EAR NOSE THROAT AND HEAD NECK SURGERY

1. Tonsillectomy
Dr.Satish Kumar Ray
1st year Resident,ENT-HNS
Moderater: Dr.Bikash Gurung
Pokhara Academy of Health Sciences

2. Overview
• Anatomy
• History
• Indication
• Tonsillectomy techniques
• Steps of tonsillectomy
• Post-operative care
• Complication

3. Tonsil
• Palatine
• Lingual tonsils
• Adenoids
• Tubal
• Diffuse aggregates of pharyngeal submucosal
lymphoid tissue
↓
Waldeyer’s ring
↓
A complete circle of lymphoid tissue surrounding the
entrance to the gastrointestinal and respiratory tracts

4. PALATINE TONSIL
• Paired aggregates of lymphoid tissue
• Located pocket between palatoglossus and
palatopharyngeus musclesoverlying folds of
mucosa ↓
Anterior and Posterior tonsillar pillars
• Common structure with lymphoid tissue
elsewhere
↓
• Gastrointestinal and respiratory
tractsadenoids ,Peyer’s patches ,appendix

5. • The stratified squamous non keratinizing mucosal
covering of the tonsils irregular convoluted
invaginations parenchyma pits or crypts.
• 12–15 crypts medial surface of tonsil.
• One of the cryptsvery large and deep
↓
• crypta magna or intratonsillar cleft.
• Microorganisms, desquamated epithelium and food
debris are frequently present within the crypts

6. Relation of palatine tonsil
• Medial surfacecrypts
• Lateral surfacefibrous capsuleBetween the
capsule and the bed of tonsil loose areolar
tissue
• Upper poleextends into soft palate medial
surface is covered by a semilunar
foldpotential space called supratonsillar fossa.
• Lower poleattached to the tongue
separated
• from the tongue by a sulcus called
tonsillolingual sulcus

7. Bed of tonsil
Tonsil is related laterally to its capsule
(1), loose areolar tissue containing paratonsillar vein (2), superior constrictor
muscle (3), styloglossus (4), glossopharyngeal nerve (5), facial
artery (6), medial pterygoid muscle (7), angle of mandible (8) and
submandibular salivary gland (9), pharyngobasilar fascia (10), buccopharyngeal
fascia (11

8. Blood supply
The tonsil is supplied by five arteries
1. Tonsillar branch of facial artery.
This is the main artery.
2. Ascending pharyngeal artery from
external carotid.
3. Ascending palatine, a branch of
facial artery.
4. Dorsal linguae branches of lingual
artery.
5. Descending palatine branch of
maxillary artery.

9. VENOUS DRAINAGE
• Drain into paratonsillar vein common facial vein and pharyngeal
venous plexus
LYMPHATIC DRAINAGE
• Drain into upper deep cervical nodes particularly the jugulodigastric
(tonsillar) node situated below the angle of mandible.
NERVE SUPPLY
• Lesser palatine branches of sphenopalatine ganglion (CN V) and
glossopharyngeal nerve provide sensory nerve supply

10. Normal flora
• Extremely variable in health & disease
• Surface of the tonsil in disease is GABHS
• Other surface organisms include Haemophilus,
Staphylococcus aureus,alpha haemolytic
streptococci, Branhamella sp.,
Mycoplasma,Chlamydia, various anaerobes
and a variety of respiratory viruses.

11. Function
• Lymphoid germinal centres
submucosallycontain both B and T lymphocytes.
• Responsible for the final differentiation, induced by
exposure to antigen B cells IgG and IgA plasma
cells
• Allow positive selection of B cells
• Generate B cells which express polymeric IgA
migrate to the upper respiratory tract mucosa
↓
associated ‘front line’ mucosal surfaces

12. HISTORY OF TONSILLECTOMY
Celsus in ‘De Medicina’ (14–37 AD)
• ‘induration’of the tonsils dissection with the
fingernail.
• If not possible grasped with a hook and pulled out
with ‘bistoury’.
Morrel McKenzie
• Improved instrumentation – snares and ‘guillotines’
• popularization of the operation
Sir Felix Semon (1849–1921)
Removed the tonsils several of Queen Victoria’s
grandchildren fashionable in the drawing rooms of the
aristocracy.

