Exploring the Intracapsular Advantage and Evolution in Tonsillectomy Methods

Join us on this week’s We Nose Noses podcast going into the intricacies of tonsillectomy, one of the oldest procedures in medicine. Dr. Reddy, Dr. Undavia and Dr. Smith shed light on the differences between extracapsular and intracapsular tonsillectomies, the historical evolution of the procedure, and the latest techniques aimed at reducing postoperative pain and enhancing recovery. Discover the reasons behind the shift towards intracapsular tonsillectomies and how cutting-edge methods are shaping a more comfortable experience for both children and adults.

What you’ll learn

  • Why intracapsular tonsillectomy is now a more preferred and patient-centric surgical option
  • What sets Intracapsular apart from extrascapsular from the risks to the recovery time
  • How the evolving technique of tonsillectomies enhance overall outcomes and patient satisfaction

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Listen to the audio version below.

Audio Transcript:

Hi, welcome to the We Nose Noses podcast. This week’s episode, we’re going to discuss one of the most common surgical procedures in medicine, which is the tonsillectomy. So we’re going to discuss a couple different things with tonsillectomy, including what’s called a traditional or extracapsular and intercapsular or partial tonsillectomy. So I’ll have Dr. Reddy here describe kind of what the differences are between the two.

Dr Reddy:
Yeah, so first just brief anatomy. You know, you have your tonsils that are in the back of your throat. And the tonsils that most people talk about are the palatine tonsils, which are the tonsils that are in the back of your throat. And those tonsils are this tissue called lymphoid tissue that’s part of, at some point, thought to be a little bit more integral to your immune system as a baby. And this lymphoid tissue is surrounded by the muscle in the back of your throat or the oropharynx. The muscle that’s there is called the posterior and anterior pillars of the tonsils, which are comprised of these certain muscles such as the palatoglossus muscle and the palatopharyngeus muscle. So you have those tonsils that are there and surrounding the tonsil is something called a capsule. And the capsule is a covering that surrounds a tonsil and it’s the interface between the tonsil and the muscle. And so when you take out your tonsils, there’s two separate ways of doing it. I’ll have Dr. Undavia maybe go over that.

Dr Undavia:
So when you talk about intracapsular versus extracapsular, you’re talking about on what side of that capsule are you on when you take out the tonsil. So the traditional tonsillectomy is called an extracapsular tonsillectomy, where you go between the capsule and the muscle.
And the tonsil is off and kept completely intact. And so you’re taking the tonsil and the capsule with it and fully taking it out. The intracapsular tonsillectomy is you’re on the other side of that capsule. Now you’re in between the tonsil and the capsule. The muscle is not touched at all, and the capsule is kept with the patient after the tonsillectomy. So you technically leave a small rim of tonsillar tissue when you take out the tonsils. So with an extracapsular tonsillectomy, you’re taking out 100% of the tonsil and the capsule. With an intracapsular tonsillectomy, you are taking maybe 80%, 90%. You’re taking a percentage of the tonsil and you’re leaving a thin percentage of the tonsil behind. Now it should be noted that when we talk about adenoid tissue, we are always doing an intracapsular adenoidectomy. No matter what way you do it, it’s always an intracapsular. So that’s the way it’s been done for… Forever.

Dr. Smith:
Speaking of forever, so yeah, tonsillectomy is probably one of the oldest procedures there is in medicine. So it goes back 3,000 years into Hindu medicine with removal of tonsillar tissue over 3,000 years ago. And it’s evolved through ancient Roman times and even into more traditional approaches where snares, which are kind of like little wire, kind of lacerations that occur, that they would just remove the tonsil, even guillotines, where they would kind of just chop out the tonsil. And so we’ve tried to, over years, evolve a more refined procedure of separating the tonsil from the muscle anatomy, which Dr. Reddy had described. And now more recently, we’ve been trying to discover, are there ways that we can make the from a tonsillectomy a little bit less risky, a little bit more palatable, so it’s not so hard of a recovery for kids.

Dr. Reddy:
No pun intended.
Dr Smith:
Yeah, no pun intended. It’s not so hard for kids or adults. And so a lot of the studies first came out with kids trying new techniques, which were more kind of minimally invasive type of styles, which is the intracapsular technique. And so the impetus for this technique was to provide the same outcome, so the same improvement in infection, same improvement in sleep issues or obstructive issues, but also to help decrease pain and other things. So Dr. Reddy, talk a little bit about then, why do we do intracapsular? What types of methods are there?
Dr. Reddy:
Yeah, so just real quick, some brief methods. You’ve touched on the older methods of removing your tonsils, which is the stainless steel methods essentially. And then there’s electrical methods of removing it, the most common of which is something called bovey electric artery. And then there’s other tools that people have tried over the years that some surgeons use. One’s called coblation tonsillectomy, and the other’s called peak plasma wand. Some people use a harmonic scalpel. Some people use a ligature device. These are all different methods on trying to take out your tonsils extracapsularly. To remove them intracapsularly, the primary methods of doing it is either with a microdebreeder or with coblation. A coblation is an energy delivery device that’s lower temperature than traditional bogey electrocautery, and it kind of melts away the tonsillar tissue from an outside-in perspective while sucking the tissue out. And a microdebreeder is an instrument that’s a stainless steel device that cuts and sucks the tonsillar tissue similar to how you remove nasal polyps in the nose. And once the tonsillar tissue is removed, then you do an additional step to decrease bleeding and stuff afterwards. In terms of, do you want to go over Dr. Undavia, why would we consider an intracapsular tonsillectomy versus an extracapsular?

