Surgical procedure

Tonsillectomy with radiofrequency: what is tonsil surgery like in adults?

Tonsil surgery in adults has two techniques: intracapsular with radiofrequency, and total. When to operate, risks, recovery and timelines.

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Deciding to have your tonsils removed is rarely a quick decision. It usually comes after years of living with the problem: the tonsil stones that keep coming back, the bad breath that no amount of brushing clears, the bouts of tonsillitis that return every winter, or the snoring that has become a subject at home.

This page answers the next step: what radiofrequency does to the tonsil, which are the two techniques most often used, how the choice between them is made, what the day of surgery is like, what recovery is like and, above all, when surgery is not the right answer.

If you are still one step earlier, trying to understand why tonsil stones form and what to do before considering surgery, start with the page on caseous tonsillitis. If your case is recurrent sore throat, the page on tonsillitis and sore throat is the starting point. And if the person having surgery is a child, the next section explains, in a few lines, which of the two operations is at stake and where to go.

What tonsillectomy with radiofrequency is

A tonsillectomy is the operation that removes the tonsils, those two structures that appear on either side of the back of the throat when you open your mouth. The radiofrequency version carries out that removal with an instrument that works inside saline solution, breaking the tissue down instead of burning it.

What lies behind this is the working temperature, and what it allows is quite specific. The tonsil sits against vessels, muscles and nerves of the pharynx, and between it and those structures there is a very thin layer, the tonsillar capsule. Working at a lower temperature is what makes it possible to remove the diseased tissue right up against that layer and stop there.

An analogy helps: it is like scraping the flesh out of a halved papaya without piercing the skin. The flesh comes out, and the thin layer that was underneath it stays whole, still covering what lies behind. It is this possibility of stopping at the capsule that radiofrequency opens up, and that is why it makes a difference.

Radiofrequency, Coblation, Coblator: why one operation has so many names

It is worth clearing up a confusion of names that gets in the way of anyone doing research, and that tends to reach the office more or less like this: “doctor, I was told mine is the one with the coblator, is it the same as this one?”. It is the same thing, and the reason there are so many names is that each one refers to something different.

Radiofrequency is the type of energy used, and it is the plain-language name of the technique.
Coblation is the trade name of the technology, registered by the manufacturer. It comes from the words for controlled ablation.
Coblator is the name of the device that delivers that technology, the equipment in the operating room.

In one sentence: the Coblator is the machine, Coblation is what it does, and radiofrequency is the energy it does it with. The three get mixed up because the technology arrived under its brand name, and that is still what many people call it. On this page we use radiofrequency, which is the plain term and the one most people search for. If you heard “coblator” at your appointment or read “Coblation” somewhere, it is this same operation.

You will also come across the expression “cold plasma”, which is how part of the literature describes the technique. The word “cold”, it is worth saying, is relative. There is no surgery without any heat at all. Radiofrequency in a saline medium works at a much lower temperature than the electrosurgical scalpel, and that is what this is about: less heat, not the absence of heat.

Tonsils only, or tonsils and adenoid?

This question comes before deciding which technique will be used. The criterion is not the age of the person having surgery. It is what is enlarged and which problem that is causing. When the problem is in the tonsils only, the operation is the tonsillectomy, which is the one on this page. When the adenoid is involved as well, the operation becomes the adenotonsillectomy, which treats both in the same procedure.

The adenoid is defence tissue that sits at the back of the nose, above the roof of the mouth, and it is part of the same ring of defence tissue that surrounds the entrance to the throat (Waldeyer’s ring). The practical difference is that the tonsil can be seen: you just open your mouth and look at the back of the throat. The adenoid cannot. It only shows up on examination in the office, with the thin camera that passes through the nose (flexible nasolaryngoscopy) or on an X-ray of that region, when indicated. That is why this doubt cannot be settled at home, and it is not for lack of attention on the part of whoever looked.

Understanding this difference helps clear up two very common misconceptions. A child can also have the tonsils alone operated on, when the adenoid is normal and the problem is the tonsil. And an adult rarely has adenoid surgery, because the adenoid tends to shrink with growth, and adenoid tissue is rarely present in adults.

From here on, this page deals with tonsil surgery in adults. If the person having surgery is a child, the starting point is the adenotonsillectomy page, which covers the more frequent scenario at that age, or the adenoid hypertrophy in children page, if the doubt is still about what the adenoid causes.

