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03 / Otolaryngology, Head & Neck · open

Tonsillectomy

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.

Part of Otolaryngology, Head & Neck →4 stages2 complications to knowopen

On the tray for this operation

Test yourself on the tray

Stage

1 / 4

Positioning 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.

🔧 Kocher clamp

Watch for: Tube displacement by the gag · Dental injury

Why are we operating?

Tonsillectomy removes the palatine tonsils from their capsular bed: for recurrent tonsillitis meeting criteria, obstructive sleep-disordered breathing in children, and the quinsy that keeps returning. It is one of surgery's commonest operations, and its teaching value is exactly that: a routine procedure whose one serious complication, post-operative haemorrhage, every doctor who ever covers a ward must know by name and by day.

Pulls toward surgery

Recurrent tonsillitis meeting frequency criteriaObstructive sleep apnoea in childrenRecurrent peritonsillar abscessAsymmetry or suspicion needing histology

Gives the team pause

Bleeding diatheses screened by history, not assumedActive infection timing the operationThe counselling that day 5-10 bleeding is a hospital visit, always

What the surgeon is thinking

  • Positioning and exposure

    Why does this operation share the airway with the anaesthetist?

    The surgeon works inside the mouth the anaesthetist is ventilating through: the gag holds the field open around the tube, and every instrument passes the airway's front door. The choreography (tube position, gag placement, the throat pack's count) is the safety system.

  • Finding the capsule plane

    What is the capsular plane, and why is it the whole operation?

    The tonsil sits in a fibrous capsule separated from the pharyngeal muscles by loose areolar tissue: dissection in that plane delivers the tonsil with minimal bleeding, while straying deep enters muscle that bleeds and hurts. The operation is the plane; everything else is retraction.

  • Delivery and haemostasis

    Why is the fossa's haemostasis so deliberate for such a common operation?

    The tonsillar bed is supplied from multiple named vessels, and its clot will spend a week dissolving next to food and speech: each point is controlled with ties or precise bipolar, and the fossa inspected after the pressure of the gag relaxes, because the bleed that matters is the one that starts when everything relaxes.

  • Recovery and counselling

    Why is the discharge counselling part of the operation?

    Because the dangerous complication happens at home: secondary haemorrhage peaks at days 5 to 10 as the slough separates, and families are taught that any bleeding, even spat streaks that stop, means hospital assessment now. Eating normally and analgesia by the clock keep the fossae clean and the swallow working.

Decision points

  • Cold steel with ties, or diathermy dissection?

    • Cold steel

      The traditional plane found sharp, vessels tied: some series show lower secondary haemorrhage, at the cost of more intraoperative blood.

    • Diathermy or coblation

      Drier fields and speed, with thermal energy in the bed as the traded variable: technique per unit and training.

    The technique debate is a lesson in audited surgery: national registries track bleeding by method, and the honest answer is that the operator's practised technique done well beats any technique done occasionally.

  • A child returns on day 6: one episode of spitting fresh blood, now stopped, observations normal.

    • Admit, observe, prepare

      The herald bleed rehearses a bigger one: admission, IV access, group and save, and ENT review of the fossae is the floor, not an overreaction.

    • Reassure and discharge

      The named error of this operation: children compensate silently, swallow their evidence, and then decompensate abruptly.

    Every post-tonsillectomy bleed is assessed in hospital, and the active bleed goes back to theatre with an anaesthetic plan that respects a stomach full of blood: this is the ward-cover knowledge the operation exists to teach.

Leaving the OR

The handoff

Procedure
Bilateral tonsillectomy, capsular plane, bipolar haemostasis
Field
Fossae dry after gag release; throat pack out and counted
Analgesia
Regular paracetamol and NSAID by the clock; no codeine in children
Watch for
Swallowing frequency (hidden bleeding), first eating and drinking, day 5-10 counselling delivered and understood

A fictional educational patient, handed over the way real ones are.

The postoperative course

  1. Day 0Eating and drinking before discharge in day-case pathways: a working, used swallow is both the analgesia test and the recovery plan.
  2. Days 1-4Sore ears (referred via glossopharyngeal) and white fossae are normal healing, not infection: analgesia by the clock keeps the throat in use.
  3. Days 5-10The secondary haemorrhage window: the counselling's one rule (any bleeding means hospital) is the safety net, and it was taught before discharge, twice.
  4. Week 2+Pain resolves, eating normalises, and for the sleep-apnoea children the nights answer whether the operation delivered its purpose.
Continue this patient as a case

Watch it done

Find Tonsillectomy videos on YouTube

What can go wrong

Postoperative bleedingSurgical-site infection
OR Prep this operationReview the instruments