Partial Tonsillectomy Research Articles

Tonsillectomy vs. partial tonsillectomy for OSAS in children—10 years post-surgery follow-up

Today, obstructive hypertrophic tonsils are completely resected to remove the obstruction. Since tonsillar tissue has important protective characteristics, it is more logical to resect only the obstructive tonsillar tissue and leave remnants in the tonsillar beds, thereby presuming to preserve the immunological function of the tonsillar tissue. However, it is as yet unclear whether or not rehypertrophy of this remnant of the tonsils and/or tonsillitis reoccur in the long-term. To evaluate the remnants of the tonsils 10-14 years post-tonsillotomy in children who suffered from obstructive sleep apnea syndrome (OSAS) due to obstructive tonsils. We conducted a retrospective study, telephone survey and selective physical examination of 33 children who had obstructive hypertrophic tonsils (suffered from OSAS due to hypertrophic tonsils), and underwent tonsillotomy (TT) at Assaf Harofeh Medical Center between July 1990 and April 1993, and compared them with a group of 16 children treated by tonsillectomy (TE) for the same diagnosis. No statistically significant difference was found between the TT and TE groups in all parameters compared: non-obstructing tonsils recurred (97% vs. 87%); snoring (3% vs. 12.5%); recurrent tonsillitis (6% vs. 6.25%); and recurrent obstruction and unilateral enlargement (3% vs. 12.5%). TT is as effective as TE for the long-term treatment of children suffering from OSAS due to hypertrophic tonsils.

Oral motor dysfunction in children with adenotonsillar hypertrophy—effects of surgery

Adenotonsillar hypertrophy is associated with a wide range of problems. The enlargement causes obstructive symptoms and affects different functions such as chewing, swallowing, articulation, and voice. The objective of this study was to assess oral motor function in children with adenotonsillar hypertrophy using Nordic Orofacial Test-Screening (NOT-S) before and 6 months after surgery consisting of adenoidectomy combined with total or partial tonsil removal. A total of 67 children were assigned to either tonsillectomy (n=33) or partial tonsillectomy, ‘tonsillotomy’ (n=34); 76 controls were assessed with NOT-S and divided into a younger and older age group to match pre- and post-operated children. Most children in the study groups had oral motor problems prior to surgery including snoring, open mouth position, drooling, masticatory, and swallowing problems. Post-surgery oral motor function was equal to controls. Improvement was independent of surgery method.

Alterations In Immunity After Total vs Partial Tonsillectomy

Problem Palatine tonsils are secondary lymphoid organs active in sampling antigens entering the upper respiratory tract and in producing immunoglobulin (Ig) both locally and distally through migrating tonsillar B cells. Their size has been found to be directly proportional to the number of B and T cells. The aim of this study is to compare the change in serum and saliva Ig levels after total and partial tonsillectomy. Methods Children with obstructive tonsils and/or adenoid undergoing total or partial tonsillectomy were recruited in a pilot study. Patients with history of recurrent infections or immunodeficiency were excluded. Blood and saliva samples were obtained immediately preoperatively and at the 1st follow-up visit. Serum Ig's (G,M&A) concentrations were determined using radial immunodiffusion. Saliva secretory IgA was measured using an Enzyme Immuoassay (EIA). Results Twenty five patients (13 partial and 12 total) were included. There were no statistically significant changes in serum Ig's levels after total or partial tonsillectomy, except for IgM which increased (1.317 to 1.632 g/L) after partial tonsillectomy, more significantly in males, in those aged 5 years and older, and when the postoperative samples were taken within a 2 month-period. Moreover, there was statistically non-significant decrease in secretory IgA level after both total and partial tonsillectomy. Conclusion The effect of partial or total tonsillectomy on immunoglobulin level seems reassuring. The increase in IgM and the non-significant decrease in SIgA may represent a kind of immunological readjustment after tonsillar surgery. Significance This is the first study (to our knowledge) that compares the changes in immunoglobulin levels (in serum & saliva) after partial vs. total tonsillectomy. The obtained results are preliminary and are reassuring to the parents and physicians who have concerns regarding the immunological sequalae of tonsillectomy in children. A longer follow up will be done in a larger future study. Support This study was supported by Medtronic.