How radiofrequency acts on the tonsil

The tip of the instrument is surrounded by saline solution. The radiofrequency current passes through that saline and forms there a very thin layer of electrically charged particles, which is called a plasma field. It is this field, and not the metal tip, that breaks the bonds of the tissue.

Two practical consequences. The effect stays concentrated in a small, defined field next to the tip, which helps in working right up against the structure you want to preserve. And the same energy coagulates the vessels it passes through, which is part of controlling bleeding during surgery.

Radiofrequency is the tool with which we perform the intracapsular tonsillectomy, but the most important part is still to come: which technique will be used and how that affects the surgery and the postoperative period.

The two techniques, and what changes between them

Tonsil surgery is not one single thing, and there is an aspect of the anatomy of the tonsils that completely changes the approach. It is what is known as the tonsillar capsule. The capsule is a thin layer that separates the tonsil itself from the vessels and the muscles of the pharyngeal wall. It is this layer that defines the two techniques.

There are two strategies, and we perform both, case by case. What separates them is how much tissue is removed and whether the capsule is opened or not.

Radiofrequency is the technology that makes the intracapsular technique possible, and that is where it makes a difference. In total removal, in which the capsule comes out as well, that advantage does not exist, and for that reason it is not the technology we use for that technique.

Intracapsular tonsillectomy with radiofrequency

It removes the tonsillar tissue and, with it, the crypts (the folds and cavities where tonsil stones lodge), preserving the capsule. Because the work does not reach the deeper layer, where the larger vessels and the nerve endings of the pharyngeal wall are, it tends to hurt less and to bleed less in the postoperative period than complete removal. A systematic review with meta-analysis published in 2023 brought together the studies that compared the two techniques and points in that direction (Sedgwick and colleagues, 2023).

Although most of the studies comparing techniques were carried out in children operated on for airway obstruction, and not in adults operated on for infection or for tonsil stones, this does not invalidate the result; it serves only as a caveat.

On the other hand, and this is the point that needs to be clear before deciding: because tonsillar tissue remains next to the capsule, there is the possibility of regrowth of that tissue and of the problem coming back over time. The authors of the review themselves record that the data on regrowth and reoperation are still insufficient. It is not possible to predict, in an individual case, whether this will happen.
Total (extracapsular) tonsillectomy

It removes the tissue and the capsule. No tonsil remains, and for that reason there is no recurrence from regrowth of tonsillar tissue. When the problem is tonsil stones, this means that the crypts where they form cease to exist. A study that measured the sulfur compounds in the breath before and after surgery found a significant drop in these compounds after tonsillectomy (Choi and colleagues, 2018).

On the other hand, the postoperative period is harder. The pain is more intense and longer lasting, and the risk of bleeding is higher, because the operated area is in direct contact with the muscle and the vessels of the pharynx. It is the technique usually reserved for the most severe, the most recurrent or the refractory cases.
How the choice is made, at the appointment

There is no technique that suits every case, and the choice is not automatic. In the office, it weighs what the examination of the throat showed (the size of the tonsils, the depth of the crypts, the state of the tissue), the reason surgery is being considered, how often the problem comes back, the history of tonsillitis and of abscesses, age and clinical conditions.

We explain both paths, with the indication, the alternative and the limit of each one, and we decide together. Someone who is self-employed and needs to know exactly how many days they will be away weighs the postoperative period one way; someone who has had an abscess twice weighs recurrence another way. The timelines for each technique are in the recovery section, and they should be taken into account as well. Both are possible, and only a specialist assessment can define the best path to follow.

When tonsil surgery is indicated

Before any surgical indication comes the same stage: well-conducted medical treatment, for long enough. Careful oral hygiene, treatment of the nasal causes that increase mucus production, control of reflux when it is present, and antibiotics only for those episodes in which they are genuinely necessary. A good share of cases does not go beyond this stage, and that is a good outcome.

Once that has been done, surgery tends to be considered in these situations.

Tonsil stones and bad breath that does not go away

This is the reason that brings most people to the office. Tonsil stones, also called tonsilloliths, are those white or yellowish lumps with a strong smell that sometimes come out on their own when you cough or speak. They form inside the tonsillar crypts, and they are neither dirt nor a lack of hygiene: they are a build-up of cells, mucus, food debris and bacteria that organises itself inside an anatomical fold.

