In this presentation, we can learn about acute and chronic tonsillitis and its management. And the surgical steps of Tonsillectomy.

1. ACUTE AND CHRONIC
TONSILLIITIS
Dr. S. Prem Davis
Department of ENT
SVMCH & RC
Puducherry

2. OVERVIEW
• Introduction
• Histology of palatine Tonsils
• Functions and Immunology of Palatine Tonsils
• Acute Tonsillitis
• Chronic Tonsillitis
• Tonsillectomy
• Various Tonsillectomy Methods
• Complications of Tonsillectomy

3. INTRODUCTION
• The palatine tonsils are dense compact
bodies of lymphoid tissue that are
located in the lateral wall of the
oropharynx.
• The palatine tonsil represent the largest
accumulation of lymphoid tissue in
Waldeyer's ring.

4. UNIQUENESS OF TONSIL
• Unlike spleen and Lymph node – not
fully encapsulated
• Don’t have afferent lymphatics
• Lymphoepithelial organs
• Presence of crypts

5. TONSILS
• Non keratinised stratified squamous epithelium
• Crypts – 295 cm2
• 4 lymphoid compartments
• Crypt epithelium
• Extrafollicular areas
• Mantle zone of lymphoid follicle
• Germinal centre of lymphoid follicle

7. PHYSIOLOGY AND IMMUNOLOGY
• Tonsil acts as a sentinel to guard against foreign introducers by two
• mechanism;
• Providing local immunity
• Providing surveillance mechanism
• Tonsils- predominantly B-cell organs;
• B cells - 50% to 65%
• T cells - 40%,
• Mature plasma cells – 3 %.
• Conversely, 70% of the lymphocytes in peripheral blood are T cells.

8. • Tonsils are particularly designed for direct transport of
foreign material from the exterior to the lymphoid
cells.
• Intra tonsillar defense mechanisms eliminate weak
antigenic signals.
• Low antigen doses effect the differentiation of
lymphocytes to plasma cells, whereas high antigen
doses produce B-cell proliferation.
• The tonsil produces antibodies (IgG, IgA, IgM )locally, as well as B cell which migrate to other sites
around the pharynx and peri glandular lymphoid tissues to produce antibodies.

9. DISEASED STATE
Inflammation of the reticular crypt epithelium results in shedding of
immunologically active cells
Decreasing antigen transport function with subsequent replacement
by stratified squamous epithelium.
Reduced activation of the local B-cell system
Decreased antibody production
Overall reduction in density of the B-cell and germinal centers in
extrafollicular areas.

10. • The size of the tonsil varies according to the age,
individuality, and pathologic status.
• Actual size of the tonsil is bigger than the one
that appears from its surface .
• At the fifth or sixth year of life, the tonsils rapidly
increase in size, reaching their maximum size at
puberty.
• At puberty, the tonsils measure 20-25 mm in
vertical and 10-15 mm in transverse diameters

11. ANATOMY OF PALATINE TONSILS
• Palatine tonsils are two in number and ovoid
in shape.
• Situated in Tonsillar fossa in lateral wall of
oropharynx.
• Tonsillar fossa - composed of three muscles.
• Palatoglossus muscle - anterior pillar.
• Palatopharyngeal muscle - posterior pillar
• Superior constrictor muscle – laterally – forms
larger part of the tonsillar bed.

12. • Tonsil has -
• Two surfaces- a medial and a lateral
• Two poles - an upper and a lower.
• Medial Surface
• Covered by non-keratinising stratified squamous
epithelium
• Epithelium dips in tonsil stroma to form crypts
• 12-15 crypts
• Crypta magna –a/k/a intratonsillar cleft, represents the
ventral part of second pharyngeal pouch.
• From the main crypts arise the secondary crypts.

13. UPPER POLE
• Extends into soft palate.
• Supratonsillar fossa – potential space
enclosed in a semilunar fold, extending
• between anterior and posterior pillars.
• Weber's glands are tubular mucous glands
located at superior pole of the tonsil. The
glands send a common duct to the tonsil and
secrete saliva on to the surface of the tonsillar
crypts.