Partial tonsillectomy with scalpel in children with obstructive tonsillar hypertrophy

To compare postoperative pain of partial tonsillectomy (PT) with scalpel and total classical tonsillectomy (TT). Prospective, randomized study at a tertiary care institution. Ninety-six children who were diagnosed with obstructive tonsillar hypertrophy were included to the study. Children's tonsils were removed totally (Group TT) by classical dissection tonsillectomy or partially (Group PT) using scalpel and tissue scissors. The parents were instructed to fill out a form daily for nine postoperative days; recording total amount of analgesics administered that day and a Visual Analog Scale (VAS) each day assessing child's life quality and daily activities. Eighty-one children (2-14 years old) who completed the study were included in the analysis. Total tonsillectomy group (Group TT) consisted of 41 patients and partial tonsillectomy group (Group PT) consisted of 40 patients. There was no difference between two groups' operative parameters such as operation time [21.3 min (PT) and 22.3 min (TT)] and blood loss [44.2 ml (PT) and 46.0 ml (TT)] (p>0.05). PT group received significantly less dosage of analgesics per day; 1.18+/-1.27 vs. 2.00+/-1.45 (p<0.005). Total used analgesic dose in PT group were also lower than TT group (10.7+/-7.13 vs. 18.02+/-6.99 doses). When each day's analgesic use was compared separately a significant difference was found (p<0.05) in all days except 9th postoperative day (p>0.05). There was no difference in the pain scores between two techniques (p>0.05). Unlike tonsillectomy, PT aims to remove the tonsilla palatina subtotally. It is especially performed in children with obstructive tonsils. PT with scalpel is an inexpensive and safe method necessitating only standard surgical instruments. It causes less postoperative pain than classical dissection tonsillectomy.

Tonsillectomy versus tonsillotomy performed with scissors in children with tonsillar hypertrophy

We sought to determine the morbidity and the short and long-term effectiveness of tonsillotomy (partial tonsillectomy) performed with scissors compared with conventional cold knife (total) tonsillectomy. We conducted a 2-year prospective non-randomized study at a tertiary children's hospital. One thousand and twenty-three children were recruited (243 in the tonsillotomy and 780 in the tonsillectomy group). Age, sex, weight, and time of operation, immediately post-operative complications and pain were recorded. Eighteen months after the operation data on weight, parents' satisfaction and recurrence of obstructed symptoms was obtained in 60 randomly selected children of each group. Post-operative complications rates were very low in both groups and their differences did not reach statistical significance. However, tonsillotomies were significantly better than tonsillectomies in relation to post-operative pain the 1st (P<0.001) and the 7th (P<0.001) post-operative day, and lasted an average of 2.5 min less. Concerning long-term effects, both methods resulted in an increase of patients' weight without the difference in weight increase be statistically significant. In addition, parents' satisfaction as well as oral malodour do not seem to differ significantly. Finally, although twice as many children in the tonsillotomy group had a recurrence of snoring compared to tonsillectomy group, only in about half of them was the problem regarded significant enough by their parents to require medical consultation or reoperation. At the end, an estimated 3.5% of the tonsillotomy group was offered a tonsillectomy in the long term. This trial shows that scissors tonsillotomy in combination with an adenoidectomy is a viable therapeutic option with less immediate post-operative morbidity than tonsillectomy in young children whose sleep disorder breathing is due to a combination of tonsilar and adenoid hypertrophy. However, parents should be informed of the possibility of regrowth and reoperation.

Skuteczność tympanopunkcji w leczeniu dzieci chorych na wysiękowe zapalenie ucha środkowego

Otitis media with effusion is the most frequent cause of conductive hearing impairement (HL) at pediatric age. This entity can be asymptomatic for an important period of time (silent OME). There is a surgical and a nonsurgical approach for OME. In case of failure of conservative treatment of OME the ventilation tube insertion (VT) with adenoidectomy alone or combined with tonsillectomy should be choosed. If the hearing loss is less than 20 dB children are candidates for conservative treatment and myringotomy. From 1999 to 2003, 50 children with bilateral and 9 with unilateral OME underwent the surgical treatment in our ENT Department. Mean age of patient population was 6,8 years. Clinical evaluation of the OME treatment outcome was done in 2004. Surgical procedure involved myringotomy, aspiration of the middle ear effusion, middle ear irrigation with soline solution 0.9 % Sodium Chloride (NaCl) followed by suction of diluted glue. Depo-Medrol (methylprednisolone acetate) was administrated into the middle ear. Our procedure included the management of the upper airways obstruction. Good long-term outcomes after surgical treatment of OME were obtained in 30 patients (79%). In this group of children the upper airways management included adenoidectomy and partial tonsillectomy. 8 children presented poor response to the treatment. In this group the surgical procedure consisted of adenoidectomy and inferior turbinate reduction. Two children presented acute otitis media and improved after conservative treatment. Other children with poor outcome were: a boy who underwent multiple surgical procedures due to laryngotracheal stenosis, a girl who suffered from chondrodysplasia. Remaining two patients presented few months ago aggravation of conductive hearing loss. According to positive familial history they underwent allergical examinations. One boy was planned for readenoidectomy and laser myringotomy, a girl already operated at the age of tree years, was planned for ventilation tubes insertion and readenoidectomy in another ENT Department.

