The document provides a comprehensive analysis of tonsillectomy, detailing its history, anatomy, techniques, and indications for the procedure. It discusses various surgical methods, including traditional dissection, electrocautery, and newer techniques like coblation and laser tonsillectomy, along with their complications. Key indications for tonsillectomy are highlighted, including recurrent infections and hypertrophy causing airway obstruction.

1. Journal club
Analysis of Different Techniques of Tonsillectomy: An
Insight

2. Palatine Tonsils
● History
● Embryology
● Anatomy
● Immune functions of tonsil
● Tonsillectomy

3. History
● A disease which is similar to tonsillitis in clinical presentation in Ayurveda
is Tundikeri which is described under Mukha Roga.
● Dealing with the treatment of the disease Tundikeri, Acharya Sushruta
mentions that Tundikeri is the Bhedya Roga and it should be treated as per
the line of treatment of the disease Galashundika

4. ● Cornélio Celsus, in the 1st century B.C., was the first to describe
tonsillectomy surgery. He reported the procedure performance for
dissection and removal of the structures. Celsus applied a mixture
of vinegar and milk in the surgical specimen to hemostasis and also
described his difficulty doing that due to lack of proper anesthesia
(1,2).

5. ● Some recommendations for removing tonsils in that time included
night enuresis (bed-wetting), convulsions, laryngeal stridor,
hoarseness, chronic bronchitis and ashma.
● Other techniques for removing tonsils arouse in the Middle Ages,
such as the ones using cotton lines to connect the base. The lines
were daily tighted and then tonsils fell.

6. ● Hildanus, in 1646, and Heister in 1763, presented devices similar to
a guillotine-cutter for uvulotomy. These instruments were modified
by Physick, who, in 1828, in the United States, created the
tonsilotome, used successfully in tonsillectomies.

7. ● Tonsillectomy was initially performed by general surgeons, but at
the end of 19th century it became an ENT doctor´s care, due to the
best techniques of illumination that they knew. Important steps in
the progress of the tonsillectomy were taken using mouth-gag and
tongue-depressors, besides the positioning of patient with leaning
and suspended head. This position was first described by Killian in
1920, but only adopted after improvements on anesthesia
techniques.

8. ● Joseph Beck was the first one to describe the use of a device with
cutting wire inside a rigid ring known as Beck-Mueller´s ring. An
instrument that also gained publicity in that period was Sluder´s
guillotine. At the beginning of 20th century, the use of forceps and
scalpels resulted in less bleeding
● From 1909, tonsillectomy surgery became a common and safe
procedure, when Cohen adopted ligature of bleeding vessels to
control perioperative hemorrhage.

9. Embryology

10. Palatine tonsils
● There are two palatine
tonsils.
● Each palatine tonsil is a
mass of lymphoid tissue.
Location-
● In tonsillar fossa, which is
situated in the lateral wall of
oropharynx between anterior
and posterior faucial pillars.
Shape- Almond shaped.

11. Boundaries of Tonsillar Fossa
Anterior- Anterior faucial pillar
(palatoglossal arch).
Posterior- Posterior faucial pillar
(palatopharyngeal arch).
Apex- Soft palate.
Base- Dorsal surface of posterior 1/3rd of
tongue.
Lateral wall [Tonsillar Bed]- Superior
Constrictor Muscle (mainly).

12. Tonsillar Bed
 Following structures form the tonsillar bed ( from inside outwards):
● Pharyngobasilar fascia.
● Superior Constrictor muscle.
● Buccopharyngeal fascia.

13. Presenting Parts
● 2 surfaces- Medial & Lateral
● 2 borders- Anterior & Posterior
● 2 Poles- Upper & Lower
Medial Surface-
● It bulges into oropharynx.
● It is covered by epithelium.
● It has crypts.
● There are ~ 12-15 crypts.
Crypta Magna-
● A very large and deep crypt located near

14. Lateral Surface
● It is covered by fibrous capsule.
Peritonsillar Space-
● A space between fibrous capsule and tonsillar bed.
● It is filled with loose areolar tissue.
● It is the site of collection of pus in peritonsillar abscess.
● During tonsillectomy, tonsil is dissected in this plane.
Internal Carotid Artery is ~2.5 cm
posterolateral to the tonsil

16.  Superior constrictor separates the lateral surface from following structures:
● Facial artery and its ascending palatine and tonsillar branches.
● Styloglossus muscle.
● Glossopharyngeal nerve.
● Angle of mandible.
● Medial Pterygoid muscle.
● Submandibular salivary gland.

