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 return to: Pediatrics

see also: Peritonsillar Abscess Management; Tonsils and Adenoids, Maximum allowable blood loss

  1. GENERAL CONSIDERATIONS: Although the incidence of the Tonsillectomy and Adenoidectomy has decreased in recent years, it is still the most common major surgery performed in children.  The procedure peaked in the 1970's with approximately one million cases performed  per year.  In general, we have also witnessed a shift in the indication for the procedure with a movement from an infective process to that of airway obstruction.

     

    1. Indications
      1. Obstruction: Upper airway obstruction, Obstructive sleep apnea, poor feeding and failure to thrive, hypernasal speech secondary to enlarged tonsils.
      2. Infective:  Recurrent tonsillitis, cryptic tonsillitis, chronic tonsillitis, peritonsillar abscess, or halitosis
      3. Misc: Asymmetric enlargement with suspicion of neoplasm; Abnormal facial growth; recurrent hemorrhagic tonsillitis; velopharyngeal insufficiency secondary to enlarge tonsils
    2. Contraindications for tonsillectomy include the following:
      1. Bleeding diathesis
      2. Poor anesthetic risk or uncontrolled medical illness
      3. Anemia
      4. Acute infection (relative) "hot tonsillectomy" or 'tonsillectomy a chaud' is reasonable treatment for peritonsillar abscess (2008 Berry et al) and (2012 Akin et al)
    3. Discuss potential complications with patient/family
      1. Bleeding, infection, reaction to the anesthesia
      2. Damage to adjacenct structures (lips,teeth, tongue)
        1. Assess for risk of VPI (velopharyngeal insufficiency) and relate the potential for nasal regurgitation of food/fluid and hypernasal speech (anatomic abnormalities such as submucous cleft is a relative contraindication)
        2. Discuss altered taste, tongue numbness
      3. Relate: may feel like 'the worst sore throat of your life' until it heals 
  2. Anatomy:
    1. Palatine tonsils:
      1. The palatine tonsils are found in the tonsillar fossa, limited by the palatoglossal arch anteriorly and the palatopharyngeal arch posteriorly.   The superior pharyngeal constrictor muscle lies laterally.  The tonsils are surrounded by a fibrous capsule
    2. Blood supply:
      1. Blood supply is from the tonsillar and ascending palatine branches of the facial artery, the ascending pharyngeal artery, the dorsal lingual branch of the lingual artery and the palatine branch of the maxillary artery.
        1. Tonsillar branch of facial artery
        2. Ascending palatine branch of facial artery
        3. Ascending pharyngeal artery
        4. Tonsillar branch of dorsal lingual artery
        5. Lesser palatine artery from maxillary artery
      2. OF NOTE:
        1. The internal carotid artery lies approximately 2.0-2.5 cm posterolaterally to the tonsil. 
        2. The tonsillar veins pierce the superior pharyngeal constrictor muscle to drain into the external palatine, pharyngeal and facial veins. 
        3. Innervation is from the sphenopalatine ganglion via the lesser palatine and glossopharyngeal nerves. 
        4. Efferent lymphatics drain into the upper deep cervical lymph nodes.
    3. Adenoids:
      1. The adenoid or pharyngeal tonsil is a single mass of pyramidal tissue with its base on the posterior nasopharyngeal wall and it’s apex pointed toward the nasal septum. The surface is invaginated in a series of folds with some crypts but without the complex crypts found in the palatine tonsils.  The epithelium is pseudostratified ciliated  epithelium and is infiltrated by the lymphoid follicles. 
      2. *Blood supply:
        1. the ascending palatine branch of the facial artery
        2. ascending pharyngeal artery
        3. pharyngeal branch of the internal maxillary artery
        4. Artery of the pterygoid canal
        5. ascending cervical branch of the thyrocervical trunk
      3. Venous drainage is through the pharyngeal plexus and the pterygoid plexus flowing ultimately into the facial and internal jugular veins.
      4. Innervation is derived from the glossopharyngeal and vagus nerves.
      1. Efferent lymphatics drain to the retropharyngeal nodes and the upper deep cervical nodes.
  1. PREOPERATIVE PREPARATIONS
    1. A full patient evaluation should be performed prior to surgery.  History including bleeding disorders, prior issues with anesthesia for both the patient and family, and degree of obstructive symptoms should be illicited.  Recent URI's should also be identified, as this places the child at an increased risk for laryngospasm.
