Tonsillectomy is one of the most common procedures that
otolaryngologists perform. Early in residency, most trainees are
heavily influenced by their instructors in tonsillectomy technique
and rarely revisit these procedures later in training. In practice,
their surgical technique reflects these early experiences. Opinions
regarding tonsillectomy are often difficult to change, possibly
because of this early exposure. In 2000, Dr Peter Kotai described a
radical new approach to tonsil surgery: intracapsular
tonsillectomy. He questioned why otolaryngologists perform
traditional extracapsular tonsillectomy (which was designed for
infectious diseases) for children with obstructive symptomatology.
As 19th century German philsopher Arthur Schopenhauer wrote, All
truth passes through three stages. First, it is ridiculed. Second,
it is violently opposed. Third, it is accepted as being
self-evident. Intracapsular tonsillectomy is a prime example of
this acceptance process. When Kotai first described it, there were
very few otolaryngologists who embraced this procedure. Over time,
much data has been collected, and this procedure has gained
increasing acceptance. This textbook was undertaken with several
ideas in mind. First, it reviews the current understanding of
tonsil and adenoid surgery in children, along with when to consider
intracapsular tonsillectomy (IT) and when to consider extracapsular
tonsillectomy (ET). It reviews the last 16 years of information
regarding differences in the surgical techniques. Concepts and data
supporting the use of the procedures are presented. Secondly, this
text will serve as a surgical atlas for those in the beginning of
training, those that have mastered many techniques but may have not
had exposure to all options, and those that are looking for even
more advanced surgical maneuvers that may enhance their results.
This will be a new type of surgical atlas, one using different
colors to depict basic and advanced techniques. Each photograph
demonstrates specific points of the procedures, with basic portions
designated in green and more advanced techniques depicted in blue.
Full length videos of each technique are also included. The
European Experience of Tonsillotomy is not included in this text
because there are no centers in the United States experienced with
that procedure. Tonsillotomy is described as removing the tonsil
tissue to the level of the anterior tonsillar pillar with a CO2
laser. It does not approach the depth of dissection of
intracapsular tonsillectomy and therefore provides difficulty with
comparisons. The text begins with Dr. Peter Koltai's description of
how he developed the concept of intracapsular tonsillectomy.
Chapter One, Powered Adenoidectomy, introduces many concepts that
are also common to tonsillectomy. Chapters Two - Four describe the
authors technique of intracapsular tonsillectomy (IT), as well as
those of Dr. Robert Ward (New York University), and Dr. John Bent
(Albert Einstein Medical College). In Chapter Five, Drs. Goldstein
and Gitman from SUNY Downstate review extracapsular tonsillectomy
(ET) and include their interpretation of IT. In Chapter Six, Dr.
Nina Shapiro, with Sophie Shay from University of California, Los
Angeles, reviews her extensive experience with coblation assisted
tonsillectomy, both for extracapsular and intracapsular techniques.
In Chapter Seven, Drs. Rubinstein and Derkay from Eastern Virginia
University discuss the results of both IT and ET from the
perspective of treatment of sleep disturbances and compare the
complication rates published over the past 16 years. In Chaper
Eight, the recent controversy of post-tonsillectomy pain treatment
is presented with recommendations from Drs. David Tunkel and Grace
Tan of Johns Hopkins University School of Medicine. Finally, in the
last chapter, conclusions are drawn and questions for the future
are presented.
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