The palatine tonsils are lymphoid organs, an integral part of Waldeyer's ring, which includes from top to bottom :
- the adenoids, located behind the soft palate, on the posterior wall of the nasopharynx
- The palatine tonsils, located on either side of the oropharynx
- The lingual or pharyngeal tonsils, located at the base of the tongue.
When the mouth is opened, only the palatine tonsils are visible
The lymphoid organs of Waldeyer's ring (the set of lymphoid formations that line the pharynx) are responsible for making certain antibodies in the early years of life. Normally the tonsils, like the vegetations, gradually decrease in volume during growth. They are then hardly visible
Excessive stimulation of the tonsils during the child's initial immune acquisition up to the age of 6 to 8 years can sometimes lead to hypertrophy or chronic infection, which is then responsible for its own pathology:
Chronic adenoiditis (inflammation of the vegetations) and middle ear pathology with recurrent or chronic otitis (see chapter on seromucosal otitis)
Recurrent or chronic tonsillitis, hypertrophy that can lead to respiratory difficulties in children, as well as in adults.
Main indications for tonsillectomy
They result from this unfavourable evolution, and today 4 main reasons allow us to propose their ablation:
Infections of the tonsils, which increase in volume, become red with sometimes white spots, and which recur rapidly as soon as the treatment is stopped. It is considered that more than 5 or 6 tonsillitis (sore throats) in a year may justify their removal. However, this situation is quite rare in children, and is more often encountered in adults whose tonsils are in fact constantly infected, with acute outbreaks from time to time.
Severe enlargement of the tonsils is often the main reason for their removal in children.
How to recognise it? There are signs that are suggestive:
- Daily and systematic snoring,
- night wakings, nightmares, enuresis sometimes,
- the observation by the family of sleep apnea.
These nocturnal respiratory difficulties have important consequences on the development and growth of the child, who is tired in the morning, agitated during the day, does not eat well and is not concentrated at school.
All these signs, associated with the observation of enlarged tonsils, possibly accompanied by exclusively oral respiration, making it possible to suspect a concomitant hypertrophy of the vegetations, allow the indication of tonsillectomy.
3. Suspicion of a haematological disease, such as lymphoma, or cancer of the tonsil (mainly in adults) is fortunately a much rarer possibility requiring removal for histological analysis.
4. Dental malposition :
The exclusive mouth breathing sometimes induced by these hypertrophies can cause an imbalance between the muscular strap of the lips and the pressure of the tongue on the teeth. As the lips are almost permanently open, the tongue will push the teeth forward, leading to a dental malposition which will require orthodontic work to "recover" a good dental articulation. The indication for surgery must be very careful here, and the benefit/risk ratio must be carefully evaluated. Although today the technique of intracapsular tonsillectomy should be proposed first here, we will discuss it further below.
Whatever the pathology that may lead to this operation, only the ENT specialist can take the responsibility of proposing this operation to you or your child.
It is necessary to establish the benefit of the surgery in relation to the risks involved. The main risk is post-operative bleeding, which can occur in 1% of cases, whatever the technique used, up to 15 days after the operation and sometimes up to the 21st day.
A recent study published in the journal Pediatrics shows that the indications must be reduced further, because in the short or long term everything returns to normal in the majority of cases.
When surgery is indicated, the operation is performed under general anaesthesia. Intubation for breathing during the operation is done through the nose so as not to interfere with the surgical procedure in the mouth. A mouth opener with a built-in tongue depressor is positioned to clear the oropharynx
The first procedure, when indicated, is the removal of the vegetations that lie behind the veil in the cavum
As far as the actual tonsillectomy is concerned, there are several techniques.
Today I no longer perform a complete tonsillectomy, but only a partial one, whatever the indication
The principle is based on the use of radiofrequency to reduce the volume of the tonsils by leaving a tonsil "wall".
The aim is therefore to perform an intra-capsular tonsillectomy by reducing the volume of the tonsil, particularly in children, allowing better breathing and the disappearance of sleep apnea.
Its advantages are
- less post-operative pain
- but above all much less risk of bleeding
It is done with the help of a tip that uses radiofrequency. Personally, I complete the procedure by carrying out a gentle bipolar coagulation of the tonsil remnant, which makes it possible to observe a few weeks after the operation an almost total disappearance of the tonsil remnant left in place.
The main disadvantage is the risk of recurrence of the hypertrophy of the tonsil remnant. However, this risk is minimised by the technique we use, i.e. gentle coagulation of the tonsil remnants with radiofrequency at the end of the operation.
During the operation the anaesthetist, if there are no contraindications, administers corticosteroids, which will be renewed on the evening of the operation and in the morning for 5 days. The combination of a dissection without excessive burning and corticosteroids considerably reduces post-operative pain, particularly in children.
The use of corticosteroids has not been irrefutably proven in scientific studies, but is recommended by the French Society of Anaesthesia and Intensive Care, as it reduces post-operative vomiting.
Nevertheless, with the current technique it is rarely necessary to give painkillers after 48 hours, as the child does not complain at all.
Post-operative monitoring is, for us, from 8 to 24 hours depending on the circumstances. The main risk is bleeding. But in reality this risk exists for 8 to 15 days after the operation whatever the technique used, but with a significant reduction in this risk by the intra-capsular technique. When certain conditions are met:
- proximity of the home, (as a rule less than one hour's travel time)
- possibility of monitoring at home and transport to the clinic in case of problems
- agreement of the parents
- Oral feeding possible, without vomiting
- pain is under control
- absence of bleeding or clot in the tonsil lodges: this implies that the child must be seen by the ENT specialist before discharge
we propose this operation as an outpatient procedure, giving strict instructions to act quickly in the event of bleeding.
The main concern after the risk of bleeding is pain. You will have been prescribed medication beforehand to combat this. It is important to know that this pain often reappears during swallowing and eating, so the painkillers must be given 1 hour before the meal so that they are effective at the right time. On the 5th or 6th day, pain may appear in the ears. This is not usually an otitis but a reflex pain coming from the operated area. Once again, in children, the intracapsular technique significantly reduces post-operative pain.
Rules to be observed after discharge
In terms of monitoring
The child must be monitored throughout the recovery period, but it is above all the existence of even minimal but repeated bleeding that must attract your attention. In very young children, the blood is sometimes swallowed and the bleeding, which is said to be occult (hidden), can be significant. If you have the slightest doubt, do not hesitate to call the practice during working hours, and the clinic the rest of the time and at night.
On the dietary level :
It is advisable to avoid foods that "stick" such as bread crusts, rusks, etc. for 8 to 10 days. Acidic foods that increase pain (tomatoes, lemons, citrus fruits in general). It should be noted that potatoes can be a source of pain. Ice creams are very popular with children, so do not deprive them of them during this period.
In terms of activity
It is strongly advised to keep the child quiet for a few days and avoid going out during the hot hours of the day. It is also important to avoid activities that may cause the child to become too agitated.