  2. NURSING CONSIDERATIONS
  3. ANESTHESIA CONSIDERATIONS
    1. Tube Placement: The ET tube should be placed at exactly midline and brought inferiorly
      1. The patient will be rotated 90-degrees and the inferior placement of the ET tube allows for extention of tubing inferiorly and laterally towards anesthesia and out of the operative field. 
      2. The Crowe-Davis will be placed and the tube sits in the groove of the tongue blade.# OPERATIVE PROCEDURE
    2. The bed is rotated 90 degrees and positioned appropriately.
      1. A shoulder roll may be used to improve neck extension and optimize the view of operative field
        1. Down Syndrome: Due to risk of atlanto-axial instability in these patients, extreme caution should be used in head positioning, including no shoulder roll and minimal head tilting.
          1. Preoperative x-rays or recent scans should be obtained or evaluated prior to the operation date.
            1. Laxity of over 4 mm suggests axial-atlanto instability
            2. Due to a low level sensitivity in flexion/extension films in detecting AAI, it is suggested to take neck precautions in all Down Syndrome patients.
    3. Carefully place the Crowe-Davis retractor. 
      1. Ensure that the tongue blade is the appropriate size.
        1. This should extend far enough to allow for retraction of the base of tongue
        2. This should not be too long as to damage the posterior pharyngeal wall.
      2. The tube is placed exactly at midline.
      3. The tongue may be manipulated into the correct position with the Hurd retractor.
    4. Prior to performing this procedure, the palate should be palpated, with close inspection of the palate and uvula. 
      1. Care should be taken if a bifid uvula is present indicating signs of a submucous cleft.

There are multiple ways to perform a tonsillectomy.  Please see the preferred protocol for individual staff members below.

  1. POSTOPERATIVE CARE
    1. Children under 3 years of age should be monitored overnight in the hospital for POPE II.   
    2. Adequate pain control is imperative in the post-operative course. 
      1. Epocrates suggests the following dosages of Lortab elixir:
        1. > 2 y/o - 12 - 15 kg - 3.75 mL PO Q4-6 hrs
        2. 16-22 kg - 5 mL PO Q4-6 hrs
        3. 23-31 kg - 7.5 mL PO Q4-6 hrs
        4. 32-45 kg - 10 mL PO Q4-6 hrs
        5. > 46 kg - 15 mL PO Q4-6 hrs
      2. Non-Opiate Pain Protocol for Post-Tonsillecotmy/Adenoidectomy Patients
        1. Tylenol (15mg/kg) scheduled every 6 hours, alternating with Motrin every 6 hours
          1. Motrin dosing for pain (from Micromedex): 6 months to 12 years old, 5 to 10 mg/kg PO every 6 to 8 hours as needed, MAX 4 doses/day; 12 years and older, 200 to 400 mg ORALLY every 4 to 6 hours as needed, MAX 1200 mg/day
          2. This way the patient will get a non-opiate pain medication every 3 hours (Tylenol then Motrin then Tylenol...) 
    3.  Non-narcotic analgesia in pediatric patients
  2. DICTATION TEMPLATES:
    1. Dr. Richard Smith preferred method:
      1. Informed consent was reviewed with the parents. The patient was transferred to the room and a time out was performed. A Crowe-Davis mouth gag was placed with good exposure of the oropharynx. First the adenoid bed was addressed. The palate was palpated and uvula inspected with no abnormalities noted. Sizing the adenoid curette on the maxillary incisors, the curette was placed at the base of the nasopharynx and the adenoids were removed. A tonsil ball was used to pack the adenoid bed. The right tonsil was then addressed. Curved Allis clamps were placed on the superior pole, and the tonsil was medialized. A Cushing toothed forceps was used to perform blunt dissection of the superior pole of the tonsil, being careful not to enter the tonsil, but to dissect out the fibrous capsule. Once a significant portion of the tonsil was free, with only a portion of the inferior pole remaining, a Tyding tonsil snare was placed around the remaining tonsil tissue, and the tonsil was subsequently removed. Two tonsil balls were placed in the right tonsillar fossa. The left tonsil was then addressed, and removed in a similar fashion as the right, with subsequent hemostasis achieved using suction cautery. The tonsil balls were then removed from the tonsillar and adenoidal beds with similar hemostasis achieved using suction cautery. 6.0 cc of Marcaine was injected along the bilateral palatoglossal and palatopharyngeal arches.The nasal and oral cavities were thoroughly irrigated with no active bleeding noted. The Crowe-Davis retractor was removed at this time. Irrigation was performed and the patient's stomach was suctioned for contents. The mouth was cleaned of debris and wiped clean, and bacitracin ointment was placed on the lips. The patient was then turned over to Anesthesia in good condition.
