This presentation is mainly for medical students to prepare for their practical examination and VIVA ,OSCE. This covers the topic of TONSILLECTOMY-INDICATIONS, CONTRAINDICATIONS,METHODS,SURGICAL STEPS AND COMPLICATIONS. Hope this is useful for you. All the best .

1. O P E R A T I V E
P R O C E D U R E S S E R I E S
TONSILLECTOMY
-INDICATIONS
-CONTRAINDICATIONS
-METHODS
-SURGICAL STEPS
-COMPLICATIONS
Dr.S.Kalyan Kumar MS ENT
Gold Medalist
KK’s
ENT
TUTORIALS

2. T O N S I L L E C T O M Y
Tonsillectomy is surgery to remove the Palatine tonsils.
The procedure is mainly performed for recurrent tonsillitis,
throat infections and obstructive sleep apnea (OSA)

3. A B S O L U T E I N D I C A T I O N S
• Recurrent infections of tonsils (Most common indication) -
Seven or more episodes in one year; five episodes per year for
2 years; three episodes per year for 3 years; two weeks or more
of lost school or work in one year.
• Quinsy-Can be done immediately (Hot tonsillectomy) or after
an interval of 6weeks (Interval tonsillectomy).
• Hypertrophy of tonsils causing airway obstruction (sleep
apnoea) or difficulty in deglutition or interference with speech.

4. A B S O L U T E I N D I C A T I O N S
• Suspicion of malignancy.
• Tonsillitis causing febrile seizures.
• Benign tumours or cysts of the tonsil.
• Foreign body embeded in the substance of tonsil which
can not be removed.
• Tonsillolith or intra-tonsillar abscess.
• Unilateral enlargement of tonsil.

5. R E L A T I V E I N D I C A T I O N S
• Diphtheria Carriers, who do not respond to antibiotics.
• Streptococcal carriers.
• Chronic tonsillitis with bad taste or halitosis which is unresponsive
to Medical treatment.
• Recurrent streptococcal tonsillitis in a patient with valvular heart
disease
• Persistent jugulodigastric lymphadenopathy following chronic
tonsillitis
• Tuberculous jugulodgastric lymphadenitis: Tonsillectomy can be
done under cover of ATT.
• Chronic otitis media: Due to enlarged tonsils empinging upon the
Eustachian tube.

6. R E L A T I V E I N D I C A T I O N S
• Chronic pharyngitis and laryngitis, Glomerulonephritis, Chronic
bronchitis, if it follows after acute tonsillitis.
• Rheumatic arthritis.
• Stunted growth or weak built.
• Dermatological conditions where the tonsils are thought to be a
septic focus.

7. R E L A T I V E I N D I C A T I O N S
As a part of another operation
• Removal of styloid process.
• Glossopharyngeal neurectomy.
• Uvulopalatopharyngoplasty.
• Branchial fistula: It is done in branchial fistula to remove the
complete tract one end of the tract being in posterior faucial pillar.

8. C O N T R A I N D I C A T I O N S
• Haemoglobin levels < 10gm%
• Acute Tonsillitis
• Children under 3 yrs of age
• Overt or Submucous Cleft Palate
• Bleeding disorders
• At the time of Polio Epidemic
• Aneurysm or abnormal vasculature of tonsil
• Uncontrolled systemic disease e.g., diabetes,cardiac
disease,hypertension or Asthma
• Tonsillectomy is avoided during the period of
menses
• Normal tonsils

9. R E A S O N F O R C O N T R A I N D I C A T I O N I N
P O L I O E P I D E M I C
• Polio viruses get concentrated in tonsils and other
Lymphoid tissues during an epidemic even in Normal
persons.
• Tonsillectomy in this situation can trigger off Bulbar
involvement causing paralytic polio due to entry of virus
into the blood stream.

10. D I F F E R E N T M E T H O D S O F T O N S I L L E C T O M Y
• DISSECTION AND SNARE METHOD(Most commonly
performed)
• GUILLOTINE METHOD
• CRYOSURGICAL TECHNIQUE
• INTRACAPSULAR TONSILLECTOMY BY MICRODEBRIDER
• HARMONIC SCALPEL OR ULTRASONIC SCALPEL
TONSILLECTOMY
• LASER TONSILLECTOMY
• ELECTROCAUTERY TONILLECTOMY
• TONSILLECTOMY WITH RADIOFREQUENCY (RF)
• COBLATION METHOD

11. D I F F E R E N T M E T H O D S O F T O N S I L L E C T O M Y
COLD METHODS HOT METHODS
• DISSECTION AND SNARE
METHOD(Most commonly
performed)
• GUILLOTINE METHOD
• CRYOSURGICAL TECHNIQUE
• INTRACAPSULAR
TONSILLECTOMY BY
MICRODEBRIDER
• HARMONIC SCALPEL OR
ULTRASONIC SCALPEL
TONSILLECTOMY
• LASER TONSILLECTOMY
• ELECTROCAUTERY
TONSILLECTOMY
• TONSILLECTOMY WITH
RADIOFREQUENCY (RF)
• COBLATION METHOD

