Do you want to learn more about tonsillectomy?

We understand that helpful information can be hard to find.

This post provides illustrations and information for tonsillectomies (surgery to remove tonsils from the throat) including what to expect before surgery, what techniques are used for tonsillectomies and how tonsillectomies are performed with step by step illustrations.

An Ear, Nose and Throat surgeon wrote this blog post.

Tonsillectomy. The left tonsil has been removed and the black arrow is pointing to the tonsil wound bed (the lines represent the superior pharyngeal constrictor muscle). CamachoMD.com
Tonsillectomy. The left tonsil has been removed and the black arrow is pointing to the tonsil wound bed (the lines represent the superior pharyngeal constrictor muscle).

Disclaimer: This blog is meant for educational purposes only. The information is not meant to provide specific medical advice. You need to contact your own healthcare provider for health information specific to you. You may need to seek urgent or emergency care depending on your situation. We reserve the right to update, change, or delete any content at any point. Our cookie policy can be found in our Privacy Policy. Also, you must agree to the Terms & Conditions of the KingsMD.com website in order to continue.

Summary for Tonsillectomy:

Tonsils (palatine tonsils) are located in the back of the throat, on either side of the tongue.

There are many reasons that tonsillectomies are performed, to include recurring tonsil infections, peritonsillar abscesses (a severe tonsil infection that spreads), obstructive sleep apnea, tonsilloliths with halitosis (tonsil stones causing bad breath) and in rare cases for cancer diagnosis and/or treatment.

Tonsillitis in a patient with pus exuding from the tonsil crypts. CamachoMD.com
Tonsillitis in a patient with pus exuding from the tonsil crypts.

Tonsillectomies are performed with the patient fully asleep and are performed in the operating room. 

A tube (endotracheal tube) is placed into the patients’ mouth and the tube stents the upper airway open so that the patient can be ventilated during the surgery.

There are many different instruments that can be used to remove the tonsils, some without heat (cold steel), and some with heat (electrocautery).

Once the tonsils are removed, the surgeon will control any bleeding.

After surgery, patients will wake up and will be taken to the recovery room.

After waking up fully, patients will either go home or be admitted to the hospital.

Most surgeons recommend that patients should then remain on a soft diet for two weeks.

Pain is almost guaranteed (throat and ears) for up to two weeks and can be much worse in adults. There is a risk of bleeding for up to two weeks as well.

What are tonsils?

Palatine tonsils are round tissues that are located to the left and the right side of the back part of the tongue.

Tonsils grade 4. Extra large tonsils, between 75 to 100% of the airway is blocked (from the side toward the middle of the throat). CamachoMD.com
Tonsils grade 4. Extra large tonsils, between 75 to 100% of the airway is blocked (from the side toward the middle of the throat).

How common are tonsillectomies?

It is estimated that over 500,000 tonsillectomies are performed in the United States each year.[1]

This makes it among the most common surgeries performed. Globally, tonsillectomy is also very common.

Indications

What are the indications for a tonsillectomy?

Tonsillectomy is a very common surgery that is performed as a treatment for many disorders to include:

  • Obstructive sleep apnea (OSA),
  • Recurring tonsillar infections,
  • Chronic tonsillitis with tonsil stones,
  • Peritonsillar abscesses,
  • Cancer, and
  • Several other disorders.

How many infections are recommended before a tonsillectomy is performed?

Because of the risks of tonsillectomy, a guideline is followed with regard to the number of infections before tonsils are removed.

The study by Dr. Paradise et al.[2] is held as the standard in the United States for infections:

  • 7 or more infections in the past year,
  • 5 or more infections per year for the past 2 years, or
  • 3 or more infections per year for the past 3 years.

Also, there should be one or more of the following:

  • Fever to 38.3°C (101 F),
  • Neck lymph nodes are enlarged (>2 centimeters) or are tender,
  • Tonsillar or throat exudate (layer of substance seen on the surface of the tonsils or throat during an infection), or
  • A positive culture for group A β-hemolytic streptococcus[2]

How many days are patients in the hospital after a tonsillectomy?

Tonsillectomies are usually performed on an outpatient basis, meaning that the patient comes into the operating room, has surgery and then goes home a few hours after surgery.

However, some patients should stay in the hospital.

If a patient has obstructive sleep apnea, then the otolaryngologist will make a decision on a case by case basis.

Generally, if the obstructive sleep apnea is mild in a child or an adult, then the children are often sent home.

