Do you want to learn more about how a tonsillotomy is performed?

We understand that helpful information can be hard to find.

This post provides illustrations and information regarding indications for how tonsillotomies are performed step-by-step.

The post was written by an Ear, Nose, and Throat (ENT) surgeon.

At the end of the post, there is a link to a post on tonsillectomy.

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

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Summary for tonsillotomies:

A tonsillotomy is the partial removal of one or both tonsils.

Tonsillotomies are performed on patients who have tonsil disorders.

Tonsillotomies have been performed for obstructive sleep apnea, tonsilloliths (tonsil stones), recurrent acute tonsillitis and other reasons.

Tonsillotomies can be performed with many instruments, but three that are commonly used include microdebriders (small tools that suction and cut tissue), coblators (controlled ablation instruments that remove tissue), and lasers.

What is tonsillotomy?

The partial removal of a tonsil or both tonsils is a tonsillotomy.

In general, tonsillotomies are performed in the operating room.

However, in cases with minimal amounts of tissue removal and with the proper equipment, some experienced surgeons might offer to perform the procedure in the clinic.

Instruments that are used are those can remove the tonsil tissue in smaller pieces at a time.

If the instrument does not have the ability to stop the bleeding, then other tools are used with cauterization (instruments with electricity) to help stop bleeding.

Very large tonsils before surgery. Note that the tonsils are crowding the upper airway. CamachoMD.com
Very large tonsils before surgery. Note that the tonsils are crowding the upper airway.

How is a tonsillotomy performed in the operating room?

First, the anesthesia provider places a breathing tube (endotracheal intubation) into the patient’s airway and lowers the fraction of inspired oxygen (fiO2) to 30 or less.

A timeout is performed to confirm the patient and procedure are correct.

The oral cavity is opened and the tongue is pressed forward to allow for access and visualization of the tonsils (palatine tonsils).

Generally, one of the three instruments is then used depending on surgeon training and equipment that is available (microdebriders, lasers, and coblation devices).

Tonsillectomy tools. A) Coblator, B) Straight microdebrider, and C) Curved microdebrider. CamachoMD.com
Tonsillectomy tools. A) Coblator, B) Straight microdebrider, and C) Curved microdebrider.

Microdebriders are small tools that suction and cut tissue away. So, when microdebriders are used, the patients will need to have electrocautery afterward to stop any bleeding.

Coblators provide coblation (COntrolled ABLATION) technology. With coblation, the instruments use radiofrequency technology combined with saline to remove tonsil tissue.

Lasers (Light Amplification by Stimulated Emission of Radiation) can be used in a manner that allows for decreasing the size of the tonsils by direct tissue cutting by using thermal ablation. 

Regardless of the instrument that is used to perform a tonsillotomy, the tonsils are made smaller by starting from the middle part (medial aspect) of the tonsils and then shrinks the tonsils toward the side of the throat (lateral aspect).

Tonsillotomy. This illustration shows that the surgery is about 25% completed on the patient's left side. CamachoMD.com
Tonsillotomy. This illustration shows that the surgery is about 25% completed on the patient’s left side.
Tonsillotomy. This illustration shows that the surgery is about 50% completed on the patient's left side. CamachoMD.com
Tonsillotomy. This illustration shows that the surgery is about 50% completed on the patient’s left side.
Tonsillotomy. This illustration shows that the surgery is about 75% completed on the patient's left side. CamachoMD.com
Tonsillotomy. This illustration shows that the surgery is about 75% completed on the patient’s left side.
Tonsillotomy. This illustration shows that the surgery is about 75% completed on both sides.
Tonsillotomy. This illustration shows that the surgery is about 75% completed on the patient’s left side.

Once the tonsil capsule is approached (the capsule is the tissue that is around the tonsils and separates the tonsil from the surrounding muscle), care is taken to preserve the capsule.

Tonsillotomy. This illustration shows that the surgery is completed on the patient's left side. There is pinpoint bleeding that will be cauterized. CamachoMD.com
Tonsillotomy. This illustration shows that the surgery is completed on both sides. There is pinpoint bleeding that will be cauterized.
Tonsillotomy on both sides with the tonsil capsules shown (white). CamachoMD.com
Tonsillotomy on both sides with the tonsil capsules shown (white).

Hemostasis techniques (cauterization or coagulation techniques that help close off small blood vessels) are then used to help prevent future bleeding.

Tonsillotomy. This illustration shows that the surgery is completed on both sides. Note that the tonsillotomy wound bed is not bleeding since it was cauterized. CamachoMD.com
Tonsillotomy. This illustration shows that the surgery is completed on both sides. Note that the tonsillotomy wound bed is not bleeding since it was cauterized.

Multiple techniques are then used to check for bleeding to include:

  • Closing the oral cavity,
  • Massaging the neck for >30 seconds and then reopening the oral cavity,
  • Using tonsil sponges on the surface of the tonsils,
  • Using a Valsalva maneuver (increasing the pressure in the airway) for 10 seconds, and
  • Using a mirror to assess for any other bleeding.

If there is no bleeding, then the throat is suctioned and the stomach is suctioned.

The patient is then turned over to the anesthesia provider for extubating (removal of the breathing tube).

What is the Common Procedure Terminology (CPT Code) for tonsillotomy?

The codes are the same as 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.

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