There are several ways in which the tonsils can be removed, most commonly is the use of cautery or a coblation technique. The coblation technique offers the option of intracapsular vs. extracapsular removal.
The tonsil capsule is a thin, fibrous partition between the tonsil and the underlying muscles of the throat. An extracapsular tonsillectomy involves the complete removal of the tonsils and results in exposure of the muscle bed and the blood vessels that lie within the muscle. An intracapsular tonsillectomy involves the removal of tonsil tissue up to but not through the capsule. The intracapsular surgery will aim to remove all of the visible tonsil tissue (more than 95%). There are different ways to perform an intracapsular tonsillectomy, but one of the most popular techniques is to use Coblation®. Coblation® uses a special plasma derived from saline, which breaks down tissue at reasonably low temperatures, resulting in less pain and discomfort than some other techniques.
Intracapsular tonsillectomy is mainly used for large tonsils causing obstruction (sleep disordered breathing/obstructive sleep apnea). There is also now increasing evidence that it should also be offered to children suffering from recurrent tonsillitis. Intracapsular surgery has the advantage of reduced risks of bleeding as well as a much speedier recovery. One of the major downsides of conventional extracapsular surgery is the risk of bleeding after the operation (most commonly between 3 to 7 days), with rates quoted between 2 and 5%. With intracapsular techniques, the risk of bleeding is thought to be as low as 0.5%. Most children who have an intracapsular operation can return to school or daycare within a week, whereas those who undergo extracapsular procedures will need up to 10 days off from school.
There is a small risk of tonsil regrowth over time using the intracapsular technique and an even smaller risk of this tissue causing similar problems in the future. In practice, this is reasonably rare. In the largest study of intracapsular surgery, 1,000 children were followed up after the procedure for more than a year, and the chance of revision surgery was found to be about 2%. This occurred in children who had their tonsils removed in early childhood, i.e., less than three years of age. The possibility of revision surgery is more than offset by the reduction in complications, including life-threatening bleeding, when compared with conventional extracapsular procedures.
Intracapsular surgery is generally offered to children, as the benefits are very clear. Children presenting with very big tonsils and/or adenoids are ideal candidates for an intracapsular procedure.
This technique is also offered to adults with large tonsils or those experiencing tonsil stones/chronic cryptic tonsillitis.