14. The SIGN guidelines
for tonsillectomy
• Based on Paradise criteria
• patients for tonsillectomy both adults and children should meet
all the following criteria
 sore throats are due to tonsillitis
 the episodes of sore throat are disabling and prevent normal
functioning
 seven or more well-documented, clinically significant,
adequately treated sore throats in the preceding year, or
 five or more such episodes in each of the preceding 2 years, or
 three or more such episodes in each of the preceding 3 years

15. Indications for tonsillectomy
• Recurrent acute tonsillitis
• Peritonsillar abscess
Further indications for tonsillectomy
 In adults with gross tonsil hypertrophy and OSA, or as part of
uvulopalatopharyngoplasty (UPPP) or laser-assisted
uvulopalatoplasty
 Severe haemorrhagic tonsillitis
 Severe infectious mononucleosis with upper airway obstruction
 Large symptomatic tonsoliths (tonsillar Concretions)
 As long-term management of IgA nephropathy

16. Tonsillectomy can be indicated for biopsy purposes in the
following scenarios
Asymmetrical adult tonsil with normal mucosa in the
absence of cervical adenopathy
Asymmetrical adult tonsil with mucosal abnormality
and or cervical adenopathy
As an oncological procedure for Ca tonsil
For obstructive sleep apnoea (OSA) in children in
conjunction with adenoidectomy

17. Hypertrophy of tonsil

18. Tonsillectomy techniques
• Undergoing something of a revolution.
• Dissection tonsillectomy (first described by Edwin Pynchon
in 1890) with haemostasis performed with ties or
diathermy standard
• Recently explosion of different dissection instruments
effort reduce postoperative pain and haemorrhage
Current trials
• Any these techniques is consistently clinically greatly
superior to any other technique

19. 1. Dissection techniques
2. Nondissection techniques
Dissection techniques
 cold dissection techniques sharp/bluntsnares and
haemostasis with ties or diathermy mono or bipolar
 diathermy or electrocautery dissection
Monopolar
Bipolar forceps tonsillectomy
bipolar scissor tonsillectomy
 Radiofrequency/electrosurgery tonsillectomy
somnoplasty tonsillectomy: bipolar thermal
radiofrequency ablation
coblation (plasma-mediated ablation)tonsillectomy
argon plasma coagulator tonsillectomy
 harmonic scalpel (ultrasound) tonsillectomy
 Laser dissection tonsillectomy: CO2 laser, potassium titanyl
phosphate (KTP) and Nd-YAG laser tonsillectomy
Nondissection techniques include:
 guillotine tonsillectomy;
 intracapsular partial tonsillectomy

20. Tosillectomy technique

21. PRINCIPLES OF DISSECTION
TONSILLECTOMY
POSITION
• Rose’s position, i.e. 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

23. The incision
• Tonsil is grasped with Luc's or similar
forceps
• Drawn -medial direction exposing an
area of mucosa medial to the free edge
of the anterior faucial pillar.
• Incision halfway between the upper
and lower 'poles'
• Scissors or other sharp instrument depth
of the surgical 'capsule' of the tonsil.
• Preserve as much as possible of the
mucosa
• Incision downwards to the base of the
tongue and upwards to the upper pole.

24. Beginning of blunt dissection
• When capsule has been
identified Howarth's nasal
raspatory or similar blunt
dissector separate tonsil
and its capsule
surrounding peritonsillar
tissues

25. Mobilization of upper pole
• upper pole must first be
mobilized keep the dissector
as close as possible to the
capsule throughout the
dissection.
• 'Digging' into the fossa
bleeding and more
postoperative scarring

26. Continuing the dissection
• Gripping upper pole
draw the tonsil towards
the midline extends the
dissection by separating
the peritonsillar tissues
capsule, until the lower
pole is approached.

27. Mobilization of lower pole
• Lower pole of the tonsil there
is a firm fibrous triangular fold
hold up the dissection at
this point.
• Triangular fold cut with
scissors
• Dissection carried on to the
base of the tongue.