17. Anterior Border-
● Passes underneath the palatoglossal arch.
Posterior Border-
● Passes underneath the palatopharyngeal arch.
Upper Pole- extends up into the soft palate.
Lower Pole-
● It is attached to the tongue by a band of fibrous tissue called suspensory ligament of tonsil.

18. Arterial Supply
 Facial Artery-
● Tonsillar branch.
● Ascending Palatine branch.
 Lingual Artery-
● Dorsalis Linguae branches.
 Ascending Pharyngeal Artery.
 Maxillary Artery-
● Greater Palatine Branch.
Dorsal Lingual branch
Greater (Descending) Palatine
branch

19. Venous Drainage
● Paratonsillar Vein.
● Paratonsillar Vein drains into pharyngeal venous plexus.

20. Lymphatic Drainage
● Upper deep cervical lymph nodes [mainly Jugulo-digastric nodes].
● Jugulo-digastric nodes are called ‘Tonsillar Lymph Nodes’.

21. Nerve Supply
 Glossopharyngeal nerve.
 Pterygopalatine ganglion-
● Lesser palatine branches.

22. Indications of Tonsillectomy
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.

23. 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.
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.

24. 3. Tonsillitis causing febrile seizures.
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.

25. 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.

26. 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.

27. Contraindications
1. Haemoglobin level less than 10 g%. 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.

28. Anaesthesia
● Usually done under general anaesthesia with endotracheal intubation.
● In adults, it may be done under local anaesthesia.
● Rose's 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.

29. Rose's position for tonsillectomy. Neck is extended by a sand bag
under the shoulders and the head is supported on a ring.
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Rose's position

30. 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

31. Boyle-Davis mouth gag

32. Set of instruments for tonsillectomy.(1) Knife in kidney tray, (2) & (3) Toothed and non-toothed Waugh's
forceps, (4) Tonsil holding forceps, (5) Tonsil dissector and anterior pillar retractor, (6) Luc's forceps, (7)
Scissor, (8) Curved artery forceps, (9) Negus artery forceps, (10) Tonsillar snare, (11) Boyle Davis mouth
gag with three sizes of tongue blades, (12) Doyen's mouth gag, (13) Adenoid curette, (14) Tonsil swabs,
(15) Nasopharyngeal pack, (16) Towel clips.
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© 2005 Elsevier

33. 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.

34. 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
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.

35. Post-operative Care
1. 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.

36. 2. Diet
a. 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.

37. 3. Oral hygiene
Betadine or salt water gargles 4-6 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

38. 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

39. Guillotine method. Largely abandoned. It can be done only when tonsils are
mobile and tonsil bed has not been scarred by repeated infections.

40. 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.

41. micro debrider micro debrider-tip blade

42. 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.

43. Harmonic scalpel knife Harmonic scalpel tonsillectomy

44. 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

45. 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

47. Electrocautery.
Both unipolar and bipolar electrocautery has been used. It reduces blood loss
but causes thermal injury to tissues.

48. 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.
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.

49. 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.

50. Coblation tonsillectomy

51. 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.

52. 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.

53. B. Delayed Complications
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.

54. 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.
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

55. Journal club
Analysis of Different Techniques of Tonsillectomy: An
Insight

56. TITLE:
Analysis of Different Techniques of Tonsillectomy: An Insight.
AUTHORS/AFFILIATION:
Ajaz Ul Haq, Chetan Bansal, Apoorva Kumar Pandey, V. P. Singh
Department of ENT, Shri Guru Ram Rai Institute of Medical Sciences, Dehradun,
Uttarakhand,India
Department of ENT, ONGC Hospital, Dehradun,Uttarakhand, India
Max Hospital, Dehradun, India

57. Was the purpose stated clearly?
Yes
Outline the purpose of the study.
The objective of this study is to compare three different surgical techniques of
tonsillectomy namely
● the Cold dissection snare technique (CDST),
● Bipolar electro-dissection technique (BEDT) and
● Harmonic scalpel technique (HST) and to identify the
method which is safe, with less operative time, which offers decreased intra-operative
blood loss and with lowest post-operative morbidity and complications.

