CPT® Code 42825

1. Indications

The tonsillectomy procedure is indicated for various conditions that may affect the tonsils, particularly in pediatric patients under the age of 12. The following are the explicitly provided indications for performing a tonsillectomy:

• Recurrent Tonsillitis Frequent episodes of tonsillitis that do not respond to medical management may necessitate surgical intervention to remove the tonsils.
• Tonsillar Hypertrophy Enlarged tonsils that obstruct the airway or cause difficulty in breathing, particularly during sleep, may require tonsillectomy to alleviate symptoms.
• Sleep Apnea Obstructive sleep apnea in children, which can be caused by enlarged tonsils, may be treated with tonsillectomy to improve airflow during sleep.
• Abscess Formation The presence of peritonsillar abscesses, which are collections of pus near the tonsils, may indicate the need for tonsillectomy if recurrent or severe.

2. Procedure

The tonsillectomy procedure involves several key steps that ensure the safe and effective removal of the tonsils. The following procedural steps are performed:

• Step 1: Anesthesia Administration The patient is placed under general anesthesia to ensure comfort and immobility during the procedure. This is crucial for a successful surgical outcome.
• Step 2: Mouth Prop Insertion A mouth prop is inserted to keep the mouth open, providing the surgeon with adequate access to the tonsils for the duration of the procedure.
• Step 3: Clamping the Tonsils Clamps are applied to the tonsils to create traction, which aids in the dissection process and allows for better visualization of the surgical area.
• Step 4: Dissection of the Tonsils The surgeon performs the dissection of the tonsils using one of several techniques, such as scissors, curettes, cautery, radiofrequency, laser ablation, or a harmonic scalpel. The standard technique involves incising the mucosa with a sickle knife, starting at the superior pole and moving inferiorly through the loose connective tissue.
• Step 5: Tonsil Amputation Once the tonsil is adequately dissected, a snare is passed around the tonsil. The tonsil is then amputated by closing the snare loop, effectively removing it from the throat.
• Step 6: Inspection and Hemostasis After the tonsil is removed, the surgical site is inspected for any remaining tonsil tissue. Any remnants are excised, and bleeding is controlled using pressure, suture ties, or cautery to ensure a clean surgical field.

3. Post-Procedure

Post-procedure care following a tonsillectomy is essential for ensuring proper recovery. Patients are typically monitored in a recovery area until they are stable. Pain management is a critical component of post-operative care, as patients may experience throat pain and discomfort. Hydration is encouraged, and a soft diet is recommended to facilitate healing. Patients should be advised to avoid strenuous activities and to refrain from consuming hard, spicy, or acidic foods that may irritate the surgical site. Follow-up appointments are necessary to monitor healing and to address any complications that may arise, such as bleeding or infection. It is important for caregivers to be aware of signs of complications and to seek medical attention if they occur.