Intracapsular Tonsillotomy

Paediatric Procedures

Intracapsular Tonsillotomy Introduction

An intracapsular tonsillotomy is a type of tonsil surgery which reduces the size of the tonsils by removing 90-95% of tonsil tissue, while leaving a thin layer of the tonsil capsule (the outer covering) intact. This is different from a traditional tonsillectomy, where the entire tonsil and its capsule are removed.

This procedure is commonly used in young children who have sleep-disordered breathing or obstructive sleep apnoea (OSA) due to enlarged tonsils.

Reasons for surgery

Intracapsular tonsillotomy is typically recommended for:

Sleep disordered breathing / Obstructive Sleep Apnoea (OSA)
Children with large tonsils causing snoring, mouth breathing, or sleep apnoea

Dr Phillips will consider this technique in young children with enlarged tonsils who have sleep disordered breathing or Obstructive Sleep Apnoea (OSA) and no frequent tonsillitis

Benefits of the procedure

Compared to a traditional tonsillectomy, intracapsular tonsillotomy offers several benefits:

Less Pain

Since the tonsil capsule and surrounding muscles are not disturbed, post-operative pain is significantly reduced. Lower pain scores at earlier time points, lower absolute pain scores and faster time to pain free. (1)

Faster Recovery

Children usually return to normal eating and daily activities faster—often within a few days.(2,3)

Lower Risk of Bleeding

Because blood vessels deep in the tonsillar bed are not exposed, the risk of post-operative bleeding (especially delayed bleeding) is much lower with an overall bleeding rate of 1.3% which is superior to traditional tonsillectomy in multiple systematic reviews and meta-analysis.(4–7)

As effective at treating Obstructive Sleep Apnoea

Similar results obtained for sleep scores, quality of life questionnaires and AHI (a measure of severity of obstructive sleep apnoea) as tradiational tonsillectomy(2,8)

Feature	Intracapsular Tonsillotomy	Traditional Tonsillectomy
Tissue Removed	Partial (90-95% tonsil removed, capsule spared)	Complete (100% tonsil and capsule removed)
Post-op Pain	Moderate	Moderate to severe
Recovery Time	7-10 days	10–14 days
Risk of Bleeding	Very low (1.3%)	Higher (1-5%)
Risk of Regrowth/ Reoperation	Uncommon (5%)	Very Uncommon (<1%)
Best for Sleep Apnoea?	Yes	Yes
Best for Recurrent Infections?	No	Yes

Risks & complications

While intracapsular tonsillotomy has many benefits, there are some potential drawbacks to be aware of:

Small Risk of Tonsil Regrowth

Because a small part of the tonsil remains, there is a chance that tonsil tissue regrows seen in 10.8%
Sleep disordered breathing is almost twice as likely to recur (4.5% of cases versus 2.5% of cases for traditional tonsillectomy(2,8)
Risk of reoperation due to symptom recurrence is 8 times more likely and occurs in 5% of cases
The younger the child the higher the revision surgery rate(9)

Not Ideal for Recurrent Infections

Intracapsular tonsillotomy is generally not recommended for children with frequent or chronic tonsillitis, as some tonsil tissue remains and infections could persist leading to a higher revision surgery rate.(9)
Post op infection rates are 1.8 times more likely (9%) versus traditional tonsillectomy at one year(8)

Less Common in Adults

Dr Phillips only performs this technique in children, as adults tend to have different indications for surgery (e.g. recurrent infections) and may not benefit as much.

As with any surgery, intracapsular tonsillotomy carries some risks

General anaesthesia risks (low in healthy children)
Pain, especially in the throat and ears for 7–10 days
Bleeding, which can occur up to 2 weeks after surgery
Infection, although this is uncommon
Dehydration, from reduced fluid intake due to pain
Tonsil regrowth (rarely requiring revision surgery)

Dr Phillips will discuss these risks in more detail and help decide if this surgery is suitable.

Pre-operative instructions

Fasting

Your child will need to stop eating and drinking for a certain period before surgery (usually 6 hours for food and 2 hours for clear fluids). The hospital or anaesthetist will give you specific instructions.

Illness

If your child is unwell before the surgery (with a fever, cough, or cold), please contact the clinic as the procedure may need to be postponed.

Medications

Let Dr Phillips know if your child is on any medications, especially blood thinners, vitamins or supplements.

Procedure details

Your child is placed under general anaesthesia.
Dr Phillips performs Coblation tonsillotomy (the most common technique used for this procedure) which uses low temperature radiofrequency energy combined with a saline (saltwater) solution. This gently dissolves tonsil tissue with minimal heat causing less damage to nearby areas.
The outer capsule of the tonsil is left intact, which helps protect the underlying muscles and blood vessels.
The adenoids (if enlarged) may be removed at the same time (adenoidectomy) using the same Coblation technique.

