IndicationsA. Absolute 1. Recurrent infections of throat 2. Peritonsillar abscess 3. Tonsillitis causing febrile seizures 4. Hypertrophy of tonsils causing obstruction 5. Suspicion of malignancyB. Relative 1. Diphtheria carriers, 2. Streptococcal carriers 3. Chronic tonsillitis with bad taste or halitosis 4. Recurrent streptococcal tonsillitis in a patient with valvular heart diseaseC. As a Part of Another Operation 1. Palatopharyngoplasty 2. Glossopharyngeal neurectomy. 3. Removal of styloid process.
Absolute Indications1. Recurrent infections of throat. This is the most common indication. Recurrent infections are further defined as: – (a) Seven or more episodes in one year, or – (b) Five episodes per year for 2 years, or – (c) Three episodes per year for 3 years, or – (d) Two weeks or more of lost school or work in one year.
Absolute Indications cont..2. Peritonsillar abscess. In children, tonsillectomy is done 4-6 weeks after abscess has been treated. In adults, second attack of peritonsillar abscess forms the absolute indication.3. Tonsillitis causing febrile seizures.
Absolute Indications cont..4. Hypertrophy of tonsils causing – airway obstruction (sleep apnoea) – difficulty in deglutition – interference with speech.5. Suspicion of malignancy. A unilaterally enlarged tonsil may be a lymphoma in children and an epidermoid carcinoma in adults. An excisional biopsy is done.
Relative Indications1. Diphtheria carriers, who do not respond to antibiotics.2. Streptococcal carriers, who may be the source of infection to others.3. Chronic tonsillitis with bad taste or halitosis which is unresponsive to medical treatment.4. Recurrent streptococcal tonsillitis in a patient with valvular heart disease.
As a Part of Another Operation1. Palatopharyngoplasty which is done for sleep apnoea syndrome.2. Glossopharyngeal neurectomy. Tonsil is removed first and then IX nerve is severed in the bed of tonsil.3. Removal of styloid process.
Contraindications1. Haemoglobin level less than 10 g%.2. Acute infection in upper respiratory tract, acute tonsillitis. Bleeding is more in the presence of acute infection.3. Children under 3 years of age.4. Overt or submucous cleft palate.5. Bleeding disorders, e.g. leukaemia, purpura, aplastic anaemia, haemophilia.6. At the time of epidemic of polio.7. Uncontrolled systemic disease, e.g. diabetes, cardiac disease, hypertension or asthma.
Anaesthesia• Usually done under general anaesthesia with endotracheal intubation.• In adults, it may be done under local anaesthesia.
Position• Roses position, i.e. patient lies supine with head extended by placing a pillow under the shoulders. In this position both the head and neck are extended.
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
• Boyles Davis mouth gag has 2 components:• 1. The tongue blade - known as the Boyles tongue blade• 2. Mouth gag - Davis mouth gag.
Boyles Davis mouth gagDavis mouth gag Boyles tongue blade
Steps of Operation (Dissection andSnare Method) 1. Boyle-Davis mouth gag is introduced and opened. It is held in place by Draffins bipods . 2. Tonsil is grasped with tonsil-holding forceps and pulled medially. 3. Incision is made in the mucous membrane where it reflects from the tonsil to anterior pillar. It may be extended along the upper pole to mucous membrane between the tonsil and posterior pillar.
Steps of Operation cont..4. A blunt curved scissor may be used to dissect the tonsil from the peritonsillar tissue and separate its upper pole.5. Now the tonsil is held at its upper pole and traction applied downwards and medially. Dissection is continued with tonsillar dissector or scissors until lower pole is reached
Steps of Operation cont..6. Now wire loop of tonsillar snare is threaded over the tonsil on to its pedicle, tightened, and the pedicle cut and the tonsil removed.7. A gauze sponge is placed in the fossa and pressure applied for a few minutes.8. Bleeding points are tied with silk. Procedure is repeated on the other side.
Post-operative Care1. Immediate general care(a) Keep the patient in coma position until fully recovered from anaesthesia.(b) Keep a watch on bleeding from the nose and mouth.(c) Keep check on vital signs, e.g. pulse, respiration and blood pressure.
Post-operative Care cont..2. Dieta. When patient is fully recovered he is to take liquids, e.g. cold milk or ice cream.b. Sucking of ice cubes gives relief from pain.c. Diet is gradually built from soft to solid food. They may take custard, jelly, soft boiled eggs or slice of bread soaked in milk on the 2nd day.d. Plenty of fluids should be encouraged.
