Tonsillectomy

Tonsillectomy (from Latin tonsillae, meaning “tonsils” and ancient Greek ἐκτομή, meaning “excision”) is a surgical procedure involving complete removal of the palatine tonsils along with their capsule. This is one of the most common elective surgeries in otorhinolaryngology.

Over the past several decades, the indications for tonsillectomy have evolved significantly. While it was once frequently performed for preventive purposes, today it is performed according to strict, evidence-based criteria, when conservative treatment is ineffective or when the expected benefits of surgery clearly outweigh the associated risks.

Indications for Tonsillectomy

All indications for tonsil removal are divided into absolute, where surgery is necessary, and relative, where the decision is made on an individual basis.

Absolute indications:

• Obstructive sleep apnea syndrome (OSAS): Hypertrophic tonsils causing snoring and episodes of apnea during sleep. This is the leading indication for surgery in children.
• Complications of chronic tonsillitis: A history of peritonsillar abscess.
• Suspicion of malignancy: Significant unilateral tonsillar enlargement that requires histological verification.
• Tonsillogenic sepsis: Systemic infection originating from tonsillar focus.

Relative indications:

• Recurrent acute bacterial tonsillitis (strep throat): Frequent, well-documented episodes that significantly impair quality of life. The widely accepted are Paradise Criteria: seven or more episodes of a throat infection in one year; five or more episodes annually for two consecutive years; three or more episodes annually for three consecutive years.
• Chronic tonsillitis (decompensated form): Persistent symptoms such as sore throat, halitosis, and signs of systemic inflammation (e.g., low-grade fever, fatigue) despite conservative therapy.

Surgical Technique

Tonsillectomy is almost always performed under general anesthesia with endotracheal intubation. Several surgical techniques are available.

Main methods:

• Classic (“cold”) extracapsular tonsillectomy: The most common method. The tonsil is dissected from its bed using a scalpel, scissors, and elevator. Hemostasis is achieved with sutures or electrocautery. Hemostasis is achieved with sutures or electrocautery.
• Electrocautery: Use of electrical current to simultaneously cut tissue and coagulate blood vessels.
• Coblation (cold plasma ablation): Use of radiofrequency energy in a saline medium to disintegrate tissue at relatively low temperatures, minimizing thermal damage to the surrounding structures.
• Laser and radiofrequency techniques.

The postoperative period is commonly marked by significant throat pain, which may persist for up to two weeks. The most serious complication is postoperative hemorrhage, which may be early (within the first 24 hours) and delayed (typically occurs on the 5th to 10th postoperative day, as the fibrin layer sloughs off the tonsillar bed).

Clinical Significance and Alternatives

Tonsillectomy is a highly effective intervention, particularly for resolving obstructive sleep apnea in children and reducing the burden of recurrent tonsillitis. However, like any surgical procedure, it carries certain risks. Therefore, in some cases alternatives to surgery may be considered. Tonsillotomy (partial tonsil removal) may be appropriate for children with hypertrophic tonsils causing obstruction but without chronic infection. In case of uncomplicated chronic tonsillitis, a course of conservative treatment (tonsillar lacunae lavage, physiotherapy) always precedes the surgical intervention.