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Certain tonsil removal technique associated with reduced postoperative pain, bleeding

September 18, 2007

Patients who have a tonsillectomy using an "intracapsular" technique-which removes at least 90 percent of tonsil tissue, but spares the tonsil capsule-appear to have less postoperative heavy bleeding and pain compared with those who undergo traditional tonsil removal surgery, according to a report in the September issue of Archives of Otolaryngology-Head & Neck Surgery, one of the JAMA/Archives journals.

Tonsillectomy (removal of the tonsils) with or without removal of the adenoids (tissue at the back of the throat) is one of the most commonly performed surgeries in the United States, according to background information in the article. "The technique for performing tonsillectomy, dissection of all tonsillar tissue free of the underlying pharyngeal constrictor muscle, has not changed significantly in more than 60 years," the authors write. "The most common serious complication of tonsillectomy is delayed hemorrhage [severe bleeding], which occurs in 2 percent to 4 percent of all patients. In addition, an expected sequela [consequence] of the procedure is pain, which typically lasts from seven to 10 days and can be moderate to severe in intensity."

Richard Schmidt, M.D., and colleagues at the Alfred I. duPont Hospital for Children, Wilmington, Del., analyzed the medical records of 2,944 patients who underwent tonsillectomy with or without adenoidectomy between 2002 and 2005. For 1,731 patients, surgeons used a newer technique known as intracapsular tonsillectomy, which involves using an instrument known as a microdebrider to remove 90 percent of the tonsil tissue and preserving a layer of tonsil (the capsule) over the throat muscles. A total of 1,212 underwent traditional tonsillectomy, in which all tonsil tissue is cut and removed.

Among those in the traditional tonsillectomy group, 3.4 percent had delayed (more than 24 hours after surgery) hemorrhage and 2.1 percent required treatment in the operating room for bleeding, compared with 1.1 percent and 0.5 percent among those in the intracapsular tonsillectomy group. Three percent of those undergoing intracapsular tonsillectomy and 5.4 percent of those undergoing traditional tonsillectomy required emergency room treatment for pain or dehydration, which often occurs after tonsil surgery when pain restricts fluid intake. Eleven patients (0.64 percent) who had intracapsular tonsillectomies and none of those who had traditional tonsillectomies needed revision tonsillectomies.

"The ideal tonsillectomy would have minimal or no risks and be completely effective," the authors write. "Although the risks for intracapsular tonsillectomy are lower than those for traditional tonsillectomy, the procedure is not always effective. Eleven patients required revision tonsillectomy in the intracapsular tonsillectomy group compared with none in the traditional tonsillectomy group. However, an additional surgical procedure (including control of hemorrhage in the operating room) may be more likely with traditional tonsillectomy than with intracapsular tonsillectomy."

JAMA and Archives Journals