Tonsillotomy: facts and fiction

In contrast to total or extracapsular tonsillectomy (TE), subtotal/intracapsular/partial tonsillectomy (SIPT) or tonsillotomy (TT) is associated with significant less postoperative morbidity. It has been stated that patients older than 8 years of age or with a history of tonsillitis should be excluded from SIPT/TT. Some health insurance companies mandate utilization of particular surgical instruments. Finally, it has been stated that the remaining tonsillar tissue may become a subject of recurrent tonsillitis or tonsillar regrowth, in both cases requiring revision surgery in terms of TE. This literature review was undertaken to clarify what has been validated in the literature concerning indications, surgical techniques, complications and outcome of SIPT/TT as reported since 1960. A Medline review was undertaken and all papers included that were published in English or German language until September 30, 2013. Exclusion criteria were: publication date 1960 and earlier, other languages, no relation to tonsil surgery, papers not available to the authors, uncommon surgical techniques, national surveys or studies without patients. The quality of the papers was classified according to “The Oxford 2011 Levels of Evidence”. The surgical techniques were classified according to Windfuhr and Werner and extended to interstitial tonsil therapy. Other issues were: study period, hemorrhage, dehydration, intake of analgesics, return to normal diet, surgical instruments, operation time, number of surgeons involved, number of patients, age, indications, follow-up, rate of tonsillar regrowth, tonsillitis and secondary TE. A total of 379 different publications were retrieved, but only 86 studies found eligible for further analysis. There were 10,499 patients in the study groups and 10,448 patients in the control groups. Utilization of the microdebrider largely prevailed, followed by Coblation, CO₂-LASER, surgical scissor, Radiofrequency, Interstitial ThermoTherapy with various instruments, Diode-LASER, and other instruments. Instruments were not specified for 1,815 patients. Data for operation time, intraoperative bleeding, return to normal diet, analgesic intake were in favor for SIPT/TT and ablation procedures. Regrowth and tonsillitis occurred in rates of <6 % on average. Secondary surgery became necessary in only every third patient of this subgroup. Studies of variable quality impede comparison of all aspects in the papers. At least every second study did not address issues like operation time, intraoperative bleeding, return to normal diet, analgesic intake, rates of tonsillar regrowth, postsurgical tonsillitis and secondary TE. There are insufficient data to show that a single surgical instrument is superior. A history of tonsillitis and an age >8 years are definitely not commonly accepted as contraindication for SIPT, TT or ablation procedures. There is a strong evidence that pain is less after SIPT, TT and tonsil ablation resulting in an earlier return to normal diet and activity. Large, well-designed randomized controlled trials with an adequate follow-up are necessary to determine whether the procedure is capable to replace TE to resolve upper airway obstruction resulting from tonsillar hypertrophy as well as recurrent episodes of tonsillitis in children and adults.