OPEN ACCESS ATLAS OF OTOLARYNGOLOGY, HEAD & NECK OPERATIVE SURGERY

TONSILLOTOMY (PARTIAL) & COMPLETE - SURGICAL TECHNIQUE Klaus Stelter and Goetz Lehnerdt

Acute is treated with steroids e.g. first and easiest-to-reach station of the , NSAIDs e.g. and mucosa associated lymphoid tissue system beta-lactam antibiotics e.g. penicillin or cef- (MALT) 2-4. As the main phase of the im- uroxime. Only 10 days of antibiotic therapy mune acquisition continues until the age of has proven to be effective to prevent rheu- 6yrs, the palatine are physiological- matic fever and glomerulonephritis. ly hyperplastic at this time 5, 6. This is followed by involution, which is reflected Tonsillectomy is only done for recurrent by regression of size until age 12yrs acute bacterial tonsillitis, or for noninfec- 7. tious reasons such as suspected neoplasia. The lymphoid tissue is separated by a cap- Partial tonsillectomy (tonsillotomy) is the sule from the surrounding muscle (superior 1st line treatment for snoring due to tonsillar pharyngeal constrictor) 8. The supply hyperplasia. It is low-risk, and postopera- originates from four different vessels, the tive pain and risk of haemorrhage are much lingual artery, the ascending pharyngeal less than with tonsillectomy. It is immate- artery and the ascending and descending rial whether the tonsillotomy is done with palatine arteries. These vessels radiate , radiofrequency, shaver, coblation, bi- mainly to the upper and lower tonsillar polar scissors or monopolar electrocautery, poles, as well as to the centre of the tonsil as long as the crypts remain open and some from laterally 9. The tonsils have deep tonsil tissue remains. crypts that create a large surface area to provide a docking surface for potential Pain and haemorrhage are the main antigens 10. morbidity of tonsillectomy. may occur anytime until the wound is complete- ly healed, which is normally at 2-3 weeks. Patients have to be informed about what to do in case of haemorrhage. Life threaten- ing haemorrhage often is preceded by smaller bleeds, which can spontaneously cease. That is why every haemorrhage, even the smallest, has to be treated as an inpatient. Massive haemorrhage is an extre- me challenge for every paramedic or emergency doctor because of difficult Figure 1: Hyperplastic tonsils in a child airway management. Tonsil diseases Function and anatomical structure of tonsils in childhood and adolescence Sore episodes (R07.0)

Tonsils allow one to acquire immunity and Synonyms include “acute ”, and provide immune defence by antigen pre- “throat ”. "Sore throat" is an im- sentation. This is why they contain T-lym- precise term and does not clinically distin- phocytes, germinal centres of B-lympho- guish between acute tonsillitis and pharyn- cytes 1 and macrophages. They are the gitis. Neither the cause nor the exact loca- tion is determined 11. In “sore throat” it ly caused by many different bacterial patho- remains unclear whether one is dealing with gens 28, 29 and flare up again a few weeks acute (bacterial) tonsillitis which, if recur- after cessation of antibiotic therapy 30. De- rent, is an indication for tonsillectomy 12. pending on the frequency and severity of such episodes, this is an indication for Acute tonsillitis (J03.0 - J03.9) tonsillectomy.

Also known as “severe tonsillitis” 13, “true (J36) tonsillitis”, or “acute sore throat” 11, this refers to viral or bacterial tonsillitis with This is also called “peritonsillitis”, or “quin- odynophagia, swelling and redness of the sy” 31, 32, and is acute tonsillitis complicated tonsils, possibly with a tonsillar exudate, by an abscess, typically unilateral 33. The cervical lymphadenopathy and fever abscess may form in the intratonsillar, para/ >38.3°C (rectal) 14, 15. Odynophagia for 24- peritonsillar or retrotonsillar spaces. The 48 hours, as part of prodromal symptoms of pathogens are typically staphylococci 34, a common cold (viral infection of upper streptococci and fusobacterium necropho- respiratory tract), is excluded from the term rum 35. In contrast to acute tonsillitis, virus- "acute tonsillitis" 11. Depending on the stage es play no role in abscesses 36. A peritonsil- and appearance of the tonsillar deposits or lar abscess is drained by aspiration or exudate, one can distinguish catarrhal drainage or by unilateral tonsillectomy. angina with redness and swelling of the tonsils (early stage), from follicular angina Tonsil hyperplasia (J35.1 and J35.3) with stipple-like fibrin deposits, from lacunar angina with confluent deposits Tonsil hyperplasia 37, also known as (idio- (late stage) 16, 17. "Acute tonsillitis" can be pathic) tonsillar hypertrophy 38, refers to ab- diagnosed by a specialist purely on clinical normal enlargement of the . It grounds 18. Smears, blood tests or viral has to be distinguished from physiological evidence are unnecessary in most cases 19- paediatric palatine tonsil hyperplasia 39, 40 23. Penicillin or another beta-lactam anti- which is not a sign or consequence of recur- biotic is the first line of treatment. rent inflammation 41, 42. Also, children with tonsil hyperplasia do not suffer from acute Chronic tonsillitis (J35.0 and J35.9) tonsillitis 43, 44 or middle ear 45. A paediatric tonsil is only "pathologically" Also called “chronic (hyperplastic) tonsilli- hyperplastic if snoring (with or without tis”, it is not well-defined and thus should obstructive sleep apnoea) or rarely dyspha- not be used 24. It is better to speak of gia 46 or even more rarely dysphonia 47 (chronic) recurrent tonsillitis 25, 26, because occur. true chronic tonsillitis with persistent symp- toms lasting >4 weeks with adequate treat- Surgical procedures ment and recovery of the mucosa (as in rhinosinusitis) does not exist. Tonsillectomy

Recurrent acute tonsillitis (J35.0) (Extracapsular) tonsillectomy means that the entire tonsil, including its capsule, is Also called “recurrent tonsillitis” or “recur- removed from the tonsil fossa; no lympha- rent throat infections” 27, this refers to recur- tic tissue remains between the anterior and rent bouts of acute tonsillitis. In contrast to posterior palatal arches 48. Since the late a single attack of acute tonsillitis, it is usual- 1960s, with the realisation that the tonsil is

2 a focus of infection 49-52, this form of tonsil Thermal- or cryotherapy of palatine tonsil operation has been the gold standard and is still the most common surgery done in the The tonsil tissue is heated (or cooled) inter- world 53. stitially; subsequent scarring causes shrink- age of the lymphoid tissue. No tissue is Video 1: Extracapsular tonsillectomy removed and a large part of the lymphoid (http://youtu.be/V__tloYXfwQ) tissue allegedly remains functional. The indication is mild tonsillar hyperplasia. Tonsillotomy (partial tonsillectomy) Synonyms and different techniques include interstitial (electro), laser coa- Only the medial part of the tonsil is remov- gulation, thermal coagulation, and cryocoa- ed. It requires that the (well-perfused) lym- gulation of the palatine tonsil 60, 61, photo- phatic tissue is resected, and that the re- dynamic therapy, therapy 62, maining crypts remain open to the orophar- radiofrequency-induced thermotherapy 63, ynx 54, 55. Active lymphatic tissue, with temperature-controlled tonsil treatment 64, secondary follicles and crypts, is left in the 65, and tonsil thermotherapy. tonsil fossae 56. Tonsillotomy can be done with most dissecting and coagulating meth- Preoperative evaluation, swabs & diag- ods. The most common are laser tonsilloto- nosis my and radiofrequency tonsillotomy and are described in detail in this chapter. Pathogens, biofilms, and normal findings