Tonsillar regrowth following partial tonsillectomy with radiofrequency

To assess regrowth potential of the tonsils following partial tonsillectomy performed by using radiofrequency. Follow-up results of 42 children (aged from 1 to 10 years) who consecutively had partial tonsillectomy with radiofrequency due to obstructive sleep apnea or snoring were evaluated for regrowth of the tonsils. Regrowth of the remaining tonsillar tissue was observed in 7 of 42 patients (16.6%). The upper respiratory tract obstruction symptoms recurred in 5 of these 7 patients while the remaining 2 patients were asymptomatic. The tonsils of symptomatic patients were removed completely. Partial tonsillectomy may have a significant potential for regrowth and thereby recurrence of the obstructive symptoms. Although the cause of this regrowth remains unknown, this problem should be remembered by the surgeons, and an informed consent should be obtained from the families prior to radiofrequency tonsillotomy.

Microdebrider-assisted partial tonsillectomy: short- and long-term outcomes

Microdebrider-assisted partial tonsillectomy has gained popularity in recent years. However, no prospective long-term follow-up exists in the literature and the risk of increase in tonsillitis is still a concern. We conducted a prospective randomized controlled study to assess the short-term benefits of microdebrider-assisted partial tonsillectomy (group 1) compared to electrocautery-assisted total tonsillectomy (group 2), to monitor the durability of the improvement and watch for any change in the rate of tonsillitis. Patients with symptomatic tonsillar hyperplasia were included and underwent either technique of tonsillar surgery. Duration of operation, amount of intra-operative blood loss, immediate and late complications, postoperative pain, return to normal activity and diet, and relief of obstructive symptoms were measured. Recurrence of symptoms and change in rate of tonsillitis in group 1 were monitored. We studied 143 patients, 77 in group 1 and 66 in group 2. There was no significant difference in the surgical time (P>0.05) or postoperative bleeding (P>0.05) but more blood loss in group 1 (P<0.05) and more dehydration in group 2 (P<0.05) were encountered. All patients had complete relief of symptoms. Group 1 returned earlier to normal activity (2.19 vs. 5.71 days; P<0.05), to normal diet (5.28 vs. 8.16 days; P<0.05) and needed less frequent analgesics (2.14 vs. 6.1 days; P<0.05). More than two-thirds of group 1 and less than one-third of group 2 were pain free after day 3. Most group 1 parents (96.1%) were highly satisfied, at initial follow-up, regarding the decision to perform the surgery in contrast to group 2 parents (19.7%). No recurrence of symptoms and no increase in rate of tonsillitis were noticed among group 1 after 20 months mean follow-up (median 20.6, range 1-36.2 months). Group 1 showed short-term benefits over group 2 and maintained the resultant improvement on the long-term with no infectious drawbacks.

Severe obstructive sleep apnoea syndrome in a 5-year-old girl

The obstructive sleep apnoea syndrome (OSAS) is a common cause of morbidity during childhood. Although pediatric OSAS usually stems from adenotonsillar hypertrophy, it is also related to craniofacial anomalies. We report a case of extremely severe OSAS in a 5-year-old girl who has undergone adenoidectomy and partial tonsillectomy 1.5 year previously. A second adenotonsillectomy was elected to resolve abnormal respiration during sleep. Polysomnography was repeated 8 weeks after surgery and revealed an outstanding improvement but not complete resolution. The residual number of apnoeas is attributed to the retrognathia of the patient.