    2. Dr. Jose Manaligod preferred method:
      1. Informed consent was reviewed with the parents and the patient was brought to the room and placed in the supine position. A Crowe-Davis retractor was placed with good visualization of the oropharynx. A red rubber catheter was then placed to retract the soft palate and allow good visualization. The soft palate was palpated, and uvula inspected with no abnormalities. An Adenoid curette was sized using the maxillary incisors and used to remove the adenoid bed. A tonsil ball was placed to help achieve hemostasis. The right tonsil was then addressed. Curved Allis clamps were used to grasp the superior pole of the tonsil and medialize it. The mucosa from the superior pole enveloping the fibrous capsule was divided using a sickle knife. Good scissors were used to dissect the tonsil from the tonsillar bed, maintaining the fibrous capsule. With only the inferior pole remaining, a Tydings tonsil snare was placed and the remaining tonsil was removed. A tonsil ball was placed into the tonsillar fossa for hemostasis. The left tonsil was then addressed. Curved Allis clamps were used to grasp the superior pole of the tonsil and medialize it. The mucosa from the superior pole enveloping the fibrous capsule was divided using a sickle knife. Good scissors were used to dissect the tonsil from the tonsillar bed, maintaining the fibrous capsule. With only the inferior pole remaining, a Tydings tonsil snare was placed and the remaining tonsil was removed. A tonsil ball was placed into the tonsillar fossa for hemostasis. The tonsil balls were removed, and suction cautery was used to achieve hemostasis in the tonsillar and adenoid beds. The nasopharynx was irrigated and suctioned, and the red rubber catheter was removed. Marcaine was injected into the tonsillar arches, and the Crowe-Davis was removed. The patients mouth was wiped clean, and ointment was placed prior to returning the patient to Anesthesia in good condition.
    3. Dr. Hoffman preferred method:
      1. Informed consent was reviewed with the patient and family immediately preoperatively after which the patient was brought to the room and placed in the supine position. A Crowe-Davis retractor was placed with good visualization of the oropharynx. The soft palate was palpated, and uvula inspected with no abnormalities. With a curved tonsil injection needle 1% lidocaine with 1:100,000 epinephrine was injected into the tonsillar pillars and deep to the tonsil. A waiting period (to permit maximal vasoconstrictive effect) was followed by addressing the right tonsil by grasping it with a curved allis clamp. The mucosa from the superior pole enveloping the fibrous capsule was divided using a sickle knife. A tonsillar hemostat (or Kelley) was used to develop a plane between the tonsil and fascia overlying the constrictor muscle. Individual blood vessels are identified and addressed using the guarded bipolary cautery. The tonsil scissors are used to incise mucosa and with a pushing action,  (using scissors, Fischer knife, hemostat or bipolar cautery) the tonsil was delivered inferiorly to the lower pole. Biplolar cautery at the lower pole then permitted final separation of the tonsil from the fossa with scissors in a bloodless fashion. The tonsillar bed was carefully inspected with additional hemostasis accomplished with bipolar cautery supplemented (rarely) with 3-0 chromic suture placed with needle driver. Tannic acid is then placed in the fossa. An identical procedure is performed on the contralateral side and the procedure terminated. Marcaine may be injected into the tonsillar arches.
    4. Monopolar Cautery
      1. Informed consent was obtained and the patient was transferred to the ASC and placed in the supine position. A Crowe-Davis retractor was placed with good visualization of the oropharynx. A curved Allis was used to grasp the superior pole of the right tonsil. Monopolar cautery was used to release the thin layer of mucosa from the fibrous layer of the tonsil. The tonsil was dissected out of the tonsillar bed with monopolar cautery while maintaining the fibrous layer of the tonsil. Two tonsil balls were placed for hemostasis of the tonsillar bed. The left tonsil was then addressed. A curved Allis was used to grasp the superior pole of this tonsil as well. Monopolar cautery was used to release the thin layer of mucosa from the fibrous layer of the tonsil. The tonsil was dissected out of the tonsillar bed with monopolar cautery along the fibrous capsule as well. Two tonsil balls were placed in this side as well. The tonsil balls were subsequently removed from both sides at that point, and suction cautery was used to achieve hemostasis of the tonsillar beds. The nasopharynx and oropharynx were copiously irrigated and suctioned. Marcaine was injected at 6 cc along the tonsillar pillars. The stomach was suctioned, and the patient was returned to anesthesia in good condition.