12. D I S S E C T I O N A N D S N A R E M E T H O D
Most commonly performed
( You can see the surgical video in our
channel’s Conventional Tonsillectomy by
dissection and snare method )

13. G U I L L O T I N E M E T H O D

14. G U I L L O T I N E M E T H O D

15. The guillotine was held in the right hand
and inserted from the right side of the
mouth when removing the left tonsil.
The lower pole and the posterior border
of the tonsil were engaged in the
fenestra of the guillotine to draw the
tonsil forward.
G U I L L O T I N E M E T H O D

16. C R Y O S U R G I C A L T E C H N I Q U E
Tonsil is frozen by application of CryoProbe and then allowed to Thaw.
Two applications each of 3-4 min are applied .Tonsillar tissue will under go
necrosis and later fall off leaving a granulating surface.
Bleeding is less due to thrombosis of vessels caused by freezing.This method
is useful in patients with Bleeding disorders.
-82 degree centigrade caused by Carbondioxide
-196 degree centigrade caused by liquid nitrogen

17. I N T R A C A P S U L A R T O N S I L L E C T O M Y B Y M I C R O D E B R I D E R
This technique has an advantage over
conventional tonsillectomy of leaving a
biological dressing or residual tonsillar
tissue and capsule to protect the
underlying musculature with its vessels
and nerves
The surgeon uses the microdebrider to precisely
remove greater than 95 percent of the tonsils, leaving a
thin layer of connective tissue intact to protect the
throat muscles, which helps reduce postoperative pain
and recovery time.

18. H A R M O N I C S C A L P E L O R U L T R A S O N I C S C A L P E L
T O N S I L L E C T O M Y
The harmonic scalpel is a device that uses
ultrasonic energy to cut tissue and coagulate
tissue at temperatures lower than those
associated with electrocautery and lasers.
Uses hot ultrasonic energy to vibrate a
special blade.The blade cuts the tonsil
tissue and stops bleeding.

19. L A S E R T O N S I L L E C T O M Y
There are various types of lasers have been used in tonsillectomy procedure
like CO2, KTP, NDYAG, and diode.
The advantages of the diode laser are good thermal effect on the perifocal
tissues with shallow depth of penetration, thus carries few side effects to the
deep tissues.

20. E L E C T R O C A U T E R Y T O N I L L E C T O M Y
This method uses heat to remove the tonsils and stop any
bleeding.
Monopolar and Bipolar cautery probes can be used for the surgery.

21. T O N S I L L E C T O M Y W I T H R A D I O F R E Q U E N C Y ( R F )
Bipolar radiofrequency is an effective and safe
technique in total tonsillectomy with acceptable intra-
operative and post-operative results regarding pain
and bleeding and can be used in pediatric population
with no major morbidities.

22. C O B L A T I O N M E T H O D
Coblation (a word derived from "controlled ablation" involves using low-
temperature radiofrequency and a saline solution to gently and precisely
remove the problematic tissues. The risk of injury to surrounding tissue is
much lower than with cautery, and patients return to their normal activities
more quickly.
For video of coblation
tonsillectomy refer
earlier videos in our
channel

23. A N A E S T H E S I A
Usually done under general anaesthesia with endotracheal
intubation. (TransNasal or Trans Oral)
In adults, it may be done under local anaesthesia.

24. P O S I T I O N O F T H E P A T I E N T
Rose’s Position
Patient lies supine with head extended by
placing a pillow under the shoulders.
A rubber ring is placed under the head to
stabilize it.
Hyperextension should always be avoided.

25. S T E P S O F S U R G E R Y
• Boyle-Davis mouth gag is
introduced and opened. It is held
in place by Drafffin Bipod Stand.
• Tonsil is grasped with tonsil-
holding forceps and pulled
medially .
Surgical video can be watched in our channel’s earlier videos-
Conventional Tonsillectomy

26. • 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.
• The tonsil is dissected from its bed with the help
of tonsillar dissector.
• Once the tonsil is attached only at its lower pole,
tonsillar snare is used to crush and cut the pedicle
before removing the tonsil.

27. • A Cotton ball soaked with H2O2 is placed in the tonsillar fossa and pressure
applied for few minutes.
• Bleeding points are cauterized or tied with silk.
• Procedure is repeated on the other side.

28. P O S T O P E R A T I V E C A R E
• Following surgery, the patient is kept in tonsillar position, where head is
kept low and the patient lies in lateral position to prevent aspiration of
blood.
• Nil orally for 6 hours.

29. P O S T O P E R A T I V E C A R E
• Strict watch over the temperature, pulse and respiration every
hour for first 4-5 hours. A rising pulse is a Sign of haemorrhage.
• Swallowing movements over anterior part of neck indicate that
the blood is being swallowed.
• Broad spectrum antibiotics are given for 5-7 days.
• Analgesics.
• Diluted Hydrogen Peroxide/AntiSeptic Mouth gargles for next
10-15 days.

