Wednesday, March 01, 2006

Intracapsular tonsillectomy

Q: I [identifying information deleted] have been treated with antibiotics 7 times in the last 12 months for 'strep throat.' It is likely that I will have a tonsillectomy soon.

I am looking for information about intracapsular tonsillectomies for adults. So far, ENTs I have talked to here seem to think it's not a surgery that works in adults. (They may not have any experience doing it which may be the issue as well.) I am writing to you because your website mentions that you have performed these surgeries.

I have looked for research confirming that it can work in adults, but have found nothing especially helpful. I am also looking for information concerning who in New England might be willing to do an adult intracapsular tonsillectomy.

Any information or help that you can provide would be incredibly helpful. I am considering writing a research proposal concerning the topic if I can not find decent research on the topic.

Thank you for your time.

A: You're right. It is difficult finding information on the web regarding adult intracapsular tonsillectomy. Here's something from Bryn Mawr Hospital:

For adults, the new procedure may not be as effective as it is in children because the tonsils will have become scared and rubbery from repeated infections, compared with the fluffy tonsils of a child. "Adult tonsils don't shave out as easily, but we will try the partial tonsillectomy first," he said. "If the procedure becomes difficult, we can convert to a traditional tonsillectomy."

I have been doing adult intracapsular tonsillectomies for the last 12 to 18 months, and I know a lot of my colleagues are doing the same. I would agree with the above author that some adults are poor candidates for this -- those whose tonsils are scarred down. Adults with larger tonsils, more typical of what we see in children, are better candidates. The trouble with scarred tonsils is that it becomes challenging if not impossible to leave behind a thin layer of tonsil tissue, which is the aim of the intracapsular technique.

As you have no doubt heard, adult tonsillectomy can be very painful, and the intracapsular technique is a definite improvement with regard to post-op pain. In my experience, even those adults who end up having a complete tonsillectomy still seem to do better post-operatively. Thus, I agree with the above author who always tries the intracapsular method first.

Hopefully, I can get a few of my colleagues to add their thoughts, too.



At 4:58 AM, Blogger Maks said...

You are strongly advised NOT to go for intracapsular tonsillectomy.

This is just a fad performed by some members of the profession.

Especially if you have a history of streptococcal infection, you are well advised to go for an ordinary cold steel tonsillectomy with diathermy for bleeding (ie, avoiding ligatures).


Predrag Maksimovich.

At 10:31 PM, Blogger Douglas Hoffman said...

Hey, Maks, tell us how you really feel ;)

Personally, I think the jury is still out on whether intracapsular tonsillectomy is good or bad in this scenario. My patients have done well, but (as I suggested in my blog post) I suspect the microdebrider is removing the whole tonsil. These tonsils are so sclerotic, it's nearly impossible to leave anything behind.

At 7:19 AM, Anonymous Anonymous said...

Maks, could you explain why you think intracapsular tonsillectomies are such a bad idea (for this patient or in general) ? They definitely seem to work in lots of children and the shortened recoverty time seems like a great benefit.

At 10:39 PM, Anonymous Doug Hoffman said...

anonymous, you might have to search for maks at his website -- he doesn't come around here regularly.

As for me, I think the benefits outweigh the risks of regrowth and/or imperfect treatment, but I am still evaluating the procedure and the results.

At 1:57 PM, Blogger crystal said...

Hi Doug - can I ask you an unrelated question?

My cat Kermit (yes, another cat :-), has one ear canal with a very small openning, due to an old hematoma. My vet gave me an earwash to use, as wax seems to be building up and not coming out of the opening. The ingredients are ... water, decyl glucoside, sodium chlorite (stabilized chlorine dioxide), hydroxypropyl methylcellulose, potassium phosphate, methylparaben, propylparaben, sodium hydroxide.

Does this seem safe and effective to you? Thank you for your time!

At 10:53 PM, Anonymous Doug Hoffman said...

Crystal, you can always come around Balls and Walnuts and ask these things, too. I don't mind (and I check it more often than I check WBP).

Sounds safe as far as ingredients are concerned. The key on ear lavage is to use as little force as possible. You can do some serious damage by forcing the fluid in. Not that your cat would permit it, but you never know . . .

At 11:30 AM, Blogger crystal said...

Thanks for the info, Doug. I've read of cats getting a kind of vestibular ear problem where they have verigo, after too forceful ear cleanings, so I alway err on the side of doing nothing.

At 10:54 PM, Anonymous Doug Hoffman said...

Crystal, anyone (cats included) will get vertigo with too forceful irrigation. It's called the caloric effect. If the water is too warm or too cold, boom, you're dizzy. The irrigant needs to be as close to body temp as possible.

At 12:16 AM, Blogger crystal said...

Thanks, Doug. I got so worried, that I did nothing but clean out her ear with a few Qtips ... actually my sister did it for me. Cats sometimes get vestibular balance disorders from inner ear infections, I think, but also from a too vigorous cleaning of the ears. I found a stray cat with that problem and kept him at the vet until we found a home for him ... he couldn't walk very well and had a head tilt. Ever since then, I worry :-)

I appreciate your help!

At 3:53 AM, Anonymous Anonymous said...

Hiya Doc,
This may sound trivial but I am getting frustrated here, When I lay down or bend down my right ear pops,it has been going on for about a year now, since a pretty nasty ear infection and also every morning I wake up blow my nose and it is full of blood, only in the mornings though, Any ideas?

At 12:17 PM, Blogger Douglas Hoffman said...

Any ideas? Sure, lots of them, but the only way to figure any of it out is to actually LOOK. Which, um, is something I can't do.

Sometimes there's no choice but to see the doctor. I know, I know -- it's all a vast conspiracy ;)

At 1:44 PM, Anonymous Anonymous said...

My daughter (5yrs old) is scheduled for intracapsular tonsillectomy. She has no major history of strep. Her tonsils are VERY LARGE and have created some issues. I don't want her to suffer but I am leaning towards regular Tonsillectomy. The thought of leaving anything behind scares me.

At 5:36 AM, Anonymous Anonymous said...

I am not a surgeon. However, I have benn personallY involved in over 600 intracapsular tonsillectomies from 2005 to present without one post operative bleed! They should only be done on obstruction patients. Also, we have done only one redue, due to infection. There is plent of literature to support this technique.

At 9:19 PM, Anonymous Anonymous said...

I had my tonsils out on Nov. 23 and i still have a phlegm tasting clog in my throat that i feel every time i swallow. I always have a horrible taste in my mouth and it feels as if I still have scabs. It makes all food taste abnormal and my doctor says this happens to less than 10% of people who have the operation. Has anyone else experienced this or have any suggestions as to what I can do to get rid of this?

At 11:36 AM, Anonymous Anonymous said...

I am sitting here with mono for the second time and am ready to cut my own tonsils out with a pair of scissors!! Also, I have tonsillotliths from cavernous tonsils. My tonsils do not protrude at all, they are in fact, the opposite. Because of the mono and tonsil stones, I am thinking of having the tonsils out at the first of the year. Will a subtotal
take care of my tonsil stones, and is the tonsillectomy more difficult to perform/recover from with tonsils like mine?

At 9:58 PM, Anonymous Anonymous said...

I just had an intracapsular tonsillectomy done a week ago today. When I look in my throat, it honestly does not look that much different than before I had the surgery. It looks like I still have tonsils. I have had so many strep infections and other tonsillitis treated with antibiotics prior to surgery. I am beginning to wish I had opted for a regular, complete tonsillectomy. Is it normal to still see so much tonsil tissue after an intracapsular tonsillectomy?


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