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Tonsil Regrowth After Intracapsular Tonsillectomy

Author Dana Schmitz covers Tonsil Regrowth After Intracapsular Tonsillectomy on BackTable ENT

Dana Schmitz • Jul 26, 2023 • 196 hits

Pediatric ENT Dr. Kevin Huoh shares his experiences with intracapsular tonsillectomy and addresses the concerns that clinicians might have regarding tonsil regrowth and revision. According to Dr. Huoh, the tonsil regrowth rate following intracapsular tonsillectomy is minimal, roughly less than 1%, with a slightly elevated rate for children under four years of age. The risk of tonsil regrowth versus the risk of postoperative bleeding is a balancing act, emphasizing the comparative simplicity and safety of a revision tonsillectomy over managing a bleeding episode. In terms of recovery, patients undergoing intracapsular tonsillectomy report minimal discomfort and a quick return to normal routines, a testament to its possible benefits over traditional methods.

This article features excerpts from the BackTable ENT Podcast. We’ve provided the highlight reel in this article, but you can listen to the full podcast below.

The BackTable ENT Brief

• According to Dr. Huoh, the rate of tonsil regrowth post-intracapsular tonsillectomy is less than 1%, increasing slightly to around 3% for children under the age of four.

• In case of tonsil regrowth, a second revision intracapsular tonsillectomy is often the approach, based on the surgeons' experiences and clinical judgment.

• A comparison of post-operative pain and recovery between intracapsular and extracapsular tonsillectomy shows favorable results for the former, with reduced discomfort and a faster return to normal activities, typically within a few days.

• The adoption and acceptance of intracapsular tonsillectomy varies globally, with the technique recommended in the national guidelines of countries like the UK and France, yet not as prominent in the United States' guidelines.

Intracapsular Tonsillectomy: Regrowth, Revision & Recovery

Table of Contents

(1) Tonsil Regrowth After Tonsillectomy

(2) Intracapsular vs Extracapsular Tonsillectomy: A Comparison of Post-Op Pain & Recovery

(3) The Adoption of Intracapsular Tonsillectomy in the United States & Abroad

Tonsil Regrowth After Tonsillectomy

Dr. Huoh delves into the specifics of intracapsular tonsillectomy, with particular emphasis on tonsil regrowth and post-operative recovery. Dr. Huoh notes that tonsil regrowth is a key concern, however, the rate is often less than 1% and typically pertains to younger patients whose lymphoid tissue is naturally proliferating. He advises parents of younger children that the tonsil regrowth rate may be slightly higher, around 3%. In the event of regrowth necessitating a revision tonsillectomy, Dr. Huoh suggests a repeat intracapsular tonsillectomy rather than an extracapsular approach.

[Dr. Kevin Huoh]
It is interesting you bring up your experience as a resident because Dr. Riley was one of the first ones to adopt the intracapsular approach that Dr. Peter Kotai wrote about. He was one of the early proponents along with Dr. Kotai, so it's interesting you had that experience as a resident.

[Dr. Gopi Shah]
Yes, so the DuPont Group, they published papers as well. Because I think the big concern is tonsil regrowth. What is the percentage of tonsil regrowth? They looked at their data and they also looked at the other factors such as pain and time to PO and bleeding. I think the tonsil regrowth rate, it's like less than 1%, maybe 1%-2% at most. In terms of some people would say, "Well, regrowth is my big concern," especially the one people-- for those of us that are still doing traditional, is there an age where you're like, "Hey, this child is three. If I do an intracap for sleep-disordered breeding, are they going to have like a little bit of regrowth that could cause issues when they're six?" Is that a silly concern or how-

[Dr. Kevin Huoh]
No, I just-

[Dr. Gopi Shah]
Because we think that it proliferates, the tonsil tissue. The lymphoid tissue will proliferate between age two to six, right?

[Dr. Kevin Huoh]
Yes, absolutely. You're absolutely right, Gopi. We have data on that. The early data for intracapsular tonsillectomy alignment was from Europe, was from Sweden, and they had really varied regrowth rates, anywhere from 1% to like 12% I saw one paper. One difference about that data over from Europe is a lot of those countries, when they do intracapsular tonsillectomy, they're just doing up to the pillars. They're not going all the way to the capsular. As you would expect, those populations might have more regrowth. In our group, we've seen a regrowth rate that's around less than 1%, but the data does show that the younger you are, the more likely you are to have regrowth. Because of what you said, it proliferates at that age.
When I counsel parents of children, usually under the age of four, three or four, I will tell them there's a little higher rate of tonsil regrowth. I'll quote them, actually, a 3% rate of regrowth. My other patients, I'll say 1% or less. It's a similar rate of regrowth to risk of bleeding for total or extracap, so you kind of weigh those two different risks. I would much rather do a revision tonsillectomy at 8:00 AM in the morning, than a bleeding tonsil at 2:00 AM trying to get an airway and having a three year old bleeding in my ER. I'll take that any day of the week, you know?

