# Tonsillectomy Techniques and Indications

> Tonsillectomy techniques in MBBS ENT: Paradise criteria, dissection methods, primary vs secondary haemorrhage and post-operative care.

- Canonical URL: https://prepelephant.com/topics/mbbs/ent/tonsillectomy-techniques
- Exam / course: MBBS · Subject: ENT
- Publisher: PrepElephant (https://prepelephant.com) — Prepared and reviewed by the PrepElephant Academic Review Team
- First published: 2026-10-02
- Last updated: 2026-10-02
- How to cite: "Tonsillectomy Techniques and Indications", PrepElephant, https://prepelephant.com/topics/mbbs/ent/tonsillectomy-techniques

## Direct answer

Tonsillectomy removes the palatine tonsils from their bed between the anterior (palatoglossal) and posterior (palatopharyngeal) pillars, and the decision to operate rests on defined criteria rather than recurrent sore throats alone: Paradise criteria — seven or more episodes in one year, five per year for two years, or three per year for three years — alongside sleep-disordered breathing, recurrent peritonsillar abscess and suspected malignancy. Techniques differ only in how the plane is entered and haemostasis achieved — cold steel dissection with ties remains a gold standard, while electrocautery, coblation, harmonic scalpel and laser trade operative bleeding for a variable post-operative pain profile. The complications that decide exam questions are primary haemorrhage within 24 hours — a return-to-theatre emergency — and secondary haemorrhage at five to ten days from slough separation.

## What you must remember

- **Indications with numbers:** Paradise criteria (7 in year one; 5 yearly for two years; 3 yearly for three years, with fever, adenopathy, exudate or positive culture), sleep apnoea in a child, two or more quinsies, asymmetrical tonsil suggesting lymphoma, and PFAPA syndrome.
- **The operation:** Rose's position with head extended, Boyle-Davis gag, incision along the anterior pillar, dissection in the subcapsular plane from superior pole to base, securing the inferior pole; haemostasis by ties, diathermy or packs.
- **Techniques in one line each:** cold steel with ligation — the pain benchmark; monopolar electrocautery — fast and dry but more thermal pain; harmonic scalpel and bipolar — intermediate; coblation — low-temperature dissection; intracapsular partial tonsillectomy — for pure obstruction in young children, with regrowth risk.
- **Primary versus secondary haemorrhage:** primary within 24 hours from slipped ligature or unsecured vessel — theatre re-exploration; secondary typically days five to ten, from infective sloughing of the eschar — managed by admission, clots evacuation, and cautery or theatre if active; describe assessment for hypovolaemia, not just local care.
- **Post-operative care:** regular paracetamol (never aspirin), early fluids and soft diet, and explicit written haemorrhage advice at discharge — most tonsillectomy deaths historically came from unrecognised bleeding at home.
- **Other complications:** odynophagia and referred otalgia, dental or temporomandibular injury from the gag, velopharyngeal insufficiency (rare, mainly after adenotonsillectomy for cleft or submucous cleft), taste disturbance, and pulmonary oedema after relief of long-standing obstruction.
- **Pre-operative checks:** bleeding history and coagulation screen where indicated, anaemia correction, and neck flexion-extension radiographs in Down syndrome before hyperextension positioning.

## From indication to post-operative night

A seven-year-old with six documented tonsillitis episodes last year and two already this year, loud snoring with pauses and failure to thrive is listed for adenotonsillectomy — both infective and obstructive indications met, and sleep-disordered breathing is today the commonest indication in Indian practice.

In theatre: induction, Rose's position, Boyle-Davis gag, traction to define the pillars, incision at the superior pole, dissection along the capsule until the inferior pole is transfixed and divided — one side, then the other, adenoids out, haemostasis confirmed. The post-operative orders write the exam answer: paracetamol around the clock, soft diet the same evening, no aspirin, and parents counselled that fresh bleeding or repeated swallowing means immediate return. A small secondary bleed on day six in a stable child means admission, clot evacuation and theatre only for active ooze; the primary bleed at hour 18 means theatre now, with the anaesthetist warned about a full stomach.

## Where examiners dig

Three traps recur. First, the candidate who lists "recurrent tonsillitis" without numbers — the Paradise criteria with their 7-5-3 arithmetic are expected verbatim in professional exams. Second, the haemorrhage timing: primary versus secondary bleeds differ in mechanism and management, and the immediate step in any active tonsillar bleed is theatre, not observation. Third, the tonsillar bed's muscle is the superior constrictor, with the glossopharyngeal nerve just lateral — the ninth nerve's tympanic branch answers the examiner's "why does the throat pull toward the ear?" question. The tonsil's open crypts versus the adenoid's folds complete the Waldeyer's ring picture.

## Frequently asked questions

### What are the Paradise criteria for tonsillectomy?

At least seven documented episodes in one year, five per year for two consecutive years, or three per year for three consecutive years, each with fever, adenopathy, exudate or positive streptococcal culture.

### How do primary and secondary tonsillar haemorrhage differ?

Primary bleeding occurs within 24 hours from an unsecured vessel and demands return to theatre; secondary bleeding occurs around five to ten days from slough separation of the eschar and is managed by admission with cautery or theatre if active.

### Which tonsillectomy techniques are in common use?

Cold steel dissection with ties, electrocautery, coblation, harmonic scalpel and intracapsular partial tonsillectomy — each balancing operative haemostasis against post-operative pain.

### What post-operative instructions follow tonsillectomy?

Regular paracetamol, early fluids and soft diet, avoidance of aspirin, and clear guidance to return immediately with fresh bleeding or constant swallowing.

### When is tonsillectomy indicated beyond recurrent infection?

Obstructive sleep-disordered breathing, recurrent peritonsillar abscess, asymmetrical tonsil suspicious for lymphoma, and periodic fever syndromes such as PFAPA.