Tonsillotomy or tonsillectomy?—a prospective study comparing histological and immunological findings in recurrent tonsillitis and tonsillar hyperplasia

We evaluated the differences in histological and immunological findings in children with recurrent tonsillitis and tonsillar hyperplasia and assessed the risk for relapsing tonsillar hyperplasia or recurrent tonsillitis after tonsillotomy in a prospective clinical study. Sixty-four children with recurrent tonsillitis underwent traditional (total) blunt dissection tonsillectomy between October 2003 and July 2004. Partial tonsillectomy (tonsillotomy) using CO(2)-laser technique was performed on 49 children with tonsillar hyperplasia and no history of recurrent tonsillitis between August 2003 and March 2005. The present study compares preoperative serum anti-streptolysin-O antibody and immunoglobulin levels (IgG, IgA and IgM), C-reactive protein levels (CRP) and blood leukocyte counts of the two study groups. Additionally the tonsillar tissue removed by tonsillotomy or tonsillectomy was histologically examined in order to determine the grade of hyperplasia, chronic inflammation and fibrosis. Furthermore, the grade of fresh inflammation within the tonsillar crypts of the specimens was analysed. The parents of 40 patients treated by laser tonsillotomy were surveyed in average 16 months. There was no statistically significant difference in preoperative serum anti-streptolysin-O antibody and immunoglobulin levels, C-reactive protein levels and blood leukocyte counts between the two study groups. All specimens showed the histological picture of hyperplasia. There was no statistically significant difference in the grades of hyperplasia between the two study groups. Signs of fresh but mild inflammation within the tonsillar crypts could be found in over 70% of both study groups. Fibrosis only occurred in children with recurrent tonsillitis (9%). In all specimens signs of chronic inflammation could be detected. The histological examinations of specimens from children with repeated throat infections more frequently showed a moderate chronic inflammation of the tonsillar tissue. Two of forty patients treated by tonsillotomy required a subsequent tonsillectomy due to a recurrence of tonsillar hyperplasia but no recurrent tonsillitis occurred. Tonsillotomy with CO(2)-laser technique is an effective surgical procedure with a long-lasting effect in patients with tonsillar hyperplasia. The benefits over conventional tonsillectomy are a lower risk for postoperative haemorrhage, reduced postoperative morbidity and accelerated recovery. Even in children with no history of recurrent tonsillitis signs of chronic inflammation histologically can be found in specimens after tonsillotomy. The occurrence of recurrent tonsillitis after tonsillotomy is rare, however. A low incidence of relapsing tonsillar hyperplasia after tonsillotomy should be expected. Preoperative laboratory investigations show few differences in patients with tonsillar hyperplasia and recurrent tonsillitis. Components of the antimicrobial defense system are also produced by chronically infected tonsils. Therefore tonsillotomy with CO(2)-laser could also be an option in some patients with mild symptoms of recurrent tonsillitis.

The evolution of tonsil surgery and rethinking the surgical approach to obstructive sleep-disordered breathing in children

Within the last 10 to 15 years, a significant amount of research in tonsil surgery has focused on reduction of post-operative pain and recovery time. In order to minimize or avoid morbidity, a number of otolaryngologists in the United States and Europe have revived a historical procedure, previously known as 'tonsillotomy', specifically for those patients with obstructive sleep-disordered breathing (OSDB) due to adenotonsillar hypertrophy. More recently, surgeons have used terms such as partial tonsillectomy, partial intracapsular tonsillectomy or subtotal tonsillectomy to describe their procedure and have employed a variety of modern instrumentation. This return to a 'partial' procedure has generated a debate similar to that which occurred amongst tonsil surgeons about 100 years ago, when tonsillotomy was the most commonly performed procedure. Today, concerns about regrowth and problems with infection of the remaining tonsillar tissue have been raised. Such concerns, combined with an incomplete understanding of why the 'partial' procedure was abandoned in the early twentieth century, may explain why tonsil surgeons hesitate to change their approach to patients with OSDB due to adenotonsillar hypertrophy. These issues can be addressed in a meaningful way only through a detailed review of the evolution of tonsil surgery, which is presented here. This information, along with a summary of the last 10 years' experience with these techniques, supports the use of a 'partial' procedure in children with OSDB due to adenotonsillar hypertrophy. Future areas of research are also discussed.

