Tonsillotomy: it's time to clarify the facts

Abstract

Finger nails, wires, specialized knives, slings and guillotines in the 19th and 20th century were used for subtotal tonsillectomy to reduce the risk of serious bleeding complications associated with complete removal of tonsillar tissues. Therefore, success of tonsil procedures at that time was widely based on revision surgery to cure patients suffering from diseases associated with tonsillitis. Complete, i.e., extracapsular, tonsillectomy (TE) was conceived in the first decade of the 20th century but became widespread only with safer anesthesiological techniques, particularly orotracheal intubation and introduction of halothan in the 1950s [1, 2]. In 1990, Rosenfeld registered a dramatic rise in obstructive sleep apnea (OSA) as a significant indication for TE. He assumed that this phenomenon is due to the increasing awareness of the prevalence and seriousness of adenotonsillar hypertrophy as a cause of sleep apnea, particularly in children [3]. His statement and findings were confirmed recently by Parker and Walner [4]. OSA belongs to the category of sleep-disordered breathing (SDB), characterized by abnormal respiratory patterns or the inadequate ventilation during sleep in terms of snoring, mouth breathing, or interrupted breathing. The patients may become symptomatic with excessive sleepiness, inattention, poor concentration, or hyperactivity during daytime. According to the latest statement of the American Academy of Otolaryngology-Head and Neck Surgery, TE still plays a major role to resolve SDB related to tonsillar hypertrophy in children [5]. Morbidity following TE is widely determined by pain and significant limitations in activity and diet. Return to normal diet and activity, intake of analgesics and type of consumed analgesics are therefore common endpoints of studies evaluating the benefit of newer surgical TE instruments. Complications like hemorrhage and dehydration eventually occur with the potential of a devastating outcome [6, 7]. While the best method to avoid surgical complications is not to operate, this is not an option for upper airway obstruction caused by tonsillar hypertrophy. TE, however, is acknowledged to control SDB in only 60–70 % of children with significant tonsillar hypertrophy, emphasizing the multifactorial background of this disease [5]. In the light of the limited success rate and the potential complications of TE alternative surgical procedures such as a Bochon loop have been suggested in 1993 [8], cited after [2]. In 1994, Krespi and Ling [9] recommended the CO2LASER for ‘‘serial tonsillectomy’’ to treat recurrent infection, sore throat, and halitosis in adults. In children, a considerably reduced morbidity after ‘‘tonsillotomy’’ with modern techniques was first reported in 1999 by Linder et al. [10] and Hultcrantz et al. [11], followed by Densert et al. [12], and Helling et al. [13] in 2001 and 2002, respectively. The results were confirmed with the first large retrospective study in 2003 by Koltai et al. [14] who used a microdebrider as surgical instrument. However, in a small pediatric patient population, a significant impact of ‘‘intracapsular tonsillectomy’’ on OSA—albeit not successful in all patients—was proven by means of polysomnographic J. P. Windfuhr (&) Department of Otorhinolaryngology, Plastic Head and Neck Surgery, Kliniken Maria Hilf Monchengladbach, Sandradstr 43, 41061 Monchengladbach, Germany e-mail: jochen.windfuhr@mariahilf.de