Video 2: Laser tonsillotomy With the discovery of rheumatic fever, (http://youtu.be/2AUzLY3rewM) group A streptococci (GAS) were primari- ly blamed for all ills in the upper respire- Video 3: Radiofrequency tonsillotomy tory tract in the 70’s 66-73. However more (http://youtu.be/eQ7bbT0mj0k) recently, anaerobes, e.g. Fusobacterium necrophorum, Streptococcus Intermedius Intracapsular tonsillectomy and Prevotella Melaninogenica and Histi- cola have also been incriminated 28, 74, 75. Intracapsular, subcapsular or subtotal ton- sillectomy describes a method in which the Children up to 8yrs of age have a tendency lymphatic tissue of the tonsil, including all towards diffuse intracellular pathogen en- crypts and follicles, is removed 57, 58, but richment with interstitial abscesses, while the capsule of the tonsil is preserved; thus in adults or adolescents a more superficial the underlying muscles are not exposed 59. bacterial accumulation at the edge of the At the end of the operation there is an empty crypts occurs. Particularly in the case of tonsil fossa without typical subsequent recurrent tonsillitis, several pathogens and scarring 59. Indications for intracapsular microorganisms play a joint role. These can tonsillectomy are foetor ex ore (halitosis) jointly form biofilms and bacterial clusters and recurrent detritus (debris) in the ton- and thus evade antibiotics 76. The oral cavity sillar crypts. It differs from tonsillotomy in and especially the furrowed tonsil is a reser- which a lot more tonsillar tissue is left voir for multiple pathogens (viruses and behind. bacteria), parasites 77 and fungi 78. Howev- er, all these microbes belong to resident Video 4: Intracapsular tonsillectomy with flora with which we have lived symbioti- radiofrequency cally for aeons 28, 79. Streptococci still play (http://youtu.be/4A6JhQJlabg) the largest role in acute tonsillitis (30%) 80,

3 followed by Haemophilus Influenzae and for patients with proven penicillin allergy 92, Neisseria 28. Mostly, however, mixed infec- 93. tions (viral and bacterial initially) are re- Postoperative antibiotic therapy is not sponsible 81. indicated as it neither reduces pain nor post- operative bleeding 94, 95. Diagnosis Steroids: In acute tonsillitis or after tonsil- "Acute tonsillitis" in children and adults is lectomy, oral or intramuscular steroids a clinical diagnosis 82. In viral tonsillitis, in (dexamethasone 10mg), as well as betame- addition to pain and fever, primarily cough, thasone (8mg) and prednisolone (60mg), hoarseness, and rhinorrhoea occur, while in significantly improve symptoms with mini- bacterial tonsillitis, in addition to pain with mal side effects and no adverse effects rela- lymph node swelling, there is mainly a ting to disease progression 96-98. tonsillar exudate and fever >38.3°C 83 . A streptococcal antigen test can confirm the Analgesics: Nonsteroidal anti-inflamma- diagnosis and is 98% specific for strepto- tory drugs have been used successfully for cocci, although not particularly sensitive. A pain relief for >40yrs 99. For acute tonsil- problem with these tests is the high number litis, ibuprofen has the best efficacy with of asymptomatic chronic carriers of staphy- minimal side-effects compared to paraceta- lococci and streptococci (10% of healthy mol and acetylsalicylic acid (ASA) 100. children), who are definitely not in need of Another advantage of ibuprofen is its longer therapy 84-89. In the early stages, a distinc- duration of action (6-8hrs) compared to tion between viral and bacterial tonsillitis is . Both substances have a large often difficult to make, especially when one therapeutic range and at the correct dosage, considers that in 97.5% of cases, at least one the safety is comparable 101, 102. Diclofenac virus, even in bacterial tonsillitis, is found and ketorolac are very effective, but in (adenovirus and parainfluenza virus re- children have fewer docking sites and are spectively in 47.5% 90, 91 ) 81. metabolised more quickly, which is why the dose should be adjusted to a higher level Conservative Treatment than in adults) 103. In postoperative manage- ment these substances play a role in Antibiotic therapy: In clinically apparent or reduction, but as first-line therapy in paed- proven bacterial tonsillitis associated with iatrics are not suitable for a sore throat 104, distress, antibiotics (beta-lactam) are justi- 105. Metamizol is not recommended as first fied. Beta-lactam antibiotic therapy also or second choice analgesic in children due provides relatively reliable protection to a small but real risk of agranulocytosis against the dreaded rheumatic fever and 106. glomerulonephritis which often cause, es- pecially in developing countries, arthritis, Complications of tonsillitis myocarditis and death. Studies have shown that antibiotic therapy can prevent sequelae In general, acute tonsillitis runs its course such as peritonsillar abscesses, acute otitis without complications and heals within 3-4 and sinusitis. The penicillins, particularly in days. Rare but serious complications after children and adolescents, have the greatest streptococcal tonsillitis are glomerulone- benefit at the lowest cost. There is no dif- phritis and rheumatic fever, which trig- ference to cephalosporins. Macrolides and gers cardiomyopathies and rheumatic-like clindamycin have more side-effects with joint pain 107. Early and a long course (10 the same efficacy and should be reserved days) of antibiotics (penicillin or cephalo-

4 sporin) reduces the frequency of both these • 5 episodes of tonsillitis per year in 2 complications by 70% 108 . In parts of the consecutive years or, developing world where rheumatic fever is • 3 episodes of tonsillitis per year in 3 more common, preventing this complica- consecutive years tion is the main argument in favour of peni- cillin therapy 108. A diagnosis of "purulent tonsillitis" must however be documented and confirmed by Peritonsillar abscess is a second, more fre- an elevated temperature (>38.3°C), tonsillar quent complication. It is typically unila- exudate, enlarged lymph nodes at the angle teral, although bilateral abscesses occur in of the jaw, and antibiotic treatment 119, 120. up to 4% 109. It is preceded by acute tonsi- The authors also reported that on average llitis in only 1/3 of cases 110. Even correctly only a few (not all) throat infections can be administered antibiotic treatment of acute prevented by tonsillectomy in the following tonsillitis cannot really prevent peritonsillar 2 years; 47 of 187 patients withdrew from abscesses (in contrast to rheumatic fever) the planned three-year follow-up 121. For 111. Since peritonsillar abscesses can rapid- less severe sore throat inflammation or less ly spread to the soft tissues of the neck and frequent throat inflammation, the risk of are potentially life-threatening, the primary tonsillectomy does not outweigh the bene- therapy is urgent and surgical 112-114. It does fits 122. not matter whether the abscess is needle as- pirated, incised or treated by tonsillectomy While tonsils contribute to immune compe- 115. But the surgeon has to keep in mind that tence until 12yrs, a negative long-term a stab incision can fail to drain inferiorly- effect on the cannot be located abscesses 109, 116. Before the opera- proven 123. Nevertheless, in children under tion, high-dose steroid therapy, as well as 8yrs, the indications for complete removal penicillin should be administered, as is must be strictly adhered to, as the risks of often done for mixed infections 117. serious or fatal bleeding are higher 124.

Indications for tonsil surgery With tonsillotomy (unlike tonsillectomy), some active lymphatic tissue is retained; it Surgery is done for infections, to relieve air- continues to grow in about 15% of cases, way obstruction, for halitosis and for diag- but rarely causes problems such as renewed nosis when a tumour is suspected. Surgery snoring or recurrent tonsillitis 125. The fear for recurrent tonsillitis depends on its fre- that frequent tonsillitis or peritonsillar ab- quency and severity, and the presence of ad- scesses will occur after tonsillotomy is ditional diseases (antibiotic allergies, im- unfounded 126-128. All crypts remain open munosuppression and PFAPA syndrome). during laser, ultrasound, shaver, high- and radiofrequency technique 129, 130. Paradise criteria for tonsillectomy 118 Surgical technique Paradise (1984) reported that tonsillectomy significantly lowers the frequency of severe Extracapsular tonsillectomy recurrent sore in children aged 3- 15yrs. Most published guidelines incorpo- Cold steel dissection is the most common- rate the so-called Paradise criteria for ly performed surgical technique in children tonsillectomy: and adults, and is described in detail in the • 7 episodes of tonsillitis per year in one chapter on Paediatric Tonsillectomy. The year or, technique is similar in adults.

5 The tonsils are dissected from the tonsil bed • Bipolar scissors 140 partly sharply and partly bluntly with a • Argon gas-assisted monopolar needle raspartorium and scissors. The feeding ves- 141 sels, especially at the upper and lower tonsil • Microdebrider 142 pole, are pinched off and then selectively ligated. After removal of the tonsil, a dry Advantages of tonsillotomy (regardless of swab is pressed for about 1 minute into the what method is used to reduce the tonsils) tonsil bed to stop bleeding from small ves- are significantly less pain 143 and a lower sels. Some surgeons perform additional postoperative bleeding rate 144 compared suturing of the lower pole (so-called “pole with tonsillectomy. 131 suturing”, a controversial method ). The quickest and easiest way to perform This method of tonsillectomy has been tonsillotomy is with monopolar high fre- known for decades and has been very com- quency dissection (Video 3). Instrumenta- monly used, especially in the 70s and 80s tion is shown in Figure 2. with the discovery of that tonsils are a source of infection 132. Optical magnifica- tion (microscope or loupes), makes it pos- sible to specifically identify the smaller vessels and perform bipolar coagulation before dissection 133.

