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Pediatric Intracapsular Tonsillectomy: Benefits of Retaining Minimal Tonsillar Tissue

Author Dana Schmitz covers Pediatric Intracapsular Tonsillectomy: Benefits of Retaining Minimal Tonsillar Tissue on BackTable ENT

Dana Schmitz • Jul 26, 2023 • 136 hits

Intracapsular tonsillectomy is a surgical method that retains some tonsillar tissue and leaves the capsule intact. The procedure has witnessed an increased uptake among ENT professionals. Intracapsular tonsillectomy dvocate Dr. Kevin Huoh, a pediatric otolaryngologist, highlights reduced pain and lower postoperative hemorrhage risk for patients as significant benefits. Intracapsular tonsillectomy can successfully address sleep-disordered breathing and obstructive sleep apnea (OSA) in children by removing the mass of the tonsil. Data indicates an equivalent rate of reduction in tonsil infections following an intracapsular tonsillectomy compared to the traditional approach. The efficacy and safety of intracapsular tonsillectomy are making it increasingly attractive even for cases traditionally approached with extracapsular tonsillectomy, such as recurrent tonsillitis and tonsil stones.

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

The BackTable ENT Brief

• Intracapsular tonsillectomy involves removing most of the tonsillar tissue while leaving the capsule intact. This prevents exposure of the pharyngeal wall muscles and larger caliber vessels.

• Intracapsular tonsillectomy provides effective treatment for recurrent tonsillitis, obstructive sleep apnea and sleep-disordered breathing, offering reduced postoperative pain, recovery time and risk of postoperative hemorrhage.

• Current data on intracapsular tonsillectomy has shown it to be effective in reducing the number of tonsil infections at rates comparable to a total or traditional tonsillectomy.

• According to Dr. Huoh, around 90-95% of tonsillectomies he performs are now intracapsular, with the exceptions being cases of peritonsillar abscess, PANDAS, PFAPA syndrome, and post-solid organ transplant.

• Despite the benefits of intracapsular tonsillectomies, some clinicians raise concerns about defining the completion point in intracapsular tonsillectomy, as well as risk of regrowth leading to surgical revision.

Pediatric Intracapsular Tonsillectomy: Benefits of Retaining Minimal Tonsillar Tissue

Table of Contents

(1) Pediatric Intracapsular Tonsillectomy

(2) Indications for Intracapsular vs Extracapsular Tonsillectomy in Pediatric Patients

(3) Intracapsular Tonsillectomy in Adolescents and Adults

(4) Intracapsular Tonsillectomy Barriers to Adoption

Pediatric Intracapsular Tonsillectomy

Intracapsular tonsillectomy is a surgical approach gaining traction among clinicians and is redefining tonsil surgery in pediatric patients. Driven primarily by considerations of pain reduction and lower risk of postoperative hemorrhage, a pediatric intracapsular tonsillectomy involves the complete removal of the tonsil, leaving a small amount of tissue intact. This protective layer of tissue, almost like a biological dressing, ensures the pharyngeal wall muscles and large caliber vessels remain covered, thus minimizing exposure. As the primary indication for tonsillectomy today centers around obstructive sleep apnea or sleep-disordered breathing — conditions contingent on the mass of the tonsils — the intracapsular tonsillectomy technique proves particularly effective. According to Dr. Huoh, this method of tonsil removal effectively removes the problematic mass while minimizing the associated risks and discomfort.

[Dr. Gopi Shah]
We're going to talk about intracapsular tonsillectomy in children today. Just to give you my exposure to it, I did my residency at Thomas Jefferson in Philadelphia and our pediatric rotation was at the DuPont-Nemours Hospital in Delaware. This was probably the mid to late 2008, 2009, 2010 when I did my pediatric rotations. We were doing some intracapsular tonsillectomies at the DuPont group there with Dr. Jim Riley, Dr. Diane Shaw. That was my main exposure.
Then I did my fellowship in Dallas at UT Southwestern and since have been doing mostly extracapsular. That's just what we did. It's just been a while but I wanted to bring this to the forefront because there's I think more people transitioning to it. I wanted to pick your brain about why you do it, who you do it for, and all that. Tell us first about intracapsular tonsillectomy because parents also ask now too because there's more and more information about the intracapsular versus a "traditional".

[Dr. Kevin Huoh]
Just a quick summary on intracapsular tonsillectomy, it's basically involving removing all of the tonsils and leaving a little bit of tissue behind and trying to leave the capsule intact. The principle of it is by leaving a little bit of tissue behind, you don't expose the muscles of the pharyngeal wall, and you don't expose the larger caliber vessels that are more lateral. The hope is that you leave almost a biological dressing overlying the pharyngeal wall.

We've seen that it's been much less painful for our patients and it's lowered the risk of post‐tonsillectomy hemorrhage as well. That's the main premise for intracapsular tonsillectomy because we know most kids now when we're doing tonsillectomy, it's because of OSA or sleep-disordered breathing and it's really the mass of the tonsil that you're trying to remove and intracapsular tonsillectomy does accomplish that.

