Tonsillectomy


By

Dr. T. Balasubramanian M.S. D.L.O.


Indications for tonsillectomy:
Infections:
1. Recurrent acute tonsillitis - more than 6 episodes / year or 3 episodes / year for more than 2 years.
2. Recurrent acute tonsillitis associated with other conditions like :
    Cardiovascular disease associated with recurrent streptococcal tonsillitis.
    Recurrent febrile seizures.
3. Chronic tonsillitis that are unresponsive to medical management and associated with
halitosis, persistent sore throat and cervical adenitis.
4. streptococcal carrier state unresponsive to medical treatment.
5. Quinsy
6. Tonsillitis associated with abscessed nodes.
7. Infectious mononucleosis with severely obstructing tonsils that is unresponsive to medical management.

Obstruction:
1. Sleep apnoea
2. Adenotonsillar enlargement associated with cor pulmonale, and failure to thrive
3. Dysphagia
4. Speech abnormalities (Rhinolalia clausa)
5. Cranio facial growth abnormalities
6. Occlusal abnormalities

 Other causes

1. Embedded foreign body
2. Tonsillar cysts
3. As a surgical approach to other structures like
    Styloid process
    Glossopharyngeal nerve
    Parapharyngeal space

Surgical indications for adenoidectomy:
Infections:
1. Purulent adenoiditis
2. Adenoid hypertrophy associated with
    CSOM with effusion
    Chronic recurrent acute otitis media
    CSOM with perforation
Obstruction:
1. Excessive snoaring
2. Sleep apnoea
3. Adenoid hypertrophy associated with
    Corpulmonale
    Failure to thrive
   Dysphagia
   Speech abnormalities
Others:
Adenoid hypertrophy associated with chronic sinusitis





















Fig showing chronic tonsillitis

 In children adenoid and tonsils are removed together in one sitting.  Removing the tonsils leaving the adenoid in situ may lead on to compensatory adenoid enlargement causing problems at a later date.
The surgery is performed under intubational general anaesthesia.
Various methods are available for removal of tonsils:
Guillotine method: The tonsils were removed during olden days using this method.  This method has been abandoned because of the risks of bleeding.  In this method a guillotine is used to simply chop off the tonsil.  This term guillotine is derived from the French which literally means chop off the head.  In medivial France prisinor's life was taken off by this method.
Dissection and Snare method:  This is the commonly used method to perform tonsillectomy today.  The tonsil is dissected along with its capsule and lifted out of its bed.  It is ultimately removed using a tonsillar snare which is also known as the Eve's snare. Snaring the tonsil has a distinct advantage. Since the tonsil is crushed before it is cut, bleeding is minimised. At this juncture it must also be pointed that blood supply to the tonsil reaches it through its lower pole. The advantage of this method is that the procedure is safe, bleeding is less and the tonsil can be removed in toto without any remnants.
The patient is put in Rose position. This position owes its name to a staff nurse by name Rose who suggested this position to the surgeon. In fact it must be called as Sister Rose position. In this position both the head and neck are extended. This is done by keeping a sand bag under the patient's shoulder blade.






















Fig showing a patient put in Rose position with a sand bag under the soulder blade.


Advantages of Rose position:

1. There is virtually no aspiration of blood or secretions into the airway.

2. Both hands of the surgeon are free. This position helps in proper application of the Boyles Davis mouth gag.

3. The surgeon can be comfortably seated at the head end of the patient






















Figure showing the Boyles Davis mouth gag applied.


Boyles Davis mouth gag has 2 components:

1. The tongue blade - known as the Boyles tongue blade

2. Mouth gag - Davis mouth gag.

The mouth gag is held in position by a M shaped stand called as the jack or by a Draffins pod. During surgery the mouth gag must be frequently released and reapplied. The mouth gag applies intense pressure to posterior 1/3 of the tongue causing certain amount of disruption to its blood supply thus leading on to intense tongue pain post operatively. Thus frequent release of the mouth gag during surgery reduces to some extent this type of pain.

