INTRODUCTION

Tonsils are lymphoid organs strategically placed at the entrance of digestive and respiratory systems. The surgical removal of tonsils has been performed as long as three thousand years, as mentioned in Hindu literature. The anatomical idioms used in this study are originated from Latin tonsa, which means "oar" and from Greek amygdala, which means "almond". Versalius, in 1543, was the first one to describe the tonsils in details, including its blood irrigation and Duverney, in 1761, made the first accurate description of the pharyngeal area (1,2). Therefore, more detailed anatomical and histological studies were done in the 19th century, mainly the ones by Wilhelm Von Waldeyer, who described lymphatic tissues in the pharyngeal area (1,2). The target of this study is to review tonsillectomy history, the anatomical study, the techniques of this surgery and technological developments


LITERATURE REVIEW

Cornélio Celsus, in the 1st century B.C., was the first to describe tonsillectomy surgery. He reported the procedure performance for dissection and removal of the structures. Celsus applied a mixture of vinegar and milk in the surgical specimen to hemostasis and also described his difficulty doing that due to lack of proper anesthesia (1,2).

Tonsillectomy, therefore, was the last way of therapy in that time. Aetius de Amida recommended ointment, oils and corrosive formulas with frog fat to treat infections. Some recommendations for removing tonsils in that time included night enuresis (bed-wetting), convulsions, laryngeal stridor, hoarseness, chronic bronchitis and ashma(2).

Other techniques for removing tonsils arouse in the Middle Ages, such as the ones using cotton lines to connect the base. The lines were daily tighted and then tonsils fell (2).

The removal procedure of tonsils was abandoned up to 16th century when tools were adjusted to perform tonsillectomy.

Paré, in 1564, and Scultetus, in 1655, created equipment that allowed placing an oval shape instrument around the uvula, which cut it off by strangulation. Hildanus, in 1646, and Heister in 1763, presented devices similar to a guillotine-cutter for uvulotomy. These instruments were modified by Physick, who, in 1828, in the United States, created the tonsilotome, used successfully in tonsillectomies (1,2).

However, even with the exaltation of Physick, it seems to be of the French surgeon Pierre Desault the priority of the use of an instrument to performe tonsilectomy accomplishment. Desault used, in 1770, a metallic device developed to break up bladder stones. This half-moon shape like instrument had, in its extremity, a small knife that suited perfectly to tonsils. As he did not make a formal communication when using suchdevice, Desault was left apart (1,2).

New instruments were created using as archetype Physick´s tonsilotome model. Fahnestock, in the United States, 1832, Mackenzie in London, 1880, Brunings in 1908 and Sluder in 1911 in the United States developed similar equipment. Greenfield Sluder, an ENT doctor, in Saint Louis was not the first to use the guillotine-cutter for tonsillectomy, but he published a study, in 1912, in which he affirmed to have reached 99.6% of success in his surgeries through this technique (1,2). They all aimed to accomplish surgery as fast as they could, especially in children, for the account of the lack of anesthetic techniques.

Tonsillectomy was initially performed by general surgeons, but at the end of 19th century it became an ENT doctor´s care, due to the best techniques of illumination that they knew. Important steps in the progress of the tonsillectomy were taken using mouth-gap and tongue-depressors, besides the positioning of patient with leaning and suspended head. This position was first described by Killian in 1920, but only adopted after improvements on anesthesia techniques(1,2).

Even with a good use of Phisick´s tonsilotome and similar instruments at the end of 19th century, another device started being attracted by the ENT doctors. Joseph Beck was the first one to describe the use of a device with cutting wire inside a rigid ring known as Beck-Mueller´s ring. An instrument that also gained publicity in that period was Sluder´s guillotine. At the beginning of 20th century, the use of forceps and scalpels resulted in less bleeding(1,2).

From 1909, tonsillectomy surgery became a common and safe procedure, when Cohen adopted ligature of bleeding vessels to control perioperative hemorrhage. Sluder´s tonsilotome had its first routinely uses in the United States in 1909, in Austria in 1910, and in Belgium in 1912(1,2).

