Tonsillectomy and adenoidectomy are common ENT procedures. Tonsillectomy indications include recurrent tonsillitis, peritonsillar abscesses, and other local or systemic issues. Methods include cold knife dissection, electrocautery, lasers, and harmonic scalpels. Potential risks are bleeding, infection, and injury to nearby structures. Adenoidectomy removes adenoid tissue and is often done with tonsillectomy. Peritonsillar abscesses are treated with needle aspiration and incision/drainage or intravenous antibiotics.

1. Tonsillectomy,
Adenoidectomy
and Quinsy
Dr. Krishna Koirala
2020/01/26

2. History
• Cornelius Celsus (30 A.D. ) : Described tonsillectomy
by finger dissection and used vinegar for hemostasis
• Philip Physick (early 1800s) : Developed
tonsillectomy
• Wilhelm Meyer (1867) : Reported removal of adenoid
through nose with a ring knife
• George Waugh(1909) : Described complete
tonsillectomy

3. Tonsillectomy

4. Indications
• Local indications
• Focal indications
• Systemic indications
• As part of other surgery

5. Local indications
1.Recurrent tonsillitis meeting Paradise criteria : (  7
episodes in 1 yr or 5 episodes / yr for 2 yrs or 3 episodes / yr for 3 yrs)
2. After second attack of Quinsy
3. Intra tonsillar abscess
4. Malignant or benign tumour or unilateral tonsillar
enlargement of suspicious cause
5. Tonsil enlargement with stridor or dysphagia
6. Tonsillolith or tonsillar cyst with halitosis
7. Impacted foreign body

6. Systemic indications
1. Rheumatic fever with arthritis
2. Sub-acute bacterial endocarditis
3. Glomerulonephritis
4. Diphtheria carrier

7. As an approach to other surgeries
1. Styloid process excision (Eagle’s syndrome)
2. Glossopharyngeal neurectomy
3. Uvulopalatopharyngoplasty
4. Branchial fistula excision

8. Contraindications
• Age < 3 yr
– Limited space; immunity is lost; blood loss not
tolerated; lingual tonsils hypertrophy
• Acute infection : More bleeding
• Aneurysm of internal carotid or tonsillar artery
• Bleeding disorders : Hemophilia
• Cleft palate : Rhinolalia aperta

9. Contraindications
• Cervical spondylosis : affects surgical position
• Diabetes mellitus; hypertension; tuberculosis
• Epidemic of polio : bulbar poliomyelitis
• Female patient during menstruation
• Granular pharyngitis : infection flares up
• Hemoglobin < 10 g / dl

10. Subcapsular vs Intracapsular Tonsillectomy
• Subcapsular total tonsillectomy
– Removes tonsil tissue completely
• Intracapsular tonsillectomy
– Removes 90% of tonsils leaving behind a layer of
tonsil tissue
– Protects tonsillar bed and reduces post-op pain
and recovery time
– Not appropriate for recurrent tonsillitis

11. Subcapsular tonsillectomy

12. Intracapsular tonsillectomy

13. Methods of Tonsillectomy
Hot
• Dissection and snare
• Microdebrider
• Harmonic scalpel
• Cryosurgery
• Cold knife
• Guillotine
Cold
• Electro-cautery
• Laser
• Coblation
• Radiofrequency

14. Tonsillectomy by Dissection and
Snare Technique

15. Rose Position and Incision

17. Blunt dissection

18. Cutting of triangular ligament

19. Snaring and Hemostasis

20. Steps of tonsillectomy
1. Rose position: patient kept supine with extension of
neck and atlanto-occiptal joint
2. Boyle Davis mouth gag inserted and fixed with
Draffin’s bipod and Mac Gauren’s plate
3. Incision made between tonsil and anterior pillar
4. Tonsil dissected from its base, till its lower pole
with tonsil dissector

21. Steps of tonsillectomy contd….
5. Lower tonsil pedicle snared with Eve’s tonsillar snare
6. Tonsil removed and fossa packed with H2O2 soaked
gauze for 5 min
7. Bleeder ligated with silk suture or cauterized by
bipolar cautery

22. Micro- debrider

23. Ultrasonic Harmonic scalpel

24. Cryosurgery

25. Cold knife dissection and snare method

26. Guillotine

27. Electro-cautery

28. Laser tonsillectomy

29. Bipolar radiofrequency

30. Post-operative care
1. Keep the patient in left lateral position with head low
2. Inform surgeon immediately in case of
– Fever above 100 0F
– Difficulty in breathing or swallowing
– Excessive bleeding from oral cavity
3. Eat soft foods and ice-cream
4. Encourage swallowing and gum chewing
5. Drink plenty of cold fluids
6. Avoid citrus fruit juice

31. Surgical
• Hemorrhage
– Primary (operative)
– Reactionary ( < 24 hrs)
• Injury to lip / teeth / uvula /
pillars/soft palate
• Surgical emphysema
• Tonsil remnant
Anesthetic
• Aspiration
• Cardiac arrest
Early Complications (within 24 hrs)

