A Better Tonsillectomy Technique

Recently, I started getting phone calls from places like Darien, Illinois and Highland, Indiana from people that wanted to schedule a consultation regarding their tonsils.  Why so far away from Homewood?   Please read on!

I’m an “ENT” (Ear, Nose, and Throat physician—unfortunately for our specialty, the high falutin’ official term, Otolaryngologist, is too hard to pronounce).  Tonsillectomy is a “bread and butter” type of procedure that I routinely perform for problems of chronic tonsil swelling, recurrent tonsillar infection, or chronic tonsil contamination.  

Of course, every patient should be evaluated by an otolaryngologist “ENT” to see if they were a true candidate for this operation.   Many think that they are, but are found to have other causes for their symptoms.

The main problem with the operation is that the patients experience significant post-operative pain which can even last two weeks or more in sensitive adults.  Children tend to bounce back quicker.  But it’s no picnic for them either. The very youngest ones (less than three years old) can even get dehydrated easier due to their small size.  Plus there can be difficulty in getting them to cooperate with taking any bad-tasting pain medication.

Yet the operation, as basic and routine as it is, can be a life-changer for children especially.  This is because it can relieve the significant problems that can result when a child has poor sleep such as day-time hyperactivity, and night-time problems such as arousals from sleep, nightmares, and bedwetting—though the latter may be controversial.

You can basically take out the tonsils “cold” or “hot.”  Cold means that the surgeon uses tools like scalpels, scissors, and snares to remove the tonsils. The surgeon then uses either sutures (“stitches”) to tie off the blood vessels or some sort of clotting paste to control the bleeding.  This type of technique is kind to the surrounding tissues, but is not in as much favor.  That is because the surgeon needs a lot of help in clearing the blood, via suction or irrigation, which otherwise blocks the view of the area that is being cut to detach the tonsil.  There is a lot more blood loss during the cold-technique operation.  And I think that surgeons may leave some tonsil tissue because it is hard to be precise when operating in a bleeding field.  Retained tonsil tissue could become re-infected or could re-grow.

A hot tonsillectomy uses an electrocautery device where a safe electric current is sent to the needle tip of a cutting device which can get as hot as 1200 degrees Celsius.  This seals the blood vessels as they are cut.   But a cautery tonsillectomy leaves a bit of collateral thermal damage to the bed of tissue from which the tonsil had been removed.  It is precise and complete, yet there is more pain and longer healing.  One of the few scientific articles that has a funny title (“Tonsillectomy--some like it hot”) discusses how cautery tonsillectomy is more painful.

I have experienced an odyssey in my techniques for tonsillectomy.  I was first taught the worst of both worlds!   The tonsil was removed with cold techniques (a lot of blood loss and lack of control). And then the bleeding was controlled with a device that combined suction and cautery—causing swelling and pain.  Once in private practice, I switched to the pure electrocautery technique.  Yet, I was always was exploring ways of reducing the patient’s pain—trying get the cold-technique tissue kindness with the control of the hot technique. 

This odyssey took me through devices like Laser (not good for bleeding control—still needed the cautery) and Harmonic Scalpel (vibrates at ultrasonic rates but not happy with the technique and the bleeding control—had swelling, too).  

Then for a decade or so I used Radiofrequency which I thought was quite good.  (This was also called cold ablation or “Coblation”™ for which my transcriptionist once typed “copulation” much to my amused proofreading.) There was less heat but good operative bleeding control and faster healing.  The pain might have been less, too.  But overall it was not really a great advance in pain control.

Then the same equipment rep that had originally showed me the radiofrequency device said that he had one that was even better—tissue-welding tonsillectomy.  (He had switched companies.)  I was skeptical and really didn’t want to learn a different technique.  But he hadn’t steered me wrong previously, and I had a feeling for my patients’ difficulties.  Plus the literature was very promising—even bettering the “gold-standard,” cold technique for pain control. 

Learning the technique was tedious because the tissue had to be pinched between the ends of a device that looks like a long tweezers--as seen in this animation.  It has a heating element that contacts the tissue that is much lower heat than any cautery.  If the device heated quickly, it would cut.  If it heated slowly, it would seal the blood vessels.

All the pinching motions were tough on the surgeon’s fingers.  It was slow, yet I stuck with it because the tissue bed after the tonsil was removed looked so good—perfectly pink like the tonsil had just been lifted out.  The control that the device provided allowed me to preserve all the tissue around the tonsil.  Here is a video of an actual surgery provided by the manufacturer.

The patient response has been very gratifying.  I had one patient in her twenties that had the tonsillectomy on a Friday and went to work as a restaurant hostess the next Thursday—Thanksgiving Day—six days later.  Obviously, every person’s pain tolerance is different and the response to surgery is unpredictable.  Most important, I have been able to reduce the medications that I give to patients for pain and have had fewer complications such as bleeding (always a concern with any surgical procedure) due to the better healing.

The medication issue is quite important because the FDA has indicated that young children should NOT be routinely given narcotic pain medication containing codeine due to some serious side effects including some deaths.  A professional organization for otolaryngologists supports this recommendation for children getting tonsillectomies.  So it is more IMPORTANT than ever that children have the least painful tonsillectomy!

Now I can tell you why those patients were calling me from distant locations recently.  It turns out that there is a tissue-welding tonsillectomy patient video that has gone viral (well as viral as these things go).  People were actually calling the company to find out who in the area is performing tonsillectomies with this technique.  And that is why I got those inquiries from Indiana and west suburban Chicago.  They told me that when they called the company, they found out that I am the only surgeon in the Chicago area that is removing tonsils with the tissue-welding technique!  I was amazed.  I did not even imagine this.  I guess my old buddy hadn’t convinced any other local surgeons to abandon their old ways of performing tonsillectomies.  (He subsequently left the company for a new surgical device manufacturer.)

I hope this has been a helpful discussion for patients.  You can visit my website, homewoodent.com for information regarding my location etc.  Maybe you or someone you know could benefit from a consultation.