28. Removal of tonsil
• A cold-wire snare is threaded over the
tonsil finally removed by closing the
snare at the level of the tonsillolingual
sulcus.
• This ensures lingual 'tongue' of lymphoid
tissue is removed with the tonsil proper
↓
Failure to do so may result in 'recurrence

29. Control of haemorrhage
• Most primary bleeding from tonsillectomy
venous
Minor bleeding controlled naturally by the
contraction and retraction of the smaller vessels
occur spontaneously if a gauze swab fossa for
2 or 3 minutes.
• Main paratonsillar vein  'holed' or sectioned
ligated with silk thread (right fossa).
• Minor persistent bleeding from smaller vessels
quickly and effectively with insulated
diathermy forceps (left fossa)

30. The various dissection techniques
• Developed  minimize tissue trauma
postoperative pain and bleeding
• while remaining simple and of short duration.
• All the techniques have their advocates and
detractors

31. Diathermy or electrocautery
dissection
• Refers to using a heated instrument to cut or coagulate
tissues.
• Heat generated 150-400˚c
Pros
• significant reduction in intraoperative blood loss and
operating time
Cons
• Increase in haemorrhage, pain and slower healing
The recent Cochrane review identified 22 studies comparing
tonsillectomy by diathermy and dissection
• Reduced intraoperative bleeding but increased pain in the
diathermy group
• Increased risk of secondary haemorrhage
Method of choice in patients at high risk of bacteraemia.

32. Radiofrequency tonsillectomy
Somnoplasty tonsillectomy
• Use radiofrequency waves at 460 kHz and have a bipolar electrode.
• The electrode has a temperature sensor for adjustment of output
power control of tissue temperature and total energy delivered
• Target temperature held constant at 85˚c
Pros significantly less pain (mucosa is not breached)
Cons trials were too small to make meaningful comments on
haemorrhage rates

34. Coblation (plasma-mediated
ablation)tonsillectomy
• Using radiofrequency signals electrodisassociation effect to
generate a plasma of excited ions or an ionized field.
• The coblator handpiece electrode as well as an irrigation and
suction channel fragment and suction tissue from the field
• Heat generated  40 -70 ˚c
Pros reduced postoperative pain, more rapid healing and quicker
resumption of normal activities
Cons 3.4 times greater haemorrhage rate than cold steel dissection
bipolar diathermy which was 3.1 times >cold steel dissection.

35. Argon plasma coagulator tonsillectomy
• Requires an argon plasma coagulation (APC) dissector, an
argon gas source & high frequency voltage generator.
• APC dissector rigid tube with a ceramic tip through which
argon flows to the tip electrode serves as one pole
frequency voltage source
Pros limited penetration & good coagulative properties 
minimizing blood loss & postoperative pain.
less postoperative haemorrhage >diathermy
Cons more complications and longer operating time

36. Harmonic scalpel (ultrasound)
tonsillectomy
• Two mechanisms to cut and coagulate tissue.
1. sharp blade vibrating at 55.5 kHz over a distance
of 80 mm.
2. The rapid forward and backward motion of the
cutting tip in contact with tissue
fragmentation and separation of tissue planes
Coagulation mechanical disruption hydrogen
bonds and thus protein denaturation

37. Harmonic scalpel (ultrasound)
tonsillectomy
• Temperature rise frictional
changes(50–100˚c)
• Pros improved visibility
• less force and tissue tension
for incisions >traditional
• Cons intraoperative blood
loss and postoperative
haemorhage rates were
similar

38. Guillotine tonsillectomy
• most suitable for protuberant tonsils in the
paediatric population
• The tonsil is pushed fully through the
guillotine closed
• All tonsil tissue is through the guillotine and
no anterior pillar mucosa is caught in the
guillotine.
• If the tonsil cannot be completely fitted
through the guillotine abandoned.
• Once the guillotine is closed a minute to
compress vessels in the lower pole before
cutting off the tonsil

39. Pros less pain and greater speed
Cons  excessive trauma to pillars,
postoperative bleeding from an inadequately removed
lower pole and persistent infection in tonsil remnants

40. Hemorrhage

41. Postoperative care
• Introduction
• Postoperative pain & analgesia
• Antiemetic therapy post-tonsillectomy
• Diet post-tonsillectomy
• Adjunctive therapy: local anaesthesia,
antibiotics and steroids

42. Postoperative care
• Tonsillectomy Discussionday case or overnight stay
–ongoing
Favours
• Economic benefits
• Minimal morbidity
• Low reactionary haemorrhage rate after eight hours
(0.49percent)
• Reasonable ability to control pain and nausea

