The document provides detailed information about the anatomy, functions, indications for removal, and surgical procedures related to the tonsils and adenoids. It describes the tonsils as oval masses of lymphoid tissue located in the oropharynx between the anterior and posterior pillars. It discusses the various surgical techniques for tonsillectomy, including dissection and snare, electrocautery, and laser methods. It notes some common complications of tonsillectomy like bleeding and infection. For adenoids, it outlines their anatomy and pathological effects like ear infections, airway obstruction, and sinusitis. It also includes grading criteria for adenoid size and methods for clinical examination.

1. TONSILLECTOMY
By-Dr Shelly Agrawal

2. GROSS ANATOMY
The palatine tonsil is an ovoid
mass of lymphoid tissue located
in the oropharynx between the
anterior and posterior pillars.
Avg size- 2.5cm*2 cm*1.2 cm
It has 2 surfaces –
1. medial surface
2. lateral surface
It ha 2 poles –
1. upper pole
2. lower pole

3. Medial surface
It is lined by stratified squamous non
keratinising epithelium which dips
into the crypts
The crypts are 12-15 in number
Secondary crypts arise from the
primary crypts and extend into the
substance of the tonsil
One of the crypts located in the upper
part is larger than the rest – crypta
magna
The crypts serve to increase the
surface area of the tonsil
The crypts may be filled with cheesy
material – epithelial debris, food
particles and bacteria

4. Lateral surface
• It is covered by the fibrous capsule of the tonsil
•
• The tonsillar bed is separated from the capsule by
loose areolar tissue
•
• This makes it is easy to dissect the tonsil from its
bed during tonsillectomy
• It is the site of collection of pus in peritonsillar
abscess (quinsy)
• Some fibers of palatoglossus and palatopharyngeus
muscles get attached to the capsule of tonsil

5. Upper pole
It extends into the soft palate
There is a semilunar fold of mucous membrane
which covers the medial part of the upper
pole
It extends from anterior pillar to posterior pillar
It encloses a potential space – supratonsillar
fossa

6. Lower pole
It is attached to the tongue
A triangular fold of mucous membrane extends from
the
anterior tonsillar pillar to the lower pole
It encloses a space – anterior tonsillar space
The lower pole is separated from the tongue by the
tonsillo-lingual sulcus
This sulcus may harbour carcinoma

7. Bed of tonsil
>FROM MEDIAL TO LATERAL:-
1] Capsule
2] Loose areolar tissue containing paratonsillar vein
3] Pharyngobasilar fascia
4] Superior constrictor muscle
5] Buccopharyngeal fascia
6] Styloglossus muscle
The other structures in relation to tonsils are:-
7] Glossopharyngeal nerve
8] Facial artery
9] Submandibular gland
10] Medial pterygoid muscle
11] Angle of mandible
12] Styloid process
13] Posterior belly of digastric muscle

8. Structures related to the bed of
tonsils

9. Blood supply
Blood supply is from the branches of 4 major arteries all of
which are the braches of a main artery i.e external carotid
artery . The arteries supplying :-
 Upper Pole are
 Descending Palatine br. Of Maxillay artery (Ant.)
 Ascending pharyngeal artery br. Of Ext. Carotid
artey (Post.)
 Lower Pole are
 Dorsal Lingual br. Lingual Artery (Ant.)
 Tonsillar br. Of Facial Artery (Main)
 Ascending palatine br. Of Facial Artery (Post.)

11. Veins, lymphatics & nerves
• Lymphatics pierce the superior
constrictor and drain into upper deep
cervical (jugulo-digastric) nodes
located below the angle of mandible.
• Veins from the tonsils drain into
paratonsillar vein which then joins the
common facial vein and pharyngeal
venous plexus
Nerves
Lesser palatine branches of
sphenopalatine ganglion and
glossopharyngeal nerve provide
sensory nerve supply.

12. Function of tonsils
• It has a protective
function in that it prevents
entry of pathogens
through the nasal and
oral route
• The crypts on the surface
of the tonsil serve to
increase the surface area
and increase the
efficiency of protection
against pathogens
• It forms a part of
Waldeyer’s lymphatic
ring.
• Most active between 4-10
yrs of age.

13. TONSILLECTOMY
• Indications
A. Absolute
1. Recurrent infections of throat
2. Peritonsillar abscess
3. Tonsillitis causing febrile seizures
4. Hypertrophy of tonsils causing obstruction
5. Suspicion of malignancy
B. 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 disease
C. As a Part of Another Operation
1. Palatopharyngoplasty
2. Glossopharyngeal neurectomy.
3. Removal of styloid process.

14. Absolute Indications
1. 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.

15. Absolute Indications cont..
2. Peritonsillar abscess. In children,
tonsillectomy is done 4-6 weeks after
abscess has been treated.
3. Tonsillitis causing febrile seizures.

16. 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.

17. Relative Indications
1. 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.

18. As a Part of Another Operation
1. 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.

19. Contraindications
1. 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.
8. Tonsillectomy is avoided during the period of
menses.

20. Anaesthesia
• Usually done under general
anaesthesia with endotracheal
intubation.

21. Rose's position for tonsillectomy. Neck is extended by a sand bag
under the shoulders and the head is supported on a ring.
Downloaded from: StudentConsult (on 6 December 2012 06:54 PM)
© 2005 Elsevier
Rose's position

22. 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

23. • Boyles Davis mouth gag has 2
components:
• 1. The tongue blade - known as the
Boyles tongue blade
• 2. Mouth gag - Davis mouth gag.