    5. Coblation
      1. Informed consent was reviewed, and the patient was brought to the OR and placed in the supine position.  The patient underwent general oral endotracheal intubation.  The table was rotated, patient positioned, eyes taped, and head was draped.  A Crowe-Davis retractor was placed with good visualization of the oropharynx.  A red rubber catheter was then placed to retract the soft palate and allow good visualization.  The soft palate was palpated, and uvula inspected with no abnormalities. The tonsils were resected in the capsular plane using blunt dissection and coblation.  The coblator tip cautery was used as needed.  The nasopharynx and hypopharynx were irrigated and suctioned.  Hemostasis was confirmed.  The red rubber catheter and Crowe-Davis retractor were removed.  There was no injury to the lips gums, teeth or tongue.  The patient was awakened, extubated, and taken to recovery.
    6. Fischer Knife
      1. Informed consent was reviewed with the parents and the patient was brought to the room and placed in the supine position. A Crowe-Davis retractor was placed with good visualization of the oropharynx. A red rubber catheter was then placed to retract the soft palate and allow good visualization. The soft palate was palpated, and uvula inspected with no abnormalities of signs of submucous cleft. An adenoid curette was sized using the maxillary incisors and used to remove the adenoid bed. A tonsil ball was placed to help achieve hemostasis. The right tonsil was then addressed. Curved Allis clamps were used to grasp the superior pole of the tonsil and medialize it. The mucosa from the superior pole enveloping the fibrous capsule was divided using a 14-blade scalple. A Fischer knife was used to dissect the tonsil from the tonsillar bed, maintaining the fibrous capsule. With only the inferior pole remaining, a Tydings tonsil snare was placed and the remaining tonsil was removed. A tonsil ball was placed into the tonsillar fossa for hemostasis. The left tonsil was then addressed. Curved Allis clamps were used to grasp the superior pole of the tonsil and medialize it. The mucosa from the superior pole enveloping the fibrous capsule was divided using a 14-blade scalple. A Fischer knife was used to dissect the tonsil from the tonsillar bed, maintaining the fibrous capsule. With only the inferior pole remaining, a Tydings tonsil snare was placed and the remaining tonsil was removed. A tonsil ball was placed into the tonsillar fossa for hemostasis. The tonsil balls were removed, and suction cautery was used to achieve hemostasis in the tonsillar and adenoid beds. The nasopharynx was irrigated and suctioned, and the red rubber catheter was removed. Marcaine was injected into the tonsillar arches, and the Crowe-Davis was removed. The patients mouth was wiped clean, and ointment was placed prior to returning the patient to Anesthesia in good condition.
  3. CPT CODING
    1. 42825  - Tonsillectomy, primary or secondary; under age 12
    2. 42826 -  Tonsillectomy, primary or secondary; age 12 or over
    3. 42820 Tonsillectomy and adenoidectomy; under age 12
    4. 42821 Tonsillectomy and adenoidectomy; age 12 or over
    5. 42830 Adenoidectomy, primary; under age 12
    6. 42831 Adenoidectomy, primary; age 12 or over
    7. 42835 Adenoidectomy, secondary; under age 12
    8. 42836 Adenoidectomy, secondary; age 12 or over
  4. SUGGESTED READING
    1. Erickson BK, Larson DR, St Sauver JL, Meverden RA, Orvidas LJ. Changes in incidence and indications of tonsillectomy and adenotonsillectomy, 1970-2005. Otolaryngol Head Neck Surg. 2009 Jun;140(6):894-901.
    2. Toh A, Mullin A, Grainger J, Uppal H. Indications for tonsillectomy: are we documenting them? Ann R Coll Surg Engl. 2009 Nov;91(8):697-9.
    3. Sia KJ, Tang IP, Kong CK, Nasriah A.  Grisel's syndrome: a rare complication of tonsillectomy..  J Laryngol Otol. 2012 Feb 24:1-3.
    4. Berry S, Pascal I, Whittet HB: Tonsillectomy a chaud for quinsy: revisited. Eur Arch Otorhinolaryngol. 2008 Jan;265(1):31-3
    5. Akin RC, Holst R, and Schousboe LP. Rick factors for post-tonsillectomy haemorrhage. Acta otolaryngol. 2012 Jul:132(7):773-7