In Brazil, the first tonsillectomy was performed in 1920´s by Schmidt Sarmento, a surgeon from Santa Casa de São Paulo (3).

It is estimated that in the United States 1,400,000 tonsil surgeries were performed in 1959, around 500,000 in 1979 and 250,000 ones per year in the last decade (1,2).

Data show that in during the 40´s and 50´s many illnesses, of which the etiology or physiopathology were not known, were associated to tonsils as possible infectious focus. This resulted in thousand of surgeries. Tonsils were, then, removed and, in many cases, when there was no symptom improvement, so were teeth (1,2,5).

As time went by, due to lack of convincing results and excess of indications, this procedure lost its reputation, and as a consequence it was not recommended even for cases when there was such need.

Therapeutical advance on medicine, especially with the use of antibiotics and improvement on work conditions on public health services and on group medicine also contributed for a reduction on tonsil removal surgery.

The use of all this, even so surpassed, left a stigma for the tonsillectomy, not very well accepted by some patients and even by some doctors from other areas. As result of surgery immunity acquisition against the virus of poliomyelitis can be slower and greater incidence of the disease in children not vaccinated might occur. However, it does not modify the occurrence of rheumatic fever, it can reduce outbrakes of hematuria (blood in urine) and proteinuria in kidney diseases and improve conditions of asthmatic bronchitis and allergic rhinitis.

At the current moment, knowing tonsil physiology and physiopathology adenoids tends to balance the correct recommendation of surgery. Also, new techniques of dissection replaced Sluder´s technique the term 'amygdala' by 'tonsils'.

Although recommendations integrate a dynamic process that modifies itself according to the development of the tonsil disease knowledge and its regional and systemic repercussions, surgery, when well recommended, brings potential benefits as reduction of severe respiratory blockage; reduction on frequency, duration and gravity of ENT disease; reduction on hearing losses, besides improvement and growth of systemic diseases.


DISCUSSION

Tonsillectomy and systemic diseases

The chronic infection of tonsils and its systemic repercussions have been affecting human beings since far-off time. One of the most famous cases is the one of the first president of the United States, George Washington, who died in 1799 of peritonsillar abscess(4).

In December 1799, George Washington fell ill in the city of Mount Vernon, Virginia, suffering from peritonsillar abscess, presenting dyspnea. He was assisted by three doctors. The newest one, Elisha C. Dick, recommended tracheostomy to improve his breath. The other two doctors' opinion prevailed. They had preferred traditional methods for treatment, such as bleedings. The president died that night, December 14, 1799.

In 1900, William Hunt proved the connection between oral sepsis and systemic disease. It was already believed in that tonsil infections could cause chronic toxemia and local infections in the joints, heart or kidneys. Studies were performed with partial and total tonsillectomies regarding recurrence of infections (1,2).

At the beginning of 20th century, many authors recommended and performed partial tonsillectomy, but from the third decade of this exactly century, the total tonsillectomy became preferential procedure. In 1950 indication for tonsillectomy were: recurrent infections, deafness in childhood, diphtheria, halitosis and others as rheumatism, hoarseness, asthma, malnutrition and fevers of unknown causes (1,2).

Practices and tools

In 1827 Philip Physick, from Philadelphia, announced an improvement in the method of handle with cotton wire. However this method caused 12 hours of pain and discomfort to patients. Physick tried another quicker method to perform tonsillectomy. He carried through research with old surgical instruments and found a device called uvulotome, which was originally created in the 16th century (1,2).

Uvulotome was used to remove the uvula. An important aspect of the uvulotome was a circular opening where the uvula was introduced. Once placed, the uvula was cut off by a retractable blade. To apply the drawing of the uvulotome in the tonsillectomies, Physick made two modifications in 1828. First, he enlarged the diameter of the circular opening. Second, a piece of hemp wire soaked in oil was placed in the posterior part of the opening to supported tonsil and to obtain a clean cut. This new instrument was called tonsilotome, which was modified along the time.