When tonsil stones are recurrent, bad breath persists despite proper care and there is a real impact on social or working life, surgery enters the conversation. There is another point to be examined before surgery: most causes of bad breath are in the mouth and on the tongue, not in the tonsils. In that case, those other causes should be ruled out before moving on to surgery. The page on caseous tonsillitis covers the causes and what to do before considering surgery.
Recurrent tonsillitis

Episodes of severe sore throat, with fever and exudate, that recur several times a year and do not respond to well-conducted medical treatment. What counts here is not an isolated episode, it is the pattern: how many times a year, for how many years, how many days off work, how many courses of antibiotics. It is worth arriving at the appointment with that count, because it is literally the criterion. A history of abscess around the tonsil (peritonsillar abscess), especially when it has happened more than once, also weighs on the indication. The clinical picture is detailed on the page on tonsillitis and sore throat.
Snoring, mouth breathing and sleep apnea

Very enlarged tonsils narrow the passage of air in the throat and may contribute to snoring, restless sleep and pauses in breathing during sleep.

This is the indication that calls for the most careful reading in adults. The tonsil is one among several structures that can narrow the upper airway, and clearing the throat may help without that making tonsillectomy a treatment for apnea in itself. Anyone who snores or feels sleepy during the day needs sleep assessment all the same, with a sleep study (polysomnography) when indicated. The subject is covered on the page on sleep apnea.

Besides these three, difficulty swallowing and changes in the voice caused by the size of the tonsils enter the assessment. And it is worth stating the obvious, which is not always stated: no item on this list indicates surgery on its own. The indication arises from the examination and from the conversation.

What tonsil surgery does not solve

Not every throat problem is solved by removing the tonsil, and it is worth knowing that beforehand.

It does not put an end to sore throats. Most sore throats are viral and come from the pharynx, not from the tonsils. After surgery, colds still happen and still hurt. What tends to change is the frequency of those specific episodes of tonsillitis with fever and exudate.

It does not treat bad breath that comes from the mouth. If the origin is the tongue, the gums or a dental problem, the tonsil was not the address. That is why assessment of the mouth comes before the decision.

It is not, in itself, a treatment for sleep apnea. It may be part of the treatment when the tonsil is large and contributes to the narrowing. It does not replace investigation of sleep or the other measures.

It does not solve the nose. Many people who breathe through the mouth also have nasal obstruction from rhinitis, a deviated septum or enlarged turbinates. Treating the throat alone tends to leave the complaint half solved. For the same reason, this operation does not treat the adenoid: when the adenoid is enlarged as well, the operation indicated is a different one, as noted at the beginning of the page.

Risks, unwanted effects and who is not usually a candidate

No surgery is free of risk, and tonsillectomy has a postoperative period that has to be taken seriously. Understanding this matters and needs to be made clear before deciding whether or not to operate.

Among the possible effects and risks are severe sore throat in the first few days, referred earache (the pain comes from the throat and is felt in the ear, through the same nerve, and it is not an ear infection), early or late bleeding, difficulty drinking and eating, nausea, infection of the operated area, and a temporary change in the voice, which tends to sound more open in the first few days. Most of these events are transient and are followed up after surgery, but none of it is dismissible when it comes to deciding.

Bleeding deserves a paragraph of its own, because it is the risk of greatest potential severity and the one that frightens most when it appears. It can occur in the first few days and also later, in the phase when the whitish healing membrane comes away from the throat. Any bleeding from the mouth after surgery is a reason to seek urgent care immediately, even if it seems small and even if it stops on its own. This instruction is given in writing on discharge, and it is not a formality.

The surgery is performed under general anaesthesia, in both techniques, and for that reason the risks of anaesthesia itself are also part of the decision. They are assessed at the pre-anaesthetic appointment, together with your clinical conditions and the medicines you take.

Who is not usually a candidate

Anyone who has not yet been through the medical route. This is the most common situation of all: the person arrives set on surgery, and the conservative measures were never carried out properly or for long enough. A good share of tonsil stone cases is controlled that way.
Anyone with occasional tonsil stones and no symptoms, noticed by chance. In that scenario, observation and hygiene are enough.
Anyone whose bad breath has another main cause, especially one originating in the mouth, a situation in which surgery does not treat what is bothering them.
Anyone with an active throat infection. Elective surgery is postponed until the episode has passed.
Anyone with a clotting disorder or taking anticoagulants, cases in which the decision is taken together with the doctor who manages that treatment. In an operation where bleeding is the main risk, this item weighs more than in others.
Pregnant women, for whom elective surgery is usually postponed.
Anyone with a change of the palate or of speech that could be made worse by the surgery, a situation that needs specific assessment before any indication.