Due to its good long-term results and low morbidity and mortality, cold steel dissec- tion is still the most common method of tonsillectomy 134 .

Tonsillotomy (partial tonsillectomy) Figure 2: Instruments to perform radio- The tonsil is not completely removed, but frequency dissected tonsillotomy / partial only the portion that bulges into the throat, tonsillectomy which due to its size causes functional pro- blems. By preserving some tonsil tissue a • Following induction of general anaes- lymphatic and immunologically active thesia the patient is positioned supine rudiment is retained. with neck slightly extended • Select an appropriate length Boyle The tonsil has a rich blood supply and has Davis blade and insert the gag to retract to be sufficiently cut and coagulated (not the and expose the tonsils crushed) during surgery so that there is no (Figure 1) postoperative bleeding, infection or pain. • Grasp a tonsil with a broad tonsil hol- To this end, several dissection procedures ding forceps and gently pull it toward have been developed (in principle, a tonsil- the midline. Avoid pulling too hard to lectomy can also be performed with all avoid doing a complete tonsillectomy these methods): • Insert a Colorado needle into the tonsil 135 136 • CO² laser at the edge of the anterior faucal pillar 137 • Monopolar high frequency current • Spare the mucosa of the velopalatinal • Ultrasound 138 arch to avoid bleeding and pain in the • Bipolar radiofrequency coblation 139 incision line

6 • Amputate the protruding part of the exposed. Severe pain and superinfection of tonsil by dissecting with continuous the wound bed can cause delayed healing movements of the needle. Do not and prolong hospital stay. Especially ado- remain too long in the same place with lescent and adult patients report pain, ex- the cutting needle as it may burn holes haustion and fatigue weeks after surgery. In in the tonsil tonsillectomy the wound remains open and • Pack the wound with a gauze swab for heals in 2-3 weeks secondarily by granula- at least 1 minute tion. Sealing the wound beds postoperative- 153 154 • Minor bleeding stops spontaneously. ly e.g. with fibrin glue or sucralfate Larger bleeding vessels can be coagula- has no advantage in terms of postoperative ted with bipolar forceps. A suture or bleeding or pain. ligature is not required • Repeat the process on the contralateral With tonsillotomy, however, pain was side reported as only around 2-3 on the numerical analogue scale. Intracapsular (subtotal) tonsillectomy Intracapsular tonsillectomy is allegedly less 155 The tonsil capsule covering the underlying painful than tonsillectomy . However, it muscle remains in the tonsil fossa 145. is unlikely that intracapsular tonsillectomy Slightly less postoperative pain and earlier produces as little pain as tonsillotomy. Pain food intake have been reported 146. The is perceived very differently by individuals. instrumentation and technique is similar to In children and adults, the differences, re- tonsillotomy. All the methods of tonsilloto- gardless of surgeon and method, can be 156-158 my previously listed may also be used. The enormous . Children of African de- microdebrider has been reported to be a scent have more postoperative pain than 159 useful tool 147-152. Europeans and respond better to opiates . • The surgeon has to pull harder on the This complicates both objective pain mea- tonsil to subluxate the capsule, but the surement (which does not exist), as well as capsule itself has to remain in place and a standard therapy. Pain therapy must not be breached therefore be individualised and adjusted, es- pecially in children. Questionnaires (e.g. • It may be very difficult to determine the 160 exact proportion of residual tonsil that Ramsay Sedation Scale ) for analgesic remains in the fossa use, food intake, otalgia, and downtime use • After tonsillitis with subsequent - popular surrogate parameters. ring it is difficult even with loupes or a microscope to identify the exact plane Because pain is perceived and processed of the tonsil capsule and only to remove multimodally, the treatment must be multi- only the active lymphatic tissue modal. Firstly, a local long-lasting pain re- liever (e.g. Bupivacaine or Ropivacaine 161) • Because the vessels are bigger in the should be injected into the wound post- abyss of the crypts and near the capsule, operatively or perioperatively to pre-vent bleeding has to be controlled with activation of the early pain pathway 162-164. bipolar forceps more often than with Then already perioperatively it should be (more superficial) tonsillotomy cooled locally by a cold compress 165 and

later a lot of ice should be eaten (local cool- Postoperative pain ing and calorie intake) 166. Mouth-washes

with gingicaine, benzocaine or tetracaine Tonsillectomy is very painful, especially if also provide pain relief, but also numb the the capsule is breached and the muscle is

7 taste buds and respiratory flow receptors, sents a special problem because it often oc- which is often perceived as very unpleasant. curs only at home and therefore the time factor to get a professional play a major The perioperative and postoperative ad- role. ministration of high-dose steroids (dexame- thasone or prednisolone) is clearly recom- The most common cause of late bleeding is mended in all guidelines. This reduces post- the physiological detachment of the fibrin operative nausea and analgesic consump- layer from the open wound bed and usually tion significantly 167-169. results in harmless bleeding. This bleeding almost always ends spontaneously, or due A fixed analgesic regimen with ibuprofen to local icing (sucking ice cubes, applying or diclofenac makes sense in adults and an ice cravat) or by tranexamic acid intra- adolescents, but for children and infants res- venously or locally (rinsing) 179. If bleeding cue medication is often enough 170, 171. An does not spontaneously subside because a increased risk of bleeding due to non- larger vessel is bleeding, vessel ligation or steroidal anti-inflammatory drugs, (except suturing under anaesthesia is required. Mas- for aspirin) should not be feared 172, 173. One sive haemorrhage is an extreme challenge should therefore adhere to the WHO staging for every paramedic or emergency doctor system 174 (http://www.who.int/cancer/ because of the difficult airway manage- palliative/painladder/en/). After tonsillecto- ment. Intubation is only possible with suc- my, it may well be that in the first days tioning the airway with suction tubes WHO stage III drugs (strong opioid, e.g. (Figure 3). piritramide iv) or even a pain pump must be administered to ensure pain under 4 on the visual analogue scale and adequate food intake 175. Pain and nausea (with and with- out ) after tonsillectomy are often trivialized by both nurses as well as physi- cians and therefore it is more likely that few analgesics will be administered postopera- tively 176-178. Figure 3: Rigid tonsil or thoracic suction device manufactured by Cardinal Health, Post-tonsillectomy bleeding IL, USA (Medi-Vac ® Yankauer Suction Handle, REF KEX80) Early and late postoperative bleeding During induction and intubation, the ENT Postoperative bleeding can occur anytime doctor should be present and prepared to until the wound is completely healed, de- perform emergency Cricothyroidotomy. spite careful intraoperative haemostasis and Aspirated blood or incorrect intubation is dissection; usually after 2-3 weeks. the most common clinical complication of postoperative bleeding. Intraoperatively the Postoperative bleeding occurs either as so- surgeon must decide whether targeted bipo- called early bleeding within the first lar coagulation and swab pressure are suffi- 24hours, or in the form of late bleeding with cient or whether suturing or ligation are a peak incidence between the 5th and 8th day necessary. If that fails, either the lingual after surgery. From the 3rd postoperative artery, ascending pharyngeal artery, facial week bleeding occurs only very rarely. artery or even the external carotid artery Therefore late postoperative bleeding pre- must be ligated from externally or emboli- sation the feeding vessels by interventional