Post-operative care & recovery

Pain

Pain is expected for up to 7-10 days, especially in the throat and ears. Regular pain relief is essential:

Use paracetamol and/or ibuprofen as advised
Give pain relief regularly, not just when pain is severe
If your child refuses oral pain relief, paracetamol can be taken as a suppository
Oxycodone syrup may be required when pain is not controlled by paracetamol and ibuprofen. It can cause drowsiness or constipation (it is important to ensure your child is hydrated and take stool softeners or laxatives as required)
Post operative pain relief information is always provided at the time of surgery however if you have any further questions please contact our practice.

Bleeding

A small amount of blood-stained saliva is normal in the first day or two. However, fresh red bleeding is not normal and should be treated as an emergency. Go to the nearest emergency department if this occurs.

Diet

Encourage your child to eat and drink as normally as possible – there are no diet restrictions
Keep your child well hydrated – encourage frequent sips of water or cool fluids.
Ice blocks, ice cream and other cool items can reduce swelling and alleviate pain

Activity

Rest at home for 7–10 days, most children will have recovered at one week.
Avoid vigorous activity, sport, or swimming for 2 weeks.
Children can return to school at two weeks

Breath and Voice Changes

Bad breath is common for several weeks after surgery.
Some children may sound a little different when speaking – this usually settles with time.

What to watch for

Call our clinic or seek urgent medical care if your child has:

Bright red bleeding (more than a tablespoon) – please present to the nearest emergency department for assessment
Persistent fever or High fever over 38.5°C
It is common to have a mild fever for the first 24-48 hours after the operation
Severe pain not relieved by medication
Refusal to drink, with signs of dehydration (dry mouth, no tears, fewer wet nappies)
Any breathing difficulties

Follow-up instructions

A review appointment will be arranged 4-6 weeks after surgery to ensure your child is healing well. If there are any concerns before this, please contact the clinic. If at any stage you wish to see Dr Phillips, our staff will be happy to arrange an appointment.

Summary

Intracapsular tonsillotomy is a safe and effective alternative to traditional tonsillectomy for children with sleep-related breathing problems caused by enlarged tonsils. It provides faster recovery, less pain, and lower risk of bleeding, making it a popular choice among ENT surgeons for appropriate cases. However it may not be suitable for all children and although rare has a higher rate of return of symptoms requiring further surgery. Dr Phillips will guide you on the best treatment option depending on your child’s symptoms and medical history.

References

1. Sedgwick MJ, Saunders C, Bateman N. Intracapsular Tonsillectomy Using Plasma Ablation Versus Total Tonsillectomy: A Systematic Literature Review and Meta-Analysis. Vol. 7, OTO Open. 2023.
2. Zhang LY, Zhong L, David M, Cervin A. Tonsillectomy or tonsillotomy? A systematic review for paediatric sleep-disordered breathing. Vol. 103, International Journal of Pediatric Otorhinolaryngology. 2017.
3. Lao J, Jian F, Ge R, Wu S. Tonsillectomy Versus Tonsillotomy in Pediatric Sleep-Disordered Breathing: A Systematic Review and Multi-subgroup Meta-analysis. Laryngoscope. John Wiley and Sons Inc; 2024.
4. Karam M, Abul A, Althuwaini A, Almuhanna A, Alenezi T, Aljadi A, et al. Coblation Versus Bipolar Diathermy Hemostasis in Pediatric Tonsillectomy Patients: Systematic Review and Meta-Analysis. Cureus. 2022;
5. Ahmad MU, Wardak AN, Hampton T, Siddiqui MRS, Street I. Coblation versus cold dissection in paediatric tonsillectomy: A systematic review and meta-analysis. Vol. 134, Journal of Laryngology and Otology. 2020.
6. Powell S, Tweedie DJ, Jonas NE, Bateman ND, Keltie K, Sims AJ. Coblation intracapsular tonsillectomy: A cohort study of NHS practice in England using Hospital Episode Statistics. Clinical Otolaryngology. 2022;47(3).
7. Soaper AL, Richardson ZL, Chen JL, Gerber ME. Pediatric tonsillectomy: A short-term and long-term comparison of intracapsular versus extracapsular techniques. Int J Pediatr Otorhinolaryngol. 2020;133.
8. Lao J, Jian F, Ge R, Wu S. Tonsillectomy Versus Tonsillotomy in Pediatric Sleep-Disordered Breathing: A Systematic Review and Multi-subgroup Meta-analysis. Laryngoscope. John Wiley and Sons Inc; 2024.
9. Sagheer SH, Kolb CM, Crippen MM, Tawfik A, Vandjelovic ND, Nardone HC, et al. Predictive Pediatric Characteristics for Revision Tonsillectomy After Intracapsular Tonsillectomy. Otolaryngology – Head and Neck Surgery (United States). 2022;166(4).

Book a consultation

If you’d like to discuss this procedure or explore suitable treatment options, please get in touch with Dr Nicholas Phillips’ clinic.

Snoring & Obstructive Sleep Apnoea (OSA)

Ear Conditions

Nose & Sinus Conditions

Throat & Neck Conditions

Paediatric Sleep Conditions

Paediatric Ear Conditions

Paediatric Nose & Sinus Conditions

Intracapsular Tonsillotomy

Table of Contents