Tonsillectomy

1. Tonsillectomy

2. It’s the surgical removal of tonsils.
- It is usually done for treatment of chronic infection
of tonsils ,obstructive sleep apnea , supporative ottits
media etc.
Tonsillectomy

3. Indications
A. Absolute
1. Recurrent infections of throat
2. Peritonsillar abscess
3. Tonsillitis causing febrile seizures
4. Hypertrophy of tonsils causing obstruction
5. Suspicion of malignancy
B. Relative
1. Diphtheria carriers,
2. Streptococcal carriers
3. Chronic tonsillitis with bad taste or halitosis
4. Recurrent streptococcal tonsillitis in a patient with valvular heart
disease
C. As a Part of Another Operation
1. Palatopharyngoplasty
2. Glossopharyngeal neurectomy.
3. Removal of styloid process.

4. 1. Haemoglobin level less than 10 g%.
2. Acute infection in upper respiratory tract, acute tonsillitis.
Bleeding is more in the presence of acute infection.
3. Children under 3 years of age.
4. submucous cleft palate.
5. Bleeding disorders, e.g. leukaemia, haemophilia.
6. At the time of epidemic of polio.
7. Uncontrolled systemic disease, e.g. diabetes, cardiac disease,
hypertension or asthma.
8. Tonsillectomy is avoided during the period of menses.
Contraindications

6.  Usually done under
General anaesthesia with
endotracheal intubation.
 In adults it may be done
under local anasthesia
 Rose’s position :
 Patient lies supine with
head extended by
placing a pillow under
the shoulders.
 A rubber ring is place
under the head to
stabilize it.
 Hyperextension should
always be avoided
Anaesthesia Position

7. Equipments for tonsillectomy
Set of instruments for tonsillectomy.(1) Knife in kidney tray, (2) & (3) Toothed and non-toothed
Waugh's forceps, (4) Tonsil holding forceps, (5) Tonsil dissector and anterior pillar retractor, (6)
Luc's forceps, (7) Scissor, (8) Curved artery forceps, (9) Negus artery forceps, (10) Tonsillar snare,
(11) Boyle Davis mouth gag with three sizes of tongue blades, (12) Doyen's mouth gag, (13) Adenoid
curette, (14) Tonsil swabs, (15) Nasopharyngeal pack, (16) Towel clips.

8.  1. There is virtually no aspiration of blood or
secretions into the airway.
 2. Both hands of the surgeon are free. This position
helps in proper application of the Boyles Davis
mouth gag.
 3. The surgeon can be comfortably seated at the
head end of the patient
Advantages of Rose position:

9. Techniques of tonsillectomy
Cold Methods
 Dissection and snare
 Guillotine method
 Intracapsular tonsillectomy
with debrider
 Harmonic scalpel
 Plasma-mediated ablation
technique
 Cryosugical technique
Hot Methods
 Electrocautery
 Laser tonsillectomy
 Coblation
tonsillectomy
 Radiofrequency

10. Steps of Operation
(Dissection and Snare Method)
1. Boyle-Davis mouth gag is introduced and opened. It is
held in place by Draffin's bipods .
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 pole to mucous membrane
between the tonsil and posterior pillar.

11. 4. A blunt curved scissor 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 traction
applied downwards and medially. Dissection is
continued with tonsillar dissector or scissors until lower
pole is reached
Steps of Operation
(Dissection and Snare Method)

12. 6. Now wire loop of tonsillar snare is threaded over 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.
Steps of Operation
(Dissection and Snare Method)

13. 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. pulse, respiration
and blood pressure.