8 radiology should be done. Such massive 5. Perry M, Whyte A. Immunology of the bleeding is signalled in most cases by a tonsils. Immunol Today. 1998 minor "warning bleeding" 180, 181, so any Sep;19(9):414-21 bleeding must be taken seriously and the 6. Kaygusuz I, Godekmerdan A, Karlidag patient must be hospitalized. T, et al. Early stage impacts of tonsillectomy on immune functions of

children. Int J Pediatr Otorhinolaryngol. Postoperative bleeding depending on 2003 Dec;67(12):1311-5 method of surgery 7. Kaygusuz I, Alpay HC, Godekmerdan A, et al. Evaluation of long-term impacts In principle, intraoperative and postopera- of tonsillectomy on immune functions of tive bleeding can occur with all intervene- children: a follow-up study. Int J tions involving the tonsils. However, for the Pediatr Otorhinolaryngol. 2009 tonsillotomy the postoperative bleeding rate Mar;73(3):445-9 is, by a factor of 5-10, lower than that for 8. Perry ME, Slipka J. Formation of the tonsillectomy 182. In cryptolysis and ther- tonsillar corpuscle. Funct Dev Morphol. motherapy of the tonsils postoperative 1993;3(3):165-8 9. Westermann J. Organe des Abwehr- bleeding is a rarity 183, 184. Only extracap- systems. Springer; 2010. 361-362. sular tonsillectomy remains problematic. 10. Drucker M, Drucker I, Neter E, "Cold dissection" with ligature or suturing Bernstein J, Ogra PL. Cell mediated has the lowest postoperative bleeding rates. immune responses to bacterial antigens Significantly more severe late bleedinghas on human mucosal surfaces. Adv Exp been reported after laser, coblation, mono- Med Biol. 1978;107:479-88 polar or bipolar techniques 185-187. 11. Georgalas CC, Tolley NS, Narula A. Tonsillitis. Clin Evid (Online). 2009 Videos 12. Paradise JL. Etiology and management of and pharyngotonsillitis in Video 1: Extracapsular Tonsillectomy: children: a current review. Ann Otol Rhinol Laryngol Suppl. 1992 http://youtu.be/V__tloYXfwQ Jan;155:51-7 Video 2: Laser Tonsillotomy: 13. Lange G. [Angina and chronic http://youtu.be/2AUzLY3rewM tonsillitis--indications for Video 3: Radiofrequency Tonsillotomy: tonsillectomy]. Z Allgemeinmed. 1973 http://youtu.be/eQ7bbT0mj0k Mar 20;49(8):366-70 Video 4: Intracapsular Tonsillectomy: 14. Österreichische Gesellschaften für Hals- http://youtu.be/4A6JhQJlabg Nasen-Ohren-Heilkunde KuH, Kinder- und Jugendheilkunde. Gemeinsame References Empfehlung zur Entfernung der Gaumenmandeln (Tonsillektomie). 1. Westermann J. Organe des Monatsschr Kinderheilkd. 2008 Mar Abwehrsystems. Springer; 2010. 361-2 7;3(156):268-71 2. Brandtzaeg P. The B-cell development 15. Stuck BA, Gotte K, Windfuhr JP, in tonsillar lymphoid follicles. Acta Genzwurker H, Schroten H, Tenenbaum Otolaryngol Suppl. 1996;523:55-9 T. Tonsillectomy in children. Dtsch 3. Nave H, Gebert A, Pabst R. Morphology Arztebl Int. 2008 Dec;105(49):852-60 and immunology of the human palatine 16. Berghaus A. [Chronic inflammation of tonsil. Anat Embryol (Berl). 2001 the upper airways. Operation instead of Nov;204(5):367-73 antibiotic]. MMW Fortschr Med. 2005 4. Brandtzaeg P. Immune functions of Sep 29;147(39):27 nasopharyngeal lymphoid tissue. Adv 17. Berghaus A, Pirsig W. Mundhöhle und Otorhinolaryngol. 2011;72:20-4 . In: Berghaus A, Rettinger G, Böhme G., eds. Hals-Nasen-Ohren-

9 Heilkunde. 1 ed. Stuttgart: Hippokrates quiescent adenoiditis and tonsillitis. J Verlag; 1996. 386-453 Clin Pathol. 2007 Mar;60(3):253-60 18. Stuck BA, Gotte K, Windfuhr JP, 30. Jensen JH, Larsen SB. Treatment of Genzwurker H, Schroten H, Tenenbaum recurrent acute tonsillitis with T. Tonsillectomy in children. Dtsch clindamycin. An alternative to Arztebl Int. 2008 Dec;105(49):852-60 tonsillectomy? Clin Otolaryngol Allied 19. Stuck BA, Genzwurker HV. Sci. 1991 Oct;16(5):498-500 [Tonsillectomy in children: preoperative 31. Raut VV. Management of evaluation of risk factors]. Anaesthesist. peritonsillitis/peritonsillar. Rev Laryngol 2008 May;57(5):499-504 Otol Rhinol (Bord). 2000;121(2):107-10 20. Stuck BA, Gotte K, Windfuhr JP, 32. Fried MP, Forrest JL. Peritonsillitis. Genzwurker H, Schroten H, Tenenbaum Evaluation of current therapy. Arch T. Tonsillectomy in children. Dtsch Otolaryngol. 1981 May;107(5):283-6 Arztebl Int. 2008 Dec;105(49):852-60 33. Dalton RE, Abedi E, Sismanis A. 21. Kurien M, Stanis A, Job A, Bilateral peritonsillar abscesses and Brahmadathan, Thomas K. Throat swab quinsy tonsillectomy. J Natl Med Assoc. in the chronic tonsillitis: how reliable 1985 Oct;77(10):807-12 and valid is it? Singapore Med J. 2000 34. Klug TE, Henriksen JJ, Rusan M, Jul;41(7):324-6 Fuursted K, Ovesen T. Bacteremia 22. Fujikawa S, Hanawa Y, Ito H, Ohkuni during quinsy and elective M, Todome Y, Ohkuni H. Streptococcal tonsillectomy: an evaluation of : as an indicator of antibiotic prophylaxis recommendations tonsillectomy. Acta Otolaryngol Suppl. for patients undergoing tonsillectomy. J 1988;454:286-91 Cardiovasc Pharmacol Ther. 2012 23. Borschmann ME, Berkowitz RG. One- Sep;17(3):298-302 off streptococcal serologic testing in 35. Klug TE, Henriksen JJ, Fuursted K, young children with recurrent tonsillitis. Ovesen T. Significant pathogens in Ann Otol Rhinol Laryngol. 2006 peritonsillar abscesses. Eur J Clin May;115(5):357-60 Microbiol Infect Dis. 2011 24. Stuck BA, Gotte K, Windfuhr JP, May;30(5):619-27 Genzwurker H, Schroten H, Tenenbaum 36. Rusan M, Klug TE, Henriksen JJ, T. Tonsillectomy in children. Dtsch Ellermann-Eriksen S, Fuursted K, Arztebl Int. 2008 Dec;105(49):852-60 Ovesen T. The role of viruses in the 25. Stuck BA, Gotte K, Windfuhr JP, pathogenesis of peritonsillar abscess. Genzwurker H, Schroten H, Tenenbaum Eur J Clin Microbiol Infect Dis. 2012 T. Tonsillectomy in children. Dtsch Sep;31(9):2335-43 Arztebl Int. 2008 Dec;105(49):852-60 37. Reichel O, Mayr D, Winterhoff J, de la 26. Burton MJ, Towler B, Glasziou P. CR, Hagedorn H, Berghaus A. Tonsillectomy versus non-surgical Tonsillotomy or tonsillectomy?--a treatment for chronic / recurrent acute prospective study comparing tonsillitis. Cochrane Database Syst Rev. histological and immunological findings 2000;(2):CD001802 in recurrent tonsillitis and tonsillar 27. Georgalas CC, Tolley NS, Narula A. hyperplasia. Eur Arch Otorhinolaryngol. Recurrent throat infections (tonsillitis). 2007 Mar;264(3):277-84 Clin Evid (Online). 2007 38. Semberova J, Rychly B, Hanzelova J, 28. Jensen A, Fago-Olsen H, Sorensen CH, Jakubikova J. The immune status in situ Kilian M. Molecular mapping to species of recurrent tonsillitis and idiopathic level of the tonsillar crypt microbiota tonsillar hypertrophy. Bratisl Lek Listy. associated with health and recurrent 2013;114(3):140-4 tonsillitis. PLoS One. 2013;8(2):e56418 39. Perry M, Whyte A. Immunology of the 29. Swidsinski A, Goktas O, Bessler C, et tonsils. Immunol Today. 1998 al. Spatial organisation of microbiota in Sep;19(9):414-21

