Tonsillectomy
Tonsillectomy is a surgical procedure in which both palatine tonsils are fully removed from the back of the throat. The procedure is mainly performed for recurrent tonsillitis, throat infections and obstructive sleep apnea. For those with frequent throat infections, surgery results in 0.6 fewer sore throats in the following year, but there is no evidence of long term benefits. In children with OSA, it results in improved quality of life.
While generally safe, complications may include bleeding, vomiting, dehydration, trouble eating, and trouble talking. Throat pain typically lasts about one to two weeks after surgery. Bleeding occurs in about 1% within the first day and another 2% after that. Between 1 in 2,360 and 1 in 56,000 procedures cause death. Tonsillectomy does not appear to affect long term immune function.
Following the surgery, ibuprofen and paracetamol may be used to treat postoperative pain. The surgery is often done using metal instruments or electrocautery. The adenoid may also be removed or shaved down, in which case it is known as an "adenotonsillectomy". The partial removal of the tonsils is called a "tonsillotomy", which may be preferred in cases of OSA.
The surgery has been described since at least as early as 50 AD by Celsus. In the United States, as of 2010, tonsillectomy is performed less frequently than in the 1970s, although it remains the second-most common outpatient surgical procedure in children. The typical cost when done as an inpatient in the United States is US$4,400 as of 2013. There is some controversy as of 2019 as to when the surgery should be used. There are variations in the rates of tonsillectomy between and within countries.
Medical uses
Tonsillectomy is mainly undertaken for sleep apnea and recurrent or chronic tonsillitis. It is also carried out for peritonsillar abscess, periodic fever, aphthous stomatitis, pharyngitis and adenitis, guttate psoriasis, nasal airway obstruction, tonsil cancer and diphtheria carrier state. For children, tonsillectomy is usually combined with the removal of the adenoid. However, it is unclear whether the removal of the adenoid has any additional positive or negative effects for the treatment of recurrent sore throat. In cases of chronic tonsillitis in adults, there is strong evidence of increased quality of life, reduction of symptoms, and economic benefit. A randomised controlled trial of tonsillectomy versus medical treatment in adults with frequent tonsillitis found that tonsillectomy was more effective and cost effective. It resulted in fewer days with sore throat.Sore throat
Surgery is not recommended for those with fewer than seven documented throat infections in the last year, fewer than five each year for the last two years, or fewer than three each year for three years. Severely affected children who undergo surgery on average have one fewer sore throat per year in the subsequent one or two years, compared to those who do not. Specifically one review of five randomized controlled trials, found a decrease from 3.6 to 3.0 episodes in the year following surgery. In less severely affected children, surgery results in an increase, rather than a decrease of sore throats when the sore throat directly following surgery is included. Surgery results in a reduction in school absence in the following year, but the strength of evidence is low. Surgery does not result in an improvement in the quality of life. Benefits of surgery do not persist over time. Those with frequent throat infections often spontaneously improve over a year without surgery. Therefore, a certain number of people who undergo surgery will do so unnecessarily as they would not have had further episodes of tonsillitis had they not had surgery. Evidence in adults is unclear.In 2019, the American Academy of Otolaryngology & Head and Neck Surgery recommended:Many cases of the sore throat have other causes than tonsillitis, and tonsillectomy is therefore not indicated for those cases. The diagnosis of tonsillitis is often made without testing for bacteria. The UK National Health Service states that it is very rare that someone needs to have their tonsils taken out, and it is usually only necessary in case of severe tonsillitis that keeps recurring.
Obstructive sleep apnea
Tonsillectomy improves obstructive sleep apnea in most children. A 2015 Cochrane review found moderate quality evidence for benefits in terms of quality of life and symptoms, but no benefit in attention or academic performance. It is recommended that physicians and parents should weigh the benefits and risks of surgery, as OSA symptoms may spontaneously resolve over time. An AHRQ review however did find improvements at school. The procedure is recommended for those who have OSA that has been verified by a sleep study. Studies have shown that treatment success of uvulopalatopharyngoplasty with tonsillectomy increases with tonsil size.Other
There is no good evidence for other uses such as tonsil stones, bad breath, trouble swallowing, and an abnormal voice in children.Complications
While generally safe, tonsillectomy may result in several complications, some of which are serious. Complications are divided into primary and secondary, with bleeding being the most common complication. Other common complications are postoperative nausea and vomiting, dehydration, trouble eating, ear pain, taste dysfunction and trouble talking. In rare cases, tonsillectomy may also cause damage to the teeth, larynx and pharyngeal wall, aspiration, respiratory compromise, laryngospasm, laryngeal edema and cardiac arrest. Throat pain typically lasts about one to two weeks after surgery.Significant post-operative primary bleeding occurs in 0.2–2.2% of people, and secondary bleeding in 0.1–3.3%.