Dr. Undavia:
Absolutely. So we always talk with our patients about three things post-op when it comes to tonsillectomy. And that’s whether it’s intra-capsular or extra-capsular. And those are the risks of surgery. So the first thing is bleeding. The second thing is pain. And the third thing is risk of regrowth. So when it comes to bleeding for an extra-capsular tonsillectomy, the general risk is about one to four percent. So that means out of every hundred patients that we perform a tonsillectomy on, one to four of them will have a post-operative bleed. And that bleed typically necessitates going to the ER, getting medications, and then sometimes going to the OR to cauterize a specific vessel. It typically happens on days five to seven, but it can happen for the first three weeks of surgery. And that can be traumatic for the patient, whether it’s a kid or an adult. It can be expensive. It can just be a disruption in your healing. So it’s not something to be taken lightly, even though it’s only 1%. The second thing we talk about is pain, and most patients will tell you a traditional tonsillectomy hurts, and it does. There’s no sugar coating it. We give you pain medication. We’re happy to refill pain medication, but even when we do that, there is a certain amount of baseline pain that patients feel.

We three care about, you know, making sure your body is healthy during that pain. So the main thing that we care about is you’re hydrating yourself enough. So we want you to be able to be peeing normally, which means drinking enough fluids. So we give you pain medication so that you can drink, but it is not to get rid of all the pain because it just hurts a lot. And then the third thing is regrowth. So with a traditional tonsillectomy, the risk of regrowth is virtually zero. That we really just don’t see tonsils coming.

Now, when it comes to intracapsular tonsillectomy, the risk of bleeding is actually close to zero. We don’t see post-operative bleeding. And if they do, they’re just a little bit of a bleed for a second or two or a minute, and it goes away all by itself. They’re not high-volume vessels that are bleeding. This is a huge game changer for our patients. When it comes to pain, if on a scale of one to 10, a traditional tonsillectomy was like a nine or a 10, this is probably like a four or five, I think.

Dr. Smith:
Yeah, yeah. Studies show that most of the time when we tell kids or adults, normally it’s like a week to two that we tell them for a traditional tonsillectomy that they’re gonna be off from work because of the pain and discomfort. But back to work or back to normal activity for an intracapsular, and this goes along with the pain, is typically closer to two to five days. So significantly reduced back to normal activity timeframe. So less pain medication.

Dr. Undavia:
Less bounces to the ER to control pain, less IV fluid needs post-op. So patients are doing so much better after this. They’re back to work and school faster. And then finally, the risk of regrowth. I’ve seen a couple studies that have quoted slightly different numbers, but in general, the risk of regrowth for tonsils and adenoids is 0.5 to 3%.

Dr. Smith:
Yeah, I think a lot of that’s just technique dependent, especially in the beginning when procedures were being discovered different ways of doing intracapsular. I think some techniques were different. So a lot of those studies were done when intracapsular tonsillectomies were kind of in their advent. And so the real number is probably closer to that half percent.

Dr. Undavia:
And so when you weigh those three things, bleeding, pain, and risk of regrowth, intracapsular versus extracapsular, then definitely the pendulum is swayed towards intracapsular, even with the risk of regrowth they may grow back a little bit and you may not need to do anything about it. So we’ve switched primarily to intracapsular tonsillectomies our patients are just so much happier for it. Yeah, even in adults, the studies are still kind of early on with adults and typically in adults we do tonsillectomies for the same either chronic tonsillitis, chronic infections and or obstructive sleep apnea reasons. Now it’s much more common to do tonsils for sleep apnea in kids, but the studies are kind of showing even in adults, there’s seems to be a benefit as far as decreased pain, decreased bleeding, and still giving the same benefit with the chronic tonsil infections and the sleep apnea. So I’m certainly recommending them and offering them frequently in adults as well.

Dr. Reddy:
There’s three main reasons for potentially getting your tonsils out. It’s either chronic infections or sleep disorder breathing like snoring or obstructive sleep apnea. And initially, intracapsular tonsillectomy was more studied with the sleep disorder breathing and population. But now people have been starting to kind of go outwards to the chronic tonsillitis, the recurrent infections and the obstructive sleep apnea. And it’s all showing relatively positive good results. So I think we tend to offer either or to most of our patients, a lot of our patients kind of make the decision, but we’re finding that more and more patients are kind of going the intracapsular route.

Dr. Undavia:
I would.

Dr. Smith:
Yeah, I would do it if it was me. Great. Excellent. Anything else to add? No, we’re trying to keep it brief and hitting with all the points. I think we covered it pretty thoroughly. If you guys have any questions, feel free to message us. Thanks for joining our podcast.

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