30. W H Y H 2 O 2 I S U S E D P E R O P E R A T I V E L Y A N D
F O R G A R G L I N G P O S T O P E R A T I V E L Y
• It is used as an oxidizer, bleaching agent and antiseptic. It is an unstable
compound. It releases the nascent oxygen.
• Local application of 3% hydrogen peroxide on the tonsillar bed after
tonsillectomy is beneficial as it decreases the procedure time and the volume
of blood loss as well as number of ties used.
• Gargling with hydrogen peroxide helps soothe a sore throat. The antibacterial
properties of hydrogen peroxide kill the bacteria that can cause sore throats.
• The bubbling action creates a foam – caused by the release of oxygen – This
foam can help loosen mucus and makes the mucus less sticky and easier to
drain.
• 20ml of hydrogen peroxide gargle which should be diluted with water in a
ratio of 1:6. this gargle should be used every 4 hours

31. I M M E D I A T E C O M P L I C A T I O N S
• Primary Hemorrhage
• Reactionary Hemorrhage
• Injury to Oral cavity and Oropharyngeal Structures
(Tonsillar Pillars,Uvula,Soft Palate,Tongue,Superior and inferior constrictor muscle and teeth)
• Aspiration
(of Blood,Tonsil tissue and tooth)
• Pulmonary edema
(in case of OSA and Corpulmonale)
• Edema of Tongue ,Nasopharynx and Palate
• Edema of face and eyelids
• Surgical Emphysema
(due to Superior Constrictor muscle injury)

32. P R I M A R Y H E M O R R H A G E
Bleeding during the operation is usually controlled by
pressure, ligation or electro-coagulation.
Application of tannic acid, bismuth subgallate or hemostatic
agents (Ethamsylate,Tranexamic Acid Intravenously,
BOTROCLOT Drops, H202 Soaked cotton balls for local
application ) may be helpful.
Coagulopathy must be ruled out.

33. R E A C T I O N A R Y H E M O R R H A G E
Bleeding after the recovery from anesthesia on the day of surgery is usually
controlled by removing the clot, applying pressure or vasoconstrictor.
Clot may prevent the clipping action of the superior constrictor muscle on
the vessels.
Immediate postoperative bleeding from nose and mouth or vomiting of dark
colored blood and rising pulse rate indicate bleeding from the operative
site.
In cases of refractory bleeding, patient is taken back to operation room and
ligation or electrocoagulation of the bleeding vessels is done under general
anesthesia.

34. D E L A Y E D C O M P L I C A T I O N S
• Secondary hemorrhage
• Infection
(may cause Parapharyngeal abscess)
• Pulmonary complications
(Aspiration of blood,mucus or tissue fragments may lead to atelectasis or lung
abscess )
• Scarring
( of soft palate and pillars)
• Hypertrophy of lingual tonsil
(compensatory to the loss of palatine tonsils)
• Tonsillar remnants
• Hypertrophy of remnant tonsil
( If plica triangularis near the lower pole of tonsil is not removed along with tonsil,
it may get hypertrophied)

35. S E C O N D A R Y H E M O R R H A G E
Bleeding seen between 5th-10th postoperative days is the result of sepsis and
premature separation of the membrane.
Clinical features: The common presentation is blood-stained sputum but
bleeding may be profuse.
Management: If bleeding 1s not controlled after removal of clot and topical
application of dilute adrenaline, hydrogen peroxide and with pressure,then
patientistaken to operation room.
• Under general anesthesia, bleeding vessel is electrocoagulated or ligated.
• Approximation of pillars with mattress sutures or external carotid ligation
may be required in rare cases.
• Transfusion of blood or plasma may be needed.
• Systemic antibiotics control the infection.

36. D E A R S T U D E N T S
In this short time, i may not cover all the topics but tried to cover most of
the relavant things.But this is not a replacememt for standard text books
and classical clinical teaching.
But this will certainly facilitate your exam preparation and for better
understanding of the subject.This is just a recap of what you have learnt.
Hope this is useful for you.
Thanks for Watching.
You can watch videos of Conventional Tonsillectomy and Coblation
Tonsillectomy in our channel’s earlier videos for better understanding of
Surgical Procedure.

37. O P E R A T I V E P R O C E D U R E S
S E R I E S
TONSILLECTOMY
-INDICATIONS
-CONTRAINDICATIONS
-METHODS
-SURGICAL STEPS
-COMPLICATIONS
Dr.S.Kalyan Kumar MS ENT
Gold Medalist
KK’s
ENT
TUTORIALS

38. Thanks for
watching
This powerpoint is in video format in our You tube channel.
Please Like - Share -Subscribe for more videos like this
KK’s
ENT
TUTORIALS
O P E R A T I V E P R O C E D U R E S
S E R I E S