Surgical Adenoidectomy and tonsillectomy

1. ADENOIDECTOMY AND
TONSILLECTOMY
Dr Joel G Mathew

2. ADENOIDECTOMY

3. ADENOIDECTOMY - INDICATIONS
• Adenoid hypertrophy causing:
• Otitis media with effusion (SOM)
• Upper airway obstruction and
obstructive sleep apnoea
• Recurrent acute otitis media
• Recurrent rhinosinusitis (Abolishing
infective episodes)

4. ADENOIDECTOMY - CONTRAINDICATIONS
• Acute upper respiratory infections
• Acute epidemic of Poliomyelitis-
>Paralytic polio (Exposed nerves)
• Bleeding disorders and Anaemia
• Cleft Palate
• Overt cleft palate

5. SUBMUCOUS CLEFT PALATE (COVERT)
• Abnormal nasal speech,
• Bifid uvula
• Thin strip of mucosa in the
middle of roof of mouth
• Notch at the back of hard
palate.

6. ADENOIDECTOMY - PROCEDURE
• Anaesthesia – General
Anaesthesia
• If combined,
Adenoidectomy before
Tonsillectomy

7. POSITION – ROSE’S POSITION
Supine with head extended by placing a
pillow or sandbag beneath the
shoulders.
Advantage –
Larynx lies at a higher level than oral
cavity – no risk of aspiration.
Excellent exposure
Both hands of surgeon are free.
Hyperextension is avoided
Makes cervical vertebral bodies
prominent-Damage to ligaments or
cartilages of vertebral spine or
bodies -> Grisel’s syndrome

8. GRISEL’S SYNDROME
• Non traumatic subluxation of atlanto axial joint
• Results from any condition that results in hyperaemia and
pathological relaxation of the transverse ligament of the
atlanto-axial joint.
• Due to infection in the periodontoid vascular plexus that
drains the region->paraspinal ligament laxity.
• Presents with persistent neck pain and torticollis 1-2 weeks
following surgery.
• More common in Down’s syndrome patients
• X-ray and CT of Cervical spine confirms diagnosis.
• Treatment: Cervical immobilisation , analgesics and
antibiotics. Arthrodesis in intractable cases

9. TECHNIQUE OF ADENOIDECTOMY
• The surgeon stands behind the patient.
• Boyle-Davis mouth gag is inserted, opened and
held in place by Draffin’s bipod stand
• Palate is palpated to exclude a submucous cleft
palate.
• The soft palate is retracted by a suction catheter
introduced through the nose, and pulled out of
the oral cavity.
• The adenoid is palpated with a finger.

10. • St Clair Thomson adenoid curette with
guard is introduced into the nasopharynx
above the upper end of adenoid tissue,
“held like a dagger”
• With a downward and forward sweeping
movement, adenoids are shaved off.
• A smaller sized curette is used to curette the
adenoids around the choana and the
Eustachian cushions
• Nasopharynx is packed with gauze packs
for a few minutes for haemostasis.

11. OTHER TECHNIQUES OF ADENOIDECTOMY
• Suction coagulator/diathermy
• Endoscopic transnasal or transpalatal adenoidectomy with microdebrider
• Coblator plasma field device

12. POSTOPERATIVE CARE
• The patient is kept in lateral position
• Kept nil orally until fully recovered from GA (4-6 hours).
• Monitor vitals
• Watch for bleeding: Earliest sign-”Frequent swallowing”
• Oral antibiotics and analgesics

13. COMPLICATIONS
• Haemorrhage ( < 0.7%) – Managed by postnasal packing.
• Surgical trauma:
• Teeth
• Soft palate
• Uvula
• Eustachian cushions-stenosis, secretory otitis media
• Cervical spine-atlantoaxial dislocation
• Velopharyngeal insufficiency
• Hypernasal speech, swallowing difficulty and rarely nasal regurgitation
• Adenoid remnant (Upto 29%)
• Pulmonary complications-Aspiration,“Coroner’s clot”
• Infection of Nasopharynx.