William Fahnestock incorporated a small hook in order to hold tonsil. Even with an expressive speed increasing of the tonsillectomies, the tonsilotome did not prevent other ENT doctors developed new equipment and techniques to perform surgical procedure.

Gregg Dillinger used to believe that tonsilotome caused hemorrhage and then he developed a method called diathermy. Diathermy was the electric flow use in high frequency to raise tissue temperature. In this technique a metallic needle-hook was connected to an electric source and inserted in tonsil. The electric flow burnt adjacent tissue this fell after that. The procedure required some sessions for the complete treatment, but it caused little bleeding and less infections (1,2).

Even with the sprouting of this technique, the tonsilotome still persisted and continued being used instead of diathermy. New techniques using acid pastes and ligatures had also appeared. However all of them became obsolete when new technologies were developed.

From 1913, radiotherapy with x-ray in chronic or hypertrophic tonsillitis started to be recommended instead of surgery for some time, mainly in Europe.

The laser of carbon dioxide, introduced in medicine in 1960, proved to better reduce and control bleedings than ruby laser, introduced soon after the World War II. The first report of laser of carbon dioxide use in tonsillectomies was in 1973. The advance on technology of intensity and frequency control of the laser allowed it to be used in such a way as a scalpel as much as coagulator (1,2,5).

Otorhinolaryngology was the first surgical specialty in which laser features of carbon dioxide were recognized and applied successfully in clinical situations in great amount (5).

Geza Jako was one of the important names in the development and application of carbon dioxide laser in laryngeal surgery. His experiments performed successfully in guinea pigs using laser stimulated Dc. Polanyi, who worked for American Optical Company, to develop equipment for laryngeal surgeries. One of first lasers, the AO-300, by Polanyi, Wallace and Jako became the first one to be commercialized in 1972 and was used in some ENT procedures, including endoscopic removal of small cancers on larynx, papillomas of the larynx and tracheobronchial tree, as well as tonsillectomies (1,2,5).


CONCLUSION

The recommendations are still a dynamic process; and, with a better knowledge on the implications of tonsil and adenoid disease, these recommendations have changed. Currently, the main recommendations are: obstructive hypertrophy during childhood, rebel recurrent infections to clinical treatment; peritonsillar abscess in recurrent tonsillitis, though there will always be the risk of formation of new abscess with great suffering for patient; adenotonsillitis with repetition otitis; correlated tonsillitis with systemic diseases; halitosis by chronic caseous tonsillitis; neoplasm.


BIBLIOGRAFIA

1. Young J.R, Bennett J. History of Tonsillectomy. ENT News. 2004;13:34-35.

2. Feldmann H., 200 year history of tonsillectomy. Images from the history of otorhinolaryngology, highlighted by instruments from the collection of the German Medical History Museum in Ingolstadt. Laryngorhinootologie. 1997;76(12):751-60.

3. Lasmar A, Seligman J: História (e histórias) da Otologia no Brasil. Revinter. 2004.

4. Balbani APS. Personagens da História da Otorrinolaringologia. Arq. Int. Otorrinolaringol. 1998;2(2):54.

5. Weir N. History of Medicine: Otorhinolaryngology. Postgrad. Med. J. 2000;76:65-69.









1. Majored in Medicine (ENT resident doctor)
2. Graduation student (5th year of Medical school)
3. PhD in ENT by Escola Paulista de Medicina - UNIFESP (ENT doctor at Centro de Otorrinolaringologia de São Paulo / Hospital Professor Edmundo Vasconcelos Assistente da Disciplina de Otorrinolaringologista de Escola Paulista de Medicina - UNIFESP)

Centro de Otorrinolaringologia de São Paulo - Hospital Prof. Edmundo Vasconcelos
João Flávio Nogueira Júnior
Address: Rua Borges Lagoa, 1450 - 3o Andar - Prédio dos Ambulatórios Vila Clementino - São Paulo - Brasil - CEP 04038-905 www.centrodeorl.com.br - email: joaoflavioce@hotmail.com

This article was submitted to SGP - Sistema de Gestão de Publicações (Publication Management System) from RAIO on September 16, 2006 and was approved on September 04, 2006 o7:25:35.