There are many reasons that an otolaryngologist might choose to have a patient admitted to include:

  • Younger children as they may refuse to eat or drink (they can get hydrated through the IV),
  • Obese children or adults (they are at higher risk of breathing problems after surgery),
  • Patients who have heart or lung disorders,
  • Seizure disorder patients,
  • Moderate to severe obstructive sleep apnea patients, and
  • Several other conditions are determined on a case by case basis.

The American Academy of Otolaryngology-Head and Neck Surgery (ENT Academy) recommends that the following children categories be admitted to the hospital after tonsillectomy:

  1. Children under 3,
  2. Children with severe obstructive sleep apnea (apnea-hypopnea index of 10 or more),
  3. Oxygen saturation of 80% or lower.[3]

What should be expected during the visits before surgery?

The following describes the preoperative counseling:

First, otolaryngologist ensures that the indications for surgery meet the standard of care based on history and physical examination.

Second, the otolaryngologist will explain the risks, benefits, and alternatives to surgery. Once the patient or the surrogate have had all their questions and concerns addressed and agree to surgery, the consent form is signed.

The consent form is generally printed out so that it can be read again if needed.

Third, the patient will undergo the standard preoperative evaluation by the anesthesia department and their consent form is signed.

Fourth, the anesthesia department will inform the patient when to stop eating and drinking (an empty stomach is very important since vomiting and inhaling the vomit can occur if the stomach is full and this can cause severe airway problems).

Fifth, the patient goes to the preoperative area on the day of surgery. Once there, the surgeon, the operating room nurse, and the anesthesia provider will meet the patient and will verify the correct procedure and will place a band on the patient’s wrist stating the procedure.

Who performs a tonsillectomy?

Generally speaking, an otolaryngologist (an ear, nose, and throat surgeon or ENT surgeon)removes tonsils. 

Otolaryngologists have usually performed well over 100 tonsillectomies before they graduate from training, therefore, they should have the experience and training to competently perform the surgery.

What are the techniques used for tonsillectomy?

There are two major categories for the techniques to remove tonsils. The first includes cold temperature methods and the second includes hot temperature methods.

The cold temperature methods include the use of tools that do not use heat during the excision. Although if bleeding is encountered, then electrocautery is usually used to stop it.

The cold temperature techniques include:

  • Snare (loop that goes around the tonsils and is narrowed until it removes the tonsils), and
  • Cold steel instruments (Scissors or Fisher’s knife).
Tonsillectomy tools. A) Coblator, B) Straight microdebrider, and C) Curved microdebrider. CamachoMD.com
Tonsillectomy tools. A) Coblator, B) Straight microdebrider, and C) Curved microdebrider.

The hot temperature techniques include:

  • Electrocautery (bovie),
  • Laser, and
  • Bipolar.
Tonsillectomy tools. A) Electrocautery device (bovie), B) Snare, and C)Laser. CamachoMD.com
Tonsillectomy tools. A) Electrocautery device (bovie), B) Snare, and C)Laser.

Newer technology:

  • Coblation (controlled ablation – uses radiofrequency ablation with saline at cooler temperatures and a plasma field is created and there is little damage to surrounding tissues). This is often used in children.

What is the difference between tonsillectomy and tonsillotomy?

The way to know the difference between tonsillectomy and tonsillotomy is to understand the anatomy of the tonsil and surrounding tissue.

Tonsils sit in a wall of muscle and they have a capsule surrounding them.

The capsule surrounds the tonsils where they touch the muscle.

Tonsillectomy is the complete removal of tonsil tissue from the throat (oropharynx).

Tonsillectomy. Note that the left tonsil has been removed. The lines represent the tonsil muscle bed (superior pharyngeal constrictor). CamachoMD.com
Tonsillectomy. Note that the left tonsil has been removed. The lines represent the tonsil muscle bed (superior pharyngeal constrictor).

Tonsillotomy is the partial removal of tonsil tissue. Some of the tonsil tissue is left behind on the surface of the tonsil capsule.

Tonsillotomy on the left side showing the capsule (white). CamachoMD.com
Tonsillotomy on the left side showing the capsule (white).

It has been reported that there is a decreased risk of bleeding during a tonsillotomy because the surgery leaves the tonsil capsule. Though, this has been debated.

Additionally, during a tonsillotomy, the pain should be less because the muscle is not directly cauterized as it is during a tonsillectomy.

How long does a tonsillectomy usually take to perform in the operating room?

A tonsillectomy could take as little as a few minutes for children who have medium-sized, exophytic (easy to see and remove) tonsils or could take as long as 1-2 hours if the tonsils are infected and do not come out easily.