14. LOWER POLE
• Attached to the tongue.
• A triangular fold of mucous
membrane extends from
anterior pillar to the
anteroinferior part of tonsil.
• Anterior tonsillar space – Space
enclosed by Triangular fold of
mucous membrane.

15. ACUTE TONSILLITIS
• Acute inflammation of the
faucial tonsils which may
involve the mucosa, crypts,
follicles and or tonsillar
parenchyma
• Children and also frequently in
adults

16. Aetiology
• Most commonly – Primary infection of the Tonsil
Or
• Occurs secondary to the infection of the Upper Respiratory tract
following Viral Infection

17. NORMAL FLORA OF ORAL CAVITY

18. Viral Causes
• Adenovirus
• Herpes simplex
• Influenza/parainfluenza
• EBV
• Measles
• CMV

19. Bacterial
• Streptococcus Pyogenes (Group A beta hemolytic)
• Streptococcus pneumoniae
• Streptococcus viridans
• Haemophilus influenza (esp in children)
• Moraxella catarrhalis
• Staphylococcus aureus

20. Other / Rare Causes
• Corynebacterium diphtheriae
• Mycoplasma
• Chlamydiae pnemoniae

21. PATHOGENESIS & PATHOLOGY
• Children of school-going age more exposed
• Maternal antibodies begin to drop – More prone for Infection

22. PATHOLOGICAL TYPES
1. Acute catarrhal or superficial tonsillitis
2. Acute follicular tonsillitis
3. Acute parenchymal tonsillitis
4. Acute membranous tonsillitis

23. ACUTE CATARRHAL OR SUPERFICIAL TONSILLITIS
• Viral etiology
• Tonsils are inflamed as a result of
generalised infection of
oropharyngeal mucosa
• Difficult to differentiate from
general pharyngitis

24. ACUTE FOLLICULAR TONSILLITIS
• Severe form, Adults
• Caused by Bacterial Organism – Strep.
haemolyticus, H. influenza
• Inflammation spreads from surface
mucosa into crypts esp. crypta magna
• And also from Crypt to surrounding
follicles
• White yellowish spots on inflamed
tonsils

25. ACUTE MEMBRANOUS TONSILLITIS
• Follicular tonsillitis -
Follicles(exudates) from crypts
unite(coalesce) to form
yellowish white
patch(membrane) over tonsil
• DD – Membrane Over the
Tonsils

26. ACUTE PARENCHYMAL TONSILLITIS
• Characterised by uniform Enlargement of Tonsils
Tonsillar parenchyma is loosely arranged with
inadequate septa
Viral infection – Low immune status
Allows for secondary bacterial infection
Invade the crypts and rapidly spread to
parenchyma

27. SYMPTOMS

28. OTHER SYMPTOMS

29. SIGNS
• Breath is foetid and tongue is coasted
• Hyperemia of pillars, soft palate and
uvula
• Tonsils – red swollen with yellowish
spots of purulent material / whitish
membrane / enlarged tonsils, congested
meet at midline
• Tender Jugulodigastric Lymph Node

30. LYMPHATIC OF TONSILS
• Upper deep cervical lymph nodes,
especially the jugulodigastric or tonsillar
node.
• JD lymph nodes belong to
Anterosuperior group of Level II LN
• Bounded by;
• IJV
• Facial Vein
• Posterior belly of Digastric
• Other areas draining into JD LN –
• Submandibular gland
• oropharynx

31. INVESTIGATIONS
• Throat Swab
• Routine investigations
• Hb%, TC, DC, Peripheral smear
• X-ray Nasopharynx- R/O Adenoid enlargement

32. ANTIBIOTIC RESISTANCE PATTERN

35. TREATMENT
• 1. Bed Rest
• 2. Plenty of Oral Fluids
• 3. Soft Diet
• 4. IV fluids if necessary
• 5. Warm Salt water gargling
• 6. Paracetamol – 15 mg/kg/dose