58. How does the study apply to your research question/clinical practice?
● Tonsillectomy is one of the most commonly performed surgical procedure in
otolaryngology especially in children.
● This is an age old procedure which has seen continuous changes in the
surgical technique from guillotine method to snare technique to coblation
tonsillectomy, and is still evolving day by day.
● But there are no consensus as to which technique is the best or most
appropriate for tonsillectomy.

59. Was relevant background literature reviewed?
Yes
Describe the justification of the need for this study.
Knowledge of different approaches and disadvantages and advantages of each
helps in choosing the most feasible approach.

60. Background literature
1. Vithayathil AA, Maruvala S (2017) Comparison between cold dissection snare method and bipolar electrodissection method in tonsillectomy. Res
Otolaryngol 6(2):17–22
2. Clenney T, Schroeder A, Bondy P et al (2011) Post-operative pain after adult tonsillectomy with plasmaknife compared to monopolar electrocautery.
Laryngoscope 121(7):https://doi.org/10.1002/lary.21806
3. Gurpinar B, Salturk Z, Akpinar ME, Yigit O, Turanoglu AK (2017) Comparison of tonsillectomy techniques and their histopathological healing
patterns. Otolaryngol Open J(3):47–53
4. Baugh RF, Archer SM, Mitchell RB et al (2011) American Academy of Otolaryngology-Head and Neck Surgery Foundation Clinical practice
guideline: tonsillectomy in children. Otolaryngol Head Neck Surg 144(1 Suppl):S8
5. Ralph F, Wetmore. (2016) Tonsils and Adenoids. In: Kliegman Robert M, Behrman RE, Jenson HB, Stanton FB. Nelson textbook
of pediatrics. 20th ed. Philadelphia: Saunders; Chap 383, p 2024.
6. Scottish Intercollegiate Guidelines Network. Management of sore throat and indications for tonsillectomy. SIGN publication No.
34. Available from: http://www.sign.ac.uk.
7. American Academy of Otolaryngology Head and Neck Surgery (2000) Clinical indicators compendirum. Alexandria, VA:
American Academy of Otolaryngology Head and Neck Surgery,
8. Sharma K, Kumar D (2011) Ligation versus bipolar diathermy for hemostasis in tonsillectomy: a comparative study. Indian J Otolaryngol Head Neck
Surg. 63(1):15–19
9. Curtin JM (1987) The history of tonsil and adenoid surgery. Otol Clin North Am 20:415–419
10. Crowe SJ, Watkins SS, Rothholz AS (1917) Relation of tonsillar and nasopharyngeal infection to general systemic disorders. Bull
Johns Hopkins Hosp 28:1

61. Describe the study design. Was the design appropriate for the study
question?
- Prospective comparitive study
- January 2018 to july 2019 ( 1 year 6 months )
- Consent taken from the guardians
- Inclusion and exclusion criteria are stated

62. ● Inclusion criteria
(1) Patient aged 4–40 years
(2) Recurrent or chronic pharyngotonsillitis with minimum number of episodes of
sore throat at least 7 episodes in the previous year, at least 5 episodes in
each of the previous 2 year, or at least 3 episodes in each of the previous 3
year for children and 3–4 episode per year for 2–3 years for adults
(3) As a part of ear surgery, uvulopalatopharyngoplasty
and quinsy surgery
(4) As part of Adenotonsillectomy

63. ● Exclusion criteria
(1) Children suffering from tonsillitis of age less than 4 years and more than 40
years
(2) Neoplasms of tonsil
(3) Underlying bleeding and clotting disorders
(4) Submucous cleft palate
(5) Chronic systemic illnesses
(6) Severe anemia

64. Was the sample described in detail?
•Yes
•Sampling - size - 150
•Prospective comparitive study
•January 2018 to july 2019 ( 1 year 6 months )
•Type of approach chosen according to patients choice ( not mentioned )

65. Intervention was described in detail?
•Yes
Description of the intervention.
•Prospective comparitive study
- First 50 cases (cases 1 to 50) were done using Cold dissection snare technique
- Patients no 51 to 100 were done using Bipolar electro dissection technique
- last 101 to 150 cases were done using Harmonic scalpel technique.
All the cases were performed by same surgical team.

