Tonsillectomy is the surgical removal of the palatine tonsils. It is indicated for recurrent throat infections, tonsillitis causing medical issues, or enlarged tonsils obstructing breathing. Pre-operative assessment involves evaluating the patient's medical history, examining the throat, and in some cases checking coagulation or doing a sleep study. Certain conditions like bleeding disorders or Down syndrome require special pre-operative management. The surgery involves using various techniques like dissection and snare to separate the tonsils from surrounding tissue and remove them. Post-operative care focuses on pain management, diet, hygiene and watching for potential complications like bleeding or infection. Newer techniques aim to reduce morbidity through less invasive procedures

1. By
Dr .muhanned Alali
S . H . O
BTC
(BASRAH TRAINING CENTER)

2. 
TONSILLECTOMY IS DEFINED AS ;
THE SURGICAL EXCISION OF PALATINE
TONSILS
WHAT IS
TONSILLECTOMY?

3. 
DIVIDED INTO 3:
 1.ABSOLUTE.
 2.RELATIVE.
 3.AS A PART OF ANOTHER OPERATION.
INDICATIONS OF TONSILLECTOMY

4. 
Recurrent infections of the throat. Paradise et al
 > 7 ep. In 1 year or
 5 ep. / year for 2 years or
 3 ep. / year for 3 years or
 >2 weeks of lost school or work in 1 year
Clinical features of each episode
 Fever
 Lymphadenopathy
 Tonsillar/pharyngeal exudate
 Positive-hemolytic streptococcus test
 Medically treated
1.ABSOLUTE

5. 
 Peritonsillar abscess.
Tonsillitis causing febrile seizures.
Hypertrophy of tonsils causing
-airway obstruction
-difficulty in deglutition.
-interference with speech.
Suspicion of malignancy:
unilaterally enlarged tonsil
(Lymphoma in children/epidermoid ca in adult)
Cont…

6. 
Diptheria carriers who do not respond to antibiotics.
Streptococcal carriers, who may be source of
infection to others.
Chronic tonsilltis with bad taste or halitosis which is
unresponsive to medicines.
Recurrent strep tonsillitis in pts with valvular heart
disease.
2.RELATIVE

7. 
 Palatopharyngoplasty which is done for sleep
apnoea syndrome.
 Glossopharyngeal neurectomy.
Tonsil is removed first and then IX nerve is severed in the
bed of tonsil.
 Removal of styloid process.
3.AS A PART OF OTHER
OPERATION

8. 
 Hb level less than 10 g%.
 Presence of a/c infection in URI.
 Children under 3 yrs of age.
 Overt or submucous cleft palate.
 Bleeding disorders eg:leukemia, hemophilia...
 At the time of epidemic of polio.
 Uncontrolled systemic diseases.
 During the period of menses.
CONTRAINDICATIONS

9. 

10. 
GRADING

11. 

12. 
Medical
Anatomical
Hematological
Cardiac
PSG & airway
Pre-operative
assessment

13. 
 A –
Medical

14. 
 B –
 potential CI e.g velopharyngeal,hematologic or
infection
 Condition with increasing risk for postponing the
surgery e.g acute pharyngitis,fever,cough and
wheeze
 C – management of pre -operative anxiety and
postoperative pain discussed with the patient and
family

15. 
Anatomical
 Examination of the oropharynx
 Uvula and palate
 Tonsil size
 Submucus cleft

16. Hematologic
 Family or past history for unusual bleeding &
bruising
 AAO-HNS & SFORL ; lab. Study indicated only
 when the pt. or family hx is suggestive
 Family hx is unavailable
 Lab .studies ; PT, aPTT,INR, PLATLATE COUNT,
BT
 Studies reveal that preoperative evaluation of coagulation
profile is NOT effective in identifying children who will
have post op. hg and it is NOT cost effective

