Removal of Adenoids and Tonsils:Which technique?How to take decision?

Removal of Adenoids and Tonsils/Adenotonsillectomy is commonly indicated in the following conditions:

1. Recurrent infections:more than 3-4/years for 2 consecutive years 
2. Upper airway obstruction due to enlarged tonsils and adenoids
3. Peritonsillar Abscess
4. Asymmetrical Size of Tonsils
5. Adenoidectomy especially if recurrent middle ear infections or sinusitis in children

Surgical Removal of adenoids and Tonsils can be done through following techniques:

in the order of older to newer techniques as they evolved.We shall discuss how we decide which technique to be used at the end of the article.

• Cold knife (steel) dissection:Gold old method using surgical dissection of tissues with bleeding controlled with taking ties.
• ElectrocauteryThermal Dissection
• Harmonic scalpelThis medical device uses ultrasonic energy to vibrate its blade at 55,000 cycles per second.
• Radiofrequency ablationMonopolar radiofrequency thermal ablation transfers radiofrequency energy to the tonsil tissue through probes inserted in the tonsil. This procedure is recommended for treating enlarged tonsils and not chronic or recurrent tonsillitis. However, tonsils may re-grow after this procedure.
• Carbon dioxide laserHand-held CO2 or KTP laser to vaporize and remove tonsil tissue.  
• MicrodebriderThe microdebrider is a powered rotary shaving device with continuous suction often used during sinus surgery.  
• Bipolar Radiofrequency Ablation (Coblation):This procedure produces an ionized saline layer that disrupts molecular bonds without using heat. As the energy is transferred to the tissue, ionic dissociation occurs.

I have personally been trained and used all above techniques.Harmonic Scalpel and Coblation while training in the U.K.I also learned Bipolar Tonsillectomy which if used carefully gives good outcomes.

As a Surgeon,my decision to use any particular technique depends on following factors :

• I have to first be familiar and learn each technique.
• Then go through medical literature about randomised controlled trails and their results about each technique.
• Availability of equipment in my setting
• One technique or combination of technique
• What has worked for my patients so far in terms of less bleeding and less pain
• Lastly..Do No Harm.

Tonsils can be examined in the opd on oral examination.

I must make a special mention about Adenoids here.Anatomically the adenoids sit at the back of the nose,behind and above soft palate.Here is a picture of nasoendoscopy done in the opd (picture 1) to look for the size of adenoid(picture 2)

The approach to adenoid has improved with endoscopes through the nose.There is a risk of incomplete removal of adenoids with traditional method.Newer techniques like Microdebrider and Coblater will ensure complete removal and avoid regrowth.

I am very comfortable to use dissection Technique for tonsillectomy with minimal bipolar for hemostasis with excellent outcomes in the last 9 years.For Adenoidectomy,I use Microdebridor or Coblator.

What medical literature says..these are articles from Medline Database

Laryngoscope. 2009 Jan;119(1):162-70. doi: 10.1002/lary.20024.
Comparison of three common tonsillectomy techniques: a prospective randomized, double-blinded clinical study.
Wilson YL1, Merer DM, Moscatello AL

Otolaryngol Head Neck Surg. 2003 Oct;129(4):360-4.
Hot versus cold tonsillectomy: a systematic review of the literature.
Leinbach RF1, Markwell SJ, Colliver JA, Lin SY

Cochrane Database Syst Rev. 2007 Jul 18;(3):CD004619.
Coblation versus other surgical techniques for tonsillectomy.
Burton MJ1, Doree C