Tonsillotomy – Partial Reduction of the Palatine Tonsils

Tonsillotomy is a surgical procedure in which the palatine tonsils are partially reduced while preserving part of the tonsillar tissue and the tonsillar capsule. The procedure is most commonly performed in children when enlarged palatine tonsils interfere with normal breathing, cause snoring or contribute to sleep-disordered breathing. Unlike tonsillectomy, during which the palatine tonsils are completely removed together with the capsule, tonsillotomy removes only the portion of tonsillar tissue that narrows the airway. In children with enlarged palatine tonsils and adenoids, tonsillotomy is often performed at the same time as adenoidectomy, i.e. removal of the adenoids.

How is a tonsillotomy performed?

The procedure is usually performed under general anaesthesia. The ENT specialist reduces the enlarged palatine tonsils through the mouth, without opening the neck or making external incisions.

Because part of the tonsillar tissue and the tonsillar capsule are preserved, children undergoing tonsillotomy generally experience less postoperative pain and a lower risk of bleeding than after a complete tonsillectomy, as well as a faster return to normal eating and everyday activities. However, the risk of bleeding is not eliminated completely.

Duration of the procedure: depends on the surgical technique used and whether the tonsillotomy is performed on its own or together with an adenoidectomy, another ENT procedure or ENT surgery.

When is a tonsillotomy indicated?

Tonsillotomy is most commonly considered when abnormally enlarged palatine tonsils narrow the upper airway and cause symptoms in a child.

Possible indications include:

• markedly enlarged palatine tonsils;

• regular or pronounced snoring;

• difficulty breathing during sleep;

• obstructive sleep-disordered breathing;

• signs of sleep apnoea;

• mouth breathing;

• restless sleep and frequent waking;

• difficulty swallowing due to markedly enlarged tonsils;

• in selected cases, recurrent tonsillitis if the ENT specialist considers tonsillotomy appropriate for the individual patient.

In children with sleep-disordered breathing and enlarged tonsils, tonsil surgery may be one of the treatment options. The need for surgery and the extent of the procedure are determined by the ENT specialist after evaluating the child.

How can enlarged tonsils affect a child’s sleep and breathing?

Markedly enlarged palatine tonsils can narrow the airway in the throat, particularly during sleep when the throat muscles are relaxed.

Parents may notice:

• loud or regular snoring;

• mouth breathing;

• restless sleep;

• sweating at night;

• pauses in breathing during sleep;

• frequent waking;

• unusual sleeping positions, for example with the head tilted backwards;

• tiredness or sleepiness during the day;

• changes in concentration or behaviour.

Snoring alone does not necessarily mean that a child requires surgery. The ENT specialist assesses the symptoms, the size of the tonsils, the condition of the adenoids and other possible causes of breathing difficulties.

Tonsillotomy or tonsillectomy – what is the difference?

Tonsillotomy

The palatine tonsils are partially reduced while preserving part of the tonsillar tissue and the capsule.

Tonsillotomy is more commonly used in children when the main problem is enlargement of the tonsils and airway obstruction.

Compared with complete tonsillectomy, studies in children have shown that tonsillotomy is generally associated with:

• a lower risk of postoperative bleeding;

• less pain;

• a faster return to a normal diet;

• a faster return to everyday activities.

Tonsillectomy

During a tonsillectomy, the palatine tonsils are removed completely together with the capsule.

A complete tonsillectomy may be more appropriate, for example, in certain cases of recurrent tonsillitis or other situations in which the tonsillar tissue needs to be removed completely.

The most appropriate type of surgery is determined by the ENT specialist, taking into account the child’s symptoms, the size of the tonsils, the frequency of infections, sleep-disordered breathing and other health factors.

Tonsillotomy and adenoidectomy

Children may often have both enlarged palatine tonsils and enlarged adenoids.

In such cases, the doctor may recommend performing both procedures under the same anaesthetic:

• tonsillotomy – reduction of the palatine tonsils;

• adenoidectomy – removal of enlarged adenoids.

The aim of combining these procedures is to improve upper airway patency and reduce symptoms such as snoring, mouth breathing and obstructive sleep-disordered breathing.

Tonsillotomy combined with adenoidectomy is an effective treatment option for appropriately selected children with obstructive sleep apnoea.

Preparing for tonsillotomy

Before surgery, a consultation with an otorhinolaryngologist (ENT specialist) is required.

The doctor assesses:

• the child’s symptoms;

• the size of the palatine tonsils;

• nasal breathing;

• possible enlargement of the adenoids;

• snoring and sleep-disordered breathing;

• previous tonsil and ear infections;

• other medical conditions and medications being taken.

In selected cases, additional ENT or sleep-related examinations may be required.

Before surgery under general anaesthesia, the child must undergo the preoperative examinations prescribed by the doctor. The medical team will provide the parents with detailed instructions regarding laboratory tests, eating, drinking and the use of medicines before surgery.

After tonsillotomy

After surgery, the child is monitored at the medical facility. The length of stay depends on the child’s age, general health, the severity of sleep-disordered breathing and the extent of the procedure.

During the first few days, the following may occur:

• pain or discomfort in the throat;

• pain that may radiate to the ears;

• unpleasant breath;

• a whitish-grey coating at the surgical site;

• a slight increase in body temperature;

• temporarily reduced appetite.

After tonsil surgery, it is important to ensure adequate fluid intake and follow the doctor’s instructions regarding diet, pain relief, physical activity and returning to nursery or school.

Recovery after tonsillotomy is generally easier and faster than after complete tonsillectomy, although recovery varies from child to child.

Can the tonsils enlarge again after tonsillotomy?

Because part of the tonsillar tissue is preserved during tonsillotomy, the remaining tissue may enlarge again over time.

This does not happen in every patient, but in some children symptoms may return in the long term and, in rare cases, repeat surgery may be required.

Studies have described a slightly higher risk of symptom recurrence or tonsillar tissue regrowth after tonsillotomy compared with complete tonsillectomy.

When should urgent medical attention be sought after surgery?

Bleeding after tonsil surgery is a complication that must be taken seriously.

Urgent medical attention should be sought if, after tonsillotomy:

• fresh, bright red blood appears from the mouth or nose;

• the child repeatedly spits up or vomits blood;

• there is difficulty breathing;

• the child is unable to drink and develops signs of significant dehydration;

• the child’s general condition deteriorates rapidly.

Although the risk of bleeding after intracapsular tonsil surgery is generally lower than after complete tonsillectomy, it is not zero.