Novel Tonsillectomy Cuts Pain, Bleeding

But Tonsils Can Grow Back After Surgery

By Salynn Boyles
WebMD Health News

Reviewed By Louise Chang, MD

Sept. 17, 2007 -- Within hours of having her tonsils out last February, Zelda Williams was home eating noodles by the bowlful.

The then 3-year-old had a new kind of tonsil surgery, called intracapsular tonsillectomy, and her mother says it made all the difference in her recovery.

"I couldn't believe it," Susan Williams tells WebMD. "She had almost no bleeding and was never really in much pain. She was completely back to normal within a few days."

Zelda's experience may not be typical, but new research shows that kids who have the newer surgery tend to experience less postsurgical bleeding and pain than those who have traditional tonsillectomies.

Pediatric ear, nose, and throat surgeon Richard Schmidt, MD, who led the study team, tells WebMD he was not surprised by the findings.

Schmidt has been performing intracapsular tonsillectomies at the Alfred I. DuPont Hospital for Children in Wilmington, Del., for the past five years.

"It has become the standard here," he says. "Probably eight or nine out of 10 of the tonsillectomies we do here are intracapsular as opposed to traditional."

Tonsillectomy: Old and New

Instead of removing the whole tonsil, the newer surgery is performed with a device called a microdebrider, which removes between 90% and 95% of the tonsil. A thin layer of outer tonsil tissue, known as the capsule, is left in place to keep delicate throat muscles from being exposed.

Protecting these muscles is believed to reduce pain and postoperative bleeding.

But leaving some tonsil tissue behind means that there is a chance the tonsils will grow back and that a second surgery will be needed.

"The risk is small, but it's definitely a downside to this procedure," Schmidt says.

Schmidt and colleagues reviewed the cases of 2,944 children who had tonsillectomies with or without adenoid removal at the Delaware hospital between 2002 and 2005. Just more than 1,700 had the intracapsular surgery and 1,200 had traditional procedures.

They report that three times as many children in the traditional tonsillectomy group experienced bleeding more than 24 hours after surgery (3.4% vs. 1.1%), and four times as many required additional surgery to control the bleeding (2% vs. 0.5%).

Just 3% of the intracapsular surgery patients required emergency room treatment for pain or dehydration caused by restricted fluid intake due to pain, compared with 5.4% of patients who had traditional surgery.

But 11 children (0.6%) in the intracapsular tonsillectomy group needed repeat tonsillectomies when tonsil tissue grew back.

This regrowth rate was in line with earlier reports suggesting that slightly more than one in 200 children who have the surgery require second tonsillectomies.

The study is published in the September issue of the journal Archives of Otolaryngology and Head and Neck Surgery.

Not All ENTs Convinced

Schmidt says the novel surgery should become the standard of care for children who require tonsil removal because of enlarged tonsils and adenoids. There is less research on outcomes among children whose indication for surgery is recurrent infection, or tonsillitis.

Pediatric head and neck surgeon David Darrow, MD, says he is not convinced that the benefits of intracapsular tonsillectomy outweigh the risk of a second tonsil surgery, regardless of the surgical indication.

He tells WebMD that he and a colleague recently conducted a similar comparison of outcomes with the intracapsular surgery and traditional tonsillectomy at the Norfolk, Va., hospital where he practices.

Children in that study who had the newer surgery also tended to have less pain and bleeding complications than children who had traditional tonsillectomies, but Darrow describes the differences as modest.

"Based on the results, my partner and I came to very different conclusions about this surgery," he says. "He now does the new surgery routinely, but I was not convinced that the differences justified the risk of leaving tonsil tissue behind, so I don't do it."

He adds that the newer surgery should never be performed unless parents fully understand the benefits and risks.

Darrow is a professor of otolaryngology in pediatrics at Eastern Virginia Medical School. He also chairs the tonsil and adenoids subcommittee for the American Academy of Otolaryngology.

"Parents may be willing to risk the chance of a second surgery for less pain, but in the end it is their decision," he says.

SOURCES: Schmidt, R. Archives of Otolaryngology and Head and Neck Surgery, September, 2007; vol 133: pp 925-928. Richard Schmidt, MD, division of pediatric otolaryngology, Alfred I DuPont Hospital for Children, Wilmington, Del. David Darrow, MD, DDS, professor of otolaryngology in pediatrics, Eastern Virginia Medical School; chairman, Tonsils and Adenoids Subcomittee, American Academy of Otolaryngology. Susan Williams.

© 2007 WebMD Inc. All rights reserved.


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