10 40. Goldberg S, Shatz A, Picard E, et al. 51. Wannamaker LW. Tonsils, rheumatic Endoscopic findings in children with fever and health delivery. N Engl J Med. obstructive : effects of age 1970 Feb 5;282(6):336-7 and hypotonia. Pediatr Pulmonol. 2005 52. Feinstein AR, Levitt M. The role of Sep;40(3):205-10 tonsils in predisposing to streptococcal 41. Reichel O, Mayr D, Winterhoff J, de la infections and recurrences of rheumatic CR, Hagedorn H, Berghaus A. fever. N Engl J Med. 1970 Feb Tonsillotomy or tonsillectomy?--a 5;282(6):285-91 prospective study comparing 53. van den Akker EH, Hoes AW, Burton histological and immunological findings MJ, Schilder AG. Large international in recurrent tonsillitis and tonsillar differences in (adeno)tonsillectomy hyperplasia. Eur Arch Otorhinolaryngol. rates. Clin Otolaryngol Allied Sci. 2004 2007 Mar;264(3):277-84 Apr;29(2):161-4 42. Ericsson E, Lundeborg I, Hultcrantz E. 54. Scherer H, Fuhrer A, Hopf J, et al. Child behavior and quality of life before [Current status of laser surgery in the and after tonsillotomy versus tonsil- area of the soft and adjoining lectomy. Int J Pediatr Otorhinolaryngol. regions]. Laryngorhinootologie. 1994 2009 Sep;73(9):1254-62 Jan;73(1):14-20 43. Stelter K, Ihrler S, Siedek V, 55. Koltai PJ, Solares CA, Mascha EJ, Xu Patscheider M, Braun T, Ledderose G. M. Intracapsular partial tonsillectomy 1-year follow-up after radiofrequency for tonsillar hypertrophy in children. tonsillotomy and laser tonsillotomy in Laryngoscope. 2002 Aug;112(8 Pt 2 children: a prospective, double-blind, Suppl 100):17-9 clinical study. Eur Arch Otorhino- 56. Reichel O, Mayr D, Winterhoff J, de la laryngol. 2012 Feb;269(2):679-84 CR, Hagedorn H, Berghaus A. 44. Sarny S, Ossimitz G, Habermann W, Tonsillotomy or tonsillectomy?--a Stammberger H. [The Austrian tonsil prospective study comparing study 2010--part 1: statistical overview]. histological and immunological findings Laryngorhinootologie. 2012 in recurrent tonsillitis and tonsillar Jan;91(1):16-21 hyperplasia. Eur Arch Otorhinolaryngol. 45. Braun T, Dreher A, Dirr F, Reichel O, 2007 Mar;264(3):277-84 Patscheider M. [Pediatric OSAS and 57. CHAMPEAU D. [Intracapsular otitis media with effusion]. HNO. 2012 tonsillectomy.]. Ann Otolaryngol Chir Mar;60(3):216-9 Cervicofac. 1961 Dec;78:866-9 46. Gronau S, Fischer Y. [Tonsillotomy]. 58. FALCAO P. [Total intracapsular Laryngorhinootologie. 2005 palatine tonsillectomy; systematization Sep;84(9):685-90 of technic.]. Rev Bras Otorrinolaringol. 47. Fischer Y, Gronau S. [Identification and 1954 Jul;22(4-5):309-32 evaluation of in 59. Anand A, Vilela RJ, Guarisco JL. children before adenotonsillectomy Intracapsular versus standard using evaluative surveys]. tonsillectomy: review of literature. J La Laryngorhinootologie. 2005 State Med Soc. 2005 Sep;157(5):259-61 Feb;84(2):121-35 60. Almqvist U. Cryosurgical treatment of 48. Alavoine J, Graber A. [Extracapsular tonsillar hypertrophy in children. J tonsillectomy under general anesthesia]. Laryngol Otol. 1986 Mar;100(3):311-4 Rev Laryngol Otol Rhinol (Bord). 1968 61. Principato JJ. Cryosurgical treatment of Sep;89(9):568-79 the lymphoid tissue of Waldeyer's ring. 49. Feinstein AR, Levitt M. Tonsils and Otolaryngol Clin North Am. 1987 rheumatic fever. N Engl J Med. 1970 May;20(2):365-70 Apr 2;282(14):814 62. Chatziavramidis A, Constantinidis J, 50. Rapkin RH. Tonsils and rheumatic Gennadiou D, Derwisis D, Sidiras T. fever. N Engl J Med. 1970 Apr [Volume reduction of tonsil hyperplasia 2;282(14):814 in childhood with a surgical ultrasound

11 device]. Laryngorhinootologie. 2007 73. Alpert JJ, Peterson OL, Colton T. Mar;86(3):177-83 Tonsillectomy and . 63. Pfaar O, Spielhaupter M, Schirkowski Lancet. 1968 Jun 15;1(7555):1319 A, et al. Treatment of hypertrophic 74. Klug TE, Henriksen JJ, Fuursted K, palatine tonsils using bipolar Ovesen T. Similar recovery rates of radiofrequency-induced thermotherapy Fusobacterium necrophorum from (RFITT.). Acta Otolaryngol. 2007 recurrently infected and non-infected Nov;127(11):1176-81 tonsils. Dan Med Bull. 2011 64. Zhu X, Yang H, Chen X, Jin Y, Fan Y. Jul;58(7):A4295 [Temperature-controlled 75. Klug TE, Henriksen JJ, Fuursted K, radiofrequency-assisted endoscopic Ovesen T. Significant pathogens in tonsillectomy and adenoidectomy in peritonsillar abscesses. Eur J Clin children]. Lin Chung Er Bi Yan Hou Microbiol Infect Dis. 2011 Tou Jing Wai Ke Za Zhi. 2011 May;30(5):619-27 Jun;25(12):551-3 76. Ramirez-Camacho R, Gonzalez-Tallon 65. Coticchia JM, Yun RD, Nelson L, AI, Gomez D, et al. [Environmental Koempel J. Temperature-controlled scanning electron microscopy for radiofrequency treatment of tonsillar biofilm detection in tonsils]. Acta hypertrophy for reduction of upper Otorrinolaringol Esp. 2008 in pediatric patients. Jan;59(1):16-20 Arch Otolaryngol Head Neck Surg. 2006 77. Mucke W, Huber HC, Ritter U. [The Apr;132(4):425-30 microbe colonization of the palatine 66. Feinstein AR, Levitt M. Tonsils and tonsils of healthy school age children]. rheumatic fever. N Engl J Med. 1970 Zentralbl Hyg Umweltmed. 1994 Apr 2;282(14):814 Aug;196(1):70-4 67. Rapkin RH. Tonsils and rheumatic 78. Mitchelmore IJ, Reilly PG, Hay AJ, fever. N Engl J Med. 1970 Apr Tabaqchali S. Tonsil surface and core 2;282(14):814 cultures in recurrent tonsillitis: 68. Wannamaker LW. Tonsils, rheumatic prevalence of anaerobes and beta- fever and health delivery. N Engl J Med. lactamase producing organisms. Eur J 1970 Feb 5;282(6):336-7 Clin Microbiol Infect Dis. 1994 69. Feinstein AR, Levitt M. The role of Jul;13(7):542-8 tonsils in predisposing to streptococcal 79. Schwaab M, Gurr A, Hansen S, et al. infections and recurrences of rheumatic Human beta-Defensins in different states fever. N Engl J Med. 1970 Feb of diseases of the tonsilla palatina. Eur 5;282(6):285-91 Arch Otorhinolaryngol. 2010 70. el Barbary Ae, Mohieddin O, Fouad May;267(5):821-30 HA, Khalifa MC. The tonsils and 80. Brook I, Foote PA, Jr. Comparison of rheumatic fever. Ann Otol Rhinol the microbiology of recurrent tonsillitis Laryngol. 1969 Jun;78(3):648-56 between children and adults. 71. Stryjecki J. [Tonsillectomy in the course Laryngoscope. 1986 Dec;96(12):1385-8 of rheumatic fever in children]. Pediatr 81. Proenca-Modena JL, Pereira Valera FC, Pol. 1968 Dec;43(12):1531-4 Jacob MG, et al. High rates of detection 72. Matanoski GM, Price WH, Ferencz C. of respiratory viruses in tonsillar tissues Epidemiology of streptococcal from children with chronic infections in rheumatic and non- adenotonsillar disease. PLoS One. rheumatic families. II. The inter- 2012;7(8):e42136 relationship of streptococcal infections 82. Stuck BA, Gotte K, Windfuhr JP, to age, family transmission and type of Genzwurker H, Schroten H, Tenenbaum group A. Am J Epidemiol. 1968 T. Tonsillectomy in children. Dtsch Jan;87(1):190-206 Arztebl Int. 2008 Dec;105(49):852-60 83. Österreichische Gesellschaften für Hals- Nasen-Ohren-Heilkunde KuH, Kinder-