CryoTonsillectomy:

Tonsillectomy can also be performed using a cryo probe. CryoSurgery is a process in which very cold instrument or substance is applied to tonsil and it is removed by the process of repeated freezing and thawing. The temperature reached during cryo is dependent on the medium used :

- 82 degrees centigrade by carbondioxide

- 196 degrees centigrade by liquid nitrogen

Any of the above can be used in tonsil surgery. The major advantage of this procedure is minimal bleeding. The major disadvantage of this procedure is the operating time involved. This procedure is used only in patients with known bleeding diathesis.

Laser tonsillectomy:

Tonsillectomy can be performed using laser. A carbondioxide laser of a KTP laser can be used. Major advantage of laser surgery is reduced bleeding. Laser seals all bleeders effeciently. The flip side being increased operating time and the cost of laser equipment.

Intracapsular tonsillectomy:

In this method tonsil is removed from its capsule. Special instruments are needed for this purpose. Micro debrider with a 45 degree hand piece is used for this surgery. The major advantage of this procedure is that it causes less trauma to the pillars and mucosa of the oro pharynx uvula and soft palate.

Harmonic scalpel tonsillectomy:

Harmonic scalpel is an ultra sound coagulator and dissector that uses ultra sonic vibrations to cut and coagulate tissues. The cutting operation is made possible by a sharp knife with a vibratory frequency of 55.5 KHz ovar a distance of 89 micro meters. Coagulation occurs due to transfer of vibratory energy to tissues. This breaks hydrogen bonds of proteins in tissues and generates heat from tissue friction. The temperature generated by harmonic scalpel is less than that of electro cautery hence it is safer (50 - 100 degrees centigrade as compared to that of 150 - 400 degrees centigrade).

The major disadvantage is the expense of the equipment and the increased duration of surgery.

Coblation tonsillectomy:

It is also other wise known as cold abalation. This technique utilises a field of plasma, or ionised sodium molecules, to ablate tissues. The heat generated varies from 40 - 80 degrees centigrade, much lower than that of electro cautery. The major advantage of this procedure is reduced bleeding and reduced post operative pain.

Complications of tonsillectomy:

Complications can be classified in to immediate, intermediate and delayed.

Immediate complications:

Mostly encountered on the table during surgery. The most common of them being the complications of general anaesthesia. Next is troublesome intra operative bleeding. This is common in poorly prepared tonsillectomies (i.e. patients who have been taken up for surgery without a pre op course of antibiotics), hot tonsillectomy (i.e. quinsy tonsillectomy). Bleeding can be controlled by proper dissection, staying in the correct plane (i.e. sub capsular plane) during dissection, ligation of bleeders, using bipolar cautery to coagulate the bleeding vessels.

Trauma to the anterior and posterior pillars. Trauma to posterior pillar causes nasal regrugitatin whenever the patient attempts to drink fluids after surgery. It may also cause undesirable changes in the voice i.e. Rhinolalia aperta.

Teeth must be taken care when mouth gag is bing applied. Any loose tooth, dentures must be removed before intubation because the loose teeth can easily be dislodged and be aspirated.

Trauma to the lips and gums: can be avoided by using the right sized tongue blade. The size of the blade can be measured by placing it between the mentum and the angle of the mandible.

Intermediate complications:

Are mostly haemorrhage. Haemorrhage during immediate post op period is also known as reactionary haemorrhage. This is caused due to

1. Wearing off of the hypotensive effect of the anaesthesia during the immediate post op period.

2. Slipping of ligature

These patients must be taken to the operation theatre, reanaesthetised and the bleeders must be ligated or cauterised.

If bleeding is diffuse and uncontrollable pillar suturing can be resorted to. This is done by suturing both the anterior and posterior pillars after placing a gauze or gelfoam in the tonsillar fossa. If gauze is used to pack the tonsillar fossa, silk is used to suture the pillars and these sutures must be removed after 48 hours and the gauze is removed. On the other hand if absorbable material like gel foam is used the pillars can be sutured with chromic cat gut and the sutures need not be removed.

Delayed complications:

Are mostly due to infections. These commonly occur a week after the surgery. Bleeding during this period is known as secondary haemorrhage. Antibiotics are used to control infections.












 






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