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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Indications for Intracapsular vs Extracapsular Tonsillectomy in Pediatric Patients

Pediatric intracapsular tonsillectomy is emerging as a favored procedure across all ages of children, from those with sleep-disordered breathing to obstructive sleep apnea. In fact, in certain practices, up to 95% of all tonsillectomies are intracapsular. The rare exceptions, making up about 5% of cases, involve unique circumstances such as peritonsillar abscess, PFAPA syndrome, PANDAS syndrome, or post-solid organ transplants. Despite initial reservations, recent data supports the use of intracapsular tonsillectomy even in cases of recurrent tonsillitis and tonsil stones, with reports of reduced tonsil infections at rates comparable to total or traditional tonsillectomy.

[Dr. Gopi Shah]
Is this something that you are doing for all ages? Is this for pretty much anybody that needs a tonsillectomy for sleep-disordered breathing or OSA regardless of size, you're going to do an intracap?

[Dr. Kevin Huoh]
Yes, so my practice goes up there around age 18, 19. For all my patients, this is my go-to operation. It's probably 90% to 95% of all tonsils I do are intracapsular tonsillectomy.

[Dr. Gopi Shah]
Who's the 5% that you're thinking to do an extracap? Are those recurrent strep, tonsil stones, or do the infection kids also do okay with an intracap?

[Dr. Kevin Huoh]
Yes, so the 5% I would say that I don't do intracap on are the really rare cases. Those are like your PFAPA kids, your PANDAS kids, post-solid organ transplant, when you're ruling out post-transplant lymphoproliferative disorder. But for recurrent tonsillitis and even tonsil stones, I think it's a great operation. The recent data shows that people who have undergone intracapsular tonsillectomy actually have a reduction in the number of tonsil infections and at an equivalent rate to a total or traditional tonsillectomy.

I used to be more shy about doing intracapsular for recurrent tonsillitis, but now it's my go-to for those patients. I will give parents the option. I'll tell them, "Here's the risks of intracapsular, here's the risks of a total or extracapsular tonsillectomy," but I'll kind of encourage them to choose the intracapsular operation.

[Dr. Gopi Shah]
I remember my initial when I was training, I had an attending that was also doing it for recurrent or chronic strep and his whole thought point was, "Well, you're opening the crypts up, you're opening the crypts." I remember thinking, "Does that?" Then I get out in practice, I'm doing mostly traditional extracap and you're still going to have a handful of kids that get strep still. It's hard to say if one method's really better than the other, especially because indications I find for infection can sometimes be softer anyways.

[Dr. Kevin Huoh]
It's interesting because if you think about it, Gopi, when we do adenoidectomy for chronic sinusitis or adenoiditis, you're not doing a total adenoid or extracapsular adenoid, right?

[Dr. Gopi Shah]

[Dr. Kevin Huoh]
You're basically doing an intracapsular adenoidectomy so to speak.

[Dr. Gopi Shah]
That's a good point, yes.

[Dr. Gopi Shah]
What about the kids that have been to the ED or hospitalized for recurrent peritonsillar abscess? For those kids, is intracap sufficient as well or do you have to consider extra cap in that situation?

[Dr. Kevin Huoh]
Yes, for a recurrent peritonsillar abscess, I would do an extracapsular total tonsillectomy. There was some really early data that some kids who had intracapsular tonsillectomy were more prone to peritonsillar abscess which I haven't seen, but I would definitely say that that is one indication for a total tonsillectomy, is that recurrent peritonsillar abscess.

Intracapsular Tonsillectomy in Adolescents and Adults

Intracapsular tonsillectomy is gaining ground not only in pediatric patients but also in the adult population, changing the management of tonsillar problems such as tonsil stones. Previously, treatment for tonsil stones relied primarily on less invasive approaches, such as the use of a Waterpik or antibiotics. However, with intracapsular tonsillectomy's ability to eliminate all tonsil crypts with minimal postoperative risks, it's becoming a compelling choice for adolescents and adults. Dr. Huoh states that intracapsular tonsillectomy is especially beneficial in patients with large, fibrous tonsils who are at a higher risk for postoperative complications with traditional tonsillectomy.

[Dr. Gopi Shah]
What else am I missing? Am I missing anything else, Kevin, specific to intracap. I know you said your patients go up to 18 to 19 year olds. Is this becoming for adult patients? Is intracap becoming more common as well in terms of tonsillectomy?

[Dr. Kevin Huoh]
I think so. I think intracapsular is becoming more and more common in adults as well. I think definitely it's still more popular in a pediatric population. Something you mentioned earlier were tonsil stones. There was a big tonsil stone rag on TikTok maybe a year ago. A lot of videos of people popping out tonsil stones. We started seeing a lot of adolescents with tonsil stones who wanted tonsils out.

