BackTable / ENT / Podcast / Transcript #110

Podcast Transcript: Intracapsular Tonsillectomy in Children

with Dr. Kevin Huoh

In this episode of BackTable ENT, Dr. Shah interviews pediatric otolaryngologist Dr. Kevin Huoh about intracapsular tonsillectomy, including the postoperative benefits of the procedure and his personal techniques. You can read the full transcript below and listen to this episode here on BackTable.com.

(1) Pediatric Intracapsular Tonsillectomy: A Shift in Clinical Preference

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

(3) Intracapsular Tonsillectomy: Regrowth and Revision

(4) Intracapsular vs. Extracapsular Tonsillectomy: A Comparison of Post-Op Pain and Recovery

(5) The Adoption of Intracapsular Tonsillectomy in the United States and Abroad

(6) Benefits of Coblation in Pediatric Intracapsular Tonsillectomy

(7) Transitioning to Using Intracapsular Tonsillectomy in Clinical Practice

(8) Intracapsular Tonsillectomy in Adolescents and Adults

(9) Intracapsular Tonsillectomy: Barriers to Adoption

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[Dr. Gopi Shah]
My name is Gopi Shah and I'm a pediatric ENT. I have a very awesome guest today. I have Dr. Kevin Huoh. He's a pediatric otolaryngologist practicing at Children's Hospital of Orange County in California. Kevin completed medical school and residency in Otolaryngology at the University of California, San Francisco. He pursued his fellowship in Pediatric Otolaryngology at Lucile Packard Children's Hospital at Stanford. Kevin is here today to talk to us about intracapsular tonsillectomy in children. Welcome to the show, Kevin.

[Dr. Kevin Huoh]
Hey, good morning, Gopi. Thanks for having me. I'm really excited to be here.

[Dr. Gopi Shah]
Thanks for coming on. I want you to first tell us how you got into pediatric ENT.

[Dr. Kevin Huoh]
Yes, it's actually a fairly long story that I'll try to distill a little bit. As you mentioned, I am practicing at Children's Orange County. It's about 10 minutes from Disneyland, just to orient everyone. I'm a SoCal native. I was born and raised in Los Angeles and actually I was born with a large lymphatic malformation involving my neck and my larynx, and that's actually how I became interested in pediatric otolaryngology from a very, very early age.

I had a tracheostomy. I had a gastrostomy tube. I've been in the business since I was a baby. I remember in first grade when you write about what you want to be when you grow. I actually wrote I want to be a pediatric otolaryngologist, spelled correctly.

[Dr. Gopi Shah]
Wow. That's pretty awesome. You have a whole different perspective when it comes to taking care of patients and families as a pediatric otolaryngologist.

[Dr. Kevin Huoh]
Absolutely. I tell families and parents that I was put here to do this, it's my calling to do this.

[Dr. Gopi Shah]
That's awesome. That's great. You're a California native, all your training is there and you're at Orange County. Tell us a little bit about your practice.

[Dr. Kevin Huoh]
Children's Hospital of Orange County is a tertiary standalone pediatric children's hospital. We are a level-one trauma center as well and we are affiliated with the University of California, Irvine, School of Medicine. We do have residents from their otolaryngology residency program who get through. It's kind of an academic children's pediatric center, I would say.

[Dr. Gopi Shah]
That's great. We're going to talk about intracapsular tonsillectomy and as a pediatric otolaryngologist, whether you're in a general practice or like uber, you know, 10 people deep academic center, we're all doing tonsils probably 50% to 70% of our cases I would say. Would you agree to that, Kevin?

[Dr. Kevin Huoh]
Yes, definitely. I always tell people-

[Dr. Gopi Shah]
Do you have a niche there? My point is do you have a niche or something that you love other than the tonsils and the tubes which we all love?

[Dr. Kevin Huoh]
Yes, it's funny because I didn't do a fellowship to be a tonsil expert. My interest is actually in pediatric thyroid surgery. I do all the thyroid surgery at CHOC and all the head and neck masses.

[Dr. Gopi Shah]
Nice. That's awesome.

[Dr. Kevin Huoh]
That's kind of my interest.

(1) Pediatric Intracapsular Tonsillectomy: A Shift in Clinical Preference

[Dr. Gopi Shah]
Cool. 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.

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

[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 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 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]
No.

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

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

(3) Intracapsular Tonsillectomy: Regrowth and Revision

[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 regrowth. What is the percentage of 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 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 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 intracap, it makes sense because the kids are usually a bit older, so that sort of 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?"

(4) Intracapsular vs. Extracapsular Tonsillectomy: A Comparison of Post-Op Pain and Recovery

[Dr. 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.

