New tonsillectomy can reduce pain, bleeding, but can recur after surgery Last February Zelda Williams went home and ate a big bowl of noodles just hours after her tonsillectomy. Three years later there is a new tonsil procedure called an intracapsular tonsillectomy, which Zelda Williams’ mother told her was completely different in terms of recovery than the previous one. Zelda’s experience may not be representative, but new research shows that children undergoing the new procedure bleed less and are less painful than those undergoing the traditional procedure. Richard Schmidt, an ear, nose and throat pediatric surgeon who led the study group, told WebMD that he wasn’t surprised by the findings. “Eighty to 90 percent of our tonsillectomies here are done intracapsularly, and it’s become our standard procedure,” says Dr. Schmidt, who has been performing intracapsular tonsillectomies on children at Wilmington Alford Hospital for five years. Old and New Tonsillectomy The newer procedure uses a device called a microdebrider to remove only 90 to 95 percent of the tonsils instead of all of them. A thin layer of podiatric tissue outside the tonsils is preserved to prevent the delicate laryngeal muscles from being exposed. Protecting these muscles can reduce pain and decrease postoperative bleeding. But preserving some of the tonsils means a recurrence is possible and a second surgery is needed. Schmidt said, “The risks, while small, are really the downside of this procedure.” Schmidt and colleagues reviewed 2,944 children who underwent tonsillectomy at Eastern State Hospital from 2002 to 2005, 1,700 of whom underwent the podoconiosis-preserving capsulotomy and 1,200 of whom underwent the traditional procedure. The study showed that three times as many children in the traditional tonsillectomy group were still bleeding at 24 hours than in the newer group (3.4% vs. 1.1%), and four times as many in the traditional group required surgical hemostasis after surgery than in the newer group (2% vs. 0.5%). Only 3% of patients undergoing endocystectomy required emergency treatment for pain or dehydration (as a result of dehydration to avoid pain), compared with 5.4% in the conventional group. However, 11 (0.6%) of the intracapsular resection group recurred and required reoperation. This recurrence rate is consistent with previous reports of slightly more than 0.5% of recurrences requiring reoperation for this procedure. The study was published in the September issue of the Journal of Otolaryngology and Head and Neck Surgery. Not all ENTs are credible Schmidt believes the new procedure should become the standard procedure for tonsillectomy in children because of the enlarged tonsils. There have been few studies of children who have had postoperative recurrences or who have had tonsillitis as a result. David Darrow, a head and neck pediatric surgeon, said he is not sure that the benefits of intracapsular tonsillectomy outweigh its risk of possible reoperation if the indications for the procedure are not considered. He told WebMD that he and colleagues recently did a similar comparison of children with different procedures at the Norfolk hospital where he works. Compared with traditional tonsillectomy, the newer procedure does result in less pain, less bleeding and other comorbidities, but Darrow describes it rather modestly. He said, “We came to a completely different conclusion in terms of surgical outcomes, and others routinely use the new procedure, but I don’t think it’s reasonable to create a risk of recurrence by preserving some of the tonsillar tissue, so I don’t use that procedure.” He goes on to say that a new procedure should not be used without the patient fully understanding the pros and cons of the procedure. darrow is a professor of pediatric otolaryngology at Virginia Eastern Hospital, and he also heads the tonsillar hyperplasia subcommittee of the American Academy of Otolaryngology. He says, “Whether a patient wants to risk another surgery for reduced pain should ultimately be up to the patient.”