A cheeseburger, please: Tonsillectomy technique speeds return to normal diet, reduces pain

Less than four hours after her tonsillectomy, Madison Boehm had a request.

A cheeseburger, please.

The 3-year-old’s mother, Lisa, was amazed. After all, it took her other child, Nick, 7, a day or two to want solid food because of soreness that lingered after his tonsillectomy.

Like the vast majority of the nearly 300,000 children who have tonsillectomies in the United States every year, Nick had both of his tonsils completely removed via a technique known as an extracapsular tonsillectomy (ET).

Madison, however, had an intracapsular tonsillectomy (IT) – a technique championed at CHOC in which 95 percent of the tonsils are removed, preserving the “capsule,” and thus protecting the muscle underneath.

The result: less risk of bleeding after surgery, vastly decreased pain after surgery, and a rapid return to normal diet.

Madison underwent an intracapsular tonsillectomy at age 3 and quickly resumed her regular diet.

Dr. Kevin Huoh, a pediatric otolaryngologist, brought the technique to CHOC when he started there in September 2013 after learning it during his fellowship at Stanford University Medical Center. So, too, did fellow pediatric otolaryngologist Dr. Nguyen Pham, who joined CHOC around the time Huoh did.

Since then, more than 1,000 children have undergone intracapsular tonsillectomies at CHOC, with the rate of tonsillar regrowth – the most cited concern for not performing ITs – remaining extremely low, Dr. Huoh says. In addition, the rate of post-tonsillectomy bleeding, the most feared post-operative complication, is pretty much zero, much lower than with traditional extracapsular tonsillectomy.

Now, in a recently published research paper in Laryngoscope, the foremost publication for otolaryngologists (also known as ENTs – for ear, nose, and throat – practitioners), Huoh predicts there will be a “paradigm shift” over the next five to seven years.

He believes ITs will become the standard surgical technique for removing tonsils in children either for snoring and sleep disordered breathing or for chronic/recurrent tonsillitis.

And CHOC, Dr. Huoh notes, was among the first pediatric hospitals in the country to adopt ITs as the standard technique.

“The reasons (most other ENTs) are not doing ITs are probably psychosocial,” Dr. Huoh says. “They’re not exposed to it. They’ve been doing tonsillectomies the same way for forever and they have a lack of exposure to this new procedure. Simply, they are set in their old ways.

“But this procedure is very, very favorable. It’s very easily learned, and it really works.”

Dr. Kevin Huoh brought the intracapsular tonsillectomy (IT) technique to CHOC in September 2013 and predicts IT will be the standard tonsillectomy technique in the U.S. in five to seven years.

Intracapsular tonsillectomies have steadily gained popularity in the United States and across the world since the procedure first was described in 2002.

But as Dr. Huoh notes in his paper, “Current Status and Future Trends: Pediatric Intracapsular Tonsillectomy in the United States,” co-written by Dr. Yarah Haidar and Dr. Brandyn Dunn, both of the UCI School of Medicine, only 20 percent of the 540 pediatric otolaryngologists who responded to a survey the three doctors sent perform intracapsular tonsillectomies.

That is certain to change in the coming years as the benefits of the technique become more widely recognized, Dr. Huoh says.

Dr. Huoh and other CHOC doctors mainly perform intracapsular tonsillectomies on children whose large tonsils cause obstructive sleep apnea.

Such was the case with Madison.

When she was 2, her parents noticed she snored a lot and woke up tired. She was sluggish and lethargic and took one or two three-hour naps per day.

“We went online and did some research, and sleep apnea popped up,” Lisa recalls.

Madison was diagnosed with having large tonsils and adenoids as well as obstructive sleep apnea, which made her a candidate for an intracapsular tonsillectomy.

Lisa says she and her husband, Cameron, researched the best hospital to take Madison to and they quickly settled on CHOC, where Dr. Pham diagnosed Madison as having large tonsils and adenoids as well as obstructive sleep apnea.

Madison had the surgery on Aug. 3, 2019.

“The doctors at CHOC were all dialed in, and I was holding her an hour after she went under,” Lisa recalls. “The recovery part is what was amazing. By the time we were home, she was totally out of the anesthesia fog and asking to eat.”

So, Lisa got Madison a cheeseburger.

She never complained about her throat – just soreness on the top of her hand from the IV.

“She completely recovered in a couple of days,” Lisa says of Madison, who enjoys dancing and gymnastics. “From that first night after surgery, she has been sleeping normally, and I feel that her personality has come out a little more.”

Lisa says she has referred her friends who have kids with tonsillar problems to CHOC pediatric otolaryngologists.

“The doctors treat their patients like they are their own kids,” she says. “I had total confidence in them. They carefully explained everything that was needed, and I could always be in touch with them. They are second to none.”

Learn more about CHOC otolaryngology.

Goodbye Popsicles and pain killers: How painless tonsillectomies are changing CHOC patients’ recoveries

After hearing her mother’s stories of the aftermath of her teenage tonsillectomy, Jenna Opp was a little worried before undergoing the procedure herself.

jenna-underwent-painless-tonsillectomy

But thanks to a different technique offered by CHOC otolaryngologists, Jenna drank a smoothie right after the procedure, and by that night, she enjoyed eggs and French toast for dinner. Only two days later she was back in school and ready for a hamburger.

“I was expecting a lot more pain and not being able to talk and all those typical things,” the 18-year-old says. “But I was totally fine. I could eat and drink. I talked to my mom while I was still in the recovery room.”

jenna-painless-tonsillectomy-preop
Jenna, before her painless tonsillectomy

Jenna underwent a procedure called an intracapsular tonsillectomy, wherein CHOC otolaryngologist Dr. Nguyen Pham deftly shaved away at her tonsil, leaving a small portion behind.

In contrast, a traditional total tonsillectomy removes the entire organ, increasing bleeding risk and exposing muscle behind the tonsil, which increases pain.

In addition to decreasing the risk of post-operative bleeds, which can be fatal, the intracapsular tonsillectomy technique has shown to dramatically lower hospital readmission rates due to pain and dehydration.

Further, patients like Jenna do not require opioid pain medication and are returning sooner to school and a regular diet, Dr. Pham says.

“They offered to do it the old way or the new way,” Jenna says. “They told me the new procedure is way less painful and only takes a couple days for recovery. I was like,  ‘I’m sold on that’ and it was awesome.”

Frequently asked questions about intracapsular or painless tonsillectomies

Do the tonsils regrow?

The regrowth rate of intracapsular tonsillectomy at CHOC is 0.5 to 1%.

Does an intracapsular tonsillectomy take longer than a traditional tonsillectomy?

No. The procedure takes the same amount of time – 30 to 45 minutes.

Has this procedure been practiced in other places?

Intracapsular tonsillectomy is growing in popularity in the United States. Elsewhere in the world, such as in Sweden and France this procedure is already the preferred method of tonsil removal.

Will a patient need pain medication after this procedure?

Usually children will require only over-the-counter pain medication for a few days after surgery. Some children do not require any pain medication.

How old does a child have to be for intracapsular tonsillectomy?

There are no age restrictions for this procedure.

Learn more about tonsillectomies at CHOC.