In several reported case series, the rate of post-tonsillectomy bleeding ranged from 2.0% to 7.0%.
Also in veterinary surgery, bleeding was a common complication. A meta-analysis reported that frequency of bleeding after tonsillectomy across different techniques did not differ.
It is estimated that 1.3% of people will have a delayed discharge due to a complication, and up to 3.9% will require repeat admission to the hospital. The main reasons for either keeping a person in hospital, or readmitting them after tonsillectomy are uncontrolled pain, vomiting, fever, or bleeding. Death occurs as a result in between 1 in 2,360 and 56,000 procedures. Bleeding accounts for one-third of deaths. As the procedure is done under general anesthesia, there are anesthesia risks.
Immune system
There is no evidence that tonsillectomy affects long-term immune function. It does not appear to affect the long-term risk of infections in other areas of the body. Some studies have found small changes in immunoglobulin concentrations after tonsillectomy, but these are of unclear significance. Tonsillectomy is a risk factor for Crohn's disease and ulcerative colitis. A 2024 meta-analysis found that tonsillectomy is associated with Crohn's disease and ulcerative colitis, with an odds ratio of 1.93 and 1.24, respectively. A 2025 meta-analysis found that tonsillectomy increases the risk of both Crohn's disease and ulcerative colitis, with a hazard ratio of 1.37 and 1.29 respectively. There is an association suggesting an increase in the risk of developing multiple sclerosis if done before the age of 20. A meta-analysis published in 2020 indicated a statistically significant association between a history of tonsillectomy and the development of Hodgkin's disease. A meta-analysis from 2022 concluded that a history of tonsillectomy is associated with an increased risk of breast cancer. The relationship between childhood tonsillectomy and the development of other cancer types in adulthood remains unclear.Surgical procedure
For the past 50 years at least, tonsillectomy has been performed by dissecting the tonsil from its surrounding fascia, a so-called total, or extra-capsular tonsillectomy. Problems, including pain and bleeding, led to a recent resurgence in interest in sub-total tonsillectomy or tonsillotomy, which was popular 60 to 100 years ago, in an effort to reduce these complications. The generally accepted procedure for 'total' tonsillectomy uses a scalpel and blunt dissection, electrocautery, or diathermy. Harmonic scalpels or lasers have also been used. Bleeding is stopped with electrocautery, ligation by sutures, and the topical use of thrombin, a protein that induces blood clotting. The most effective surgical approach has not been well studied.It is unknown whether the benefits of subtotal tonsillectomy in obstructive sleep apnea are enduring. However, this is also the case for tonsillectomy for sleep apnea. There have been no randomised controlled trials of the long-term effectiveness of tonsillectomy for sleep apnea.
Methods
The scalpel is the preferred surgical instrument of many ear, nose, and throat specialists. However, there are other techniques, and a brief review of each follows:- Dissection and snare method: Removal of the tonsils by use of a forceps and scissors with a wire loop called a snare was formerly the most common method practiced by otolaryngologists, but has been largely replaced in favor of other techniques. The procedure requires the patient to undergo general anesthesia; the tonsils are completely removed and the remaining tissue surface is cauterized. The patient will leave with minimal post-operative bleeding.
- Electrocautery: Electrocautery uses electrical energy to separate the tonsillar tissue and assists in reducing blood loss through cauterization. Research has shown that the heat of electrocautery may result in thermal injury to surrounding tissue. This may result in more discomfort during the postoperative period.
- Radiofrequency ablation: Monopolar radiofrequency thermal ablation transfers radiofrequency energy to the tonsil tissue through probes inserted in the tonsil. The procedure can be performed in an office setting under light sedation or local anesthesia. After the treatment is performed, scarring occurs within the tonsil, causing it to decrease in size over a period of several weeks. The treatment can be performed several times. The advantages of this technique are minimal discomfort, ease of operation, and immediate return to work or school. Tonsillar tissue remains after the procedure, but is less prominent. This procedure is recommended for treating enlarged tonsils and not chronic or recurrent tonsillitis.