12 und Jugendheilkunde. Gemeinsame 94. Al-Layla A, Mahafza TM. Antibiotics Empfehlung zur Entfernung der do not reduce post-tonsillectomy morbi- Gaumenmandeln (Tonsillektomie). dity in children. Eur Arch Otorhino- Monatsschr Kinderheilkd. 2008 Mar laryngol. 2013 Jan;270(1):367-70 7;3(156):268-71 95. Dhiwakar M, Clement WA, Supriya M, 84. Kaplan EL. The group A streptococcal McKerrow W. Antibiotics to reduce upper respiratory tract carrier state: an post-tonsillectomy morbidity. Cochrane enigma. J Pediatr. 1980 Sep;97(3):337- Database Syst Rev. 2012;12:CD005607 45 96. Hayward G, Thompson MJ, Perera R, 85. Kaplan EL, Top FH, Jr., Dudding BA, Glasziou PP, Del Mar CB, Heneghan Wannamaker LW. Diagnosis of CJ. as standalone or add- streptococcal pharyngitis: differentiation on treatment for sore throat. Cochrane of active infection from the carrier state Database Syst Rev. 2012;10:CD008268 in the symptomatic child. J Infect Dis. 97. Hayward G, Thompson MJ, Perera R, 1971 May;123(5):490-501 Del Mar CB, Glasziou PP, Heneghan 86. Tanz RR, Shulman ST. Chronic CJ. Corticosteroids for the common pharyngeal carriage of group A cold. Cochrane Database Syst Rev. streptococci. Pediatr Infect Dis J. 2007 2012;8:CD008116 Feb;26(2):175-6 98. Hayward G, Thompson M, Heneghan C, 87. Tanz RR, Shulman ST. Streptococcal Perera R, Del MC, Glasziou P. pharyngitis: the carrier state, definition, Corticosteroids for pain relief in sore and management. Pediatr Ann. 1998 throat: systematic review and meta- May;27(5):281-5 analysis. BMJ. 2009;339:b2976 88. Wessels MR. Clinical practice. 99. Moore N. Forty years of ibuprofen use. Streptococcal pharyngitis. N Engl J Int J Clin Pract Suppl. 2003 Med. 2011 Feb 17;364(7):648-55 Apr;(135):28-31 89. Roberts AL, Connolly KL, Kirse DJ, et 100. van den Anker JN. Optimising the al. Detection of group A Streptococcus management of fever and pain in in tonsils from pediatric patients reveals children. Int J Clin Pract Suppl. 2013 high rate of asymptomatic streptococcal Jan;(178):26-32 carriage. BMC Pediatr. 2012;12:3 101. Hay AD, Redmond NM, Costelloe C, et 90. Drago L, Esposito S, De VE, et al. al. Paracetamol and ibuprofen for the Detection of respiratory viruses and treatment of fever in children: the atypical bacteria in children's tonsils and PITCH randomised controlled trial. . J Clin Microbiol. 2008 Health Technol Assess. 2009 Jan;46(1):369-70 May;13(27):iii-x,1 91. Piacentini GL, Peroni DG, Blasi F, et al. 102. Hay AD, Costelloe C, Redmond NM, et Atypical bacteria in adenoids and tonsils al. Paracetamol plus ibuprofen for the of children requiring treatment of fever in children (PITCH): adenotonsillectomy. Acta Otolaryngol. randomised controlled trial. BMJ. 2010 May;130(5):620-5 2008;337:a1302 92. Chiappini E, Regoli M, Bonsignori F, et 103. Forrest JB, Heitlinger EL, Revell S. al. Analysis of different Ketorolac for postoperative pain recommendations from international management in children. Drug Saf. 1997 guidelines for the management of acute May;16(5):309-29 pharyngitis in adults and children. Clin 104. Romsing J, Ostergaard D, Drozdziewicz Ther. 2011 Jan;33(1):48-58 D, Schultz P, Ravn G. Diclofenac or 93. Chiappini E, Principi N, Mansi N, et al. acetaminophen for analgesia in Management of acute pharyngitis in paediatric tonsillectomy outpatients. children: summary of the Italian Acta Anaesthesiol Scand. 2000 National Institute of Health guidelines. Mar;44(3):291-5 Clin Ther. 2012 Jun;34(6):1442-58 105. Romsing J, Ostergaard D, Walther- Larsen S, Valentin N. Analgesic

13 efficacy and safety of preoperative 117. Powell J, Wilson JA. An evidence-based versus postoperative ketorolac in review of peritonsillar abscess. Clin paediatric tonsillectomy. Acta Otolaryngol. 2012 Apr;37(2):136-45 Anaesthesiol Scand. 1998 118. Paradise JL, Bluestone CD, Bachman Aug;42(7):770-5 RZ, et al. Efficacy of tonsillectomy for 106. Barzaga AZ, Choonara I. Balancing the recurrent throat infection in severely risks and benefits of the use of over-the- affected children. Results of parallel counter pain medications in children. randomized and nonrandomized clinical Drug Saf. 2012 Dec 1;35(12):1119-25 trials. N Engl J Med. 1984 Mar 107. Feinstein AR, Levitt M. The role of 15;310(11):674-83 tonsils in predisposing to streptococcal 119. Paradise JL, Bluestone CD, Bachman infections and recurrences of rheumatic RZ, et al. Efficacy of tonsillectomy for fever. N Engl J Med. 1970 Feb recurrent throat infection in severely 5;282(6):285-91 affected children. Results of parallel 108. Del Mar CB, Glasziou PP, Spinks AB. randomized and nonrandomized clinical Antibiotics for sore throat. Cochrane trials. N Engl J Med. 1984 Mar Database Syst Rev. 2006;(4):CD000023 15;310(11):674-83 109. Lehnerdt G, Senska K, Fischer M, 120. Paradise JL, Bluestone CD, Bachman Jahnke K. Bilateral peritonsillar RZ, et al. History of recurrent sore abscesses. Eur Arch Otorhinolaryngol. throat as an indication for tonsillectomy. 2005 Jul;262(7):573-5 Predictive limitations of histories that 110. Segal N, El-Saied S, Puterman M. are undocumented. N Engl J Med. 1978 Peritonsillar abscess in children in the Feb 23;298(8):409-13 southern district of Israel. Int J Pediatr 121. Paradise JL, Bluestone CD, Bachman Otorhinolaryngol. 2009 RZ, et al. Efficacy of tonsillectomy for Aug;73(8):1148-50 recurrent throat infection in severely 111. Powell EL, Powell J, Samuel JR, Wilson affected children. Results of parallel JA. A review of the pathogenesis of randomized and nonrandomized clinical adult peritonsillar abscess: time for a re- trials. N Engl J Med. 1984 Mar evaluation. J Antimicrob Chemother. 15;310(11):674-83 2013 Apr 23. 122. Paradise JL, Bluestone CD, Colborn 112. Segal N, El-Saied S, Puterman M. DK, Bernard BS, Rockette HE, Kurs- Peritonsillar abscess in children in the Lasky M. Tonsillectomy and adenoton- southern district of Israel. Int J Pediatr sillectomy for recurrent throat infection Otorhinolaryngol. 2009 in moderately affected children. Aug;73(8):1148-50 Pediatrics. 2002 Jul;110(1 Pt 1):7-15 113. Powell J, Wilson JA. An evidence-based 123. Kaygusuz I, Alpay HC, Godekmerdan review of peritonsillar abscess. Clin A, et al. Evaluation of long-term impacts Otolaryngol. 2012 Apr;37(2):136-45 of tonsillectomy on immune functions of 114. Herzon FS, Martin AD. Medical and children: a follow-up study. Int J surgical treatment of peritonsillar, Pediatr Otorhinolaryngol. 2009 retropharyngeal, and parapharyngeal Mar;73(3):445-9 abscesses. Curr Infect Dis Rep. 2006 124. Windfuhr JP, Schloendorff G, Baburi D, May;8(3):196-202 Kremer B. Serious post-tonsillectomy 115. Powell J, Wilson JA. An evidence-based hemorrhage with and without lethal review of peritonsillar abscess. Clin outcome in children and adolescents. Int Otolaryngol. 2012 Apr;37(2):136-45 J Pediatr Otorhinolaryngol. 2008 116. Lehnerdt G, Senska K, Jahnke K, Jul;72(7):1029-40 Fischer M. Post-tonsillectomy 125. Stelter K, Ihrler S, Siedek V, haemorrhage: a retrospective Patscheider M, Braun T, Ledderose G. comparison of abscess- and elective 1-year follow-up after radiofrequency tonsillectomy. Acta Otolaryngol. 2005 tonsillotomy and laser tonsillotomy in Dec;125(12):1312-7 children: a prospective, double-blind,

