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    4. Tonsillectomy & Adenoidectomy

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    4. Tonsillectomy & Adenoidectomy

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    9 views72 pages

    4. Tonsillectomy & Adenoidectomy

    Uploaded by

    pkvmkcfchs

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    © All Rights Reserved
    Download as PPT, PDF, TXT or read online from Scribd
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    Tonsillectomy

    Adenoidectomy
    & Quinsy
    Dr. Vishal Sharma
    History
    Cornelius Celsus first described tonsillectomy by
    finger dissection in 30 A.D. Used vinegar for
    hemostasis.
    Philip Physick developed tonsillotome in early
    1800s
    In 1867 Wilhelm Meyer reports removal of adenoid
    through nose with a ring knife
    George Waugh first described complete
    tonsillectomy in 1909
    Tonsillectomy
    Indications
    • Local indications

    • Focal indications

    • Systemic indications

    • As part of other surgery


    Local indications
    1. Recurrent tonsillitis:  7 episodes in 1 yr or
    5 episodes / yr  2 yr or 3 episodes / yr  3 yr
    2. Quinsy (2nd attack)
    3. Intra tonsillar abscess
    4. Malignant / benign tumour
    5. Tonsil enlargement with stridor / dysphagia
    6. Tonsillolith / tonsillar cyst with halitosis
    7. Impacted foreign body
    Focal indications
    Tonsil acts as focus of infection in:

    1. Suppurative otitis media

    2. Chronic jugulo-digastric node enlargement

    3. Chronic tuberculous node enlargement


    Systemic indications
    1. Rheumatic fever with arthritis
    2. Sub-acute bacterial endocarditis
    3. Glomerulonephritis
    4. Diphtheria carrier
    5. Chronic bronchitis / bronchial asthma
    6. Phlyctenular conjunctivitis
    7. Urticaria / erythema 8. Failure to thrive
    As part of other surgery

    1. Stylalgia (Eagle syndrome)

    2. Glossopharyngeal neuralgia

    3. Uvulopalatopharyngoplasty in sleep apnea

    4. Branchial fistula
    Contraindications
    Age < 3 yr  limited space; immunity is lost;

    blood loss not tolerated; lingual tonsil ed

    Acute infection  bleeds more

    Aneurysm of internal carotid or tonsillar artery

    Bleeding disorder  hemophilia

    Cleft palate  rhinolalia aperta


    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
    Types of Tonsillectomy
    • Subcapsular total tonsillectomy:

    Removes tonsil tissue completely.

    • Intracapsular tonsillectomy:

    Removes 90% of tonsils leaving behind a layer

    of tonsil tissue. It protects tonsillar bed &

    reduces post-op pain + recovery time. Not

    appropriate for recurrent tonsillitis.


    Subcapsular tonsillectomy
    Intracapsular tonsillectomy
    Methods of tonsillectomy
    Cold Hot
    Dissection & snare Electro-cautery

    Microdebrider Laser

    Harmonic scalpel Radiofrequency coblation

    Cryosurgery

    Cold knife

    Guillotine section: obsolete


    Tonsillectomy by
    Dissection &
    Snare Technique
    Rose Position & mouth gag
    Tonsil holding forceps
    Incision
    Mollison’s tonsil dissector
    + anterior pillar retractor
    Blunt dissection
    Cutting of triangular ligament
    Eve’s tonsillar snare
    Snaring & Haemostasis
    Birkett straight artery
    forceps
    Negus replacement artery
    forceps
    Negus ligature pusher
    Steps for tonsillectomy
    1. Rose position: pt supine with extension of
    neck & atlanto-occiptal joint.

    2. Boyle Davis mouth gag inserted & fixed with


    Draffin’s bipod & Mac Gauren’s plate.

    3. Incision made b/w tonsil & anterior pillar.

    4. Tonsil dissected from its base, till lower pole


    with tonsil dissector.
    Steps for tonsillectomy
    5. Lower tonsil pedicle snared with Eve’s

    tonsillar snare.

    6. Tonsil removed. Tonsil fossa packed with

    H2O2 soaked gauze for 5 min.

    7. Bleeder ligated with silk suture or cauterized

    by bi-polar cautery.
    Micro-debrider
    Ultrasonic Harmonic scalpel
    Ultrasonic Harmonic scalpel
    Cryosurgery
    Cold knife
    Guillotine
    Electro-cautery
    Laser tonsillectomy
    Bipolar radiofrequency
    Post-operative advice
    1. Inform surgeon immediately in case of
     fever above 100 degrees F
     difficulty in breathing or swallowing
     excessive bleeding from oral cavity
    2. Eat soft foods & ice-cream
    3. Encourage swallowing & gum chewing
    4. Drink plenty of fluids. Avoid citrus fruit juice.
    5. Two white patches will form in tonsil fossa
    Early Complications ( 24 hrs)
    Surgical Anesthetic

    1. Hemorrhage 1. Aspiration
     Primary (operative) 2. Cardiac arrest
     Reactionary ( < 24 hr)
    2. Injury to lip / teeth / uvula / pillars
    3. Surgical emphysema
    4. Tonsil remnant
    Late Complications (> 24 hrs)
    Surgical Anesthetic
    1. Secondary hemorrhage 1. Lung collapse
    2. Scarring of soft palate 
    velo pharyngeal insufficiency
    3. Lingual tonsil hypertrophy
    4. Tonsil fossa infection
    5. Granular pharyngitis
    Tonsillectomy Hemorrhage
    Primary hemorrhage occurs during surgery,

    due to injury to blood vessels. Normal = 80 ml.

