Treating persistent tonsillitis and obstruction in children with an intracapsular tonsillectomy

Tonsillitis is common in children and usually gets better on its own. It occurs when two pads of tissue on either side of the back of the throat become inflamed. However, in recurrent cases of tonsillitis, surgery may be needed. Before we explore the surgical treatments, it helps to understand a little about the anatomy of the back of your throat. 

Tissues at the back of your throat

Tonsils form part of a ring of lymphoid tissue that sits around the back of your mouth and nose. Lymphoid tissue can also be found in lymph glands in your neck, armpits, chest, abdomen and groin. Lymphoid tissue helps protect your body against infections by recognising harmful germs.

At the back of your throat, this lymphoid tissue includes four different types of tonsils, which are named according to their location: the pharyngeal tonsil (often referred to as the adenoids), tubal tonsils (near the opening of the Eustachian tubes), lingual tonsils (at the back of the tongue) and palatine tonsils.

The trouble with tonsils

The palatine tonsils can often become inflamed in children, particularly after having a cold, as the tonsils become infected by a virus or bacteria. This causes them to swell, with symptoms including discomfort, a sore throat and a fever.

If your child frequently develops recurrent tonsillitis frequently (between five to seven times per year), your doctor may recommend surgery to remove their tonsils. Removal of their tonsils and adenoids may also be recommended if they are very enlarged and are causing severe snoring or obstructive sleep apnoea (OSA), which disturbs their sleep. 

OSA can leave children feeling tired and irritable, result in poor behaviour and even stunt their growth due to the reduced production of growth hormones at night and a poor or limited appetite eg children often favour exclusively soft foods due to the difficulty of eating with enlarged tonsils and adenoids. 

If your child needs to have their tonsils removed, there are two surgical options: an intracapsular tonsillectomy or an extracapsular tonsillectomy.

Intracapsular tonsillectomy vs extracapsular tonsillectomy

Extracapsular tonsillectomy

Extracapsular tonsillectomy is a traditional technique to remove the tonsils and has been performed for decades. It involves identifying where the tonsils meet the muscles of the throat and then peeling or dissecting the tonsils off the muscles on either side of the throat.

Intracapsular tonsillectomy

Intracapsular tonsillectomy is a newer technique that uses special surgical instruments to remove the tonsils up to the point of the fibrous base that sits between the main body of the tonsils and the throat muscles. This surgery therefore removes most but not all of the tonsils — around 95–98% of the tonsil tissue — and protects the underlying throat muscles.

View an animation of extracapsular tonsillectomy versus intracapsular tonsillectomy.

The main approach to perform an intracapsular tonsillectomy is called coblation.

Coblation

Coblation uses a special surgical instrument that passes radiofrequency energy through a saline solution. This creates a plasma bubble that destroys the tissue it comes into contact with, namely the tonsils. This approach uses much lower temperatures, around 40–80°C, than traditional electrical cautery which operates at around 400°C and lasers which operate at around 1,000°C.

Thanks to the very low temperatures used, the thermal energy produced during coblation spreads less and better protects the underlying muscles from damage.

The benefits of intracapsular tonsillectomy

As I’ve already mentioned, compared to extracapsular tonsillectomy, intracapsular tonsillectomy better protects the muscles beneath the tonsils. This not only reduces the risk of complications during and after surgery but it also speeds up recovery. 

After an extracapsular tonsillectomy, around 5 to 8% of children will return to hospital due to complications, such as pain or bleeding. This is reduced to just 0.2–0.4% after an intracapsular tonsillectomy.

As for recovery, children need 10 to 14 days to fully recover from an extracapsular tonsillectomy and then return to nursery or school. With an intracapsular tonsillectomy, this is reduced to seven days or less. 

The benefits of intracapsular tonsillectomy are so significant that the NHS recommends this approach for tonsil removal in children as part of its GIRFT programme, Getting It Right First Time, which focuses on improving the treatment and care of patients through an in-depth review of services.

What are the risks of intracapsular tonsillectomy?

As with any surgical procedure, there are risks associated with having an intracapsular tonsillectomy. However, these risks are far lower than for an extracapsular tonsillectomy, where around one in 100 children subsequently need emergency surgery.

The main risk of an intracapsular tonsillectomy comes from the very small amount of tonsil tissue that is left behind. About 2% of children who have an intracapsular tonsillectomy may need further surgery to address problems caused by remaining tonsil tissue. 

This risk is most likely to occur in very young children, who due to their age, have rapidly growing tonsils and may therefore have symptoms of tonsillitis or obstruction return in the future. Symptoms almost never return in older children. 

Recovering from an intracapsular tonsillectomy

After having an intracapsular tonsillectomy, your child can go home on the same day as their surgery. Within a few hours of their surgery, they will be able to eat as normal. To relieve any pain or discomfort, they should take paracetamol and ibuprofen regularly for up to one week. After a week, they can return to school or nursery, with some children recovering faster and able to return sooner. 

Author biography

Mr Sameer Khemani is a Consultant ENT Surgeon at Spire Gatwick Park Hospital and Surrey and Sussex NHS Trust, specialising in tonsillectomy and adenotonsillectomy, Eustachian tube balloon dilatation, obstructive sleep apnoea and snoring, and grommets insertion. He graduated from Guy's and St Thomas' Hospital Medical Schools, London and trained at a number of prestigious surgical centres, including University College Hospital, Charing Cross Hospital and the Royal National Throat, Nose and Ear Hospital. He also holds a Masters in Surgical Education with distinction from Imperial College London.