[Dr. Gopi Shah]
Yes. Well, we consider two questions for you. One is if you do have a child that you did intracap on, that you have to go back for some regrowth, are you doing intracap again or do you switch techniques at that point? Then the second question is I wanted to get a little bit more into like the pain and recovery after an intracap.

[Dr. Kevin Huoh]
You asked great questions, Gopi. No wonder you're the host of the podcast.

[Dr. Gopi Shah]
Because I'm sitting here like-- no, one of my partners came on, not came on, one of my partners a couple years younger than me started-- an old partners when I was in Dallas. Stephen Chorney, he trained at CHOP and he's so brilliant. He's wonderful. Came in was like, "No, I'm going to do intracap." He's such a scientific, evidence-based mind. He saw in practice, he knows the data, and that's what he was doing. Yet the rest of us were still doing extracap. I remember getting out of fellowship being like, "Well, this is what we do here, so this is what I'm going to do because this is how we know how to handle. This is our algorithm." These are just the questions. Because I'm like, "Do I need to like-- am I a dinosaur now? What do I need to do?" That's why I have these questions for you.

[Dr. Kevin Huoh]
There's so much unpacked there.

[Dr. Gopi Shah]
[laughs].

[Dr. Kevin Huoh]
We'll, start with you-

[Dr. Gopi Shah]
About the being a dinosaur. What are we unpacking, Kevin? [laughs]

[Dr. Kevin Huoh]
There's so much to unpack about data, about surgeons following data. Let's go back to your original question, which is what do you do if you have to revise intracapsular tonsillectomy. I've done probably around 5 to 10 of these. Our rate is about less than 1%, but when I had my first regrowth, this was early in my career, and I was like, "Oh my gosh, am I doing the right thing?" Right?

[Dr. Gopi Shah]
Right.

[Dr. Kevin Huoh]
For those patients, I did a bovie tonsillectomy, I did a traditional extracapsular tonsillectomy. Then my partner, Nguyen Pham, said to me once, she like, "Kevin, why don't we just do this again? Do another intracapsular." I'm like, "Huh, okay." That's what we do now. I just do another intracapsular tonsillectomy. Now, your colleague, Stephen Chorney, he's absolutely right about following data.

There's very few things in surgery in otolaryngology where we have data. There's actually randomized control trials. Actually, one of my old attendings Dr. Kay Kane, at Lucile Packard, he did a randomized control trial on extra versus intracapsular using Coblator, so we have good data, we've got meta-analysis on this that show improved recovery, decreased post-op morbidity, et cetera. I think you're not a dinosaur, but-

[Dr. Gopi Shah]
Thank you. Yes. There is time to keep up with the data-

[Dr. Kevin Huoh]
Time's are a-changin'.

[Dr. Gopi Shah]
Yes, times are a-changin'. I guess, if you are doing a revision intracapsular tonsillectomy, it makes sense because the kids are usually a bit older, so that sort of tonsil regrowth period that we worried about isn't maybe as much. I think there was a point where I think an intracap, I would think about it for my young kids, the under two that have really bad OSA, that 15 month old for some reason that, you know what I mean? Then I'm like, "Well, is this going to regrow or my cardiac kids on the aspirin?" It's just like, "Well, why am I not just switching over completely," but when you explain, tell me about the post-op recovery, because on the other hand, and again, this is where I'm so excited you're here, because it's like, "Well, do you want your kid to have a potential for a tonsillectomy all over again?"

Listen to the Full Podcast

Intracapsular Tonsillectomy in Children with Dr. Kevin Huoh on the BackTable ENT Podcast)
Ep 110 Intracapsular Tonsillectomy in Children with Dr. Kevin Huoh
00:00 / 01:04

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Intracapsular vs Extracapsular Tonsillectomy: A Comparison of Post-Op Pain & Recovery

After intracapsular tonsillectomy, patients typically experience minimal discomfort, necessitating only 24 hours of Tylenol/Motrin, followed by as-needed medication. Recovery is typically fast, allowing children to return to school within a few days, and they can consume a regular diet right after surgery. Unlike extracapsular tonsillectomy, there is no "second bump" of pain around day seven or eight. An interesting highlight is the decrease in patient calls post-op, indicating fewer complications or concerns. Dr. Huoh and Dr. Shah also discuss the declining use of narcotics in pediatric post-op pain management, showing how medical practices are evolving to ensure patient safety.

[Dr. Gopi Shah]
Is the recovery like post-op to 3 to 7 to 11? Is there going to be a second bump of the pain? All that kind of stuff. Tell me about all that.

[Dr. Kevin Huoh]
Yes, so post-op, our patients have very minimal discomfort. We put them on Tylenol/Motrin for 24 hours, and then as needed after that. Most of my tonsils I do on Thursday or Friday, all my kids go back to school Monday or Tuesday the next week. We start them on a regular diet post-op day zero. I just tell them not to eat sharp food like Doritos, or tortilla chips for the first week. They do really, really well. My son had tonsillectomy right before COVID back in February, 2020. I asked my friend to do intracapsular and my son did great.

