from the throat associated with the anatomical features of the nasopharynx in childhood.

Painkillers are always prescribed after tonsillectomy (most often Paracetamol); the use of NSAIDs should be avoided, since long-term use or excess doses of non-steroidal anti-inflammatory drugs reduce the level of platelets in the blood.

Subfebrile temperature does not cause concern, as doctors consider it a sign of activation of the immune system and the beginning of postoperative recovery. But if the temperature after tonsillectomy rises above +38.5°C, this is a bad sign: most likely, a secondary bacterial infection has become active, which can cause inflammation of the regional lymph nodes, pharyngeal abscess after tonsillectomy, and even septicemia. That is when systemic (injectable) antibiotics are needed after tonsillectomy (most often, 3rd generation cephalosporins and combined penicillins are prescribed).

In cases of severe weakness, dry mouth, headache and a simultaneous decrease in the amount of urination, doctors state that the patient is dehydrated, which is simply explained by the restriction of fluid intake due to pain when swallowing.

Halitosis after tonsillectomy – bad breath after tonsillectomy – is associated with necrosis of the remaining damaged tissue in the wound area, covered with a whitish fibrous film, under which a scab forms from a blood clot (in about 12 days). In addition, while healing is in progress, proper oral hygiene is problematic, so doctors recommend rinsing the mouth (not the throat!) with salt water.

When examining the throat of some operated patients (especially children with weakened immunity), doctors may find a cheesy coating on the surface of the wounds and on the mucous membrane lining the oral cavity after the removal of the tonsils - a symptom of candidiasis. Of course, the presence of a fungal infection complicates the condition of patients in the postoperative period and forces the use of fungicidal drugs.

A list of later and rare complications includes oropharyngeal adhesions after tonsillectomy, which can occur between the root of the tongue and the palatine arch area due to adhesion of scar tissue at the site of the postoperative wound. The formation of adhesions creates problems with swallowing and articulation.

Reviews of some adult patients contain complaints that the voice changes after tonsillectomy. Indeed, tonsillectomy can affect the voice, and this has been proven by several studies that have confirmed the fact of an increase in the size of the oropharynx after this operation and some changes in the resonance characteristics of the vocal tract. It has been established that some experience an increase in the frequency of sound (formants) in the range of up to 2 kHz and an increase in the overtones of the voice in the frequency range of about 4 kHz. Therefore, the timbre of the voice can change.

[ 12 ], [ 13 ]

Care after the procedure

The early postoperative period requires medical monitoring of the patient's condition in order not to miss the development of bleeding, the risk of which, according to clinical statistics, is about 1.5-2%.

After the operation, patients are required to lie on their side, and discharge from the wound cannot be swallowed (they must be spat out). When it is possible to drink after the tonsils have been removed, the doctor decides after examining the wounds in the throat and determining the amount of blood in their discharge. As a rule, in the first five to six hours, patients are prohibited not only from talking, but also from swallowing anything: when the vocal cords are strained and swallowing movements occur, the muscles of the larynx are strained, and their contraction spreads to the blood vessels, which creates the prerequisites for bleeding.

Rehabilitation and recovery after the tonsil removal procedure can take a month or more: both the method of tonsil removal and the individual characteristics of patients play a role here. But a sick leave after tonsil removal is issued by a medical institution for 14 days.

Sore throats persist for approximately two weeks after surgery. In order to avoid additional trauma to postoperative wounds, a post-tonsillectomy diet is followed for 7-10 days, which involves eating non-hot homogenized food.

What to eat after tonsillectomy? You can eat liquid mashed porridge, vegetable and fruit purees, broths, cream soups, etc. You can eat mousses and ice cream after tonsillectomy; you can drink jelly, juices, compotes, milk, fermented baked milk and kefir after tonsillectomy. You should also drink enough water to maintain normal homeostasis of the body.

What is prohibited after tonsillectomy? You cannot eat solid hot food, drink hot tea or other hot drinks. Spicy, peppery, sour and, of course, alcohol are absolutely prohibited after tonsillectomy. Until the postoperative wounds are completely healed, intense physical activity is prohibited (any sports training, gym classes); you cannot take a hot shower or bath, go to a sauna, or sunbathe on the beach. And, probably, you yourself can guess what the doctors will answer to the question - is it possible to smoke after tonsillectomy?

In general, if you often suffer from tonsillitis, remember: this problem can be solved. And in most cases, life after tonsillectomy can become healthier - without annoying sore throat and a host of other negative consequences of chronic tonsillitis.

[ 14 ], [ 15 ]

Medical errors during tonsil removal

Serious complications can result from medical errors during tonsil removal, and unfortunately, no one is immune from them.

First of all, these are intraoperative burns during high-frequency electrocoagulation, laser ablation and other electrosurgical procedures, as well as dentoalveolar injuries.

Hypersalivation (increased saliva production) occurs when the submandibular salivary gland, located near the tonsils, is affected.

The palatine tonsils are innervated by branches of the maxillary division of the trigeminal nerve and the glossopharyngeal nerve. Due to damage to the maxillary branch - due to excessive tissue resection during tonsillectomy - the passage of nerve impulses to the temporomandibular joint may be disrupted, which causes difficulties with chewing and opening and closing the mouth.

The glossopharyngeal nerve innervates the posterior third of the tongue, providing, in particular, taste sensations, and when this nerve is damaged, the sense of taste is reduced or lost.

The soft palate is innervated by the branches of the pharyngeal nerve plexus, damage to which limits the elevation of the soft palate with the development of its partial paresis. As a result, patients experience nasopharyngeal regurgitation - the reverse flow of the contents of the esophagus into the nasopharynx.

Resumption of tissue growth in the tonsils may also occur if, during surgery, the surgeon, through mistake or oversight, did not completely remove the tonsils.