There are many other factors that determine how long it will take to perform a tonsillectomy.

Things that can make a tonsillectomy take longer include:

  1. If it is difficult to view the tonsils – this can be caused by a small mouth, large tongue or extra-large tonsils.
  2. If the surgeon is not as experienced – if the surgeon is a younger resident, it may take longer as they are being cautious.

How are tonsillectomies performed step-by-step?

Once the consent is verified, the patient is taken to the operating room and is transferred onto the operating room table.

The anesthesia provider then uses general anesthesia in the form of either masked anesthesia or intravenous (IV) anesthesia medications or a combination of both.

Children are usually put to sleep with masked anesthesia first and then once they are asleep, an IV is placed and then the IV anesthesia medications are used.

The anesthesia provider then places a tube into the airway (endotracheal tube into the trachea) and secures it in place.

Next, the otolaryngologist places an oral cavity retractor into the mouth to open it.

The retractor holds the mouth open and holds the ventilating tube and tongue out of the way so that the tonsils can be seen, grasped and removed.

The retractor is then suspended using either rolled up towels or a metallic stand (known as a Mayo stand).

Intubation in a patient for throat surgery. BladeMD.com
Intubation in a patient for throat surgery.

The oxygen level is turned to a lower level (the fraction of inspired oxygen is generally brought down to below 30 to get the oxygen closer or at room air) and the surgery starts.

There are many different instruments that the tonsillectomy can be performed with. The more common instruments include electrocautery and coblation, less common include microdebriders, snares, lasers and other instruments.

The tonsils are then grasped one at a time and are removed.

A common method for removal includes grasping the tonsil on the top part and then moving it toward the middle of the throat and then using the surgical instrument to cut the tonsil out from top to bottom.

Care is taken throughout the surgery to minimize bleeding.

Sometimes tonsils can be challenging to remove, especially if there has been a recent infection.

The tonsils sit in a pocket that is surrounded by and capsule and next to that is muscle.

One of the main reasons for pain after tonsillectomy is that the muscle is bare and exposed and has to regrow the mucosa (similar to skin, but it is in the throat).

After the tonsils are removed on both sides, then the otolaryngologist will often perform multiple steps to help check for bleeding.

The techniques to check for bleeding include:

  • Closing the oral retractor and massaging the neck. This checks for blood vessels that might be on stretch or might have physical pressure with the instrument open.
  • Once the oral retractor is opened again, a dental mirror is used to look around the tonsil wound bed to see if there is any bleeding in the areas that are hard to see directly.
  • A cotton sponge is gently pressed against the tonsil wound bed to see if there are any blood spots.
  • Normal saline is placed in the mouth and it fills the throat. The anesthesia provider will then increase the pressure in the circuit (similar to a Valsalva maneuver) to raise the blood pressure in the vessels.
Tonsillectomy. The illustration shows that both tonsils have been removed. Note the muscle (superior pharyngeal constrictor muscle) can be seen. CamachoMD.com
Tonsillectomy. The illustration shows that both tonsils have been removed. Note the muscle (superior pharyngeal constrictor muscle) can be seen.

Once the otolaryngologist is confident that they have done all they can to ensure there are no bleeding areas, they will then pass a tube (an orogastric tube) to suction out the contents of the stomach (which helps reduce nausea).

The patient is then turned over to the anesthesia provider to allow the patient to wake up.

Complications can occur after a tonsillectomy.

Warning: the following information is not meant to scare you, but it is important to provide the information because they are rare possibilities that need to be considered during the consent process (which your surgeon will perform with you).

What are the complications that patients need to know about?

In general, tonsillectomy is a safe surgery. In the United States alone, it is estimated that 500,000 people have their tonsils removed each year. There are expected side effects from a tonsillectomy and then there are complications. Complications vary from minor to major complications.

Damage to structures in the oral cavity (mouth) or throat. This can be due to the instrumentation that is placed in order to intubate the patient or to keep the mouth open or it can be due to the instruments that are used to remove the tonsils.

What rare severe tonsillectomy complications can happen during the surgery?

Very rare risks and complications that can happen during the surgery include death, airway fire, severe bleeding, aspiration, and malignant hyperthermia. These risks should not be taken lightly.

Death is a very scary thing to think about, but it is always on the consent form as it is a possibility. Four main circumstances can lead to death or to severe debilitations: airway fire, aspiration, severe intraoperative bleeding, and malignant hyperthermia.