What the day of surgery is like

The surgery is performed entirely through the mouth. There is no external incision, there is no scar on the skin and nothing changes on the outside.

It is performed under general anaesthesia, always, in both techniques. The pre-anaesthetic assessment takes place beforehand, and it is there that fasting, the suspension or continuation of regular medicines and the preoperative tests are defined. Control of pain during surgery is handled by the anaesthetic team.

The procedure itself is relatively short, and discharge is planned in advance, according to the technique that is going to be performed:

Intracapsular tonsillectomy: discharge on the same day.
Total (extracapsular) tonsillectomy: discharge the following day, with one night in hospital.

It is worth knowing this before booking: the difference between going home on the same day and spending a night in hospital is known in advance, because it depends on the technique chosen at the appointment.

Recovery: what to expect

It is worth knowing in advance something that almost nobody mentions: the pain is usually not worst on the first day. It tends to increase afterwards, when the operated area forms the whitish healing membrane, and only then does it ease. Anyone who is not warned of this reads an absolutely normal recovery as surgery that went wrong, and it is precisely in that phase that people give up on drinking, which makes everything worse.

What tends to be part of the first few days:

Hydration, which is the most important part. Drinking hurts, and that is exactly why it has to be done with discipline. A hydrated throat hurts less and heals better; dehydration is the most common reason for returning to the emergency department after this surgery.
Painkillers at set times, and not only when the pain appears. The instructions are given in writing on discharge.
Eating according to the schedule for the technique used, respecting temperature and consistency. The timelines are in the calendar just below. Avoid hard, acidic and very hot foods while the throat is healing.
Avoid physical exertion, which is the last clearance to arrive, also in the calendar below.
The whitish patch in the throat is healing, not infection. The passing bad breath in that phase comes from it, and it is not a sign that something has gone wrong.
A follow-up appointment at 1 week and then at 1 month, to check healing. Both appointments apply to both techniques.

The recovery calendar depends on which of the two techniques was used, because the postoperative period of the total tonsillectomy is longer than that of the intracapsular. These are the timelines we work with.

After the intracapsular tonsillectomy

Cold liquid diet for the first 24 to 48 hours, and normal eating from then on.
Back to work in 5 days.
Back to physical activity in 15 days.

After the total tonsillectomy

Cold liquid diet for the first 4 to 5 days, soft food until around the 8th or 9th day, and normal eating from then on. The whole schedule takes about nine days.
Back to work in 7 days.
Back to physical activity in 15 days.

Two things in these lists tend to cause surprise, and both matter to anyone organising life around the surgery.

With the total tonsillectomy, the return to work happens before the diet ends. On the 7th day the person is back at work, and soft food continues until around the 8th or 9th. There is no arithmetic error: it is possible to work while eating soft food, and what counts is planning what to take from home on those two or three overlapping days.

Physical activity is always the last restriction to be lifted. In both techniques, physical exertion is only cleared at 15 days, after eating has already returned to normal and after the person has already gone back to work. Feeling well before that is common and does not bring the date forward, because the throat is still healing on the inside when energy has already returned.

If tonsil surgery has already been mentioned as a possibility in your case, or if you have been living with tonsil stones and bad breath long enough to be researching this, book a consultation. The examination of the throat and of the nose is what shows the size of the tonsils and the depth of the crypts, and it is from there that the conversation about operating or not makes sense.

Frequently asked questions

Does tonsil surgery hurt a lot?

It has a painful postoperative period, and there is no point in softening that. The sore throat tends to get worse after the first few days, when the operated area forms the healing membrane, and only then does it ease. It is common to feel earache along with it, which comes from the throat through the same nerve and is not an ear infection. The intensity varies from person to person and tends to be lower with the intracapsular technique than with complete removal. Painkillers are prescribed to be taken at fixed times, and not only when the pain appears, and hydration is what helps the pain ease most.

What is the difference between intracapsular and total tonsillectomy?

The intracapsular removes the tonsillar tissue and the crypts, preserving the capsule that separates the tonsil from the vessels and muscles of the pharynx. For that reason it tends to hurt less and to bleed less, but tissue remains next to the capsule, with the possibility of regrowth and of the problem coming back. The total removes tissue and capsule: no tonsil remains, and for that reason there is no recurrence from regrowth of tonsillar tissue. On the other hand, it has a more painful postoperative period and a higher risk of bleeding. We perform both, and the choice is individualised.