14. TONSILLECTOMY

15. TONSILLECTOMY-INDICATIONS
Absolute Indications:
 Obstructive
symptoms and
Obstructive sleep
apnoea
 Malignancy or
suspected
malignancy
 Recurrent
peritonsillar abscess
 Tonsillitis causing
febrile seizures in
children
Relative Indications:
Recurrent tonsillitis:
 >= 7 episodes in 1 year
 >=4 episodes per year for 2 consecutive
years
 >= 3 episodes per year for 3 consecutive
years
Halitosis due to chronic tonsillitis
Tonsilloliths
Tonsillar cysts
Dental and orofacial abnormalities
Dipheria carriers
Rheumatic fever and Acute
glomerulonephritis

16. TONSILLECTOMY AS PART OF ANOTHER
PROCEDURE
• Excision of elongated styloid process (Eagle syndrome) – Nagging throat pain and a
palpatory finding in the tonsillar fossa. Confirmed by palpation and injection of
anaesthetic.
• Glossopharyngeal neuralgia
• UPPP (Uvulopalatopharyngoplasty)or LAUP (Laser-assisted uvulopalatoplasty) or
CAUP (Coblation assisted uvulopalatoplasty)

17. CONTRAINDICATIONS
• Bleeding disorders
• Cleft palate or submucous cleft palate
• Velopharyngeal insufficiency
• Acute infection
• Uncontrolled systemic disease
• Anaemia
• Extremes of age

18. PROCEDURE
• Anaesthesia: General anaesthesia
• Position-Rose’s position-supine with head extended by placing a pillow or sandbag
under the shoulder
• Operative techniques
• DISSECTION AND SNARING -> Classical
• Diathermy
• Coblation tonsillectomy
• Ultrasonic dissection
• Laser tonsillectomy
• Capsulotomy techniques
• Guillotine method (Ancient)

19. DISSECTION AND SNARE METHOD
• Boyle Davis mouth gag is inserted, opened and held in position
with Draffin’s bipod stand
• Upper pole of tonsil is held with tonsil holding forceps and pulled
medially
• Mucosa is incised with blunt scissors, knife, forceps or diathermy
at the point where it reflects from tonsil to anterior pillar. Incision
is continued inferiorly towards base of tongue.
• The tonsil is separated from its bed by blunt dissection, upto the
lower pole
• The plane of dissection is the loose areolar tissue separating
tonsil from its bed.

20. • Once lower pole is reached, a tonsillar snare is passed over the tonsil holding
forceps, placed over the tonsil, threaded down to the lower pole, tightened to crush
the pedicle, and the tonsil is removed
• Gauze packs are kept in the tonsillar fossa
• Bleeding points are looked for, and bleeding arrested with non absorbable sutures

22. POSTOPERATIVE CARE
• Patient is nursed in the lateral position
• Kept nil orally until fully recovered from GA (4-6 hours).
• Monitor vitals
• Watch for bleeding: Earliest sign-”Frequent swallowing”
• Ice cold fluids and ice cream given on the first day
• Oral antibiotics and analgesics

23. COMPLICATIONS OF TONSILLECTOMY
• HEMORRHAGE
• Primary
• During the surgery
• Controlled by pressure packing, ligation, cauterisation

24. • Reactionary
• Within 24 hours of surgery
• CAUSES OF REACTIONARY HEMORRHAGE (VIVA):
1. Formation of a blood clot or Dislodgement of blood clot from lumen
2. Vasodilation of blood vessel
3. Postoperative rise in blood pressure
4. Increased venous pressure by coughing or retching
5. Slipping of ligature

25. • Management of Reactionary haemorrhage:
• Blood is cross matched
• Tonsillar fossa is inspected and clot removed
• Pressure with a swab soaked in 1:1000 Adrenaline
• Administration of hemostatic agents (Ethamsylate,Tranexamic acid)
• May require taking to the operation theatre and ligation under General Anaesthesia.

26. • Most dangerous form of haemorrhage because:
• It may be missed (Patient may still be under the effect of GA)
• It may cause fatal aspiration
• Large hemorrhages may require ligation or electrocoagulation under GA. Two GAs at a
short interval is dangerous.
• Secondary haemorrhage (>24 hours – 2 weeks)
• Cause: Infection of the granulating tonsillar bed
• Treated with Antibiotics

27. • OTHER COMPLICATIONS OF TONSILLECTOMY:
• Injury to:
• Temporo-mandibular joint
• Lips and commisures of mouth
• Tongue, uvula, soft palate
• Very rarely Glossopharyngeal nerve, pharyngeal venous plexus, carotid sheath
• Grisel syndrome (Non traumatic atlanto axial dislocation)
• Aspiration of blood-> Pneumonia, collapse of lung, or lung abscess

28. • Hematoma and oedema of uvula
• Referred earache
• Velopharyngeal insufficiency
• Tonsillar remnants