Airway fire can occur, but it is rare. A review by Dr. Day and colleagues found that 11% of the reported airway fires happened during oral cavity or oropharyngeal procedures. [4] Of the reported articles, only 1% found that the fire occurred when the oxygen was kept at room air.[4]

Airway fire can occur because there is oxygen that is given to patients during surgery.

Although the oxygen is turned down to room air during the surgery, it is still possible for oxygen to accumulate and it can then serve as a fuel source for an airway fire.

If there is an airway fire, then the tube has to be pulled from the airway, the oxygen from the anesthesia circuit is turned off and saline is placed into the airway to douse the fire.

After the fire, the airway is evaluated with direct viewing (laryngoscopy and bronchoscopy) and the patient is then usually re-intubated and is kept in the intensive care unit until they are safe to extubate.

Aspiration is when contents from the throat are inhaled (aspirated) into the airway.

Aspirated material includes blood, blood clots, fluid, food content and foreign bodies such as plastic or loose teeth.

Aspiration is an emergency because anything that is in the airway can affect the ability to provide oxygen throughout the body.

Preventing aspiration is key.

This is why anesthesia providers require specific timeframes for not eating or drinking. When they give anesthetic medications to relax the body so that they can pass an endotracheal tube into the airway, the stomach and esophagus can also relax depending on the medications given, and if the patient ate food, then the food can be vomited up and then inhaled (aspirated) into the airway.

If aspiration occurs, the patient can develop severe breathing problems including pneumonia.

Catastrophic bleeding is when there is significant bleeding during the surgery that requires a transfusion or requires a large vessel to be tied off or the neck to be opened in order to get control of the bleeding.

Because the external carotid artery has a significant amount of blood, severe bleeding can happen. It is very, very rare to have catastrophic bleeding during surgery; however, it is possible, unfortunately.

A few situations in which there can be catastrophic bleeding include:

Severe infection and the dissection of the tonsils is very difficult,

Difficult view of the tonsils because of a small mouth, large tongue or very large tonsils,

Carotid artery that is more to the midline than normal or expected (medialized carotid artery), or

Bleeding disorders in the patient that make removal very difficult.

Malignant hyperthermia is a very rare genetic disorder in which the drugs that are used to provide anesthesia for patients causes calcium to build up in skeletal muscles.

The temperature of the body to rise and muscles develop severe contractions. If this emergency happens, the anesthesia provider will use dantrolene (an antidote) as treatment.

In summary, what happens is that some patients have a rare disorder (mutation of ryanodine receptor 1) that causes stored calcium ions that are within muscle cells to be released and this causes muscle cells to contract and the patients develop a fast heart rate, a fever, and rigidity of the muscles.

Malignant hyperthermia affects approximately 1 in 5,000 to 1 in 50,000 patients who receive gas anesthesia.

For more information on malignant hyperthermia, read the following US National Library of Medicine (NIH) information website:

https://ghr.nlm.nih.gov/condition/malignant-hyperthermia#statistics

What tonsillectomy complications can happen after surgery in the short-term?

  • Uvula swelling,
  • Bleeding, and
  • Infection (patients can present with fever, neck pain and/or cough).

What tonsillectomy complications can happen after surgery in the long-term?

  • Taste problems,
  • Dysphagia (trouble swallowing),
  • Oropharyngeal stenosis (narrowing in the back of the throat, where the tonsil bed meets the soft palate),
  • Nasopharyngeal stenosis (narrowing in the back of the nose, where it meets the throat),
  • Velopharyngeal insufficiency (air and fluid can go into the nose because the soft palate cannot close properly), and
  • Undesirable voice changes.

What very rare tonsillectomy complications can happen?

  • Post-obstructive pulmonary edema (the relief of chronic obstruction in the throat can cause the lungs to fill with fluid),
  • Pseudoaneurysm  or stroke,
  • Deep vein thrombosis (blood clot, such as in the legs),
  • Pulmonary embolus (when a blood clot travels to the blood supply of the lungs and can cause shortness of breath and sometimes death),
  • Severe bleeding, and

Death can happen but is quite rare.

What is post-tonsillectomy bleeding?

Tonsillectomy is a common procedure in which the tonsils (tissue that sits in the back of the throat) are removed in the operating room and bleeding is a concerning complication. There are three main times that a patient can bleed:

  • During the surgery,
  • Within 24 hours of surgery – known as primary tonsillectomy bleeding, and
  • After 24 hours of surgery – known as secondary tonsillectomy bleeding.

Bleeding during surgery is stopped with electrocautery (electricity applied through the tip of an instrument).

Sometimes, the surgeon might through a suture around the small bleeding vessel to stop the bleeding.