Post-operative Care cont..3. Oral hygiene Condys or salt water gargles 3-4 times a day. A mouth wash with plain water after every feed helps to keep the mouth clean.4. Analgesics Pain, locally in the throat and referred to ear, can be relieved by analgesics like paracetamol. An analgesic can be given half an hour before meals.5. Antibiotics A suitable antibiotic can be given orally or by injection for a week. Patient is usually sent home 24 hours after operation unless there is some complication. Patient can resume his normal duties within 2 weeks
Methods for tonsillectomyCold HotDissection and snare ElectrocauteryGuillotine method Laser tonsillectomy (CO2 or KTP)Intracapsular (capsule Coblation tonsillectomypreserving)tonsillectomyHarmonic scalpel Radio frequencyPlasma-mediatedablation techniqueCryosurgical technique
Other methods for tonsillectomy1. Guillotine method. Largely abandoned. It can be done only when tonsils are mobile and tonsil bed has not been scarred by repeated infections.2. Electrocautery. Both unipolar and bipolar electrocautery has been used. It reduces blood loss but causes thermal injury to tissues.
• 3. Laser tonsillectomy. It is indicated in coagulation disorders. Both KTP-512 and CO2 lasers have been used but the former is preferred. Technique is similar to one used in dissection method.• 4. Laser tonsillotomy. Another method is laser tonsillotomy which aims to reduce the size of tonsils. It is indicated in patients who are unable to tolerate general anaesthesia. Tonsils are reduced by laser ablation up to anterior pillars by stage repeated applications.
• 5. Intracapsular tonsillectomy. With the use of powered instruments (micro debrider with a 45 degree hand piece ) tonsil is removed but its capsule is preserved in the hope to reduce post-operative pain.
6. Harmonic scalpel.• It 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.
• 7. Plasma-mediated ablation technique. In this ablation method, protons are energized to break molecular bonds between tissues. It is a cold method and does not cause thermal injury
• 8. 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.
• 9. Cryosurgical technique.• Tonsil is frozen by application of cryoprobe and then allowed to thaw. Two applications, each of 3-4 minutes, are applied. Tonsillar tissue will undergo necrosis and later fall off leaving a granulating surface. Bleeding is less due to thrombosis of vessels caused by freezing.• - 82 degrees centigrade by carbondioxide• - 196 degrees centigrade by liquid nitrogen
Complications A. Immediate • 1. Primary haemorrhage. Occurs at the time of operation. It can be controlled by pressure, ligation or electrocoagulation of the bleeding vessels. • 2. Reactionary haemorrhage. Occurs within a period of 24 hours and can be controlled by simple measures such as removal of the clot, application of pressure or vasoconstrictor. • 3. Injury to tonsillar pillars, uvula, soft palate, tongue or superior constrictor muscle due to bad surgical technique.
Immediate Complications cont.. 4. Injury to teeth. 5. Aspiration of blood. 6. Facial oedema. Some patients get oedema of the face particularly of the eyelids. 7. Surgical emphysema. Rarely occurs due to injury to superior constrictor muscle.
B. Delayed Complications1. Secondary haemorrhage. Usually seen between the 5th to 10th post-operative day. It is the result of sepsis and premature separation of the membrane.• Simple measures like removal of clot, topical application of dilute adrenaline or hydrogen peroxide with pressure usually suffice.• For profuse bleeding, general anaesthesia is given and bleeding vessel is electrocoagulated or ligated.• Sometimes, approximation of pillars with mattress sutures may be required.• Sometimes, external carotid ligation may also be required.• Transfusion of blood or plasma, depending on blood loss, is given.• Systemic antibiotics are given for control of infection.
Delayed Complications cont..• 2. Infection. Infection of tonsillar fossa may lead to parapharyngeal abscess or otitis media.• 3. Lung complications. Aspiration of blood, mucus or tissue fragments may cause atelectasis or lung abscess.• 4. Scarring in soft palate and pillars.
Delayed Complications cont..• 5. Tonsillar remnants. Tonsil tags or tissue, left due to inadequate surgery, may get repeatedly infected.• 6. Hypertrophy of lingual tonsil. This is a late complication and is compensatory to loss of palatine tonsils. Sometimes, lymphoid tissue is left in the plica triangularis near the lower pole of tonsil, which later gets hypertrophied. Plica triangularis should, therefore be removed during tonsillectomy