43. The criteria for day case tonsillectomy
• an available competent adult at home to manage
potential problems
• access to a car to return the patient to hospital;
• access to a telephone
• a home-to-hospital driving time of less than
20minutes;
• no medical contraindications

44. Postoperative care
• Monitoring for haemorrhage most important aspect of
post-tonsillectomy care
Clinical observation
• Excessive swallowing
• Pallor
• Increases in pulse rate
• Monitoring blood volumes coughing or vomiting up
blood ,assess the bleeding point.
• Record blood losses in theatre, in recovery and ward

45. • Total expected patient blood volumes
100mL/kg
• All cases of reactionary haemorrhage in children
theatre in order to obtain reliable control.
• In adults greater blood volume short period
of conservative treatment attempted prior to
surgical reintervention.

46. POSTOPERATIVE PAIN/ANALGESIA
REQUIREMENTS
• Little informationpracticeindividualized
• paracetamol (20 mg/kg) and diclofenac (1
mg/kg), except in asthmatics, two hours
preoperatively as well as the uniform
postoperative prescription of up to 100 mg/kg
of paracetamol and 3 mg/kg of diclofenac in
24 hours with DF118 as rescue analgesia

47. POSTOPERATIVE PAIN/ANALGESIA
REQUIREMENTS
• NSAIDs, for example ketoprofen combined with full dosages
of paracetamol and codeine as rescue analgesia was
sufficient
• Median time for cessation of pain 11 (3–24) days
• Median duration of analgesia taken of 12 (5–25) days.
• Median time for cessation of pain on drinking (1–18) &
on eating solids 11 (1–20) days.
• First normal night of sleep at 7(0–18) days
• Normal daily activities 12 (2–24) days

48. ANTIEMETIC THERAPY POST-
TONSILLECTOMY
• Prophylactic single-dose antiemetic therapy
using ondansetron or other selective 5HT type
3 receptor antagonists
DIET POST-TONSILLECTOMY
• No evidence rate of recovery or
complication rates

49. ADJUNCTIVE THERAPY: LOCAL
ANAESTHESIA, ANTIBIOTICS
AND STEROIDS
• Perioperative injection LA pain reduction, diminished
perioperative bleeding and facilitation of dissection
New metaanalysis
• Postoperative oral antibiotics pain(no role) but earlier
return to normal activity1 day
• single intraoperative dose of dexamethasone -↓emesis
first 24 hours & ↑ soft or solid diet on postoperative day 1
• Intravenous hydration for 24 hours postsurgery reduced
postoperative pain

50. Complication

53. Reactionary haemorrhage
• Bleeding peroperatively and within the first 24
hoursmost feared complication
↓
• Risk of airway obstruction
• Shock
• Death if inappropriately treated or untreated.

54. SECONDARY HAEMORRHAGE
• More common than is widely appreciated
• 9 percent of cases  1.4 percent were severe
requiring a return to theatre.
• ↑ with age, peaking between 30 and 34 years
• Serious haemorrhage ↑ in older age
• Most (70 percent) present between days 4 and 7

55. POSTOPERATIVE FEVER
• No association between colony count, core
cultures, blood cultures and fever
• suggesting that fever is not caused by
infection not require antibiotics

56. Tonsillectomy outcomes
• Short term deficits in cellular and humoral
immunity up to six months in children
following adeno-tonsillectomy

57. Bibliography
• Scott-Brown's Otorhinolaryngology and Head
and Neck Surgery
• Rob & Smith’s Operative Surgery
• Dhingra’s Diseases Of Ear, Nose And Throat &
Head And Neck Surger

58. Next presentation
• Case presentation by Dr. Bimal Pokharel on
Friday

59. Thank you

60. • General anaesthesia In adults, cuffed endotracheal tubes are preferable
• Appropriate exposure Boyle Davis mouth gag.
In all techniques apart from guillotine tonsillectomy
• Tonsil is grasped and retracted forcefully towards the
• midline indentification intended plane of dissection,
↓
Soft areolar tissue between the capsule of the tonsil & the constrictor muscle of the
pharynx.
• The surgical plane is then entered minimal loss of or trauma to the mucosal
tissue of the anterior pillar of the fauces and uvula.
Instruments directed at the tonsil rather than laterally into the tonsillar fossa