Very rarely, there can be bleeding from a large vessel such as the carotid artery that can require a blood transfusion or opening the neck in order to stop the bleeding.

When does bleeding occur after a tonsillectomy?

There are three main times that a patient can bleed:

  • During the surgery,
  • Within 24 hours of surgery – known as primary tonsillectomy bleeding, and
  • After 24 hours of surgery – known as secondary tonsillectomy bleeding.

Bleeding during surgery is stopped with electrocautery (electricity applied through the tip of an instrument).

Sometimes, the surgeon might place a suture around the small bleeding vessel to tie it off.

Very rarely, there can be bleeding from a large vessel such as the carotid artery that can require a blood transfusion or opening the neck in order to stop the bleeding.

How is the risk of bleeding reduced after a tonsillectomy?

There is no one way to prevent bleeding after a tonsillectomy.

Rather, there are multiple ways to help reduce the chance of bleeding to include:

  • Staying hydrated (keeps the healing tissue moist),
  • Avoiding hard-edged foods (could scrape off a scab),
  • Avoiding hot temperature foods and drinks (could wash off a scab),
  • Try to avoid strenuous activities (raises blood pressure),
  • Try to avoid bearing down during a bowel movement (raises blood pressure), and
  • Take pain medications by following the prescriptions.

Will tonsillectomy hurt?

Child in significant pain after tonsillectomy and he is crying. SkullMD.com
Child in significant pain after tonsillectomy and he is crying.

It is almost a guarantee that there is going to be significant pain after a tonsillectomy.

Sometimes the pain is not too severe, but in most patients, it is, unfortunately.

Some things can help reduce pain to include proper pain control, by following the instructions of an otolaryngologist. 

Staying hydrated can help keep the throat moist and allow it to heal better.

Is it normal to have ear pain after tonsillectomy?

Child with ear pain on both sides. BladeMD.com
Child with ear pain on both sides.

Yes, it is normal to have ear pain after tonsillectomy.

The nervous system connects structures throughout the body to the brain.

The tonsils and ears share a common nerve pathway to the brain.

Therefore, it is normal to have ear pain after a tonsillectomy.

The specific nerve that supplies the ears is the tympanic branch of the glossopharyngeal nerve which is also known as Jacobson’s nerve.[5]

Child with ear pain. His right finger is in the ear canal. BladeMD.com
Child with ear pain.

When will the tonsillectomy pain end?

Pain can last for up to a few weeks from surgery.

Generally speaking, however, the pain usually will increase a couple of days after surgery and then will last for a week or two.

Usually, by two weeks, the pain is significantly better.

Will a tonsillectomy affect the immune system?

A study reviewing articles, summarized them with a meta-analysis and concluded that there was no negative effect of tonsillectomy on the immune system.[6]

What are the CPT (Current Procedural Terminology) Codes for tonsillectomy?

CPT Codes for tonsillectomy:

  • <12 years old 42825,
  • >12 years old 42826.

CPT Codes for tonsillectomy with adenoidectomy:

  • <12 years old 42820,
  • >12 years old 42821.

CPT Codes for adenoidectomy:

  • <12 years old 42830,
  • >12 years old 42831.

Government Disclaimer: The views expressed in this website are those of the author(s) and do not reflect the official policy or position of the Department of the Army, Department of Defense, or the US Government.

References:

1.            Cullen, K.A., M.J. Hall, and A. Golosinskiy, Ambulatory surgery in the United States, 2006. Natl Health Stat Report, 2009(11): p. 1-25.

2.            Paradise, J.L., et al., Efficacy of tonsillectomy for recurrent throat infection in severely affected children. Results of parallel randomized and nonrandomized clinical trials. N Engl J Med, 1984. 310(11): p. 674-83.

3.            Roland, P.S., et al., Clinical practice guideline: Polysomnography for sleep-disordered breathing prior to tonsillectomy in children. Otolaryngol Head Neck Surg, 2011. 145(1 Suppl): p. S1-15.

4.            Day, A.T., et al., Surgical Fires in Otolaryngology: A Systematic and Narrative Review. Otolaryngol Head Neck Surg, 2018. 158(4): p. 598-616.

5.            Kim, K.S., Referred otalgia induced by a large tonsillolith. Korean J Fam Med, 2013. 34(3): p. 221-3.

6.            Bitar, M.A., A. Dowli, and M. Mourad, The effect of tonsillectomy on the immune system: A systematic review and meta-analysis. Int J Pediatr Otorhinolaryngol, 2015. 79(8): p. 1184-91.