36. ANTIMICROBIAL
THERAPHY

37. SPECIFIC ANTIMICROBIAL THERAPY
• Parenteral
• 1. Benzathine Penicillin (ATD)
Adult – 1.2 Million Units IM one Dose
Children – 25,000 Units /kg IM to max of 1.2 Million units One Dose
• 2.INJ Amoxycillin + Clavulanate
Adult – 1.2 gm 8th hrly
Children – 40mg/kg/day every 8th hrly

38. OTHERS PARENTERAL
• INJ CEFTRIAXONE + CLINDAMYCIN
• INJ CEFUROXIME + CLINDAMYCIN
CEFTRIAXONE CLINDAMYCIN
ADULT 1 gm 12 Hrly or 2gm OD 600 mg/ day 6th hrly
CHILDREN 50-75 mg/kg daily in single
or 12th hrly dose
10-20 mg/kg/day 6th hrly
CEFUROXIME CLINDAMYCIN
ADULT 750MG-1/5 GM 8TH hrly 600 mg/ day 6th hrly
CHILDREN 50-75 mg/kg daily 8th hrly 10-20 mg/kg/day 6th hrly

39. ORAL ANTIBIOTICS
Antibiotics Adult Children
Amoxycillin 500 mg tds 30-40 mg/kg/ day every 8th hrly
Amox + Clavulanate 1 gm bd 40 mg/kg/day every 8th hrly
Erythromycin 250 or 500 mg TID 30-60mg/kg/day

42. MENDL’S PAINT
• CONSTITUENTS
• 1. Iodine – 1.25 gm - Antiseptic
• 2. Potassium Iodide – 2.5 Gm -
• 3. Distilled Water – 2.5 ml - Solvent
• 4. Peppermint Oil – 0.6 ml –
Flavouring Agent
• 5. Glycerin – 10 ml
• Apply over twice daily for 3 days

43. DD for Membrane over the Tonsil
• “ALL VITAMIN D”
• A – Agranulocytosis
• L – Leukemia
• V – Vincent Angina
• I – Infectious Mononucleosis
• T – Trauma
• A- Aphthous Ulcer
• M- Moniliasis
• I – Infection of Throat
• N – Neoplasia
• D- Diphtheria

44. OTHER CAUSES
• Viral:
• IMN, Herpes simplex, HIV
• Bacterial:
• Membranous tonsillitis
• Faucial diphtheria
• Vincent’s angina
• Keratosis of the tonsil
• Secondary syphilis
• Tuberculous tonsillitis
• Others:
• Aphthous ulcers

45. • Fungal:
• Candidiasis
• Trauma:
• Mechanical traumatic ulcers
• Post-tonsillectomy slough
• Corrosive poisoning
• Thermal /radiation injuries
• Pre-malignant lesions:
• Leukoplakia
• Submucous fibrosis
• Tumor/ tumor-like conditions:
– Malignancy
– Tonsillolith /tonsillar cyst
– Papilloma / fibroma
• Systemic causes:
– Leukemia
– Agranulocytosis
– Blood dyscrasias/ aplastic anemia
• Autoimmune:
– Lichen planus, WG

46. COMPLICATIONS
• 1. Chronic Tonsillitis
• 2. Peritonsillar Abscess
• 3.Retropharyngeal Abscess
• 4. Para pharyngeal abscess
• 5. Internal Jugual Vein
Thrombosis
• 6. Ascending Infection – AOM
• 7. Acute Glomerulonephritis
• 8. Rheumatic Fever
• 9. Bronchitis
• 10. Acute Exacerbation of
Bronchial Asthma
• 11. Septicaemia
• 12. Subacute Bacterial
Endocarditis

47. CHRONIC TONSILLITIS
• Chronic Inflammation of the
Palantine Tonsils

48. ETIOPATHOGENESIS
• M/C Agent – Beta-hemolytic streptococcus
• Children and Young Adults
• Repeated attacks of acute tonsillitis
• Inadequately resolved acute tonsillitis
• Subclinical infections of tonsils without an acute attack
• Chronic infection in sinuses, oral cavity and teeth.