17.  Cardiac evaluation
Otherwise healthy children do not require a preoperative
cardiac evaluation for tonsillectomy and/or adenoidectomy
(T&A).
 PSG & airway
 A 2011 guideline recommends PSG in children who are
obese, have Down syndrome, craniofacial abnormalities,
neuromuscular disorders, sickle cell disease, or
mucopolysaccharidoses.
 The PSG useful in ;
 Level of post op. Care and the need for post op. oxymetry
 Postponing or avoiding surgery
 When the parental hx and physical ex. Are discordant

18. 
Bleeding disorders
 VWD and platelet function defect leads to increasing
perioperative hg.
 Post op. hg in mild vwd who receive prophylactic
intervention can approach those unaffected
 Autosomal dominant bleeding disorder
 Increased bleeding time and prolonged aPTT.
 Perioperative management
o IV Desmopressin (0.3ugm/kg)
o Serum Sodium
Pre-operative care in
specific condition

19. 
Sickle cell disease
 Risk for pain crisis ,acute chest syndrome, priapism and
strok if they became hypoxic ,acidotic or hypovolemic
during perioperative period
 Pead.heamtologist included in periop. Period
 To solve ;
 Preoperative blood transfusion
 Preoperative hydration
 Preop. PSG

20. 
Down syndrome
 Risk of anaesthia related comp. due to soft and
skeletal alterations
 OSA is common with DS so requir PSG
 Increasing risk of delayed hospital stay due to
pulmonary comp.
 Possibility of delayed oral intake

21. Emotional and pain preparation
 Anxiety leads to increase post op. pain experience
 So decrease in anxiety leads to decrease in post op.
pain
 A prospective study of 241 children aged 5-12 yrs
who undergoes T&A surgery shows
 More anxiety=
 More postop. Pain
 More consumption of pain medication
 Hi incidence of delirium after op.
 Hi post op. anxiety and sleep problem

22. 
Other Tests
 Antibodies for streptolysin-O (ASLO) have been
studied as possible indicators for tonsillectomy. [2]
 These antibodies are correlated with previous
infection with group A beta-hemolytic streptococcus
(GABHS)..
 When the diagnosis of recurrent GABHS is
questioned, high ASLO titers can shed light on the
patient's history.

23. 
Imaging Studies
 Imaging studies include plain radiography, CT
scanning, and MRI in an appropriate patient with a
tonsillar mass suggestive of malignancy.
 In addition, a patient with a pulsatile area adjacent to
the tonsil should undergo magnetic resonance
arteriography (MRA) before routine tonsillectomy to
evaluate for an aberrant internal carotid artery.

24. 
Histologic Findings
 Histologic examination of the tonsils is unnecessary
unless cancer is suspected. If tonsils are asymmetric,
they should be submitted separately and examined
histologically to rule out cancer.

25. 
Evaluation for allergy
 Several studies have shown a higher-than-expected
incidence of allergy in children with adenotonsillar
disease. Therefore, evaluation for allergy may be
helpful, but only in children with the signs and
symptoms of allergic disease.

26. 
Anaesthesia
 The total duration of anesthesia should be as brief as is
practicable, certainly less than 30 minutes.
 Total intravenous anesthesia with propofol and
remifentanil is associated with fast 'wake up' and little
'hangover
 Propofol has the added merit of being an antiemetic agent.
perioperative

27. 
Steroid therapy
single intravenous dose of dexamethasone was an effective,
relatively safe and inexpensive treatment for;
 reducing morbidity from pediatric tonsillectomy.
 an antiemetic.
 Many units use a single dose of 2-4 mg
Cont..

