Tonsillectomy

Why are we operating?

Removal of the palatine tonsils from their fossae, high-volume, deceptively routine, and owner of one of surgery's most feared small complications: the post-tonsillectomy bleed.

Indication: Recurrent tonsillitis meeting frequency criteria, obstructive sleep apnoea in children, suspected malignancy, and quinsy that recurs.

The operation in 4 steps

1. 01Positioning and exposure

   Under a shared airway with the tube fixed midline, the mouth is held open with a gag, the tonsil grasped and drawn medially to display its fold.

   Why: The whole operation happens inside the anaesthetist's workspace; the gag and tube are a negotiated settlement. Medial traction opens the peritonsillar plane the dissection lives in.

2. 02Finding the capsule plane

   The mucosa of the anterior pillar is incised and the avascular plane between the tonsil capsule and the pharyngeal muscle bed developed from upper pole downward.

   Why: The capsule is the operation: on it, the dissection is nearly bloodless; through it, the muscle bed bleeds and hurts for weeks. The plane rewards patience at the upper pole where it is easiest to find.

3. 03Delivery and haemostasis

   The tonsil is freed to its lower pole pedicle and delivered; the fossa is packed, then each bleeding point tied or precisely bipolar-coagulated until bone dry.

   Why: There is no drain and no dressing possible in the pharynx; haemostasis is the only protection the patient leaves with. The lower pole vessels are the usual offenders and get named attention.

4. 04Recovery and counselling

   The bed is re-inspected before waking, and the family counselled: pain peaks around day 5, eating protects, and any bleeding at home, however small, returns to hospital immediately.

   Why: Secondary haemorrhage arrives around days 5 to 10 as the slough separates, at home, not on the ward. The counselling is the safety net: a 'small spit of blood' can herald the big one, and everyone must know it.

Danger zones

• Internal carotid artery

  Deep or lateral diathermy and deep suture bites pass toward it through a wall the operator cannot see beyond.

Anatomy you need

The mouth and pharynx: the tonsils sit in the lateral wall you see, with the internal carotid closer behind than anyone likes.

What can go wrong

• Postoperative bleeding

  Tachycardia first, hypotension late; falling urine output; a distending abdomen or rising drain output.

• Surgical-site infection

  Wound erythema, warmth, discharge, and pain out of proportion, typically from postoperative day 4–7.