49. CLINICO PATHOLOGICAL TYPES
1. Chronic follicular tonsillitis
2. Chronic parenchymatous tonsillitis
3. Chronic fibrotic tonsillitis

50. CHRONIC FOLLICULAR TONSILLITIS
• Tonsillar crypts are full of infected cheesy material
• Adults
• Due to repeated attacks of acute tonsillitis
• Recurrent acute inflammations - Inadequate clearance of exudates
• Pressure over tonsillar substance extrudes more debris.
• Tonsils may be enlarged to variable extent.

51. CHRONIC PARENCHYMATOUS TONSILLITIS
Following repeated attacks of Acute Tonsillitis
Lymphoid follicles in the tonsillar parenchyma –
Hypertrophy
Uniform enlargement of the tonsil
Causing food and air way obstruction

52. Patients also have adenoid hypertrophy
Causing snoring and sleep apnoea
• Interfere with speech, deglutition and respiration

53. CHRONIC FIBROTIC TONSILLITIS
• Repeated inflammations atrophy during healing process
• More Fibrotic tissue than the normal parenchyma
• Diagnosis
• Anterior pillars are congested
• Tonsillar size??
• Jugulo-digastric lymphadenopathy is the diagnostic feature for
diagnosis in these patients

54. Symptoms
• Recurrent Attacks of Sore Throat – 3 to 4 times /
year
• Cough – due to chronic irritation
• Hawking sensation or frequent clearing actions of
throat
• Dysphagia
• Halitosis
• Bad taste in mouth – due to pus in crypts
• Thick speech
• Acute excerbations

55. FOUR CARDINAL SIGNS
• Persistent Congestion of anterior pillar
• Ervin-Moore sign – Positive
• Enlarged non-tender Jugulodigastric nodes
• Tonsils - Varying Degree of Enlargement

56. CAUSES FOR U/L TONSILLAR ENLARGEMENT
• Inflammatory
• Acute
• Peri tonsillitis
• Peritonsillar abscess
• Intra tonsillar abscess
• Parapharyngeal abscess
• Chronic
• Tuberculosis of tonsil
• Granulomatous conditions

57. • Trauma
• Surgical trauma
• Hematoma
• Foreign body in the tonsil
• Tumour and tumour like conditions
• Papilloma
• Fibroma
• Tonsillolith
• Tonsillar cyst
• Parapharyngeal Tumours
• Aneurysms of ICA
• NHL
• Kaposi Sarcoma
• Squamous cell carcinoma

58. Grading of Tonsillar Enlargement
• Friedman Grading
Scale
• Brodsky grading scale

59. COMPLICATIONS
1. Peritonsillar abscess
2. Parapharyngeal abscess
3. Intratonsillar abscess
4. Tonsillolith
5. Tonsillar cyst
6. Obstructive sleep apnea
7. Cor pulmonale
8. Focus of infection>>eye, skin, lungs, prosthetic materials
9. AGN, RHD

60. INVESTIGATIONS
• CBC
• Coagulation profile
• Blood grouping/typing
• ASO titers
• Throat swab for C/S
• Renal and Cardia functions if Rheumatic disease is suspected
• X ray nasopharynx lateral view

61. TREATMENT
• Conservative
1. General health (nutrition, hygiene)
2. Co-existing septic focus in Head/Neck: caries tooth, recurrent
rhinitis/sinusitis, nasopharyngitis, allergic rhinitis
3. Treatment of acute episodes
• Surgical
Tonsillectomy

62. LATERAL SURFACE
• Presents a well-defined fibrous capsule.
• The tonsillar capsule is a specialized
portion of the Pharyngobasilar fascia
• TONSILAR BED
• 1. Loose areolar tissue with Paratonsillar vein
• 2. Pharyngobasilar fascia
• 3. Superior constrictor muscle
• 4. Buccopharyngeal fascia
• 5. Styloglossus
• 6. Glossopharyngeal nerve
• 7. facial artery
• 8. Medial pterygoid muscle
• 9. Angle of mandible
• 10. Submandibular salivary gland