Tonsillectomy

Tonsillectomy

Long-term effects of intracapsular partial tonsillectomy (tonsillotomy) compared with full tonsillectomy

To compare the long-term effects (six years after surgery) of two techniques for pediatric tonsil surgery with respect to snoring, apneas, eating difficulties, infections and general health. The two methods were intracapsular partial tonsillectomy (tonsillotomy, "TT") using CO(2)-laser technique and traditional (total) blunt dissection tonsillectomy (TE). A questionnaire distributed by mail to the parents of children, who, in 1998, were included in a prospective clinical randomized study in one tertiary care ENT clinic. A 10 question survey follow-up of 41 children, between 9 and 15 years of age, who originally, six years earlier had been randomized to either TT with CO(2)-laser (n=21) or TE (n=20). The main indication for the surgery was a history of sleep related breathing distress (SRBD). Before the present study, all of the children had participated in earlier follow-ups at six months and one year after surgery. All the children in both groups answered the questionnaire. There were no significant differences between the answers from the two groups in any respects: the effect on snoring and apneas was equally stable for both groups. The number of children who remained free from snoring decreased from 40 after the first year to 25 after six years (11 TT, 14 TE). Snoring in the recurrent cases was not rated to be as frequent or as loud as before the surgery. Infections of the upper respiratory tract (URI) that had been treated with antibiotics occurred to the same extent in both groups. None had eating difficulties. The patients' satisfaction with the results of the surgery was high or very high in 18/21 TT and 20 TE cases, and the vast majority of the parents rated their children's present health status as improved compared with the preoperative condition. Tonsillotomy with CO(2)-laser seems to be a reliable method for tonsil surgery with substantially less primary morbidity than conventional tonsillectomy and with the same positive long-term effects after six years.

INTRACAPSULAR TONSILLAR REDUCTION (PARTIAL TONSILLECTOMY): REVIVING A HISTORICAL PROCEDURE FOR OBSTRUCTIVE SLEEP-DISORDERED BREATHING IN CHILDREN

Koltai PJ, Solares CA, Koempel JA, et al. Otolaryngol Head Neck Surg . 2003;129:532–538 To compare the safety and efficacy of intracapsular tonsillar reduction (partial tonsillectomy) with those of conventional tonsillectomy for treating obstructive sleep-disordered breathing among children. The authors reviewed the medical records for a total of 350 children who underwent either partial (243 children) or standard (107 children) tonsillectomy for treatment of obstructive sleep-disordered breathing. The diagnosis of sleep-related obstruction was made on the basis of history findings. This was a retrospective chart review of patient records for all children with obstructive sleep-disordered breathing who underwent either partial or standard tonsillectomy, performed by 1 of 3 primary surgeons. The choice of surgical technique was made by the parents, who were told that the new partial tonsillectomy might be …

Intracapsular tonsillar reduction (partial tonsillectomy): reviving a historical procedure for obstructive sleep disordered breathing in children.

We sought to reintroduce a historical procedure-intracapsular tonsillar reduction (partial tonsillectomy or tonsillotomy)-for tonsillar hypertrophy causing obstructive sleep disordered breathing (OSDB) in children, as well as to determine whether partial tonsillectomy, compared with conventional (total) tonsillectomy when performed by more than one surgeon, is equally effective for the relief of OSDB while resulting in less pain and more rapid recovery. We conducted a retrospective case series at a tertiary children's hospital. The charts of children who underwent partial tonsillectomy and total tonsillectomy (1998 through 2002) for postoperative complications were reviewed. The caregivers were surveyed to assess postoperative pain, rapidity of recovery, and effectiveness of surgery for relieving symptoms of OSDB. Two hundred forty-three children underwent partial tonsillectomy and 107 children underwent total tonsillectomy. There were no significant differences in immediate and delayed complications between the groups. Both operations were equally effective in relieving OSDB. Children who had partial tonsillectomy had significantly less postoperative pain and significantly more rapid recovery. Intracapsular tonsillar reduction with an endoscopic microdebrider relieves OSDB as effectively as conventional tonsillectomy, but results in less postoperative pain and a more rapid recovery.

Intracapsular tonsillar reduction (partial tonsillectomy): reviving a historical procedure for obstructive sleep disordered breathing in children

Objective We sought to reintroduce a historical procedure—intracapsular tonsillar reduction (partial tonsillectomy or tonsillotomy)—for tonsillar hypertrophy causing obstructive sleep disordered breathing (OSDB) in children, as well as to determine whether partial tonsillectomy, compared with conventional (total) tonsillectomy when performed by more than one surgeon, is equally effective for the relief of OSDB while resulting in less pain and more rapid recovery. Study design We conducted a retrospective case series at a tertiary children's hospital. The charts of children who underwent partial tonsillectomy and total tonsillectomy (1998 through 2002) for postoperative complications were reviewed. The caregivers were surveyed to assess postoperative pain, rapidity of recovery, and effectiveness of surgery for relieving symptoms of OSDB. Results Two hundred forty-three children underwent partial tonsillectomy and 107 children underwent total tonsillectomy. There were no significant differences in immediate and delayed complications between the groups. Both operations were equally effective in relieving OSDB. Children who had partial tonsillectomy had significantly less postoperative pain and significantly more rapid recovery. Conclusion Intracapsular tonsillar reduction with an endoscopic microdebrider relieves OSDB as effectively as conventional tonsillectomy, but results in less postoperative pain and a more rapid recovery.

