Resident Pearls: Pediatric Otolaryngologists Share Tips for Safer, Smarter Tonsillectomies

Tonsillectomy is a rite of passage in otolaryngology— one of the most common pediatric surgeries, and often one of the first operations a junior resident gets to perform (Laryngoscope. doi:10.1002/lary.28427). But despite its frequency, the procedure carries real risks, particularly when it comes to post-operative bleeding (StatPearls. https://tinyurl.com/3xwmkdzj; World J Clin Cases. doi:10.12998/wjcc.v9.i7.1543). That’s why mastering this deceptively routine surgery early in training is so important, and medical educators must balance ensuring optimal patient outcomes with allowing junior residents to gain essential surgical experience.

To support this learning curve, pediatric otolaryngologists from around the globe shared their go-to tonsillectomy tips and pearls for resident trainees. Their advice—candid, practical, and grounded in years of experience—highlights not only what residents need to know, but what they need to feel confident in the OR. This article brings together the top themes that emerged from their responses, drawn from a larger international survey on tonsillectomy practices. Consider it a global mentorship session, boiled down to its essentials.

Materials and Methods

The advice comes from 64 pediatric otolaryngologists who responded to a global survey conducted in 2024. The survey ran for six weeks from April 4 to May 16, 2024, and was developed by specialists from Canada, the U.S., Australia, and the U.K. Participation was voluntary, anonymous, and conducted via a secure online platform hosted by Lawson Health Research Institute. The inclusion criteria required participants to be pediatric otolaryngologists proficient in reading and writing English. Recruitment occurred through an international WhatsApp group of 293 verified pediatric otolaryngologists, whose identities were confirmed by group administrators. The diversity of participants’ countries of origin contributed to a sample that was reasonably representative of the target study population. As described by Braun and Clarke (Qual Quant. doi:10.1007/ s11135-021-01182-y), two of the authors (G.S. and V.N.) followed six systematic stages of thematic data analysis. Direct quotations that supported coded themes were reported. Survey results were double-coded and reviewed, and inconsistencies were discussed to increase intercoder reliability. Of the 132 total participants (45.1% response rate), 64 respondents (48.4% of respondents, 21.8% response rate overall) answered the open-ended question, “What is your top tonsillectomy tip/pearl you would tell a student or resident trainee?” The goal? To collect wisdom from the field and pass it down to the next generation of ENT surgeons. What emerged were four central themes: 1) Emphasis on Safety and Emergency Preparedness, 2) Conservative Patient Selection and Surgical Approach, 3) Adaptation and Openness to Innovation, and 4) Expanding the Circle of Care. Let’s dive into the advice, straight from the surgeons who know this operation best.

Safety First—Every Time

If there’s one message residents need to hear, it’s this: Never underestimate a tonsillectomy. “Not to take the tonsillectomy procedure lightly. You may land in trouble even in your 1001st case,” one respondent warned. “Be ready for any emergency, any time.” Over half of the surgeons emphasized the importance of meticulous technique and constant vigilance for bleeding, the most feared complication. “Although it is a simple surgery, complications can be serious,” said another. “Trust is the worst enemy.” “Ensure strict hemostasis throughout the surgical procedure … which may reduce post-operative morbidities, including bleeding, which may impair patient outcomes. This is after careful dissection, identification, and ligation of vessels and respecting all the adjacent structures …,” said another. Safety isn’t just a checkbox—it’s the foundation.

Know When Not to Operate

Tonsillectomy isn’t always the answer. More than a third of respondents encouraged residents to be cautious about patient selection, particularly when it comes to recurrent throat infections.

“It is a serious and potentially life-threatening operation,” one expert emphasized. “The decision to operate should not be made without confirmation that it is necessary, following recognized international guidelines.”

The best way to prevent complications? Fewer surgeries—and only when truly indicated. “Tailor the technique to the patient and indication,” another respondent stressed.

It is important to apply stricter indication criteria and align more closely with national patient selection guidelines. Guidelines are a foundation for refining surgical decision making, balancing the benefits of tonsillectomy with associated risks. The message here is clear: Let guidelines and clinical judgment guide you, not routine.

Stay Curious, Stay Current

Half of the surveyed surgeons urged trainees to remain open to new techniques and technologies—from intracapsular approaches to the use of tranexamic acid.

“Learn as many methods as possible and never forget: This is not a routine operation for the family, only for the surgeon,” one said. Another added, “Coblation intracapsular tonsillectomy in experienced hands has been a major advance. After 3,000, you get better.”

Even seasoned surgeons continue refining their craft. Residents should, too.

Bring Everyone In

Success in tonsillectomy isn’t just about the otolaryngologist. Surgeons highlighted the role of anesthesiologists, nurses, and—most critically—parents.

“Anecdotally, patients whose parents ensure early and regular eating, drinking, and analgesics have fewer post-op complications,” noted one respondent. “Operative counseling pre- and post-operatively is as important as surgical technique.”

