ISSN 1808-8686 (on-line)

10/11/2015

s selected for print:

2768 - Vol. 67 / Ed 3 / in 2001

Section: Artigos Originais

Pages: 319 to 324

Authors:
Edson C. M. Monteiro*,

Tonsillectomy: Dissected x Sluder.

Fabiana M. N. Rocha**,
Erika Y. Ikeda**,
Ctia M. R. Lemes***,
Giovana P.
Dall'Oglio****.

Keywords: tonsillectomy, conventional dissection, Sluder's guillotine

Abstract: Introduction: The tonsyllectomy by Sluder technique hasn't been used for many
complications in the present. The aim of this study was to compare the morbidity in Sluder
and conventional dissection technique. Study design: Clinical prospective. Material and
method: We studied a hundred children with hypertrophics tonsills who underwent a
tonsyllectomy by conventional dissection and Sluder tecnique, where was made a
questionary. Results: The Sluder technique had a minor surgical time and bleeding than
conventional dissection technique. The post-operative analysis proved better clinic
recovery in the Sluder technique. Conclusion: We concluded that both techniques are
resolutive however the Sluder technique suggested statically minor morbidity.
INTRODUCTION
Resection surgeries of palatine tonsils and adenoids, especially those indicated in
adenotonsillar hypertrophy, leading to impairment of breathing in children, are ancient
procedures and restricted to few techniques5,6,11,13,14. In recent years, authors have
frequently employed traditional dissection by detachment, putting aside the technique
described by Sluder.
According to some authors, in the eight published volumes of Medical Encyclopedia,
dated the year 3 AD, Cornelius Caesus provided one of the first descriptions of
tonsifectomy9. The most common procedure is dissection by traditional method13, and
most recently, by laser.

Tonsillectomy using Sluder tonsillectome is no longer a used technique because of clinical

risks unfairly imputed to the surgery, which were partly caused by anesthetic procedures.
We performed a comparative study between Sluder's technique and traditional dissection,
under general anesthesia and with orotracheal intubation, in order to analyze morbidity
comparing both procedures.
MATERIAL AND METHOD
Between November 1997 and June 1998, we studied children who underwent
adenotonsillectomy in the age range from 4 to 8 years. The surgical indication was due to
upper respiratory obstruction affections caused by adenoid and tonsil hypertrophy.
Selected cases were submitted to nasofibroscopy to confirm enlargement of adenoids.
Next, we checked the need for adenotonsillectomy and not only tonsillectomy.
Classification of size of palatine tonsils
Size of palatine tonsils was classified according to the following criteria (Figure 1):
A - Small - tonsils aligned with the palatoglossal folds (anterior pillar);
B -Moderate - projection of tonsils between palatoglossal folds (anterior pillar) and
midline (uvula);
C -Large - tonsils reach the midline that goes through the uvula.
In our study, we selected cases that had palatine tonsil hypertrophy classified as large.
We subdivided the subjects into two groups:
Group 1 - conventional dissection (50 cases);
Group 2 - dissection with Sluder guillotine (50 cases).
We also designed a protocol that was filled in by the responsible surgeon.

Figure 1. Classification of size of tonsils.

Criteria for evaluation of method

The study involved more than 100 patients but we selected only those that met the criteria
determined for the study (protocol). The cases included actually came to post-operative
visits. Cases not followed during the postoperative period were excluded from the sample.
The surgical time was counted as from the moment the mouth opener was introduced,
until its final removal. Blood losses were measured in milliliters found in the aspiration
tube.
In the comparative study we used two statistical tests: independent t test (for numerical
information) and quisquare test (for categorized information). In the independent t test (p),
we considered statistically significant difference if p was equal or below 0.05. In the quisquare test, we considered statistically significant difference if the value observed was
equal or below the critical value.
Description of conventional dissection method
The patient was positioned at Rose's position, under general anesthesia with Halothane
(halogen anesthetic) and orotracheal intubation, placing Mc'Ivor mouth opener and gauze
anchored on the hypophatynx.
After visualization, the tonsils were pulled medially with a Brunnings' clamp,
perpendicular to the pillar. Pharyngeal mucosa was incised at the level of the anterior
pillar (Figure 2), with a knife number 12, from the lingual fold up to the posterior pole. We
looked for the tonsil capsule, and using Hurd's aspirator-detacher (Figure 3), we released
the tonsil from the lateral wall of pharynx with cranio-caudal firm movements, reaching
the inferior pole until complete exeresis of the tonsil (Figure 4). Alternatively, we cut the
tonsil pedicle using Metzembaum curved scissors (Figure 5). Next, we made hemostasis
with gauze and, if necessary, we sutured with simple catgut 2-0. The same procedure was
followed on the other side.

Figure 2. Incision of pharyngeal mucosa at the level of anterior pillar.

Figure 3. Dissection of tonsillar capsule.

Figure 4. Detachment of tonsil from the inferior pole.

Figure 5. Exeresis of tonsil.

Figure 6. Placement of tonsil (inferior pole) in Sluder's guillotine.

Figure 7. Pressure of anterior pillar with the indicator finger of the opposite hand.

Description of dissection method with Sluder guillotine.