66. All cases were performed under general anesthesia after oral endotracheal
intubation under all aseptic precautions.
- Patient was positioned at the edge of the operating table and Rose’s position was
achieved by applying sand bag between the shoulders.
- Davis-Boyle mouth gag was inserted into the patient’s mouth and fixed into
position using Draffin bipod for adequate exposure of the oro-pharynx.
- In cases of adenotonsillectomy, adenoidectomy was done first and then
tonsillectomy.
- Time and blood measurement was done separately for both the procedures.

67. In Cold dissection snare technique (CDST), tonsillectomy was done by
palatoglossal incision using toothed Waugh forceps.
Peritonsillar loose areolar plane was dissected from superior pole to inferior pole
by mollison’s blunt dissector.
Inferior pedicle was snared with the help of Eve’s tonsillar snare.
After removal tonsillar fossa was packed with gauze for a few minutes depending
on bleeding and clotting time of the patient.
On removal of gauze, bleeders were ligated manually using suture material
till hemostasis is achieved.

68. In Bipolar electro-dissection technique (BEDT), dissection and coagulation
were done with the same bipolar forceps.
- Using the bipolar forceps, a palatoglossal incision was given, the peritonsillar
loose areolar plane was dissected from superior to inferior pole.
- Minimum voltage current was used to allow coagulation.
- Fibro vascular bundles were coagulated and dissected.
- Low energy bipolar cautery technique of 25 watts was used to reduce heat
trauma to the tonsillar bed and post-op pain.
- Tonsillar pericapsular plane dissection was also bluntly performed.
- Vascular bundles of tonsillar capsule and bed were coagulated
to achieve hemostasis.

69. In harmonic scalpel technique (HST), ultrasonic cut ‘N seal device which is a handheld device, is used
which utilizes ultrasonic energy at the blade tip to cut and coagulate the vessels or tissues
simultaneously at low temperature heat (50–100 degrees Celsius).
This technology controls bleeding by coaptive coagulation at low temperature.
Coagulation occurs by means of protein denaturation when the blade vibrates at 55.5 kHz.
This consists of a generator, a hand piece with a connecting cable, a blade
system and a foot pedal.
Tonsil retracted medially using Dennis Brown tonsil holding forceps.
Using the harmonic hand piece, a palatoglossal incision was given, the peritonsillar loose areolar plane
was dissected from superior to inferior pole and tonsillectomy performed using ultrasonic dissection.
Hemostasis achieved simultaneously.
The scalpel has lower temperature heat (50–100 degrees Celsius) as compared to standard electro
cautery (400 to 6,000 degrees Celsius).

70. Were the outcome measures reliable?
•Yes
Describe the outcomes and their reliability and applicability.
• Outcomes were documented which are reliable and can be used in clinical
practice.

71. 75 patients
All female patients
24 - bilateral, 27 - unilateral ( total earlobes - 75 )
1. Inferior notching - 2 cases
2. Inferior bulging - 3 cases
3. Suture line grooving - 2 cases
4. Recurrence - 3 cases ( 2 - other metals not gold 1- trauma )

73. Are the inclusions, Interventions and outcomes relevant/applicable to your
setting?
Yes it is applicable in our setting as we have more tonsillitis cases

74. Conclusions were appropriate given study methods and results
• Yes
What did the study conclude? What are the implications of these results for
practice?
● Harmonic Scalpel Technique (HST) is the latest technique as it is associated
with quicker procedure, less intraoperative blood loss and less post-operative
pain.
● Morbidity in terms of post-operative hemorrhage and other complications
(vomiting, dehydration, halitosis, odynophagia, infection of tonsillar bed) were
also minimal with HST.,

75. What were the main limitations or biases in the study?
● No
Do you agree with the author’s interpretations?
•Yes

76. Do you propose further studies on this topic? If so, why and how?
•Yes further studies are needed to compare different approaches with
conventional methods to know the feasibility and safest, quickest best approach.

77. THANK YOU