Complete excision versus tonsil ablation for surgical management of tonsillar disease

The surgical approaches and techniques for tonsillar disease have evolved over the years. Complete subcapsular tonsillectomy has traditionally been the procedure of choice for all tonsillar surgery indications. Although new surgical modalities such as ultrasonic-activated scalpel and ionized field ablation appear to decrease the postoperative pain of tonsillectomy, patients continue to have a significant incidence of postoperative hemorrhage. Subsequently, supracapsular partial tonsillectomy has been used for patients with obstructive tonsillar hypertrophy with efficacy equal to that of complete subcapsular tonsillectomy. Partial tonsillectomy seems to offer a less painful postoperative course and a decrease in the complications common after complete tonsillectomy. Although originally the CO2 laser was used for surgical ablation of the tonsils, ionized field ablation and radiofrequency tissue ablation also have very promising results. The authors conclude that although traditional complete tonsillectomy continues to be the procedure of choice for recurrent infections or chronic tonsillitis, partial supracapsular tonsillectomy is a viable alternative for obstructive disease, offering lower postoperative morbidity with equal efficacy.

Abscess tonsillectomy; seven hundred twenty-five cases.

The first abscess tonsillectomy was performed nearly 100 years ago (1859) by Chassaignac. He also described the course of development of peritonsillar abscess. His operation, however, fell into disuse. It was not until 30 years later that interest in the treatment of peritonsillar abscess was stimulated by Chiari, who suggested a simple incision for opening "ripe" abscesses. Winckler (1911) was the first to suggest the use of tonsillectomy as a routine method, and the appellation "Father of abscess tonsillectomy" has been given to him. The advantages and disadvantages of the two methods have since been the subject of much discussion. Methods differing to some extent from these two have been reported. Thus, Levinger suggested so-called partial tonsillectomy: he removed the upper pole of the tonsil and left the lower pole intact. In Finland, Meurman previously used Levinger's method. Loch performed abscess tonsillectomy in two stages. He made a fairly wide

Abscess tonsillectomy: preliminary report.

Chassaignac, in 1859, described abscess formation in the loose connective tissue between the tonsillar capsule and the pharyngeal wall. He also performed the first abscess tonsillectomy in the same year. His operation, however, fell into disuse. It was not until 30 years later that interest in the treatment of peritonsillar abscess was stimulated by Chiari, who suggested a simple incision for opening “mature” abscesses. Winckler (1911) was the first to suggest the use of tonsillectomy as a routine method, and the name “Father of abscess tonsillectomy” has been applied to him. The advantages and disadvantages of the two methods have later been the subject of much discussion. Methods differing to some extent from these two have been reported. Thus, Levinger suggested a so-called partial tonsillectomy: he removed the upper pole of the tonsil and left the lower pole intact. In Finland, Meurman has used Levinger's method. Loch performed abscess tonsillectomy in two stages. He made a fairly wide incision over t...

ANOMALOUS INTERNAL CAROTID ARTERY AND ITS CLINICAL SIGNIFICANCE IN OPERATIONS ON TONSILS

In view of the increasing number of operations on the tonsil because of the focusing of medical eyes on it as a primary source of metastatic infections, because of the discovery of more cases in the systematic inspection of schoolchildren, and because of the popularity of complete ablation of the tonsil in preference to partial tonsillectomy, a timely note of warning should be sounded of the liability of serious if not fatal hemorrhage from wounding a loop of an anomalous internal carotid artery. The following specimen, found in the Anatomical Laboratory of the University of Pennsylvania, serves as a striking example of this: Anomalous Sigmoid Tortuosity of Cervical Portion of Internal Carotid Artery. —Specimen consists of left side of skull containing the internal carotid arteryin situand dissected free from surrounding tissues. The artery is of uniform caliber throughout its length, and its walls neither thickened nor calcareous. Beginning