The patient was placed in a semi-seated position, forming a 45 angle from the horizontal
plan, under general anesthesia with Halothane (halogen anesthetic) and orotracheal

intubation; we placed Studer's mouth opener to expose the tonsils. We used anchored
gauze on the hypopharynx to protect the lower airways. Next, we placed the inferior pole
in the Studer guillotine (Figure 6), aided by the indicator finger of the opposite hand that
pressed the anterior pillar (Figure 7), trying to protect the uvula and the muscles. Next, we
pressed firmly the guillotine, making a clockwise upwards rotation movement on the right
tonsil site (Figure 8) and anti-clockwise on the left tonsil site, to the lateral, resulting in
medial, inferior and posterior vectors. At that point, after having dissected completely the
tonsil, we used the indicator finger in hook (Figure 9) and maintained the pulled guillotine
in order to extract the tonsils. Next, we proceeded with hemostasis using anchored gauze.
If necessary, we used simple catgut 2-0 for suture.

Figure 8. Guillotine closure using clockwise rotation movements.

Figure 9. Dissection of tonsil with opposed indicator finger up to its extraction.

RESULTS
In order to analyze the results, we compiled data in tables.
Table 1 analyze the duration of surgery in minutes for both techniques. We observed,
after using independent t test (p), that Sluder's technique takes significantly less time than
the dissected technique (p<0.001). In Table 2, comparing blood loss in milliliters, there

was no statistically significant difference between the techniques (p=0.229).

Table 3 shows the number of ligations demonstrating that in Sluder's technique the number
of ligation was statistically significant lower than in the dissected technique (p=0.044).
As to debris of tonsil site (Table 4), we did not notice statistically significant differences
between the surgical techniques using qui-square test, and the observed value was 0.00
and critical value was 3.84.
Table 5 analyzes the presence of fever on postoperative days 1, 7 and 14. We used quisquare test to analyze it. On the first post-operative day, the observed value was 1.92 and
the critical value was 3.84; on days 7 and 14, the observed value was 0.00 and the critical
value was 3.84. We concluded, therefore, that there were no statistically significant
differences between the techniques concerning fever.
TABLE 1 - Duration of surgery in minutes.

TABLE 2 - Blood loss in milliliter.

TABLE 3 - Number of ligations.

TABLE 4 - Tonsillar debris.

Key: N - number of cases.

TABLE 5 - Fever on post-op days 1, 7 and 14.

Key: N - Number of cases.

TABLE 6 - Bleeding on post-op days 1, 7 and 14.

We observed bleeding (Table 6) with both techniques on post-operative days 1, 7 and 14

and we did not detect statistically significant difference with qui-square test (observed
value = 0.00; critical value = 3.84).
Table 7 demonstrates post-operative pain (post-op days 1, 7 and 14). When we applied the
qui-square test, there was no statistically significant difference on day one (observed value
= 0.05 and critical value = 5.99), on day seven (observed value = 1.30 and critical value =
3.84) or on day 14 (observed value = 0.00 and critical value = 3.84).
DISCUSSION
Reduction of morbidity in tonsillectomy benefits the patients, reducing hospital and drug
costs1,3,7,11. Owing to a number of objections to the use of Sluder's technique, the
procedure has lately become unpopular2,12, and therefore, there are no current medical
residence programs that train young physicians on how to use Sluder tonsillectome. The
reported disadvantages of the technique were lack of control of blood loss, remaining
tonsil debris, accidents such as uvulectomy, partial accidental glossectomy and pillar
damage, as well as blood aspiration into the lower respiratory trees10. However, some
authors reported low incidence of post-operative bleeding and presented as one of the
main advantages the speed of the procedure13, showing that appropriate application of the
technique results in safe removal of tonsils, with no damage to other structures. The risk
and unacceptable habit of using Sluder's guillotine without orotracheal intubation should
not doom a good technique to failure, but it is in fact a dangerous technique depending on
the kind of anesthesia used. Tonsillectomy with Sluder's technique may be considered a
good option provided that it is appropriately employed, by experienced surgeons and
under orotracheal intubation. If patients are intubated, well monitored and under
appropriate care, all surgical procedures are safe, and Sluder's guillotine does bring
advantages to the surgeon and the patient, as we concluded in the present study.
TABLE 7 - Pain on post-op days 1, 7 and 14.
(TABELA 7, PG. 324)
CONCLUSION
Based on the results, we concluded that:
- both procedures are equally good and efficient;

- tonsillectomy using Sluder's guillotine is statistically faster, requiring a smaller number

of intra-operative ligations;
- analysis of morbidity was similar in both groups.
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* Otorhinolaryngologist, Coordinator of the Advanced Course in Otorhinolaryngology at
CLINORL - Institute, de Otorrinolaringologia a Oftalmologia, So Paulo/SP
** Resident Physician at CLINORL - Instituto de Otorrinolaringologia a Oftalmologia,
So Paulo/SP
*** Otorhinolaryngologist at CLINORL - Instituto de Otorrinolaringologia a
Oftalmologia, So Paulo/SP
**** Otorhinolaryngologist, Former Resident at CLINORL - Instituto de
Otorrinolaringologia a Oftalmologia, So Paulo/SP
Study conducted at CLINORL - Instituto de Otorrinolaringologia a Oftalmologia, So
Paulo /SP, and presented at the 34 Congresso Brasileiro de Otorrinolaringologia, on
November 22, 1998, in Porto Alegre/RS.

Address correspondence to: Edson Carlos Miranda Monteiro - Av. Lencio de Magalhes,
750 - 02042-000 So Paulo/SP - Tel: (55 11) 6950-2339.
E-mail: clin_orl@uol.com.br
Article submitted on June 26. 2000. Article accepted on January 18, 2001.