Partial Tonsillectomy Found to be Safer, as Effective, and Less Painful than Complete Removal

Today's physicians are paying more attention to enlarged tonsils, realizing that this upper airway obstruction leads to obstructive sleep disordered breathing in children, the cause of a myriad of behavioral and health problems. The conventional treatment for this medical condition is complete removal of the tonsils (total tonsillectomy) by a variety of surgical procedures (cold dissection, electrocautery, microbipolar, and harmonic scalpel).

A total tonsillectomy (combined with adenoidectomy) does eliminate the obstruction in most children's upper airway, leading to improved nighttime breathing. Although the total tonsillectomy is effective, the patient often has a difficult recovery with prolonged pain and a low, but predictable, rate of delayed post-operative hemorrhage.

In their search for a less invasive, but equally effective technique, a team of ear, nose, and throat specialists revisited an old procedure, tonsillotomy, or partial tonsillectomy, but in this case, performed with contemporary technology. The procedure involves a reduction in the tonsil size, partially shaving them away using an endoscopic microdebrider, a very small, high-speed device that shaves soft tissue. The partial tonsillectomy eliminates the obstructive portion of the tonsil while preserving the tonsillar capsule. The capsule integrity is maintained, and a natural biologic dressing is left in place over the pharyngeal muscles, preventing them from injury, inflammation, and infection. The procedure results in less post-operative pain, a more rapid recovery, and perhaps fewer delayed complications.

The study reviewed the historical context of the procedure and assessed whether initially reported benefits could be reproduced by other surgeons with a larger cohort of patients. Treatment techniques were compared on the ordinal outcomes (pain during recovery and improved post-operative quality of life), and normally distributed continuous outcomes (days to normal activity, days to normal diet, days of analgesic, and blood loss. An adjustment was made for pre-operative factors such as age at surgery, gender, pre-op life affected, in-out patient status, tonsillar hypertrophy, adenoidal hypertrophy, OSA or OSA symptoms, snoring, sinusitis, peritonsillar abscess, and recurrent otitis, sleep problems, or apnea.

The authors of the study, "Intracapsular Tonsillar Reduction (Partial Tonsillectomy): Reviving an Historical Procedure for Obstructive Sleep Disordered Breathing in Children," are Peter J. Koltai MD, C. Arturo Solares MD, James Chan, MD, Keiko Hirose MD, Tom I. Abelson MD, Paul R. Krakovitz MD, Meng Xu, and Edward J. Mascha, all from The Children's Hospital at the Cleveland Clinic Foundation, Cleveland, Ohio; and Jeffery A. Koempel MD, from the Children's Hospital of Los Angeles, Los Angeles, CA. Their findings were presented at the American Academy of Otolaryngology--Head and Neck Surgery Foundation Annual Meeting and OTO EXPO, September 22-25, 2002, at the San Diego Convention Center, San Diego, CA.

Methodology: A review was conducted of 243 children with tonsillar hypertrophy (enlarged tonsils) and associated obstructive sleep disordered breathing, all undergoing intracapsular (partial) tonsillectomy. The subjects were at the tertiary children's hospital; the procedures were performed between October 1998 and June 2002. A comparison group consisted of 308 children who underwent a standard tonsillectomy. A telephone survey of primary caregivers of the children (211 [87 percent of caregivers] in group 1 and 260 [84 percent] in group 2) assessed the children's post-operative recovery.

Data collected from the records were patient's age, sex, and primary diagnosis; amount of intra-operative blood loss, intra-operative and subsequent complications; number of days until return to normal activity and diet; number of days of analgesic use; and pain during recovery (on post-operative days 1-3, 4-6, 7-9, after day 9, and globally).

Results: Key findings of the research included:

Univariable Results: Partial tonsillectomy was significantly better than total tonsillectomy with less pain during recovery on day 1-3, day 4-6, day 7-9, day 9+, global pain, days to normal activity, days to normal diet, and days of analgesic. Researchers did not detect significant differences between techniques on blood loss or post-operative life improved. The incidence of delayed postoperative complications did not differ between techniques.

Multivariable Results: Partial tonsillectomy was still significantly better than total tonsillectomy with less pain during recovery on day 1-3, day 4-6, day 7-9, day 9+, global pain, days to normal activity, days to normal diet, and days of analgesic after adjusting for significant covariates. Multivariable regression analysis detected a significantly greater blood loss in the partial tonsillectomy group compared to the total tonsillectomy group after adjusting for significant covariates.

The researchers did not detect a significant difference between techniques on improvement of post-operative quality of life after adjusting for covariates. Improvement in patients with apnea, snoring, or infection problems before surgery did not differ by surgical technique.

Among 291 patients (either technique) that had apnea before surgery and had follow-up data, 285 (98 percent) showed improvement. Of the 401 patients who had snoring before surgery and had follow-up data, 387 of them improved. Among 145 patients who had infection before the surgery and had follow-up data, 136 (94 percent) had a positive outcome.

The researchers believe the endoscopic microdebrider is the most useful device for partial tonsillectomy, although not ideal. No other techniques, including the guillotine, electrocautery, CO2 laser, coblation, radio-frequency ablation, and the harmonic scalpel, provided nearly as rapid, complete yet precise control in resecting the tonsil without violating the capsule. One disadvantage of the instrument is it increases the intra-operative blood loss, which can obscure tissue specificity, especially in the deeper sections of the tonsillar excavation, risking injury of the pharyngeal musculature. This is preventable by maintaining visual contact with the cutting tip of the shaver blade, performing a layered resection, and intermittently using the suction cautery to control excessive bleeders.

Conclusions: The research findings showed that a "partial tonsillectomy" effectively removed the pharyngeal obstruction. Its advantages are that the procedure preserves some of the native tissues as a surgical barrier and reduces post-operative inflammation in the pharyngeal muscles, resulting in significantly less post-operative pain and a more rapid recovery.

The researchers acknowledge the concern that a partial tonsillectomy does not prevent tonsillar regrowth and subsequent infection of the tonsillar remnant. This was not observed among the study subjects, historical evidence suggests that eventually this will happen in some percentage of cases. However, in this environment, when most tonsillectomies in children are done for hypertrophy, the partial tonsillectomy relieves OSDB as effectively, but with less pain and possibly a greater margin of safety.

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