Another added, “Be proficient in more than one surgical method, and have a good working relationship with your anesthetist.” Education, communication, and trust with families and colleagues are just as vital as the operation itself.

Where Experience Meets Apprenticeship

Teaching tonsillectomy early in training fosters confidence and clinical independence (Laryngoscope. doi:10.1002/lary.25046). But in the modern surgical world, mentorship happens in fast-paced, high-stakes environments (J Am Coll Surg. doi:10.1016/j.jamcollsurg.2014.01.047; Neurosurg Rev. doi:10.1007/s10143-020- 01314-2). Pearls like these help bridge that gap—bringing real-world nuance to textbook knowledge.

Bleeding was the central concern voiced by many respondents. Bleeding, though rare, can cause significant morbidity or fatality. A key strategy to mitigate these risks is to reduce the number of tonsillectomies performed, guided by detailed histories and adherence to national guidelines. Tonsillectomy for recurrent throat infections, as highlighted by our respondents, is important in weighing the modest short-term benefits of the procedure against the natural history observed in control groups, as described by American guidelines (Otolaryngol Head Neck Surg. doi:10.1177/0194599818801757). To reduce harm, strategies have been examined for increased caregiver understanding of post-operative pain control, and are well-represented in national guidelines (Anaesthesia. doi:10.1111/anae.15299; Int J Pediatr Otorhinolaryngol. doi:10.1016/j. ijporl.2015.03.003; Eur Ann Otorhinolaryngol Head Neck Dis. doi:10.1016/j.anorl.2012.03.003). Patient and caregiver satisfaction can be increased when misconceptions surrounding safe and effective pain management have been reconciled.

While there’s healthy debate over technique—some prefer traditional methods, others embrace evolving technologies—the lack of consensus reflects the ongoing evolution of the field. This debate is mirrored in the literature, which highlights new instruments that may reduce hemorrhage rates, operating time, tissue damage, and post-operative pain, and support a quicker return to normal diet and activity (Int J Head Neck Surg. doi:10.5005/jp-journals-10001-1273). As newer approaches like intracapsular tonsillectomy gain popularity, many surgeons are watching closely. But for now, most guidelines remain rooted in tried-and-true practices.

The Takeaway

How can this global perspective sharpen residents’ approach to tonsillectomy?

• Always prepare for bleeding—even in “routine” cases.
• Don’t rush to operate—follow the guidelines.
• Embrace innovation, but master the basics.
• Bring caregivers into the circle of care.

By compiling lived experience across continents, the study offers a crowdsourced training supplement that fills gaps left by textbook algorithms or guidelines. As tonsillectomy techniques and technologies continue to evolve, ongoing dialogue—at the bedside, in the literature, and within clinical guidelines—will be key to advancing training and optimizing patient outcomes. This piece is adapted from a larger survey study approved by the Western University Health Sciences Research Ethics Board. For more on the study’s methodology or to request supplementary data, contact the corresponding author.

Ms. Spencer is a fourth-year medical student at Queen’s University School of Medicine in Kingston, Ontario. Mr. Nanthakumar is a fourth-year medical student at Queen’s University School of Medicine in Kingston, Ontario. Ms. Wilson is a research associate for the division of paediatric surgery at the Children’s Hospital, London Health Sciences Centre in London, Ontario. Mr. Davidson is the research coordinator for the division of paediatric surgery at the Children’s Hospital, London Health Sciences Centre in London, Ontario. Dr. Strychowsky is a pediatric otolaryngologist and division chief of pediatric otolaryngology at Children’s Hospital, London Health Sciences Centre, and associate professor at the Schulich School of Medicine and Dentistry at Western University in London, Ontario. Dr. Bhargava is a pediatric otolaryngologist at Sheffield Children’s Hospital in the U.K., senior clinical lecturer at the  University of Sheffield Faculty of Health, a visiting researcher at the Advanced Food Innovation Centre at Sheffield Hallam University, and co-director of SMELL (Sheffield cheMosensory Exploratory Laboratory). Dr. Lawlor is an assistant professor at Harvard Medical School, an attending pediatric otolaryngologist at Boston Children’s Hospital, an editor at JAMA Otolaryngology–Head and Neck Surgery, and chair-elect of the Young Physicians Section of the Academy of Otolaryngology–Head and Neck Surgery. Dr. Burns is a pediatric otolaryngologist at Queensland Children’s Hospital in Brisbane, Australia, senior lecturer in otolaryngology at the University of Queensland, incoming president of the Australian and New Zealand Society of Paediatric Otolaryngology, and editor-in-chief of the Australian Journal of Otolaryngology. Dr. Fowler is a general otolaryngologist at the Cape Breton Regional Hospital in Sydney, Nova Scotia, and an assistant professor in the department of surgery at Dalhousie University in Halifax, Nova Scotia. Dr. Graham is a pediatric otolaryngologist at the IWK Health Centre, an associate professor at Dalhousie University, both in Halifax, Nova Scotia, and a Triological Society
fellow.