(5) The Adoption of Intracapsular Tonsillectomy in the United States and Abroad

[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.

(6) Benefits of Coblation in Pediatric Intracapsular Tonsillectomy

[Dr. Gopi Shah]
That's cool. In terms of techniques, I know there's microdebrider, there's the Coblation device. What are the different techniques out there and what do you like to use?

[Dr. Kevin Huoh]
I think the one that was earliest described by Dr. Kotai was a microdebrider. That's what I initially learned during my fellowship.

[Dr. Gopi Shah]
Those bleed. [chuckles]

[Dr. Kevin Huoh]
Yes, so they do.

[Dr. Gopi Shah]
That's how I learned. I was like, "What is this?"

[Dr. Kevin Huoh]
It's kind of a bloodbath, right?

[Dr. Gopi Shah]
Yes. It is.

[Dr. Kevin Huoh]
You take a specially designed tonsil blade and you set it I think at 1,500 rpm on your microdebrider machine. Then you just go at it. The tonsil is a big polyp, so you just go at it. What happens is it bleeds, and then you have to use a suction bovie to kind of to cauterize the base.

[Dr. Gopi Shah]
Yes. You're charring everything.

[Dr. Kevin Huoh]
Then by charring everything, you're almost defeating the purpose of reducing pain because you can get the diffusion of thermal energy when you're trying to char the whole tonsil bed. That's where I started with in practice, but I quickly changed to the Coblator. My partner, Nguyen Pham, learned the Coblator method during fellowship. We did the same fellowship, but he just learned from someone else.
The Coblator is what I use now. There's several wands that you can choose to do an intracapsular tonsillectomy. I use a Procise Max Wand. The Procise XP, I think, is a good one for beginners. When I have residents starting out with me, sometimes I'll reach for the Procise XP. It's less aggressive. The active area is smaller than the Procise Max. It's just a little bit slower. I'm all about speed for tonsillectomy.
Then the new product they have out is the Halo Wand, which is very promising. I've used it now for a few months. It's very promising addition to the Coblator system. That uses a different console. For the old ones, a Procise XP or Max, I'll use a setting of seven for Coblate and three for Coag. I'll just start at the medial aspect of the tonsil. For the left tonsil, I'll hold the wand in my right hand, so kind of opposite of what you would do for a bovie, and then start from medial to lateral. Then basically you want the tonsil bed to look like a total tonsillectomy except you have some tonsil tissue left, and that's when you know you're done.

[Dr. Gopi Shah]
You're definitely going more lateral than just the pillars?

[Dr. Kevin Huoh]
Correct.

[Dr. Gopi Shah]
When I think of tonsils, they're not just like round globes. I feel there's some areas that are a little bit more that frowned out a little bit, more lateral. You just have to know the plane that you're looking for to know how deep you want to go. What does it look like? Does it look lacy? Somebody used to tell me that it should look a little bit lacy or something.

[Dr. Kevin Huoh]
When you use a microdebrider, you start seeing more, I guess, lacy or thicker fibers. When you use a Coblator, it's a little harder. I think it looks more striated. You're not looking at muscle, but it starts to look more striated, more fibrous. Tonsil tissue itself is squishy, soft, that whitish stuff. When you're looking at more striated-type tissue appearance, then you know you're getting close to the capsule.
I always tell my residents it's fine to leave a little bit of extra tonsil tissue. I'd rather them do that than dig a hole into the pharyngeal wall. It's not a rocket science. I know that's the most common question I get asked. It's how do you know when you're done? Any surgeon who's done enough total tonsillectomies, you kind of have a feeling. When you get that scooped out concave appearance, you know like, "All right, I'm done."
I would encourage surgeons to follow the regrowth rate. You know we always encourage surgeons to follow your bleed rate. You don't have to follow your bleed rate anymore, I'll tell you that, but you should follow your regrowth rate. That will inform you on whether you're doing enough.

[Dr. Gopi Shah]
Just to get a little bit more granular into the technique, one, in terms of your preference. Do you like a red rubber, not a red rubber to lift up your soft palate?

[Dr. Kevin Huoh]
I do. I use two red rubber catheters, actually. I don't know if that's super common.

[Dr. Gopi Shah]
I think I do too as well.

[Dr. Kevin Huoh]
A lot of my partners use one. [crosstalk]

[Dr. Gopi Shah]
It just depends on the mouth.

[Dr. Kevin Huoh]
A lot of my partners use one.

[Dr. Gopi Shah]
It just depends on your exposure. I use one, too. Some people don't. That's why I asked. Again, this is 10, 15 years later. With the Coblator, the way I had learned was literally you're just lopping it off. What you're describing is with your wand lateral and just taking it down. Letting it melt through the-- [crosstalk]

[Dr. Kevin Huoh]
Medial to lateral.