24. Boyles Davis mouth gag
Davis mouth gag Boyles tongue blade

25. Boyle-Davis mouth gag

26. Boyle-Davis mouth gag

27. Steps of Operation (Dissection and
Snare Method)
1. Boyle-Davis mouth gag is introduced and
opened. It is held in place by Draffin's
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.

28. 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

29. (A) Tonsil being dissected from its bed. (B) The pedicle at the lower pole of
tonsil being cut with a snare.
Downloaded from: StudentConsult (on 6 December 2012 06:54 PM)
© 2005 Elsevier

30. 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.

31. Methods for tonsillectomy
Cold Hot
Dissection and snare Electrocautery
Guillotine method Laser tonsillectomy (CO2
or KTP)
Intracapsular (capsule
preserving)
tonsillectomy
Coblation tonsillectomy
Harmonic scalpel Radio frequency
Plasma-mediated
ablation technique
Cryosurgical technique

32. Other methods for tonsillectomy
1. 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.

34. • 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.

35. Laser tonsillectomy Laser tonsillotomy( ablation)

36. • 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.

37. Intracapsular tonsillectomy

38. micro debrider micro debrider-tip blade

39. 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.

40. Harmonic scalpel knife Harmonic scalpel tonsillectomy

41. 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.

42. 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.

43. B. Delayed Complications
1. 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.

44. 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.

45. 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

46. ADENOIDECTOMY
By- Dr. Aditi Pareek

47. • Adenoid forms part of Waldeyers ring of
lymphoid tissue at the portal of upper
respiratory tract.
• First site of immunological contact for
inhaled antigens

48. ANATOMY
• Covered by stratified squamous epithelium
• Blood supply
1.Ascending palatine branch of Facial
2.Ascending pharyngeal branch of ECA
3.Pharyngeal branch of third part of maxillary
artery
4.Ascending cervical branch of inferior thyroid
artery of thyrocervical trunk

49. Venous drainage to internal jugular and
facial veins
• Lymphatic drainage: retropharyngeal
nodes and upper deep cervical nodes
• Nerve suply: sensory branches of
glossopharyngeal and vagus nerves

50. Pathological Effects of Adenoid
• Otitis media with effusion
– Recurrent acute or chronic inflammation of
adenoid and increased bacterial load of H
influenzae causes
• Squamous cell metaplasia
• Reticular epithelium extension
• Fibrosis of interfollicular interconnective tissue
• Reduced mucociliary clearance
– This contributes to development of Biofilm
middle ear effusion
– OME is also implicated by chronic GERD

51. • Recurrent acute otitis media
– Benefit of surgery was modest and limited
to first year of follow up
– Neither adenoidectomy/
adenotonsillectomy should be considered
as initial surgical procedure

52. • Upper airway obstruction and OSA
– Prevalence: 1%, peak at 3-6 years
– Adenoid hypertrophy causes depressed
arterial PaO2 and increased PaCO2

53. • Rhinosinusitis
– Improvement occurs in majority after
adenoidectomy or adenotonsillectomy
– Adenoidectomy helps by abolishing
infective episodes

54. • Olfaction
– Is reduced in relation to adenoid size
– Also attributed to poor appetite in children
with adenoidal hypertrophy
• Neoplasia
– NHL

55. Clinical examination
• External nose- skin crease in supratip
due to frequent rubbing
• Anterior rhinoscopy
• Nasal endoscopy

56. Grading of adenoid Size
Clemens et al
• Grade I : filling one-third of the vertical
portion of choanae
• Grade II : one-third to two-third
• Grade III: two-third to near complete
• Grade IV : complete obstruction

57. INDICATIONS
1.Adenoid hypertrophy causing snoring ,
mouth breathing , sleep apnoea
syndrome or speech abnormalities.
2. Recurrent rhinosinusitis
3. Chronic otitis media with effusion
4. Dental malocclusion . Adenoidectomy
does not correct dental abnormalities but
will prevent its recurrence after
orthodontic treatment.

59. CONTRAINDICATIONS
1. Cleft palate
2. Haemorrhagic diathesis
3. Acute infection of upper respiratory
tract

60. Adenoidectomy
• Curettage
• Suction coagulator
• Microdebridder
• Coblator

61. Steps of Adenoidectomy
1.Boyle- Davis mouth gag
is inserted .Nasopharynx
is examined.
2. Proper size of adenoid
curette with guard is
introduced into
nasopharynx till its free
edge touches the
posterior border of nasal
septum and is then
pressed backwards to
engage the adenoids .
.

62. 3. With gentle sweeping movement
adenoids are shaved off
4.Haemostasis is achieved by packing or
electrocoagulation.

63. Endoscopic adenoidectomy
Adenoids can be
removed more
precisely by using a
microdebrider under
endoscopic control .
. This technique
provides the
advantage of direct
visualization leading to
less complications and
less blood loss.

65. • Complications
– Bleeding
• Reactionary hemorrhage: within 6-20 hours
<0.7% postnasal packing
• Secondary hemorrhage :rare bleeding from
aberrant ascending pharyngeal artery
• Rule out clotting or coagulation defect
– Dental trauma
– Retained Swab
– Nasopharyngeal blood clot- coroners clot
– Infection: rare, retropharyngeal and
mediastinal abscess can occur rarely

66. • Cervical Spine
– Nontraumatic atlantoaxial subluxation (
Grisel Syndrome) is rare
– Postoperative torticollis should raise
suspicion
– Care to be taken in down syndrome
• Velopharyngeal dysfunction
– 1:1500- 1:10000
– Hypernasal speech, swallowing difficulty
• Regrowth of adenoid
– 71 % gets no residual obstructing
adenoids

67. Thank You