In the old days, you would say, "Oh, absolutely not. I'm not going to take your tonsil out. Get a Waterpik. Put them on antibiotics. No, we're not taking tonsil out." Now I say, sure, let's do intracapsular tonsillectomy. We get rid of all the crypts, all the nooks and crannies, and very minimal post-up this time. I'm not worried that they're going to bleed. I've had pretty good success. I think it's a really good operation to offer these teenagers, adolescents, who come to your office. I've had people travel quite a long way to see me for it.

[Dr. Gopi Shah]
Wow. What about the tonsils that are like one plus? Are those more difficult to do, or is it the same?

[Dr. Kevin Huoh]
No. They're faster.

[Dr. Gopi Shah]
You kind of lifting that pillar up and you just got to--[laughs]

[Dr. Kevin Huoh]
They're faster. The hardest ones to do, Gobi, are the more overweight, obese, adolescent OSA patients who have really large fibrous tonsils. Those are so tedious and a lot of times, when I'm doing it, I'm cursing. I'm saying, "Oh, my God, just give me my bovie”, but I know that those are the patients who actually will come back with bleeds [laughs] after a total tonsillectomy. Those are the patients who will have the most pain after surgery as well.

I think intracapsular, for me, has also changed my way of thinking. It's almost changed the indications for tonsillectomy. If I'm taking a kid to the OR for ear tubes, revision ear tubes, let's say, and I'm getting to do the adenoids and they're tonsils are at two-plus, and then they snore. In the old days, maybe we would just do tubes and adenoids. Now I'm like, "No, I'm going to do intracapsular tonsillectomy." I'm not worried they're going to bleed. It's not going to add much pain. I know that kid, I won't have to take them back to OR in the future when the tonsil grows, so it's changed kind of the thought process.

Intracapsular Tonsillectomy Barriers to Adoption

Intracapsular tonsillectomy has demonstrated transformative potential in tonsillar procedures, but some reservations exist. A common concern among surgeons is determining the right amount of tonsil tissue to remove during an intracapsular procedure. Reimbursement issues are another point of discussion, particularly internationally, with some locations providing different rates for intracapsular versus traditional tonsillectomies. Nevertheless, the benefits of intracapsular tonsillectomy—reduced postoperative complications, increased patient satisfaction, and less disruption to medical staff—are making it a popular choice, even in areas with traditionally different approaches.

[Dr. Gopi Shah]
When you are at these conferences or talking to other people about intracap, what are some of the other concerns? Any other concerns or questions that you're like, "Oh, okay. That's a non-issue. I guess when you put it that way," anything like that?

[Dr. Kevin Huoh]
Yes. The most common one I get, we touched on already, which is how do you know when you're done? How do you know when you've taken enough tonsil tissue? When talking to some of our international colleagues, they'll mention that the reimbursement is different for intracapsular tonsillectomy versus a total. I had a fortune of training with Dr. Kotai who described this in 2002. He told me, he said, "Kevin, I called it intracapsular tonsillectomy for a reason." As opposed to tonsillectomy or partial tonsillectomy because he wanted it to be seen as equivalent to the traditional operation. One question I have seen from international colleagues is that in some places the reimbursement is different for tonsillectomy or partial operation.

[Dr. Gopi Shah]
Well, as we round this out, any final pearls or thoughts specific to this?

[Dr. Kevin Huoh]
Yes, I would just encourage everyone to go for it. I think, like I said, it's one surgery that makes a big impact in our patients' lives. It's one of the most common surgeries that we do as otolaryngologists or pediatric otolaryngologists. It's a very big change you can provide for your patients, and I've gotten many emails from surgeons all across the United States who have seen my talks at CME Courses who have switched and they email me thanking me. I think there's a whole city in Oregon; Bend, Oregon where all the otolaryngologists have switched to intracapsular and it's just change their lives. They don't have to worry about tonsil bleeds in the middle of the night, and so it's never too late to change.

[Dr. Gopi Shah]
It's good for the ER, it's good for the clinic staff. Efficiency and cost, when you're thinking about quality and safety metrics as well-

[Dr. Kevin Huoh]

[Dr. Gopi Shah]:
-and how it affects pretty much everybody. That's awesome. If anybody wants to learn more about it, how can they find you? Are you on any social media? I know LinkedIn. That's how I connected with you.

[Dr. Kevin Huoh]
Yes. I'm not too active on social media professionally, but you can always reach out to me, look me up at CHOC, Children's Hospital, and reach out that way.

[Dr. Gopi Shah]
In Kevin's paper from The Laryngoscope, it was 2020, looking at intracapsular tonsillectomy. It's a good paper to check out. I looked at that and I was like, "Oh gosh, this is what Stephen Chorney [laughs] has been reading. I need to be reading this." My partner, former partner, and then it sounds like we all need to read Malcolm Gladwell's The Tipping Point.

[Dr. Kevin Huoh]
Absolutely. Yes. It's important, it's interesting how surgical innovation follows a lot of these other innovations in other parts of our society.

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

Disclaimer: The Materials available on 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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