1. TONSILLECTOMY
E.S.Paul
MS(ENT).,FAGE

2. 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.

3. Absolute Indications
1. Recurrent infections of throat. This is
the most common indication. Recurrent
infections are further defined as:
– (a) Seven or more episodes in one
year, or
– (b) Five episodes per year for 2 years, or
– (c) Three episodes per year for 3 years, or
– (d) Two weeks or more of lost school or
work in one year.

4. Absolute Indications cont..
2. Peritonsillar abscess. In
children, tonsillectomy is done 4-6
weeks after abscess has been treated.
In adults, second attack of peritonsillar
abscess forms the absolute indication.
3. Tonsillitis causing febrile seizures.

5. Absolute Indications cont..
4. Hypertrophy of tonsils causing
– airway obstruction (sleep apnoea)
– difficulty in deglutition
– interference with speech.
5. Suspicion of malignancy. A unilaterally
enlarged tonsil may be a lymphoma in
children and an epidermoid carcinoma
in adults. An excisional biopsy is done.

6. Relative Indications
1. Diphtheria carriers, who do not
respond to antibiotics.
2. Streptococcal carriers, who may be the
source of infection to others.
3. Chronic tonsillitis with bad taste or
halitosis which is unresponsive to
medical treatment.
4. Recurrent streptococcal tonsillitis in a
patient with valvular heart disease.

7. 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.

8. Contraindications
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. Overt or submucous cleft palate.
5. Bleeding disorders, e.g.
leukaemia, purpura, aplastic
anaemia, haemophilia.
6. At the time of epidemic of polio.
7. Uncontrolled systemic disease, e.g.
diabetes, cardiac disease, hypertension or
asthma.

9. Anaesthesia
• Usually done under general
anaesthesia with endotracheal
intubation.
• In adults, it may be done under local
anaesthesia.

10. Position
• Rose's position, i.e. patient lies supine
with head extended by placing a pillow
under the shoulders. In this position
both the head and neck are extended.

11. Rose's position
Rose's position for tonsillectomy. Neck is extended by a sand bag
under the shoulders and the head is supported on a ring.
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12. Advantages of Rose position:
• 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

13. • Boyles Davis mouth gag has 2
components:
• 1. The tongue blade - known as the
Boyles tongue blade
• 2. Mouth gag - Davis mouth gag.

14. Boyles Davis mouth gag
Davis mouth gag Boyles tongue blade

15. Boyle-Davis mouth gag

16. Boyle-Davis mouth gag

17. 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)
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© 2005 Elsevier

18. 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.

19. Steps of Operation cont..
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

20. (A) Tonsil being dissected from its bed. (B) The pedicle at the lower pole of
tonsil being cut with a snare.
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21. Steps of Operation cont..
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.

22. 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.

23. Post-operative Care cont..
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.

24. Post-operative Care cont..
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

25. Methods for tonsillectomy
Cold Hot
Dissection and snare Electrocautery
Guillotine method Laser tonsillectomy (CO2
or KTP)
Intracapsular (capsule Coblation tonsillectomy
preserving)
tonsillectomy
Harmonic scalpel Radio frequency
Plasma-mediated
ablation technique
Cryosurgical technique

26. 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.

27. Tonsil guillotine Guillotine tonsillectomy

29. • 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.

30. Laser tonsillectomy Laser tonsillotomy( ablation)

31. • 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.

32. Intracapsular tonsillectomy

33. micro debrider micro debrider-tip blade

34. 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.

35. Harmonic scalpel knife Harmonic scalpel tonsillectomy

36. • 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

37. • 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.

38. Coblator wand

39. Coblation tonsillectomy

40. • 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

42. 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.

43. Immediate Complications cont..
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.

44. B. 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.

45. Delayed Complications cont..
• 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.

46. Delayed Complications cont..
• 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

47. Thank You