Tuesday, December 28, 2010

Tonsillectomy

Indications
They are d ivided inro:
A. Absolute
1. ReculTent infections of throat. This is the most common
indication. Recurrent infections are further defi ned as:
(a) Seven or more episodes in one year, or
(b) Five episodes per year fo r 2 years, or
(c) Three ep isodes per year for 3 years, or
(d) Two weeks or more of lost sch ool or work in one
year.
2. PeritonsiliLlr absces~. In children, tonsillectomy is done
4-6 weeks after abscess has been treated. In adults,
second attack of peri tonsillar abscess forms the
ahsolute indication.
3. Tons ill itis causing febrile se izures.
4. H ypertro phy of tonsils causing
• airway obstruction (s leep apnoea)
• difficul ty in deglutition
• interfe re nce with speech.
5. Suspici.on of malignancy'. A unilaterally enlarged tonsil
may be a lymphoma in c hildren and an epidermoid
carcinoma in adults. An excisional biopsy is done.
B. Relative
1. Diphther ia carriers, who do not respond to antibiotics.
2. Streptococcal carriers , who may be the source of
infection to orhers.
3. Chronic tonsillitis with bad tas te or halitosis which
is unresportS ive to medical treatment.
4. Recurrent streptocccal tonsillitis in a patient with
valvular heart disease.
C. 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.
Contraindications
1. Haemoglobin level less than 10 g%
2. Presence of acute infection in upper respira tory
tract, even ac ute tonsillit is. Bleeding is more in the
presence of acute infection.
3. Children under 3 years of age. They are at poor
surgica I risks.
4. Overt or submucous cleft palate.
5. Bleeding disorders, e.g. leukaemia, purp ura, aplastic
anaemia, haemophilia.
6. At the time of epidemic of polio.
7. Uncontrolled systemic disease, e.g. diabetes, cardiac
disease, hypertension or asthma.
S. Tonsillectomy is avoided during the period of menses.
Anaesthesia
Usually done under ge neral anaesthesia with endotracheal
intubatio n. In adu lts, it may be done under loca l
anaest hesia.
Position
Rose's position, i. e. patient lies supine with head
extended by plac ing a pillow under the shoulders. A rubber
ring is placed under the head to stabilise it (Fig. 90.1).
Hyperextension shou ld always be avo ided.
Steps of Operation (Dissection and
Snare Method)
1. Boyle-Davis mouth gag is introduced and opened. It
is held 111 place by Draffin 's bipods or a string over a
pulley (Fig. 90.2).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 po le to mucous membrane
between the tonsil and posterior pillar.
4. A blunt curved sc issor 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 trac tion
applied downwards and media ll y. Dissection is continued
with tonsillar dissector or scissors until lower
pole is reached (Fig. 90.3).
6. Now wire loop of tonsillar snare is threaded \.wer 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.
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. purse, respiration and
blood pressure.
2. Diet. When patient is fully recovered he is permitted
to take liquids, e.g. cold milk or ice cream. Sucking of ice
cubes gives relief from pain. Diet is gradually built from soft
to solid food. They may take custard, jell y, soft boiled eggs
or slice of bread soaked in milk on the 2nd day. Plenty of flu ids
should be encouraged.
3. Oral hygiene. Patient is given Condy's or salt
water gargles 3-4 times a da y. 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· giv en
rally or by injection for a week.Patient is usually sent home 24 hou rs after operation
unless there is some complication. Patient can resume his
normal duties within 2 weeks.
Other methods for tonsillectomy (Table 90.1)
1. Guillotine method Largely abandoned. It can be
done ani y when tonsils are mobile and tonsil bed has not
been scarred by repeated infections.
2. Electrocautery. Both unipo lar and bipolar e lectrocautery
has been used. It reduces blood loss but causes
thermal injurr to tissues.
3. Laser tonsillectomy. !t is indica ted in coagu lat ion disorde
rs. Both KTP-5 I 2 and CO2 lasers have been used but
the former is preferred. Technique is similar to one used in
dissection method.
4. Laser ronsillorom)' , 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
ante rior pillars by stage repeated applications.
5. Intmcapsular tonsillectomy. With the use of powered
instruments (debrided tonsil is removed but its capsule is
preserved in the hope to reduce post-operative pain.
6. Harmonic scalpel. It uses ultrasound to cut and coagulate
tissues. It is a cold method with less tissue damage
and post-operative pain compared to electrocautery
t,echnqu e.
7. 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.
8. Coblation tonsil/ectom)'.
9. Cr)'osurgical technique. Tonsil is frozen by app lication
of cryoprobe and then allowed to thaw. Two applications,
each of 3-4 minutes, are applied. Tons illar tissue will
undergo necrosis and later fall off leav ing a granulating
surface. Bleeding is less due to thrombosis of vesse ls
caused by freezing.
Complications
A. Immediate
1. Primary haemorrhage. Occurs at the time of operation.
It can be contro lled 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.
Presence of a clot prevents the clipping action of
the superior constrictor muscle on the vessels which pass
through it (compare post-partum uterine bleeding). If
above measures fail, ligation or electrocoagulation of the
bleeding vessels can be done under general anaesthesia.
3. Injur)' to tonsillar pillars, uvula, soft palate, tongue or
superior constrictor muscle due to bad surgical technique.
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 (()
superior constrictor muscle.
B. Delayed
1. Secondary haemorrhage . Usually seen between the 5rh
to 10th posr-ope rative day. It is the result of sepsis and
premature separation of the membrane. Usually, it is heralded
by bloodstained sputum but may be profuse.
Sim ple measu res like removal of clot, topical application
of dilute adrenaline or hydrogen peroxide with pressure
usually suffice. For profuse bleeding, genera l
anaesthesia is given and bleeding vessel is electrocoaglllated
or ligated. Sometimes, approximation of pillar.with
mattress sutures may be required. Sometimes, external
carotid ligation may also be required.
Transfu sion of blood or plasma, depending on blooJ
loss, is given. Systemic antibiotics are given for control or
infection.
2. Infection. Infection of tonsillar fossa may lead t(
parapharyngeal abscess or otitis med ia.
3. Lung complications. Asp irat ion of blood, mucus ,lr
tissue fragments may cause atelectasis or lung abscess.
4. Scarring in soft palate and pillars.
5. Tonsillar remnants. Tonsil tags or tissue, left due tl
inadequate surgery, may get repeated ly infected.
6. Hypertrophy of lingual tonsil. This is a late complication
and is compensatory to loss of palati ne tonsils.
Sometimes, lymphoid tissue is left in the plica triangu ,
laris near the lower pole of tonsil, which later gets hype rtrophied.
Plica triangularis should, therefore be removed
during tonsillectomy.

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