63. IMPORTANCE OF TONSILAR BED
• Capsule - Because of the septa, tonsil is not easily separated from its capsule.
• Loose areolar tissue - One can easily dissect the tonsil by separating the capsule from
the muscle through this loose connective tissue.
• Glossopharyngeal nerve –
• This nerve can be easily injured if the tonsillar bed is violated
• Commonly affected temporarily by edema after tonsillectomy, which produces both a
transitory loss of taste over the posterior third of the tongue and referred otalgia.
• Can be addressed surgically through tonsillar bed for its neuralgia.
• Styloid process -
• Can be addressed surgically through tonsillar bed for Eagle syndrome.

64. ARTERIAL SUPPLY OF TONSILS
• The arterial blood supply of the tonsil enters
primarily at the lower pole, with branches also at
the upper pole.
• At the lower pole:
• Tonsillar branch of the facial artery
• Tonsillar branch of the dorsal lingual artery
Anteriorly
• Ascending palatine artery (a branch of the facial
artery) posteriorly
• At the upper pole:
• Ascending pharyngeal artery enters posteriorly
• Lesser palatine artery enters on the anterior
surface.

65. NERVE SUPPLY
• Tonsillar branches of the
glossopharyngeal nerve about
the lower pole of the tonsil
• Descending branches of the
lesser palatine nerves, which
course through the
pterygopalatine ganglion.

66. TONSILLECTOMY - 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 1 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 1 year.

67. 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 which causes febrile seizures.
4. Hypertrophy of tonsils causing
• (a) airway obstruction (sleep apnoea),
• (b) difficulty in deglutition and
• (c) interference with speech.
5. Suspicion of malignancy. A unilaterally enlarged tonsil may be a lymphoma
in children and an epidermoid carcinoma in adults.

68. 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.

69. Tonsillectomy in non-inflammatory conditions
/ normal tonsils / as a part of other surgeries
1. Styloid process resection in elongated styloid process
2. Resection of ossified stylohyoid ligament
3. Glossopharyngeal neurectomy
4. As a part of Uvulo-palato-pharyngo-plasty (UPPP)

70. PARADISE CRITERIA

71. • Documentation :
• Each episode and its qualifying features had been substantiated by
contemporaneous notation in a clinical record
Or
• If not fully documented, subsequent observance by the clinicians of 2
episode of throat infection with patterns of frequency and clinical
features consistent with the initial history

72. CONTRAINDICATIONS
• 1. Haemoglobin Less than 10 gm%
• 2. Presence of Acute infection – Acute Tonsillitis, Upper Respiratory
Tract Infection (2-3 Weeks)
• 3. Children less than 3 years of age
• More than average amount of Blood Loss – Haemodynamic instability
• Compensatory hypertrophy of other lymphoid tissues
• Peak Action of Defence Function
• 4. Bleeding disorders – Leukaemia, Purpuras, Aplastic Anaemia,
Haemophilia
• 5. uncontrolled Diabetes, Heart diseases, Hypertension

73. BLOOD LOSS ESTIMATION (15 Kg)
CLASS I CLASS II CLASS III CLASS IV
Blood Loss (%) Upto 15% 15 – 30% 30 – 40% >40%
80 ml / kg =
80 x 15 = 1200
ml
Blood Loss (ml) 180 ml 180-360 360-480 >480
Pulse Rate <100 100-120 120-140 >140
Systolic Blood
Pressure
Normal Normal Decreased Decreased
Children – BLOOD LOSS – 80 ml/ kg
Adults – BLOOD LOSS – 65-75 ml / kg

74. Pre –Op Workup
• Careful History and Clinical Examination
• Bleeding Disorders, Previous surgeries
• Investigations
• HB, TC,DC, Platelet
• BT,CT, PT,APTT
• Blood Grouping
• Urine Routine Examination
• HIV, HbSAg
• Chest X ray
• X Ray Nasopharynx
• Down Syndrome child – Neck Xray – c1 c2 subluxation