[Dr. Gopi Shah]
Medial to lateral.

[Dr. Kevin Huoh]
Medial to lateral. You tap it. You just keep on tapping. You literally keep on tapping that tonsil or kind of scoop that tonsil. You don't want to stay on it too long because then you'll char it. You just tap, tap, tap, tap. A lot of people have used a Coblator for other things. I know it's probably for JNAs or other nasal masses. It's a similar thing.

[Dr. Gopi Shah]
Use the tip. How do you deal with clogging? Do they clog in the hole or is the Procise suction hole bigger than the slower XP wand?

[Dr. Kevin Huoh]
Early on, that was a problem for me. The way I've eliminated that is you have to remember, you have to turn up your suction. We have a [unintelligible 00:27:08]. I put it at like 250 to 300. The suction has to be pretty high. Your saline flow has to be pretty brisk. It's all reliant on that repetitive tapping motion. Just not staying on a tissue too long. Then, in my other hand, I hold a suction, actually. You can do a hurd or a suction.

[Dr. Gopi Shah]
I was going to ask you, is it a hurd?

[Dr. Kevin Huoh]
You can start with the hurd. That's what I first started with. Then one of my residents who is now one of my partners said, "Hey, why don't we hold a suction in the other hand?" I'm like, "Yes. It's a great idea." I can manipulate the tonsil with the suction, and it suctions all that excess saline from the oropharynx. I hold a suction in my other hand, and then it tends to work well.

[Dr. Gopi Shah]
Just a regular Yankauer, like the metal tonsil Yankauer suction?

[Dr. Kevin Huoh]
Yes. The metal one. I think [unintelligible 00:28:06] tip vascular suction, I think is the correct name. Some people hold a plastic Yankauer too, but I don't like those. I think they're too big.

[Dr. Gopi Shah]
They're kind of big. Then let's say, do you then have to go over and Coblate the whole area? You know how sometimes when you do a bovie tonsillectomy, then you're like, "Okay." You sometimes need to start-- Do you have to do that or just what's bleeding? Do you do that with vessels you may come across or what is that?

[Dr. Kevin Huoh]
I actually coagulate the whole tonsil that remains, the capsule. It doesn't take very long, but I think that might be why our regrowth rate is lower. Similar to when you're using a suction bovie on the adenoids, you just have a bed of charge sometimes, and that's what we have. You just use a Coag setting on the Coblator device and go over the whole bed.

(7) Transitioning to Using Intracapsular Tonsillectomy in Clinical Practice

[Dr. Gopi Shah]
If you're somebody that's been practicing 5 to 15 years and you've been doing, because I would say, wait, that's going to be the majority of the people that haven't transitioned over. It sounds compelling enough in terms of post-op pain and recovery, in terms of bleeding, even with the regrowth when you compare it to a potential post-op bleed and how difficult and complicated those can be. If somebody is interested, how should they start making that transition? What do you recommend for that?

[Dr. Kevin Huoh]
It's not hard to switch. I think it's never too late to switch to intracapsular tonsillectomy. Funny story is when I first came into practice at CHOC, I joined a group of three other otolaryngologists. Like I said, my partner, Nguyen Pham, had done a fellowship right before me. We started doing intracapsular together. The older partners, who were in their 50s and 60s, saw our post-op complications were much lower than theirs, lower bleed rates, didn't get the phone calls in the middle of the night. Our residents were happier, didn't have to come in to see tonsil bleeds.
Our senior partners just basically watched us do one or two in the OR and then they started doing it and they switched. Another one of my partners joined us three years ago. She had already been in practice for several years, and when she first joined us, she's like, "No, I'm just going to do bovie, that's what I've been doing," and then she had a bleed, and then she's like, "All right." Then she switched.

It's not a hard operation to learn. You're basically just ablating tissue. You can watch videos. There's a lot of videos online of intracapsular tonsillectomy. I would invite anyone. If you want to come out, visit Disneyland and watch me do some tonsils, now in this post-COVID era, we can do that again. If you want to come watch me do something, I'm happy to have anyone join me in the OR.

(8) Intracapsular Tonsillectomy in Adolescents and Adults

[Dr. Gopi Shah]
That's awesome. 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 changed also 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 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.

(9) Intracapsular Tonsillectomy: Barriers to Adoption

[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 a 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.

[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]
Absolutely.

[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.

[Dr. Gopi Shah]
Cool. All right. Well, thank you so much for coming on the show. For our listeners, thank you for stopping by and I think it's a wrap.

[Dr. Kevin Huoh]
Thank you.

Podcast Contributors

Dr. Kevin Huoh

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

Dr. Ashley Agan

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

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.