14 clinical study. Eur Arch Otorhinolaryn- 136. Unkel C, Lehnerdt G, Schmitz KJ, gol. 2012 Feb;269(2):679-84 Jahnke K. Laser-tonsillotomy for 126. Stelter K, de la CR, Patscheider M, treatment of obstructive tonsillar Olzowy B. Double-blind, randomised, hyperplasia in early childhood: a controlled study of post-operative pain retrospective review. Int J Pediatr in children undergoing radiofrequency Otorhinolaryngol. 2005 tonsillotomy versus laser tonsillotomy. J Dec;69(12):1615-20 Laryngol Otol. 2010 Aug;124(8):880-5 137. Davies J, Coatesworth AP. Double-blind 127. Scherer H, Fuhrer A, Hopf J, et al. randomized controlled study of [Current status of laser surgery in the coblation tonsillotomy versus coblation area of the and adjoining tonsillectomy on post-operative pain. regions]. Laryngorhinootologie. 1994 Clin Otolaryngol. 2005 Dec;30(6):572-3 Jan;73(1):14-20 138. Haegner U, Handrock M, Schade H. 128. Ericsson E, Graf J, Hultcrantz E. ["Ultrasound tonsillectomy" in Pediatric tonsillotomy with comparison with conventional radiofrequency technique: long-term tonsillectomy]. HNO. 2002 follow-up. Laryngoscope. 2006 Sep;50(9):836-43 Oct;116(10):1851-7 139. Pfaar O, Spielhaupter M, Schirkowski 129. Scherer H, Fuhrer A, Hopf J, et al. A, et al. Treatment of hypertrophic pala- [Current status of laser surgery in the tine tonsils using bipolar radiofrequen- area of the soft palate and adjoining cy-induced thermotherapy (RFITT). regions]. Laryngorhinootologie. 1994 Acta Otolaryngol. 2007 Apr 23;1-6 Jan;73(1):14-20 140. Isaacson G. Pediatric intracapsular 130. Stelter K, de la CR, Patscheider M, tonsillectomy with bipolar electro- Olzowy B. Double-blind, randomised, surgical scissors. Ear Nose Throat J. controlled study of post-operative pain 2004 Oct;83(10):702, 704-702, 706 in children undergoing radiofrequency 141. Huber K, Sadick H, Maurer JT, tonsillotomy versus laser tonsillotomy. J Hormann K, Hammerschmitt N. Laryngol Otol. 2010 Aug;124(8):880-5 [Tonsillotomy with the argon-supported 131. Watson MG, Dawes PJ, Samuel PR, et monopolar needle--first clinical results]. al. A study of haemostasis following Laryngorhinootologie. 2005 tonsillectomy comparing ligatures with Sep;84(9):671-5 . J Laryngol Otol. 1993 142. Lister MT, Cunningham MJ, Benjamin Aug;107(8):711-5 B, et al. Microdebrider tonsillotomy vs 132. Kristensen S, Tveteras K. Post- electrosurgical tonsillectomy: a tonsillectomy haemorrhage. A randomized, double-blind, paired retrospective study of 1150 operations. control study of postoperative pain. Arch Clin Otolaryngol Allied Sci. 1984 Otolaryngol Head Neck Surg. 2006 Dec;9(6):347-50 Jun;132(6):599-604 133. Andrea M. Microsurgical bipolar 143. Stelter K, de la CR, Patscheider M, cautery tonsillectomy. Laryngoscope. Olzowy B. Double-blind, randomised, 1993 Oct;103(10):1177-8 controlled study of post-operative pain 134. Ewah B. An evaluation of pain, in children undergoing radiofrequency postoperative nausea and vomiting tonsillotomy versus laser tonsillotomy. J following the introduction of guidelines Laryngol Otol. 2010 Aug;124(8):880-5 for tonsillectomy. Paediatr Anaesth. 144. Scherer H. [Tonsillotomy versus 2006 Oct;16(10):1100-1 tonsillectomy]. Laryngorhinootologie. 135. Scherer H, Fuhrer A, Hopf J, et al. 2003 Nov;82(11):754-5 [Current status of laser surgery in the 145. Windfuhr JP, Werner JA. Tonsillotomy: area of the soft palate and adjoining it's time to clarify the facts. Eur Arch regions]. Laryngorhinootologie. 1994 Otorhinolaryngol. 2013 Aug 22 Jan;73(1):14-20 146. Sobol SE, Wetmore RF, Marsh RR, Stow J, Jacobs IN. Postoperative

15 recovery after microdebrider 155. Cantarella G, Viglione S, Forti S, intracapsular or monopolar Minetti A, Pignataro L. Comparing electrocautery tonsillectomy: a postoperative quality of life in children prospective, randomized, single-blinded after microdebrider intracapsular study. Arch Otolaryngol Head Neck tonsillotomy and tonsillectomy. Auris Surg. 2006 Mar;132(3):270-4 Nasus . 2012 Aug;39(4):407-10 147. Cantarella G, Viglione S, Forti S, 156. Lavy JA. Post-tonsillectomy pain: the Minetti A, Pignataro L. Comparing difference between younger and older postoperative quality of life in children patients. Int J Pediatr Otorhinolaryngol. after microdebrider intracapsular 1997 Oct 18;42(1):11-5 tonsillotomy and tonsillectomy. Auris 157. Stelter K, Hempel JM, Berghaus A, Nasus Larynx. 2012 Aug;39(4):407-10 Andratschke M, Luebbers CW, 148. Nguyen CV, Parikh SR, Bent JP. Hagedorn H. Application methods of Comparison of intraoperative bleeding local anaesthetic infiltrations for between microdebrider intracapsular postoperative pain relief in tonsillectomy and electrocautery tonsillectomy: a prospective, tonsillectomy. Ann Otol Rhinol randomised, double-blind, clinical trial. Laryngol. 2009 Oct;118(10):698-702 Eur Arch Otorhinolaryngol. 2009 Jan 22 149. Reilly BK, Levin J, Sheldon S, Harsanyi 158. Stelter K, Hiller J, Hempel JM, et al. K, Gerber ME. Efficacy of Comparison of two different local microdebrider intracapsular anaesthetic infiltrations for postopera- adenotonsillectomy as validated by tive pain relief in tonsillectomy: a polysomnography. Laryngoscope. 2009 prospective, randomised, double blind, Jul;119(7):1391-3 clinical trial. Eur Arch Otorhinola- 150. Vaughan AH, Derkay CS. ryngol. 2010 Jul;267(7):1129-34 Microdebrider intracapsular 159. Sadhasivam S, Chidambaran V, Ngam- tonsillectomy. ORL J Otorhinolaryngol prasertwong P, et al. Race and unequal Relat Spec. 2007;69(6):358-63 burden of perioperative pain and opioid 151. Sobol SE, Wetmore RF, Marsh RR, related adverse effects in children. Stow J, Jacobs IN. Postoperative Pediatrics. 2012 May;129(5):832-8 recovery after microdebrider 160. Tekelioglu UY, Apuhan T, Akkaya A, et intracapsular or monopolar al. Comparison of topical tramadol and electrocautery tonsillectomy: a ketamine in pain treatment after prospective, randomized, single-blinded tonsillectomy. Paediatr Anaesth. 2013 study. Arch Otolaryngol Head Neck Jun;23(6):496-501 Surg. 2006 Mar;132(3):270-4 161. Ozkiris M, Kapusuz Z, Saydam L. 152. Sorin A, Bent JP, April MM, Ward RF. Comparison of ropivacaine, bupivacaine Complications of microdebrider-assisted and lidocaine in the management of powered intracapsular tonsillectomy and post-tonsillectomy pain. Int J Pediatr adenoidectomy. Laryngoscope. 2004 Otorhinolaryngol. 2012 Feb;114(2):297-300 Dec;76(12):1831-4 153. Segal N, Puterman M, Rotem E, et al. A 162. Stelter K, Hiller J, Hempel JM, et al. prospective randomized double-blind Comparison of two different local trial of fibrin glue for reducing pain and anaesthetic infiltrations for bleeding after tonsillectomy. Int J postoperative pain relief in Pediatr Otorhinolaryngol. 2008 tonsillectomy: a prospective, Apr;72(4):469-73 randomised, double blind, clinical trial. 154. Sampaio AL, Pinheiro TG, Furtado PL, Eur Arch Otorhinolaryngol. 2010 Araujo MF, Olivieira CA. Evaluation of Jul;267(7):1129-34 early postoperative morbidity in 163. Stelter K, Hempel JM, Berghaus A, pediatric tonsillectomy with the use of Andratschke M, Luebbers CW, Hage- sucralfate. Int J Pediatr Otorhinolaryn- dorn H. Application methods of local gol. 2007 Apr;71(4):645-51 anaesthetic infiltrations for postopera-