75. • Poliomyelitis Epidemic – 6 weeks delay
• Overt or submucous cleft palate
• Medications to be stopped:
• Aspirin – 2 weeks Before
• NASAIDS- 2 days before
• Preoperative Consideration
• Consent : Loose tooth- Consent for Removal is advised
• Patient kept NPO for 8 hours before surgery
• Prophylactic IV Antibiotics

76. • Anaesthesia
• General Anaesthesia with endotracheal Intubation
Position:
Rose Position: Patient lies supine with head extended by placing a
pillow under the shoulder. A Rubber ring is placed under the head to
stabilise it.

77. Advantages of Rose Position
• Larynx lie at a higher level than the oral cavity – No risk of aspiration
• Excellent exposure
• Both the hands of the surgeons are free
• Hyperextension should be avoided
• Makes cervical vertebral bodies prominent – Damage to ligaments or
cartilages of Vertebral spine or Bodies – Grisel’s Syndrome
• Grisel’s Syndrome – Atlanto axial subluxation

78. TONSILLECTOMY (DISSECTION & SNARE)

79. INSTRUMENTS NEEDED FOR TONSILLECTOMY

80. STEPS OF SURGERY
• 1. Patient is placed in Rose’s Position
• 2. Check for any loose teeth and if any
use gauze for protection of teeth

81. • 3. Boyle Davis Mouth gag is engaged to
open the mouth & retract the tongue.
• Tongue blade – should be able to retract the
base of tongue
• Shouldn’t Injure Post. Pharyngeal Wall
• The split Blade hold the ET Tube and the
tongue in midline
• The Gag is suspended with Draffin’s bipod
and with Magauren plate

82. • 4. Throat packed with Wet roller gauze
• Prevent Aspiration
• Avoid Dry Gauze
• 5. Tonsil is caught at the upper pole by Dennis
Browne tonsil holding forceps & pulled medially
• Tonsil is grasped and moved back & froth to identify the
border b/w Tonsil and Anterior Tonsillar Pillar
• 6. Incision is made at the mucosa b/w anterior pillar
and tonsil at the upper pole with Waugh’s forceps
and carried till the base of the anterior pillars.

83. • 7. Tonsil is held medially by tonsil holding forceps and blunt
dissection with Mollison tonsillar dissector
• Separates the upper pole of the tonsil with the capsule from the
loose areolar tissue and from Ant and Post. Pillars.
• Plane of Dissection
• Easy dissection
• White glistening colour
• Minimal Bleeding
• With Medical traction, tonsil is separated with its capsule
from the loose areolar tissue.

84. • While dissecting –
• Dissect away from the tonsil with mollison tonsillar dissector
• Tonsil should be bluntly dissected from peritonsillar tissue
• Scar Adhesions – Sharply dissection
• The dissection is continued to lower pole
• 8. Eve’s Tonsillar snare is passed around the pedicle and
snared off. Tonsils gets separated

85. • 9. Tonsillar Fossa is packed with gauze soaked with
Hydrogen Peroxide for few minutes to stop oozing
• In case or prominent bleeding points, they caught
ligated
• 11. The bleeding Vessel is grasped with the tip of
the long slender Birkett’s straight First artery
forceps.
• Followed by Negus curved second artery forceps
under the tip of the first artery and straight forceps
is removed.

86. • 12. 2-0 Linen or Silk is placed under the curved clamp using
a Negus knot pusher.
• 13. Tonsillar fossa – Packed with Gauze soaked in H2O2
• 14. Repat the same procedure on Other side
• 15. After Haemostasis is achieved, Post nasal space,
pharynx, larynx should be cleared off from blood.
• 16. Release Boyle’s Davis Mouth gag, Check again the lower
pole for any bleed.
• 17. Remove throat pack, total count of swabs should be
checked before and after the procedure.

