Until the mid-1980s, the primary indication for tonsillectomy and adenotonsillectomy was recurrent throat infections. Beginning in late-1970s, Paradise and colleagues published a series of reports and randomized controlled trial results showing that only those children severely affected by throat infections benefitted from the removal of the tonsils, while moderate to minimally affected children merely showed modest benefit that may not outweigh the risk of surgery. These studies also revealed the self-limiting nature of throat infections [4–8]. Along with numerous studies questioning the efficacy of tonsillectomy, gradual decline in tonsillectomy rate was noted.
Currently recognized criteria warranting surgical removal of the tonsils are recurrent throat infections and SDB, with the latter being the more commonly found indication [1]. Recurrent throat infections indicative of tonsillectomy are defined as more than seven episodes of sore throats in 1 year, more than five episodes per year for 2 years, or more than three episodes per year for three consecutive years [9]. Each episode of sore throat should present with one or more of the following clinical signs or test results: temperature higher than 38.3 °C, cervical adenopathy, tonsillar exudates, or positive test for group A ß-hemolytic streptococci. If the frequency of sore throats is fewer than the above criteria, watchful waiting is recommended. However, if the patient has any of the modifying factors, surgical intervention is warranted. The modifying factors include multiple antibiotic allergies or intolerance, a combination of periodic fever, aphthous stomatitis, pharyngitis, and adenitis (PFAPA), or a history of peritonsillar abscess [9].
Sleep-disordered breathing (SDB) includes a broad range of signs, symptoms, and disorders from simple primary snoring at mildest to serious life-threatening disorders such as severe obstructive sleep apnea syndrome (OSAS) [10]. SDB is a disease of multifactorial cause at various levels of the upper airway [11]. Tonsillar hypertrophy is one of major contributing factors, and tonsillectomy has been shown to be beneficial in treating SDB in children with hypertrophic tonsils [12]. When only recurrent throat infections were considered, tonsillectomy was not a procedure commonly performed by oral and maxillofacial surgeons. With the shift in indication to pediatric and adult SDB, tonsillectomy has become a necessary tool for comprehensive care of SDB patients.
While all tonsillectomies in this report were done via conventional total extracapsular dissection method, partial intracapsular tonsillectomy is recently gaining attention for potentially lower complication rate and faster recovery. The main difference of intracapsular tonsillectomy from conventional total tonsillectomy is that a small portion of the tonsillar tissue along with the tonsillar capsule is left attached. It is theorized that this layer of attached tissue may prevent from damaging surrounding pharyngeal tissue, reducing post-operative discomfort and a chance of significant bleeding [13]. Recently, a microdebrider-assisted IT, also known as powered intracapsular tonsillectomy and adenoidectomy (PITA), has been shown to result in fewer post-operative complications and faster recovery [14]. The application of microdebrider is not limited to tonsillectomy and adenoidectomy but also include sinus surgery and nasal turbinectomy. The microdebrider seems to carry potential for various applications in the field of head and neck surgery.
The tonsillectomy procedure itself is not technically demanding, but unexpected excessive hemorrhage is a constant risk due to a surplus of blood supply to the tonsils and surrounding pharyngeal soft tissues. The superior tonsil pole is supplied by the descending palatine artery (DPA), the midfossa region by the ascending pharyngeal artery, and the inferior pole by the tonsillar and ascending palatine branches of the facial artery and the tonsillar branches of the lingual artery. In spite of the abundant circulation, no serious immediate or delayed postoperative hemorrhage was noted in this case series.
The main postoperative concerns are primary and secondary hemorrhage, postoperative nausea and vomiting (PONV), respiratory complications, and pain management. Primary hemorrhage (bleeding within the first 24 h of surgery) and secondary hemorrhage (bleeding more than 24 h after surgery, usually between 5 and 10 days) are reported to occur in 0.1 to 3 % of patients [15]. The best management strategy is meticulous intraoperative hemostasis using ligation, electrocautery, or coblation. However, for intraoperative or postoperative hemorrhages that cannot be controlled locally, external carotid artery (ECA) ligation is warranted in order to prevent life-threatening situations. Intraoperative administration of steroid (dexamethasone) has been shown to significantly reduce PONV [16]. Intraoperative intravenous steroid administration has also been shown to reduce postoperative pain [17]. Postoperative respiratory complications may result either from hemorrhage or edema. A clinical guideline from American Academy of Pediatrics recommends that children with cardiac complications of OSA, neuromuscular disorders, prematurity, obesity, failure to thrive, craniofacial anomalies, or a recent upper respiratory tract infection should be admitted overnight due to increased risk of postoperative respiratory complications [18].
Although not as thoroughly studied as pediatric population, tonsillectomy in the treatment of adult SDB patients has also been shown to be effective. Unlike the pediatric counterpart, the efficacy of tonsillectomy for the treatment of adult SDB lacks prospective randomized controlled trials and large-scale literature reviews. However, a number of retrospective studies report that, in carefully selected patients, tonsillectomy should be considered as one of the first surgical interventions for adult patients with SDB [19].
All patients included in this study were adults diagnosed with SDB or at high risk of developing airway stenosis due to mandibular setback surgeries. There have been reports of developing OSAS following mandibular setback surgery [20]. Also, the narrowing of pharyngeal airway space after mandibular setback has been studied and supported by a number of researches [21–23]. Therefore, when extensive mandibular setback surgery on patients with hypertrophic tonsils is planned, staged or concomitant tonsillectomy should be considered.
Since all tonsillectomies were performed along with other surgical treatment modalities such as UPPP, uvulopalatal flap, genioglossus advancement genioplasty, and orthognathic surgery, efficacy of tonsillectomy alone is difficult to assess. The most common concomitant procedure was UPPP. Since tonsillectomy is often required to precede UPPP, surgeons treating SDB patients should be capable of performing tonsillectomy in order to perform UPPP which is one of the most effective surgical procedures in treating SDB.