16 tive pain relief in tonsillectomy: a 173. Riggin L, Ramakrishna J, Sommer DD, prospective, randomised, double-blind, Koren G. A 2013 updated systematic clinical trial. Eur Arch review & meta-analysis of 36 Otorhinolaryngol. 2009 Jan 22 randomized controlled trials; no 164. Arikan OK, Ozcan S, Kazkayasi M, apparent effects of non steroidal anti- Akpinar S, Koc C. Preincisional inflammatory agents on the risk of infiltration of tonsils with ropivacaine in bleeding after tonsillectomy. Clin post-tonsillectomy pain relief: double- Otolaryngol. 2013 Apr;38(2):115-29 blind, randomized, placebo-controlled 174. Zernikow B, Smale H, Michel E, Hasan intraindividual study. J Otolaryngol. C, Jorch N, Andler W. Paediatric cancer 2006 Jun;35(3):167-72 pain management using the WHO 165. Rotenberg BW, Wickens B, Parnes J. analgesic ladder--results of a prospective Intraoperative ice pack application for analysis from 2265 treatment days pain reduction: a during a quality improvement study. Eur randomized controlled trial. J Pain. 2006 Oct;10(7):587-95 Laryngoscope. 2013 Feb;123(2):533-6 175. Hadden SM, Burke CN, Skotcher S, 166. Sylvester DC, Rafferty A, Bew S, Voepel-Lewis T. Early postoperative Knight LC. The use of ice-lollies for outcomes in children after pain relief post-paediatric tonsillectomy. adenotonsillectomy. J Perianesth Nurs. A single-blinded, randomised, 2011 Apr;26(2):89-95 controlled trial. Clin Otolaryngol. 2011 176. Stelter K, Hempel JM, Berghaus A, Dec;36(6):566-70 Andratschke M, Luebbers CW, 167. Steward DL, Grisel J, Meinzen-Derr J. Hagedorn H. Application methods of Steroids for improving recovery follow- local anaesthetic infiltrations for ing tonsillectomy in children. Cochrane postoperative pain relief in Database Syst Rev. 2011;(8):CD003997 tonsillectomy: a prospective, 168. Windfuhr JP, Chen YS, Propst EJ, Guld- randomised, double-blind, clinical trial. ner C. The effect of dexamethasone on Eur Arch Otorhinolaryngol. 2009 Jan 22 post-tonsillectomy nausea, vomiting and 177. Kamarauskas A, Dahl MR, Hlidarsdottir bleeding. Braz J Otorhinolaryngol. 2011 T, Mainz J, Ovesen T. Need for better Jun;77(3):373-9 analgesic treatment after tonsillectomy 169. Randel A. AAO-HNS Guidelines for in ear, nose and throat practices. Dan Tonsillectomy in Children and Adoles- Med J. 2013 May;60(5):A4639 cents. Am Fam Physician. 2011 Sep 178. Stanko D, Bergesio R, Davies K, 1;84(5):566-73 Hegarty M, von Ungern-Sternberg BS. 170. Baugh RF, Archer SM, Mitchell RB, et Postoperative pain, nausea and vomiting al. Clinical practice guideline: tonsillec- following adeno-tonsillectomy - a long- tomy in children. Otolaryngol Head term follow-up. Paediatr Anaesth. 2013 Neck Surg. 2011 Jan;144(1 Suppl):S1- May 13 30 179. Chan CC, Chan YY, Tanweer F. 171. Sutters KA, Miaskowski C, Holdridge- Systematic review and meta-analysis of Zeuner D, et al. A randomized clinical the use of tranexamic acid in trial of the effectiveness of a scheduled tonsillectomy. Eur Arch Otorhino- oral analgesic dosing regimen for the laryngol. 2013 Feb;270(2):735-48 management of postoperative pain in 180. Sarny S, Habermann W, Ossimitz G, children following tonsillectomy. Pain. Stammberger H. Significant post- 2004 Jul;110(1-2):49-55 tonsillectomy pain is associated with 172. Lewis SR, Nicholson A, Cardwell ME, increased risk of hemorrhage. Ann Otol Siviter G, Smith AF. Nonsteroidal anti- Rhinol Laryngol. 2012 inflammatory drugs and perioperative Dec;121(12):776-81 bleeding in paediatric tonsillectomy. 181. Windfuhr JP, Schloendorff G, Baburi D, Cochrane Database Syst Rev. 2013 Jul Kremer B. Serious post-tonsillectomy 18;7:CD003591 hemorrhage with and without lethal

17 outcome in children and adolescents. Int Prof. Dr. med. Götz Lehnerdt J Pediatr Otorhinolaryngol. 2008 Dep. of Otorhinolaryngology, Head and Jul;72(7):1029-40 Neck Surgery 182. Hessen Soderman AC, Ericsson E, St. Anna Clinic Wuppertal Hemlin C, et al. Reduced risk of primary Vogelsangstr. 106 postoperative hemorrhage after tonsil 42109 Wuppertal surgery in Sweden: results from the National Tonsil Surgery Register in [email protected] Sweden covering more than 10 years and 54,696 operations. Laryngoscope. Editor 2011 Nov;121(11):2322-6 183. Krespi YP, Kizhner V. Laser tonsil Johan Fagan MBChB, FCS(ORL), MMed cryptolysis: In-office 500 cases review. Professor and Chairman Am J Otolaryngol. 2013 Apr 10 Division of Otolaryngology 184. Pfaar O, Spielhaupter M, Schirkowski University of Cape Town A, et al. Treatment of hypertrophic Cape Town, South Africa palatine tonsils using bipolar [email protected] radiofrequency-induced thermotherapy

(RFITT.). Acta Otolaryngol. 2007 Nov;127(11):1176-81 THE OPEN ACCESS ATLAS OF 185. Sarny S, Ossimitz G, Habermann W, OTOLARYNGOLOGY, HEAD & Stammberger H. Hemorrhage following NECK OPERATIVE SURGERY tonsil surgery: a multicenter prospective www.entdev.uct.ac.za study. Laryngoscope. 2011 Dec;121(12):2553-60 186. Sarny S, Ossimitz G, Habermann W,

Stammberger H. [Austrian tonsil study part 3: surgical technique and The Open Access Atlas of Otolaryngology, Head & Neck postoperative haemorrhage after Operative Surgery by Johan Fagan (Editor) tonsillectomy]. Laryngorhinootologie. [email protected] is licensed under a Creative Commons Attribution - Non-Commercial 3.0 Unported 2013 Feb;92(2):92-6 License 187. Windfuhr JP, Wienke A, Chen YS. Electrosurgery as a risk factor for secondary post-tonsillectomy hemorrhage. Eur Arch Otorhino- laryngol. 2009 Jan;266(1):111-6

Authors

PD Dr. med. Klaus Stelter Dep. of Otorhinolaryngology, Head and Neck Surgery RoMed Clinic Bad Aibling Harthauser Str. 16 83043 Bad Aibling [email protected]

18