87. POST OP ADVICE
• NPO till 4 hours / full recovery from anaesthesia
• Head low and Left Lateral Position
• Monitor Vitals
• Inj. DEXAMETHASONE Intraoperative and 6 hours after surgery
• Anti inflammatory, antipyretic, antiemetic, mood elevator
• Inj. ONDANSETRON single dose intraoperatively
• Paracetamol sos

88. POST OP DIET
• First Day : Start with ice cold water followed by ice cream
• Jelly, pudding, yorgut, banana
• Second day to 1 week – Same as first day + milk, honey, smashed rice
with mashed vegetables, grapes
• Second Week – Normal Diet
• Things to be avoided:
• Hot, spicy food, cola and pepsi beverages
• Physical exertion

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

90. DIATHERMY / ELECTROCAUTERY TONSILLECTOMY
• One of the most common technique
• Electrocautery tip – standard electrocautery tip –
20 W, Micro dissection needle – 6 W
• Technique –
• Anterior Pillar
• Dissection from superior to inferior
• Haemostasis – packing/cautery / absorbable ties

91. MICRODEBRIDER TONSILLECTOMY
• Microdebrider
• Intracapsular method
• Powered rotatory shaving device with
continuous suction
• Partial tonsillectomy is completed with 90 to
95% tonsils
• Capsule is preserved.

92. COBALATION TONSILLECTOMY
• Means “cold” and “removal”
• Controlled ablation
• Unique method of rapid and controlled
removal of tissues at lower temperature
• extra and intracapsular tonsillectomy
• Uses radio frequency in bipolar mode
with a conductive solution (saline)
• This field created high energy particles
like ionized vapour layers OH, H, Na free
radicals and electron.

93. • Enough to break the tissues molecular bonds, creating
ablative path.
• The heat generated varies from 40 - 80 degrees
centigrade, much lower than that of electro cautery.
• Results in volumetric removal of target tissue with
minimal damage to surrounding tissue.
• The major advantage of this procedure is reduced
bleeding and reduced post operative pain.

94. LASER TONSILLECTOMY
• Laser tonsillectomy. It is indicated in coagulation disorders.
• CO2 laser – 10.6 Micrometre
• M/C applied in oral and laryngeal practice.
• Laser output – continuous or pulsed laser. Laser operates with a continuous
output for longer or less than 0.1 sec
• Laser in living tissue – Photoablation, Photochemical, photomechanical and
Photothermal reaction.
• Tissue effect can be cutting, coagulation or vaporisation.

95. 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 over 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.

96. HARMONIC SCALPEL

97. 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

98. 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

100. RADIOFREQUENCY ABLATION
• Similar to Coblation
• Literature
• Using radiofrequency technique to perform partial tonsillar ablation or tonsil
reduction in children with tonsil hypertrophy.
• Temperature controlled radiofrequency technique operates by heating the target
tissue through an electrode placed submucosally.
• Radiofrequency generator regulates energy flow to form a precise lesion which
gradually reabsorbed by the body.
• Thus shrinking tissue volume while leaving underlying mucosa intact.

101. GUILLOTINE TONSILLECTOMY

102. 35 years (1979- 2013)- 2500 patients

103. Surgical Techniques

104. PER OPERATIVE BLEEDING

105. COMPLICATIONS

106. POST OPERATIVE PAIN

107. RETURN TO NORMAL ACTIVITY

108. COMPLICATIONS
• 1. Primary Haemorrhage
• Occurs at the time of operation
• Causes:
• 1. Improper Pre op Preparation
• Acute tonsillitis
• Quinsy
• Bleeding tendency
• 2. Massive fibrosis in tonsillar fossa
• 3. Bad Plane to dissection
• 4. A larger tonsillar branch of facial artery
• 5. Section of Paratonsillar vein
• Rarely – Aberrant internal carotid artery

