Tonsillectomy using laser - interventional procedures consultation document (second consultation)


Interventional Procedure Consultation Document

Tonsillectomy using laser

The National Institute for Health and Clinical Excellence is examining tonsillectomy using laser and will publish guidance on its safety and efficacy to the NHS in England, Wales and Scotland. The Institute’s Interventional Procedures Advisory Committee has considered the available evidence and the views of Specialist Advisors, who are consultants with knowledge of the procedure. The Advisory Committee has made provisional recommendations about tonsillectomy using laser.

This document summarises the procedure and sets out the provisional recommendations made by the Advisory Committee. It has been prepared for public consultation. The Advisory Committee particularly welcomes:

  • comments on the preliminary recommendations
  • the identification of factual inaccuracies
  • additional relevant evidence.

Note that this document is not the Institute's formal guidance on this procedure. The recommendations are provisional and may change after consultation.

The process that the Institute will follow after the consultation period ends is as follows.

The Advisory Committee will meet again to consider the original evidence and its provisional recommendations in the light of the comments received during consultation.

The Advisory Committee will then prepare draft guidance which will be the basis for the Institute’s guidance on the use of the procedure in the NHS in England, Wales and Scotland.

Closing date for comments: 27 April 2006

Target date for publication of guidance: July 2006

Note that this document is not the Institute's guidance on this procedure. The recommendations are provisional and may change after consultation.

1 Provisional recommendations

Current evidence on the safety and efficacy of tonsillectomy using laser appears adequate to support the use of this technique provided that normal arrangements are in place for consent, audit and clinical governance.


Use of tonsillectomy using laser may result in higher rates of haemorrhage than some other techniques, and clinicians wishing to use ultrasound scalpel should be specifically trained. The British Association of Otorhinolaryngologists – Head and Neck Surgeons has agreed to produce standards for training.


Surgeons should ensure that patients or their parents/carers understand the risk of haemorrhage after tonsillectomy using laser. In addition, use of the Institute’s Information for the public is recommended (available from


Surgeons should audit and review the rates of haemorrhage complicating tonsillectomy in their own practices and in the context of the techniques they use. Publication of further information about the influence of different techniques and other factors (such as age) on the incidence of haemorrhage after tonsillectomy would be useful in guiding future practice.

2 The procedure
2.1 Indications

Indications for tonsillectomy include recurrent acute or chronic tonsillitis, peritonsillar abscess and pharyngeal obstruction/obstructive sleep apnoea. Life-threatening complications of these conditions are rare, and the main aim of surgery is to relieve symptoms.

2.1.2 Surgical removal of the tonsils (tonsillectomy) is one of the most common surgical procedures in the UK. Traditional ‘cold steel’ tonsillectomy is done with traditional surgical instruments and with the use of thermal energy. The operation consists of two stages: removal of the tonsil followed by haemostasis. Bleeding is controlled by pressure, then by ligatures. The use of ligatures may be supplemented by diathermy and the use of packs.
2.1.3 Techniques using thermal energy can be used for dissection and haemostasis in tonsillectomy. Diathermy uses radiofrequency energy applied directly to the tissue, and can be bipolar or monopolar. The heat generated may be used in dissection to incise the mucosa and remove the tonsils, as well as for haemostasis, by coagulating the bleeding vessels. Other methods that use thermal energy include coblation and lasers.
2.2 Outline of the procedure
2.2.1 Lasers used in tonsillectomy include CO 2 , KTP and contact diode lasers. Lasers both dissect tissue and coagulate blood vessels. Lasers can be used to resect completely ( laser tonsillectomy), reduce ( laser assisted serial tonsillectomy) or vaporise ( laser vaporisation tonsillectomy) tonsillar tissue. Tonsillectomy is done under general anaesthetic.

For laser tonsillectomy, the tonsil is retracted medially and is then dissected with the laser.

2.2.3 For laser assisted serial tonsillectomy (also referred as laser assisted tonsil reduction) a laser is swept across the tonsil, vaporising to a depth of approximately 3−5 mm, and so partially resecting the tonsil. Further sessions are needed to achieve reduction of around 95% of tonsillar tissue.