28. 
 TECHNIQUES OF TONSILLECTOMY
COLD METHODS
HOT METHODS

29. 
COLD METHODS
Dissection and snare(most common)
Guillotine method.
Intracapsular tonsillectomy with debrider.
Harmonic scalpel(ultrasound)
Plasma mediated ablation technique.
Cryosurgical technique

30. 
HOT METHODS
Electrocautery.
Laser tonsillectomy or tonsillotomy.
Coblation tonsillectomy.
Radio frequency

31. 
The operation

32. 
 Boyle-Davis mouth gag is introduced and
opened.It is held in place by Draffins bipods or a string
over a pulley.
STEPS OF OPERATION
(DISSECTION AND SNARE
METHOD)

33. 
 Tonsil is grasped with tonsil holding forceps and pulled medially.
  Incision is made in the mucous membrane where it reflects from
the tonsil to anterior pillar.
  A blunt curved scissors may be used to dissect the tonsil from
the peritonsillar tissue and seperate its upper pole.
  The tonsil is held in the upper pole and traction applied
downwards and medially.Dissection is continued until lower pole is
reached.
  Wire loop of tosillar snare is threaded over the tonsil on to its
pedicle, tightened and the pedicle cut and tonsil removed.
  A guaze is placed in the fossa and pressure applied for few mnts.
  Bleeding points are tied with silk.
 Procedure is repeated on the other side.

34. 
IMMEDIATE GENERAL CARE
 -keep the patient in coma position until fully recovered
from anesthesia.
 - keep a watch on bleeding from nose and mouth.
 -keep check on vitals ie pulse,BP,and RR.
POST OP CARE

35. 
Diet
 -after fully recovered; cold milk or icecream.
 -sucking of ice cubes gives relief from pain.
 -gradually from soft to solid food.
 -plenty of fluids should be encouraged.

36. 
Oral hygeine
 -Pt is given Condy’s or hot water gargles 3-4 times a
day.
 -Mouth wash with plain water after every feed.
Analgesics
 -Pain, locally in the throat and reffered to ear can be
relieved by analgesics like paracetamol.
Antibiotics
 -A suitable antibiotic can be given orally or by injection
for a week

37. 
COMPLICATIONS
 EARLY
 •Primary h’ge(0.56%)
 •Reactionary h’ge!!!!
 •Injury to tonsillar
pillars,uvula,soft
palate,tongue or superior
costrictor muscle.
 •Injury to teeth
 •Aspiration of blood.
 •Facial oedema.
 DELAYED
 •Secondary h’ge.(16.8%)
 •Infection
(halitosis+fever)
 •Lung complications
 •Scarring in soft palate
and pillars.
 •Tonsillar remnants.
 •Hypertrophy of lingual
tonsil

38. 
Innovative Techniques
Intracapsular
Tonsillectomy
Harmonic Scalpel
Laser
Coblation
Guiding Principle:
reduce morbidity
Hemorrhage
Pain
Diet
Activity
Cost

39. 
• Koltai et al, 2002
• Microdebrider at 1500 rpm in oscillating mode
• Hemostasis with suction cautery
 Tonsil capsule is not violated thereby
avoiding pharyngeal muscle exposure to
secretions, injury, and inflammation As a
result, postoperative pain and recovery
time reduced
 tonsillar regrowth with snoring
Intracapsular Tonsillectomy

40. 
• Ultrasonic dissector and coagulator
• Vibratory energy
• Cutting: sharp blade with frequency of
55.5kHz
• Temp. of surrounding tissue is 80
• Coagulating: vibration breaks H-bonds,
thermal energy
Harmonic Scalpel Tonsillectomy

41. 
 No significant difference in intraoperative blood loss and postoperative
ability to eat and drink
 Level of activity for the first postop day significantly lower in harmonic
scalpel group
 Postoperative pain scores tended to be lower in harmonic scalpel
group
Willging et al

42. 
• Kothari et al, 2002K
• KTP laser provides little benefit over dissection tonsillectomy
except to minimize intraoperative bleeding
 higher postop pain scores
 greater difficulty resuming postoperative diet
More risk for secondary bleeding
 Limitations
• Technical expertise
Laser Tonsillectomy

43. 
COBLATION TONSILLECTOMY
 Technology combines radiofrequency
energy and saline to create a plasma
field. The plasma field remains at a
relatively low temperature 40-70°
 as it precisely ablates the targeted tonsil
tissue.
 The COBLATION plasma field
removes target tissue while minimizing
damage to surrounding areas.
 The probes or 'wands' are single use
and there is a cost consideration

44. 