109. • Management :
• Managed with packing, pressure, electrocautery, slipknot
• External carotid artery ligation – If above methods fails
• Surgical Trauma
• Trauma to lips, tongue, tonsillar pillars, posterior pharyngeal wall
• Burn injury to tongue – due to usage of cautery
• Management:
• Proper Placement of Mouth gag
• Tooth is missing – Chest x Ray - Bronchoscopy
• Aspiration – due to uncuffed ET tube
• Prevented by – Rose Position, Placement of throat packs
• After surgery- surgical sites and nasopharynx is properly irrigated with saline
to remove clots and tissues

110. • Airway Compromise – Occur Intraoperatively
• Malposition / kinking of ET tube
• Inhaled Foreign body like blood clot
• Pulmonary edema
• Treatment – Diuretics, continuous positive airway pressure
• Airway fire – due to diathermy
• Prevented by wet gauze
• Cut the anaesthetic gas immediately and pour saline into oral cavity

111. POST OPERATIVE COMPLICATIONS
• Reactionary haemorrhage – occurs within a period of 24 hours
• Causes
• Clot dislodges
• Vasodilatation of blood vessels
• Post operative blood pressure changes
• Increased venous pressure due to coughing
• Slippage of Ligature
• Failure to ligate all bleeding vessels

112. • C/F – H/O spitting of fresh blood, vomiting of altered blood
• Signs – cold extremities, tachycardia, low BP, excessive swallowing
(earliest sign of haemorrhage), examination of oral cavity and
oropharynx coated with blood and blood clots
• PPW – stained with blood
• Preparation: NPO, Consent for Surgery including consent for ligation
of external carotid artery, inform anaesthetist and OT staff, arrange 1
pint of blood
• Investigations
• Treatment:
• Conscious – Make the patient sit upright and ask to spit the blood to
make the airway clear
• Unconscious – recovery position with head of bed down and lateral
position

113. • 1. Rehydration with crystalloids
• When sufficiently hydrated – shift the patient to OT
• 2. Intubated – properly suctioning and bleeding controlled by proper
suctioning from tonsillar fossa followed by ligating and cauterizing
blood vessels
• 3. Bleeding Not controlled – Sututing of anterior and posterior pillars
with / without packs. Remove pack after 24 hrs.
• Disadvantages of Pack – dislodgement of pack with looseing of sutures
• Severe dysphagia
• Re-anaesthesia to remove the pack
• 4. Ligation of External Carotid Artery – in neck after it gives off its first
branch.
• 5. Bleeding Controlled – Ryle’s tube passed to stomach and gastric
lavage is done until clear fluid is spirated.

114. • Surgical Trauma – Trauma to teeth, Palate, Pillars, Uvula
• Inj Dexa and gargle of ice cold hydrogen peroxide
• Severe Oedema of uvula results in resection of anterior pillars
• Respiratory Obstruction
• Laryngeal Spasm – extubation / irritation of vocal cord
• Failing back of tongue
• Inhaled foreign body as blood clots, secretions, neglected loose gauze,
tonsillar tissue
• Aspirated vomitus – due to poor pre op preparation
• Laryngeal oedema/ spasm – oversized ET tube or poor technique of
intubation
C/F – Inspiratory Stridor, cough, tachycardia, tachpnoea
Auscultation - decreased air entry
decreased oxygen saturation
Bradycardia and cyanosis

115. • Treatment
• Reintubation and administration of oxygen
• Suction of secretions, blood and vomitus and removal of foreign body
• Steroids
• Intermediate Complications
• Secondary haemorrhage
• Infection of tonsillar fossa
• Oedema and necrosis of uvula
• Pulmonary complications – pneumonia, bronchitis
• Subacute bacterial endocarditis

116. SECONDARY HAEMORRHAGE
• Occurs 24 hours to 5-7 days after surgery
• Cause – infection
• Treatment –
• Systemic antibiotics
• Injectable analgesics
• Hydrogen peroxide gargles of each feed
• Blood transfusion if needed
• In case of severe bleed – shift to OT – management as like primary
haemorrhage

117. LATE COMPLICATIONS
• Scarring
• Tonsillar remnants
• Pharyngeal stenosis
• Velopharyngeal insufficiency
• Taste distortion
• Hypertrophy of lingual tonsils

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