Intracapsular Tonsillectomy
What are the Tonsils and Adenoids and why do we have them?
The tonsils are small pads of lymphoid tissue at the sides of the throat. There is a similar pad of lymphoid tissue at the back of the nose called the adenoids. In very early childhood they form part of the immune recognition system and are important in teaching the immune system and protecting the body against infections by recognising harmful germs. In some children they can cause problems through infection or obstruction.
What are the main reasons for surgery?
Enlargement of the adenoids and tonsils can cause snoring and mouth breathing. In more severe cases it can cause periods where a child stops breathing – known as obstructive sleep apnoea. Tonsil and adenoid surgery can cure this. Tonsillectomy is also performed for frequent sore throats and Adenoidectomy can sometimes be performed at the same time as insertion of grommets to reduce the chances of glue ear recurring or to reduce ear infections.
Are there alternatives to surgery?
The adenoids tend to shrink with age and are usually absent in teenagers and adults. There is also evidence that nasal steroids can reduce the size of the adenoids over time. Unfortunately, steroids have little impact on the size of the tonsils. Long-term prophylactic antibiotics can help tonsillitis for a while but are not as effective as surgery. Waiting for symptoms to improve over time is sometimes a reasonable option if symptoms are mild.
What age should surgery be performed?
Surgery is normally performed after the age of 3 at Spire Gatwick Park Hospital in children over 12kgs in weight. If a child is less than 3, then the surgery can be performed as a private patient in one of the local NHS Hospitals. Children less than 12kgs need to have surgery at a centre with a Paediatric High Dependency Unit.
How are adenoidectomy and tonsillectomy carried out?
Our preferred method of surgery is to perform a Coblation ® Intracapsular Tonsillectomy and Adenoidectomy. Coblation ® uses a special plasma derived from saline (salt water) to break down tissue in a very precise manner. The changes to tissue take place at around 40 °C to 70 °C, resulting in very little heat transfer to the surrounding tissue, thereby reducing complications and pain. Almost all patients are discharged on the same day just 3-4 hours after surgery.
What is the difference between intracapsular and extracapsular tonsillectomy?
The tonsil capsule is a thin fibrous partition between the tonsil and the underlying muscles of the throat. An extracapsular tonsillectomy involves complete removal of the tonsils and results in exposure of the muscle bed and the blood vessels that lie within the muscle. An intracapsular tonsillectomy involves removal of tonsil tissue up to, but not through the capsule. In the UK, most surgeons performing intracapsular surgery will aim to remove all the visible tonsil tissue (more than 95%). Coblation® is the most popular technique in the UK for Intracapsular surgery and the same instrument can be used for adenoidectomy.
This video depicts the principal differences between intracapsular and extracapsular surgery:
What are the advantages of an intracapsular tonsillectomy?
Intracapsular tonsillectomy has been pioneered for use in children and is mainly used for large tonsils causing obstruction (obstructive sleep apnoea). There is excellent evidence for it to also be offered to children suffering with recurrent tonsillitis. Intracapsular surgery has the advantage of reduced risks of bleeding as well as a much speedier recovery. One of the major downsides of conventional extracapsular surgery is the risk of bleeding after the operation (most commonly between after 3 to 7 days) with rates quoted between 2 and 8%. With intracapsular techniques the risk of bleeding is thought to be as low as 0.2-0.4%. Most children who have an intracapsular operation can return to school or nursery within a week whereas those that undergo extracapsular procedures will need 14 days off school.
Are there any disadvantages of an intracapsular tonsillectomy?
There is a small risk of tonsil regrowth over time using the intracapsular technique and an even smaller risk of this tissue causing similar problems in the future. In practice, this is reasonably rare. In the largest study of intracapsular surgery, more than 1,000 children were followed up after the procedure for 5 years and the chance of revision surgery was found to be about 2%. This occurred more frequently in children who were very small (less than 15kgs in weight) at the time of their surgery. The possibility of revision surgery is more than offset by the reduction in complications, including life-threatening bleeding, when compared with conventional extracapsular procedures. In our experience, revision surgery is very unusual in children above the age of 3.
How widely available is the procedure in the UK?
Intracapsular tonsillectomy, particularly with Coblation®, is becoming much more widespread within the UK. Most of the major paediatric hospitals in the UK are already using this as their main surgical technique. Large scale studies in the UK, Europe and USA support the use of this technique particularly in children due to the reduced risk and enhanced recovery. The benefits of intracapsular tonsillectomy are so significant that the NHS recommends this approach for tonsil removal in all children needing surgery as part of its “Getting It Right First Time” (GIRFT) programme, which focuses on improving the treatment and care of patients through an in-depth review of services.
What are the complications of Tonsillectomy & Adenoidectomy?
Bleeding
Bleeding is the most serious consequence of this type of surgery but occurs in less than 0.4% of cases. Bleeding can occur at any point in the recovery period and so it is important to be vigilant for signs of this. If bleeding is encountered, take your child straight to the Emergency Department at your local NHS Hospital immediately. It is highly unlikely that a child who has had an intracapsular tonsillectomy will require further surgery to correct bleeding, but it is essential that they are assessed fully.
Infection
Infection is the commonest cause for increased discomfort and bleeding after surgery. The routine use of antibiotics following surgery does not reduce infection but can sometimes reduce discomfort and the unpleasant oral smell that is sometimes encountered. The tonsillar areas will normally appear white after surgery – this is normal and not a sign of infection.
Pain
Discomfort is common and is usually worst around day 3 following surgery. It is important to use regular painkillers for up to 7days (paracetamol and ibuprofen at maximum doses) even if your child is not experiencing too much pain to reduce the chances of more severe pain or complications.
Dental Trauma, or damage to the lips and gums.
This can occur very rarely from tonsil or adenoid surgery. Please inform your surgeon /anaesthetist if your child has any loose teeth, before surgery. The risk of dental trauma is about 1 in 3000.
Taste disturbance
As pressure is placed on the tongue during surgery, some children can report a change in their sensation of taste. It normally improves very rapidly.
Tonsil and Adenoid regrowth
After intracapsular surgery the rate of regrowth is thought to be around 2% and more likely to occur in very young children. In older children it is reasonably rare. Revision surgery can be carried out if there are ongoing symptoms but in practice this is very rare.
What should my child eat during the recovery period?
A normal diet is suggested after surgery. No special precautions are required.
How soon after surgery can we fly?
It is safe to fly 3-4 weeks after surgery but it is always worth checking with you travel insurance provider.
The following videos show intracapsular surgery being carried out:
Please note that these videos show real surgery being performed and viewer discretion is therefore advised.
Adenoidectomy
The following videos show Coblation Adenoidectomy surgery being carried out: