A Novel Technique for Intracapsular Complete Tonsillectomy: Flower Technique

Introduction: Intracapsular tonsillectomy (IT) is effective for alleviating pediatric obstructive sleep apnea (OSA), but concerns about regrowth of residual tonsil tissue persist. To address this, we introduced the Flower technique, a novel approach for total intracapsular resection with precise excision of tonsil tissue at upper and lower poles under direct visualization.

Methods: This retrospective case-control study was conducted at the Department of Otolaryngology-Head and Neck Surgery, Sixth People’s Hospital, from January 2019 to October 2023, including patients aged 3 to 12 years who underwent tonsillectomy with adenoidectomy for adenotonsillar hypertrophy. The case group received total IT using Flower technique (FT group) and the control group underwent conventional combined extracapsular and intracapsular tonsillectomy (CEI group).
In the FT group, the upper pole was retracted medially with a Kelly clamp, and partial excision was performed above the capsule. Residual tonsil tissue was clamped, twisted, and turned outward in a "flower bud" pattern for total ablation. The process was repeated until all tonsil tissue within the fossa was removed, with the inferior pole excised intracapsularly. Postoperatively, daily records were kept for 2 weeks tracking pain severity (VAS), analgesic use, hemorrhage severity, and the return to normal diet and activity.

Results: The FT group (159 subjects) showed lower pain levels from days 2 to 7 compared to the CEI group (120 subjects), with shorter analgesic use ( 0.62 [1.08] days vs. 0.83 [1.15] days, P < 0.05). No primary hemorrhage occurred in either group. Minor secondary hemorrhage episodes were recorded in 3 children in the FT group and 4 in the CEI group. The FT group resumed normal diets and activities earlier (5.30 [3.16] days vs. 7.59 [2.95] days; 5.53 [3.72] days vs. 8.03 [3.33] days, P < 0.01).No recurrence of OSA symptoms or recurrent tonsillitis was reported during 6-month follow-up.

Conclusions: Complete IT using the flower technique ensures total removal of tonsil tissue, potentially preventing regrowth, while reducing postoperative pain and accelerating recovery.