Does the surgery solve tonsil stones and bad breath?

It treats the origin of tonsil stones, which is the crypts of the tonsils. The total tonsillectomy removes the tissue and the crypts completely, and a study that measured the sulfur compounds in the breath found a significant drop after surgery. The intracapsular removes the crypts, but tissue remains next to the capsule, and there is the possibility of recurrence over time. It is worth remembering that most bad breath originates on the tongue and in the gums, and that is why assessment of the mouth is part of the investigation before operating.

Do I need to have my tonsils removed, or can it be treated without surgery?

In most cases, it starts without surgery. Careful oral hygiene, hydration, treatment of the nasal causes that increase mucus production and control of reflux when it is present resolve or control a good share of tonsil stone cases. Surgery comes in when the problem is recurrent, persists despite proper care and genuinely affects the person’s life, or when the picture is one of recurrent tonsillitis that does not respond to medical treatment.

Can tonsil stones come back after surgery?

It depends on the technique. After the total tonsillectomy no tonsil remains, and therefore there are no crypts for tonsil stones to form in. After the intracapsular, tissue remains next to the capsule, and there is the possibility of regrowth and of the problem returning over time. It is not possible to predict, in an individual case, whether this will happen.

Does removing the tonsils lower immunity?

This is one of the most common questions in the office. The tonsils are part of the defence system of the throat, together with the adenoid and other tissues of the same ring, and they play a larger role in the first years of life. In adults, removing them does not leave the person without defences: the other tissues of the region carry on performing that function, and that is why removal is considered acceptable when there is an indication. This does not mean that the surgery suits everyone. It means that, where there is an indication, the burden of living with the problem tends to be greater than that of removing the tonsils.

Will I have to stay in hospital?

It depends on the technique, and the answer is known before surgery, not afterwards. With the intracapsular tonsillectomy, discharge is on the same day. With the total tonsillectomy, discharge is the following day, with one night in hospital. As the technique is defined at the appointment, you already know which of the two scenarios you will need to organise at home and at work.

My child needs tonsil surgery. Is it the same operation?

It may be exactly the same, and what decides is not age, it is what is enlarged. If the problem is the tonsil alone, the operation is the tonsillectomy, which is the one on this page, and it is performed in children in the same way. If the adenoid is involved as well, which is frequent in children, the operation becomes the adenotonsillectomy, which treats both in the same procedure. The tonsil can be seen by opening the mouth and the adenoid cannot, because it sits behind the nose and only shows up on examination, and that is why this answer comes after examining the child. The timelines and the postoperative period described on this page are those for adults.

References

1. Sedgwick MJ, Saunders C, Bateman N. Intracapsular Tonsillectomy Using Plasma Ablation Versus Total Tonsillectomy: A Systematic Literature Review and Meta-Analysis. OTO Open. 2023;7(1):e22. doi:10.1002/oto2.22

2. Choi KY, Lee BS, Kim JH, et al. Assessment of Volatile Sulfur Compounds in Adult and Pediatric Chronic Tonsillitis Patients Receiving Tonsillectomy. Clinical and Experimental Otorhinolaryngology. 2018;11(3):210-215. doi:10.21053/ceo.2017.01109

If you live with tonsil stones, with bad breath that does not go away or with recurrent tonsillitis, the next step is not choosing the technique. It is confirming that the tonsils really are the origin of the problem, and that the medical route has already been followed. At the office of Dr. José Eduardo Marcondes, the examination of the throat and of the nose is carried out during the appointment itself, and the treatment plan is built together, with the indication, the alternative and the limit of each option explained beforehand. Care is private (out-of-pocket), at the Morumbi, Itaim Bibi and Alphaville offices. Book a Consultation.

Tonsillectomy with radiofrequency: what is tonsil surgery like in adults?

What tonsillectomy with radiofrequency is

Radiofrequency, Coblation, Coblator: why one operation has so many names

Tonsils only, or tonsils and adenoid?

How radiofrequency acts on the tonsil

The two techniques, and what changes between them

Intracapsular tonsillectomy with radiofrequency

Total (extracapsular) tonsillectomy

How the choice is made, at the appointment

When tonsil surgery is indicated

Tonsil stones and bad breath that does not go away

Recurrent tonsillitis

Snoring, mouth breathing and sleep apnea