32. Late Complications (After 24 hrs)
• Surgical
– Secondary hemorrhage
– Scarring of soft palate leading
to velopharyngeal insufficiency
– Lingual tonsil hypertrophy
– Tonsil fossa infection
– Granular pharyngitis
Anesthetic
• Lung collapse

33. Hemorrhage after Tonsillectomy
• Primary hemorrhage
– Occurs during surgery, due to injury to blood vessels
– Normal = 80 ml.
• Reactionary hemorrhage
– Within 24 hr of surgery (commonly within 8 hr)
• Secondary hemorrhage
– Occurs after 24 hrs of surgery , usually on 6th - 8th
day ,due to infection

34. Causes for reactionary hemorrhage
• Slippage of ligature
• Displacement of clot
• Re-opening of collapsed blood vessels
– Caused by high B.P. due to cough / retching and
wearing off effect of hypotensive anesthesia
• Clots in tonsillar fossa
– Prevent contraction of superior constrictor muscle
(required for hemostasis)

35. Management of Post- op tonsillar bleeding

36. • Remove blood clots from tonsillar fossa
• H2O2 gargle (causes thermal cautery and vasoconstriction by
releasing nascent oxygen)
• Pressure gauze packing of fossa for 5 min
• If bleeding continues, shift the patient to operation theatre
• In operation theatre
• Treat shock, blood transfusion if required
• Head low, continuous pharynx suction
• Ryle's tube insertion, remove aspirated blood
• Intubate + inflate cuff + put throat pack
• Remove all blood clots from tonsil fossa to identify any
bleeder

37. Bleeder identified
Yes No
Ligation or bipolar
cautery
Adrenaline pack or AgNo3 application or
Tincture benzoin paint
Bleeding still continues
Suture both pillars over gelfoam kept in fossa
Bleeding still continues
External carotid artery ligation distal to superior thyroid artery
(so that retrograde thrombus aneurysm involves superior thyroid
artery and not Internal carotid artery)

38. Adenoidectomy

39. • First do adenoidectomy then only tonsillectomy
(hemostasis performed by blind nasopharynx packing)
• Indications:
• Adenoids with
– Adenoid facies
– Sleep apnea / snoring
– Rhinolalia clausa
– Recurrent sinusitis
– Refractory O.M.E.
– C.S.O.M.

40. Procedure

41. Procedure
• Rose position but atlanto-occipital joint neutral
• Mouth gag inserted
• Finger palpation done
– To assess the size of adenoids
– To bring the adenoid mass in midline
– To check the position of Eustachian tube
• Adenoid curetted keeping head slightly flexed to avoid
trauma to atlanto-occipital joint
• Nasopharyngeal pack kept for 5 min for hemostasis

42. Microdebrider adenoidectomy

43. Complications
• Hemorrhage  10, R0, 20  post nasal pack
• Damage to E.T. orifice  scarring  O.M.E.
• Subluxation of Atlanto - Occipital joint (Griesel
disease) torticollis
• Velopharyngeal insufficiency  nasal twang and
regurgitation from nose
• Nasopharyngeal scarring and stenosis
• Adenoid remnant and recurrence ( up to 40%)

44. Contraindications
• Acute infection
• Bleeding disorders
• Cleft palate: symptoms will be worsened

45. Peritonsillar abscess (Quinsy)

46. Etiopathogenesis
• Collection of pus between tonsillar capsule and
superior constrictor muscle
• Pathology: Aerobic + anaerobic organisms
– De novo
– Acute tonsillitis  blockage of crypts  intra
tonsillar abscess  peritonsillitis  quinsy
– Abscess of Weber's salivary gland in supra tonsillar
fossa  quinsy

47. Clinical features
• Symptoms: Young adult with severe odynophagia,
fever, halitosis and muffled voice
• Signs:
– Peritonsillar area swollen and congested
– Tonsil hidden behind the anterior pillar, pushed
medially and congested
– Jugulo -digastric lymph node enlarged and tender
– Trismus
– Torticollis

48. Management
• Diagnosis:
– Wide bore needle aspiration (18G) reveals pus
• Medical treatment:
– Urgent admission, I.V. fluids
– I.V. ceftriaxone + ornidazole
– Antihistamine - decongestant + analgesic
– Antiseptic mouth gargle ( Betadine )

49. Incision and Drainage
• Incision made with # 11 blade or Thilenius
peritonsillar abscess drainage forceps
• Nick made above and lateral to junction of 2
imaginary lines, horizontal along base of uvula and
vertical along anterior tonsillar pillar
• Incision widened with sinus forceps & pus drained

50. Incision line and quinsy forceps

51. Surgical treatment
1. Interval tonsillectomy  after 4 – 6 wk.
2. Hot tonsillectomy or abscess tonsillectomy is
avoided as it leads to
– More bleeding
– Septicemia

52. Complications of quinsy
1. Parapharyngeal abscess
2. Retropharyngeal abscess
3. Laryngitis and laryngeal edema
4. Lung abscess
5. Internal jugular vein thrombosis
6. Septicemia