[Dr. Gopi Shah]
That's awesome. Because I would tell you for the traditional extracap, I would say my patients were on Tylenol/Motrin for several days, even up to a week after, around the clock, the alternating every three. In terms of school, I'd say probably not earlier than day seven. If there's a second bump, they might be out a little bit longer.

[Dr. Kevin Huoh]
Absolutely. That's what I see with my tonsillectomy, my bovie tonsillectomy, it's like exactly, right. You get that second bump in pain day seven or eight. I didn't know about that until I became an attending. [laughs] You get the phone calls, right?

[Dr. Gopi Shah]
Yes. I was going to say, well, so for your intracap, tell me about the phone calls in the clinic. Meaning when do the patients call and what are they calling for?

[Dr. Kevin Huoh]
They don't.

[Dr. Gopi Shah]
[laughs] Stop.

[Dr. Kevin Huoh]
They don't. Eh, no, I'm serious. It's interesting because the other thing we didn't talk about, Gopi, is narcotics. That's huge. Honestly, don't tell anyone this, but I don't even know where my triplicate pad is right now. I-

[Dr. Gopi Shah]
Oh, yes, I don't either. I haven't prescribed that, even with traditional, I'm just thinking, I haven't prescribed triplicates or narcotics in more than five years.

[Dr. Kevin Huoh]
Right. A lot of people still do. A lot of people still do. When you go to the meetings now, there's all those panels on post-op pediatric console pain, things like that. They rarely talk about intracapsular tonsillectomy. I think that's a big aspect of what intracapsular can offer.

The Adoption of Intracapsular Tonsillectomy in the United States & Abroad

Clinical guidelines and discussions at academy meetings reveal a relative lack of attention towards intracapsular tonsillectomy in the United States when compared to other countries like the UK and France. Dr. Huoh notes that despite the existence of randomized controlled trials and meta-analyses underscoring the benefits of intracapsular tonsillectomy, the method has yet to achieve widespread adoption in the U.S. However, Dr. Huoh observes a hopeful trend: a survey from 2017 showed that 20% of American Society of Pediatric Otolaryngology (ASPO) members were utilizing intracapsular tonsillectomy, a figure that he expects to have grown since then.

[Dr. Gopi Shah]
Yes. You said that, at the conferences, we're not talking about tonsillar intracap as much right now.

[Dr. Kevin Huoh]
Yes, I think at the last academy meeting in Philadelphia, there was a panel on how to manage pain after pediatric tonsillectomy. The elephant in the room is intracapsular. They're talking about all these other ways of reduce pain, Tylenol/Motrin alternating, but they failed to talk about intracapsular. I always raised my hand to talk about it.

Then when you look at the latest clinical practice guidelines from our academy, they didn't mention intracapsular tonsillectomy once in the guidelines, but they did have an addendum this time saying that intracapsular is around, like you can try it, we need "more data". If you look at the guidelines in England and the UK, if you look at guidelines in France, it's on their national guidelines. Actually the National Health Service in the UK, they recommend intracapsular tonsillectomy because they have the data, they've looked at the data.

[Dr. Gopi Shah]
Well, it sounds like we have data too, because we have randomized control trials and meta-analysis. It's just hasn't quite taken off I guess. Would you agree with that?

[Dr. Kevin Huoh]
Yes. I would. I think some of it has to do with the free-thinking, independent spirit of Americans in general. I think it takes a little time for any new innovation to spread. I did my survey five years ago of ASPO members, American Society of Pediatric Otolaryngology members. I think only 20% were doing intracaps. That was 2017, thereabouts. My guess is that it's higher than that now. I think probably 40%, I would hope by now. If we look at Malcolm Gladwell's book, The Tipping Point, he talks about the 20% being the tipping point or the point at which diffusion increases at exponential rate. After seeing that number, I felt encouraged.

Podcast Contributors

Dr. Kevin Huoh discusses Intracapsular Tonsillectomy in Children on the BackTable 110 Podcast

Dr. Kevin Huoh

Dr. Kevin Huoh is a pediatric otolaryngologist and assistant professor in Southern California.

Dr. Ashley Agan discusses Intracapsular Tonsillectomy in Children on the BackTable 110 Podcast

Dr. Ashley Agan

Dr. Ashley Agan is a practicing ENT and assistant professor at UT Southwestern Medical Center in Dallas, TX.

Dr. Gopi Shah discusses Intracapsular Tonsillectomy in Children on the BackTable 110 Podcast

Dr. Gopi Shah

Dr. Gopi Shah is a practicing ENT at UT Southwestern Medical Center in Dallas, TX.

Cite This Podcast

BackTable, LLC (Producer). (2023, May 16). Ep. 110 – Intracapsular Tonsillectomy in Children [Audio podcast]. Retrieved from https://www.backtable.com

Disclaimer: The Materials available on BackTable.com are for informational and educational purposes only and are not a substitute for the professional judgment of a healthcare professional in diagnosing and treating patients. The opinions expressed by participants of the BackTable Podcast belong solely to the participants, and do not necessarily reflect the views of BackTable.

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