- Coblation tonsillectomy: This surgical procedure is performed using plasma to remove the tonsils. Coblation technology combines radiofrequency energy and saline to create a plasma field. The plasma field can dissociate molecular bonds of target tissue while remaining relatively cool, which results in minimal or no damage to surrounding healthy tissue. A Coblation tonsillectomy is carried out in an operating room setting, with the patient under general anesthesia. Tonsillectomies are generally performed for two main reasons: tonsillar hypertrophy and recurrent tonsillitis. It has been claimed that this technique results in less pain, faster healing, and less postoperative care. However, review of 21 studies gives conflicting results about levels of pain, and its comparative safety has yet to be confirmed. This technique has been criticized for a higher than expected rate of bleeding presumably due to the low temperature which may be insufficient to seal the divided blood vessels but several papers offer conflicting results. More recent studies of coblation tonsillectomy indicate reduced pain and otalgia; less intraoperative or postoperative complications; lesser incidence of delayed hemorrhage, more significantly in pediatric populations, less postoperative pain and early return to daily activities, fewer secondary infections of the tonsil bed and significantly lower rates of secondary hemorrhage. Unlike the electrosurgery procedure, Coblation Tonsillectomy generates significantly lower temperatures on contacted tissue. Long-term studies seem to show that surgeons experienced with the technique have very few complications.
- Harmonic scalpel: This medical device uses ultrasonic vibrating of its blade at a frequency of 55 kHz. Invisible to the naked eye, the vibration transfers energy to the tissue, providing simultaneous cutting and coagulation. The temperature of the surrounding tissue reaches 80 °C Proponents of this procedure assert that the result is precise cutting with minimal thermal damage.
- Thermal Welding: A new technology which uses pure thermal energy to seal and divide the tissue. The absence of thermal spread means that the temperature of surrounding tissue is only 2–3 °C higher than normal body temperature. Clinical papers show patients with minimal post-operative pain, zero edema, plus almost no incidence of bleeding. Hospitals in the US are advertising this procedure as "Painless Tonsillectomy". Also known as Tissue Welding.
- Carbon dioxide laser: When a laser is used to perform tonsillectomy, it can be under local anaesthetic with anaesthetic spray only, called tonsillotomy, or it can be performed under general anaesthetic when it is called intra-capsular tonsillectomy, using an operating microscope for magnification. The carbon dioxide laser in scanning mode is an excellent vapouriser of tissue, and in conjunction with a computerised pattern generator and operating microscope with micromanipulator, it can result in near total removal of tonsil tissue whilst preserving the capsule of the tonsil. This leads to a significantly reduced bleeding and pain rate. The local anaesthetic technique takes around 10 minutes, the general around 20 minutes depending on the size of the tonsils - the bigger they are, the longer it takes. The general anaesthetic operation has a revision rate of 1:50, the local anaesthetic tonsillotomy 1:4.5. This is different from procedures where a laser is used to reduce or resurface the tonsils. Providing the absence of certain contraindications such as sensitive gag reflex, LAST can be performed under local anesthetic as an outpatient procedure. A carbon dioxide laser is commonly used, and is swept over each tonsil 8–10 times. The smoke is aspirated out of the mouth to prevent smoke inhalation. Often, more than one procedure is required, each lasting about 20 minutes. Due to the frequent requirement for multiple sessions, this treatment may work out more expensive than a single session tonsillectomy. A degree of patient compliance is required, making it unsuitable for young children and anxious persons, who risk harm if they move during the procedure.
- Microdebrider: The microdebrider is a powered rotary shaving device with continuous suction often used during sinus surgery. It is made up of a cannula or tube, connected to a handpiece, which in turn is connected to a motor with foot control and a suction device. The endoscopic microdebrider is used in performing a partial tonsillectomy by partially shaving the tonsils. This procedure entails eliminating the obstructive portion of the tonsil while preserving the tonsillar capsule. A natural biologic dressing is left in place over the pharyngeal muscles, preventing injury, inflammation, and infection. The procedure results in less post-operative pain, a more rapid recovery, and perhaps fewer delayed complications. However, the partial tonsillectomy is suggested for enlarged tonsils, not those that incur repeated infections.