14. 2. Diet
a. When patient is fully recovered he is to take liquids, e.g.
cold milk or ice cream.
b. Sucking of ice cubes gives relief from pain.
c. Diet is gradually built from soft to solid food. They may
take custard, jelly, soft boiled eggs or slice of bread soaked
in milk on the 2nd day.
d. Plenty of fluids should be encouraged.
Post-operative Care

15. Post-operative Care
3. Oral hygiene
Condy's or salt water gargles 3-4 times a day.
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 given
orally or by injection for a week.
Patient is usually sent home 24 hours after operation
unless there is some complication. Patient can resume his
normal duties within 2 weeks

16. Other methods
for tonsillectomy
1. Guillotine method. Largely abandoned. It can
be done only when tonsils are mobile and tonsil
bed has not been scarred by repeated infections.
2. Electrocautery. Both unipolar and bipolar
electrocautery has been used. It reduces blood
loss but causes thermal injury to tissues.

17.  3. Laser tonsillectomy. It is indicated in coagulation
disorders. Both KTP-512 and CO2 lasers have been used but
the former is preferred. Technique is similar to one used in
dissection method.
 4. Laser tonsillotomy. 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
anterior pillars by stage repeated applications.
 5. Intracapsular tonsillectomy. With the use of powered
instruments (micro debrider with a 45 degree hand piece )
tonsil is removed but its capsule is preserved in the hope to
reduce post-operative pain.
Other methods of tonsillectomy

18. Other methods of tonsillectomy
6. Harmonic scalpel.
 It is an ultra sound coagulator and dissector that uses ultra sonic
vibrations to cut and coagulate tissues.
 The cutting operation is made possible by a sharp knife with a
vibratory frequency of 55.5 KHz ovar a distance of 89 micro
meters.
 Coagulation occurs due to transfer of vibratory energy to tissues.
This breaks hydrogen bonds of proteins in tissues and generates
heat from tissue friction.
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

19.  8. Coblation tonsillectomy.
 It is also other wise known as cold abalation. This technique utilises a field of
plasma, or ionised sodium molecules, to ablate tissues. The heat generated
varies from 40 - 80 degrees centigrade, much lower than that of electro
cautery. The major advantage of this procedure is reduced bleeding and
reduced post operative pain.
 9. Cryosurgical technique.
 Tonsil is frozen by application of cryoprobe and then allowed to thaw. Two
applications, each of 3-4 minutes, are applied. Tonsillar tissue will undergo
necrosis and later fall off leaving a granulating surface. Bleeding is less due to
thrombosis of vessels caused by freezing.
 - 82 degrees centigrade by carbondioxide
 - 196 degrees centigrade by liquid nitrogen
Other methods of tonsillectomy

20. Complications
A. Immediate
 1. Primary haemorrhage. Occurs at the time of
operation. It can be controlled 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.
 3. Injury to tonsillar pillars, uvula, soft palate,
tongue or superior constrictor muscle due to bad
surgical technique.

21. 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 to
superior constrictor muscle.

22. Delayed Complications
1. Secondary haemorrhage. Usually seen between the 5th to 10th post-
operative day. It is the result of sepsis and premature separation of the
membrane.
 Simple measures like removal of clot, topical application of dilute
adrenaline or hydrogen peroxide with pressure usually suffice.
 For profuse bleeding, general anaesthesia is given and bleeding vessel is
electrocoagulated or ligated.
 Sometimes, approximation of pillars with mattress sutures may be
required.
 Sometimes, external carotid ligation may also be required.
 Transfusion of blood or plasma, depending on blood loss, is given.
 Systemic antibiotics are given for control of infection.

23.  2. Infection. Infection of tonsillar fossa may lead to
parapharyngeal abscess or otitis media.
 3. Lung complications. Aspiration of blood, mucus or tissue
fragments may cause atelectasis or lung abscess.
 4. Scarring in soft palate and pillars.
 5. Tonsillar remnants. Tonsil tags or tissue, left due to
inadequate surgery, may get repeatedly infected.
 6. Hypertrophy of lingual tonsil. This is a late complication and
is compensatory to loss of palatine tonsils. Sometimes,
lymphoid tissue is left in the plica triangularis near the lower
pole of tonsil, which later gets hypertrophied. Plica triangularis
should, therefore be removed during tonsillectomy
Delayed Complications

24. Thank You