Laser vaporisation tonsillectomy is performed using microscopic control so that around 95% of the tonsils are vaporised in one setting.

2.3 Efficacy

Two studies assessed outcomes following laser assisted serial tonsillectomy. Outcomes in both studies were poorly reported.

2.3.2 Three of the above studies also reported on healing following laser tonsillectomy. This was typically assessed by noting the amount of mucosa regrowth in the tonsillar bed. In all three studies the authors noted that wound healing appeared to be slower on the laser side compared with cold steel dissection .
2.3.3 Five comparative studies assessed pain following laser dissection tonsillectomy. In four of these studies patients treated with laser reported feeling less pain at the first postoperative assessment (usually within 24 hours) compared with those treated by cold steel dissection, but at subsequent assessments patients in the laser group had higher pain scores than those in the cold steel group until at least 2 weeks after surgery. In the fifth study the authors noted that mean pain scores were consistently lower in the laser group. However, this study included child patients, used a different laser and compared laser with diathermy. For more details, refer to the sources of evidence (see appendix).

Most of the Specialist Advisors expressed no concerns about the efficacy of the procedure but noted that postoperative pain was often greater than with other tonsillectomy methods. They also noted that very few clinicians in the UK use lasers for tonsillectomy.


2.4 Safety

Bleeding is an important complication of tonsillectomy. It can occur intraoperatively, during the first 24 hours after the operation (defined in most studies as primary haemorrhage) or after 24 hours (secondary haemorrhage). Postoperative haemorrhage may require the patient to be readmitted to hospital and possibly undergo further surgery.


In general it was noted that intraoperative blood loss was less with the use of the KTP laser compared with cold steel dissection. Two out of seven studies reported cases of primary haemorrhaging following laser tonsillectomy. In one randomised controlled trial 11% of patients (9/79) had a primary haemorrhage following laser tonsillectomy compared with 6% of patients (4/72) in the cold steel dissection group (difference not significant). In the second study, a UK cases series of 54 patients, two patients (4%) had primary haemorrhages.

2.4.3 Secondary haemorrhage rates varied among the studies (range 0% to 18%). In a small randomised controlled trial of 38 patients undergoing KTP laser tonsillectomy on one side and dissection on the other side, six patients had delayed bleeding in the tonsil site operated by laser (two of those events required readmission and treatment with antibiotics to control the bleeding). No patients had delayed bleeding in the dissection group. The highest secondary haemorrhage rates were reported in a case series, where 18% of patients (10/54) had delayed bleeding. One patient in this study also suffered a tongue burn.
2.4.4 These data are in general agreement with results from the National Prospective Tonsillectomy Audit, which found that the lowest rates of secondary haemorrhage (both those requiring and those not requiring further operation) were associated with cold steel dissection with suture haemostasis, with higher rates reported with the use of other thermal techniques such as diathermy.

In two studies (of 86 and 66 patients), no peri-operative or anaesthesia-related complications, or early or delayed bleeding, were reported following laser assisted serial tonsillectomy. For more details, refer to the sources of evidence (see appendix).


The Specialist Advisors considered that there was a slight increase in postoperative haemorrhage compared with cold steel dissection. They also noted the risk of laser damage to the patient’s face and heat damage to the upper airway.

2.5 Other comments

It was noted that a number of different types of laser can be used.


It was also noted that the National Prospective Tonsillectomy Audit recommended that all surgeons undertaking tonsillectomy should be trained in the use of cold steel dissection and ligature haemostasis, as well as in the use of any electrosurgical techniques.

3 Further information

The Institute has issued guidance on electrosurgery (diathermy and coblation) for tonsillectomy ( The Institute is also producing guidance on tonsillectomy using ultrasonic scalpel (

Bruce Campbell
Chairman, Interventional Procedures Advisory Committee
April 2006

Appendix: Sources of evidence

The following document, which summarises the evidence, was considered by the Interventional Procedures Advisory Committee when making its provisional recommendations.

This page was last updated: 04 February 2011