    Reactionary hemorrhage occurs within 24 hr of

    surgery (commonly within 8 hr).

    Secondary hemorrhage occurs after 24 hr

    (commonly 6th - 8th day); due to infection.


    Causes for reactionary hge
    1. Slipping of ligature.

    2. Displacement of clot

    3. Re-opening of collapsed blood vessels

    (caused by  B.P. due to cough / retching /

    wearing off effect of hypotensive anesthesia)

    4. Clots in tonsil fossa  prevent contraction of

    superior constrictor (required for hemostasis)


    Post-op tonsillar bleeding
     Remove blood clots from tonsil fossa

     H2O2 gargle (causes thermal cautery + vaso-

    constriction by releasing nascent oxygen)

     Pressure gauze packing of fossa for 5 min

     bleeding continues

    Shift 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


    Bleeder identified?
    Yes No

     Ligation or  Adrenaline pack or

     Bipolar cautery  AgNO3 application or

     Tincture benzoin paint

     Bleeding 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 & not Internal carotid artery)

    • Ligation done in neck via incision made along

    anterior border of sternomastoid.


    Adenoidectomy
    Adenoidectomy
    First do adenoidectomy then tonsillectomy
    (haemostasis is by blind nasopharynx packing)

    Indications: adenoids with


    1. Adenoid facies 2. Sleep apnea / snoring
    3. Rhinolalia clausa 4. Recurrent sinusitis
    5. Refractory O.M.E. 6. C.S.O.M.
    Tonsillectomy &
    Adenoidectomy positions
    Adenoid curette with guard
    Procedure
    Procedure
    • Rose position with AO joint in neutral position

    • Mouth gag inserted, finger palpation done for:

    1. size of adenoid. 2. bring adenoid in midline

    3. check position of Eustachian tube.

    • Adenoid curetted keeping head slightly flexed to


    avoid trauma to atlanto – occipital joint.

    • Nasopharyngeal pack put for 5 min.


    Adenoidectomy specimen
    Microdebrider adenoidectomy
    Complications
    1. Hemorrhage  10, R0, 20  post nasal pack
    2. Damage to E.T. orifice  scarring  O.M.E.
    3. Subluxation of Atlanto-Occipital joint 
    torticollis (Griesel disease)
    4. Velopharyngeal insufficiency  nasal twang +
    regurgitation from nose
    5. Nasopharyngeal scarring & stenosis
    6. Adenoid remnant
    Contraindications

    • Acute infection

    • Bleeding disorders

    • Cleft palate: adenoidectomy will make

    symptoms worse
    Peritonsillar
    abscess or Quinsy
    Etiopathogenesis
    Pus present between tonsillar capsule &

    superior constrictor muscle.


    Pathology: aerobic + anaerobic organisms
    1. Acute tonsillitis  blockage of crypts  intra
    tonsillar abscess  peritonsillitis  quinsy
    2. Abscess of Weber's salivary gland in supra
    tonsillar fossa  quinsy
    Clinical features
    Symptoms: Young adult with severe odyno-

    phagia, fever, halitosis & muffled voice

    Signs: 1. Para-tonsil area swollen & congested

    2. U/L tonsil ed, pushed medially, congested

    3. Jugulo-digastric lymph node tender, ed

    4. Trismus

    5. Torticollis
    Peri-tonsillitis & Quinsy
    Management
    Diagnosis:
    Needle aspiration  reveals pus
    Medical treatment:
    1. Urgent admission, I.V. fluids
    2. I.V. Cefotaxime + Metronidazole
    3. Antihistamine - decongestant + analgesic
    4. Betadine gargle
    Needle aspiration
    Incision
    Incision line & quinsy forceps
    Alternate incision site at
    maximum bulge
    Abscess drainage
    Incision drainage
    • Incision made with # 11 blade or Thilenius
    peritonsillar abscess drainage forceps.

    • Nick made above & lateral to junction of 2


    imaginary lines. Horizontal along base of uvula,
    vertical along anterior tonsillar pillar.

    • Incision widened with sinus forceps & pus


    drained. No anesthesia is required.
    Surgical treatment
    1. Interval tonsillectomy  after 4 – 6 wk.

    2. Hot tonsillectomy or abscess tonsillectomy is

    avoided as it leads to:

     more bleeding

     septicemia
    Complications of quinsy
    1. Parapharyngeal abscess

    2. Retropharyngeal abscess

    3. Laryngitis & laryngeal oedema

    4. Lung abscess

    5. Internal jugular vein thrombosis

    6. Septicemia
    Thank You

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